The complicated environment of health care involves many types of distress. Health professionals sometimes experience the psychological distress of staff shortages, difficult co-workers, or overbearing supervisors. They often experience the emotional distress of a patient’s death, a family member’s neglect, or the tragedies that result from a patient’s inability to pay for care, or from patients’ lack of citizenship. Most people are well-aware that they will face these kinds of distress when they become health professionals. It is understood to be part of the job.

But there is a distinct type of distress that is not as well known, at least not by name, though research suggests it is widely experienced. It is distress that comes loaded with moral content—This patient should have X, but the doctor won’t let me. Or, I shouldn’t have to do this to this patient; it is not good. 

Moral Distress in the Health Professions traces the history and evolution of the concept of moral distress (chs. 1, 2, and 4), demonstrates the variety of ways it is experienced by health professionals in the US (chs. 3 and 9) and around the world (ch. 8), explains common sources of moral distress (chs. 5 and 9), and reviews some projects aimed at identifying and addressing moral distress (chs. 6, 7, and 9).

The term “moral distress” was first used to describe a common experience among nurses. Nurses have a moral perspective on their patients’ care that is distinct from those of doctors, other skilled providers (like respiratory or physical therapists), and the families of patients. Traditionally, however, nurses’ place in the hospital hierarchy of authority has been close to the bottom, and so their voices have not been as prominent in care planning or decision-making. This has led to cases where nurses feel compelled to do things they judge to be morally problematic. And cases where they feel prevented from doing something they believe to be ethically required. Not only is this distressing, it is distressing in a particular way: It challenges the deep sense of their moral agency. They may feel complicit or guilty or as if they lost their integrity. 

In his 1984 book, Nursing Practice: The Ethical Issues, philosopher Andrew Jameton gave the name “moral distress” to this experience, and a new research agenda emerged. There, Jameton defined moral distress as the distress that “arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (6). Jameton distinguished moral distress from two other ethical phenomena associated with medical decision-making: moral uncertainty—lack of knowledge about what to do—and the moral dilemma—a decision one perceives to have no morally acceptable option.

Despite its widespread acclaim, Jameton’s original definition faces serious challenges. For example, Jameton says that a person has to “know” the right thing to do. But subsequent discussions suggest that, even if someone is mistaken about their moral obligation, the perception that they have that obligation is enough to be morally distressing. In fact, getting moral clarification—and discovering that your initial moral intuition was incorrect—is one way to alleviate moral distress. Further, the claim that moral distress is only a function of “institutional constraints” proves too narrow. It turns out that constraints can be personality-based, unit-based, society-based, or imposed by a patient’s family. There is a further question of whether all constraints involved in causing moral distress are “external.” For example, it may be that the internal constraint called akrasia (the failure of willpower) could also be a source of moral distress. Most scholars agree that Jameton’s original definition is inadequate, and at least twelve others have been proposed.

But despite the difficulty of getting the details right, Jameton’s new concept pointed to a phenomenon that was (a) readily recognizable to many health professionals and (b) called out for sustained attention. The ensuing discussions have borne fruit in the form of consensus on three basic elements of moral distress. In chapter 4, Stephen Campbell and the editors, Connie Ulrich and Christine Grady, note that almost everyone who studies moral distress now agrees that moral distress:

1. Arises when one believes one knows the morally right thing to do (or avoid doing), but one’s ability to do this is constrained by internal and/or external factors.

2. Comes in two phases. There is “initial distress” at the time of potential action (or inaction); later, there is “reactive distress” or “moral residue” that occurs in response to the initial episode of moral distress.

3. Involves the compromising of one’s moral integrity or the violation of one’s core values. (59-60)

It is also widely agreed that moral distress reaches far beyond nursing, affecting social workers, respiratory therapists, doctors, and others. And Ulrich and Grady have curated a set of chapters that highlight how moral distress affects a diversity of health professions.

The centerpiece of the discussion on the nature of moral distress is chapter 4, where Stephen Campbell and the editors, Ulrich and Grady, argue that the concept of moral distress should be expanded from the three criteria above to include distress over a wider array of moral experiences: moral uncertainty, mild distress, delayed distress, moral dilemmas, moral bad luck, and distress by association. They offer six cases to motivate this broader conception, and they argue that what ties these cases to moral distress is that they each involve “an individual in a health care context experiencing distress because he or she feels morally compromised in some way” (61). 

The authors acknowledge that the central concern about such a view that it renders the concept so broad that it is unusable. If it covers every negative emotion associated with every situation perceived to be morally compromising, this does not give us any indication of how to respond to it. For example, if an experience is an instance of moral distress related to a moral dilemma, should we respond differently than if it were just regarded as a moral dilemma? To be sure, there may be some distress associated with facing a moral dilemma, and since this distress stems from a moral problem, it might be tempting to call it a species of moral distress, rather than emotional or psychological distress. But since the way to handle the distress in this situation is to handle the dilemma, then it is not clear how regarding it as moral distress adds anything to our conceptual understanding of the problem. 

