Moral Distress

The term moral distress acknowledges the situations in which the health care professional is frustrated from feelings of powerlessness when a perceived wrong is occurring but he or she is unable to act. Basically, it is the feeling experienced when an individual cannot do what he or she believes ought to be done because of a system issue, resistance of a powerful person, or a restraint in the situation. The use of this term came from the nursing profession to describe situations in which the nurse feels powerless to act ethically.3,4 Although this is a relatively newer term, the resulting distress, emotional toll, anger, guilt, and depression are familiar to many health care providers who must balance conflicts of conscience with professional expectations. An example of this for the dentist or dental hygienist could be when treatment recommended by another provider for a patient is deemed excessive or unnecessary. To deal with this distress, several tools have been created to help a clinician process through this type of situation.

The American Association of Critical Care Nurses (AACCN) advocates a model for rising above moral distress called the “four A’s.”5 The four A’s are ask, affirm, assess and act used in this way to help the clinician remember the steps.

Ask Ask about the problem. Be aware of situations around you that may be affecting you or others.
Affirm Affirm that you are in distress and that you have a professional obligation to act.
Assess Identify sources of distress and analyze risk and benefits.
Act Prepare to take action both personally and professionally.

The goal in this model is to preserve the integrity and authenticity of the health care professional but does require making changes and addressing the issue.

Morally courageous professionals are encouraged to persevere in standing up for what is right even when it means they may do so alone. Murray provided a listing of seven critical checkpoints to use in ethical decision-making.6 His guiding checkpoints start with evaluating the need for moral courage and end with avoiding things that might restrain moral courage. In a clinical setting, whether it is a small or large group of practitioners, there can be an unwillingness to face the challenge of addressing unethical behaviors. Those who have the courage to stand up and speak out need the support of their peers.

Guidelines to apply when dealing with moral distress:

  1. Evaluate the circumstances to establish whether moral courage is needed in the situation.
  2. Determine what moral values and ethical principles are at risk or in question of being compromised.
  3. Ascertain what principles need to be expressed and defended in the situation – focus on one or two of the more critical values.
  4. Consider the possible adverse consequences/risks associated with taking action.
  5. Assess whether or not the adversity can be endured – determine what support/resources are available.
  6. Avoid stumbling blocks that might restrain moral courage, such as apprehension or other reflection leading to reasoning oneself out of being morally courageous in the situation.
  7. Continue to develop moral courage through education, training, and practice.