The authors admit that their broad definition could make research on moral distress difficult, if research is intended to capture the full range of moral distress. But they contend this need not be the case. Researchers are still free, they argue, to study specific types of moral distress, such as those captured by the three criteria above. Further, this broader conception can inspire more robust moral imagination, keeping researchers and those interested in addressing moral distress “from becoming narrowly focused on a particular type that does not have moral priority over various other types” (71). They also claim that not all types of moral distress “require or merit intervention.” 

For my own part, I am concerned that this response simply re-raises the central concern. What is the study of moral distress aimed to accomplish? If it is to clarify a distinct problem facing health care professionals in order to devise ways of mitigating it, then a conception that either encompasses problems we already have resources to solve (e.g., moral dilemmas, moral uncertainty, distress by association, etc.) or that includes experiences not properly considered problems that need solving is not a conception that satisfies the aim. But even if this minor criticism is correct, discussion around this broader conception of moral distress pushes the debate forward in important ways.

Overall, there are a number of benefits of this book. First, it is one of very few publications that explains in detail how the concept of moral distress is situated in the broader history of nursing ethics. Anne Davis and Marsha Fowler (ch. 3) do a superb job of tracing the history of nursing ethics, highlighting changes in the nursing profession that made ethics in nursing education less prominent, and exploring the implications of those changes on nursing practice. Importantly, they highlight how those changes may have increased moral distress among nurses because they now have fewer tools to understand, express, or mitigate their or their colleagues’ ethical concerns.

Second, the book captures many of the most prominent discussions around the concept of moral distress (Lynn Musto and Patricia Rodney, ch. 2). Though this discussion is brief, literature on moral distress has been growing steadily since Jameton’s original formulation, and it was certainly time for a more systematic treatment. Musto and Rodney explain competing accounts, highlight some strengths and weaknesses of these accounts, and explain various factors that must be considered when developing an account of moral distress.

Third, this is the only book I know that explores in detail the sources of moral distress. In chapter 5, Mary Walton explains the “major root sources” of moral distress. Well-known sources include advances in technology that raise questions about the appropriate use of medicine, hospital hierarchies that leave some professionals (like nurses and respiratory therapists) out of care conversations, and perceived powerlessness in the face of hospital hierarchy, institutional or system-level policies, or state or federal laws. Lesser discussed sources include the lack of sufficient ethics knowledge, disagreements over what professionalism requires, and difficulties forming care plans around social barriers that keep patients from being able to access the standard of care (e.g., lack of transportation for dialysis or chemotherapy appointments). While most of these examples are listed as contributing to moral distress, authors usually lack space to explain precisely how they do. And Walton’s chapter fills this gap.

Finally, this volume is distinct from many other academic collections in that it dedicates two chapters (3 and 8) to first-hand experiences with moral distress. These chapters include short testimonies from voices around the world, including the UK, Africa, and Singapore, and from a variety of health professions, including nursing, social work, physician, and pharmacy. These personal stories show how the abstract concept of moral distress concretely affects the day-to-day practice of health professionals.

As with any book, there are a handful of ways this volume could have been better. First, the chapters are not organized in a way that makes clear sense. Chapters 2 and 4, which cover competing conceptions of moral distress, are separated by chapter 3, which explores experiences of moral distress among different types of provider in the US. And this chapter is separated by four chapters from chapter 8, which explores experiences of moral distress among different types of provider outside the US. Further, chapter 6, which covers challenges with measuring moral distress, comes before a chapter that outlines general strategies for studying moral distress (ch. 7). If I were assigning this book to students, I would have them read chapters 1, 2, 4, and 5 (and the part of chapter 3 on the history of nursing ethics) to cover the nature and sources of moral distress. I would assign the rest of chapter 3 and chapter 8 to cover provider experiences with moral distress. And I would assign chapters 7, 6, and 9 to cover research on and strategies for addressing moral distress.

A second shortcoming of the volume is its failure to explain or engage with much of the empirical research on moral distress, whether on tools to identify it or strategies to address it. For example, though there are passing references to Ann Hamric’s Moral Distress Scale (and Moral Distress Scale-Revised) and Lucia Wocial’s Moral Distress Thermometer, there is no review or explanation of the research on these tools or discussion of whether or how they might be used as part of strategies for addressing moral distress. Further, there is only passing reference to Cynda Rushton’s extensive work on resilience training as a method of mitigating moral distress. And there is no mention at all of the resources on University of Kentucky’s Moral Distress Project website. If the authors were to plan a second edition of this book, I would recommend adding an appendix with tools, initiatives, and activities that have been developed to address moral distress in different types of institution, along with data on their success.

Despite these limitations, this collection fills a much-needed gap in the moral distress literature. It brings academic and bedside perspectives together in ways that are mutually informative, it highlights current points of consensus and disagreement on the concept of moral distress, and it identifies some possible ways forward, both for future research on moral distress and for strategies to address it.

Jamie Carlin Watson, Ph.D.