A Response to the Idea of Moral Resilience as a Remedy for Moral Distress
Rick Garlikov

I think that despite its precise definition, the typical use of the concept of moral distress confuses and conflates too many things, and that while ‘moral resilience’ is important for coping with any of them, moral resilience is not the answer or even an appropriate solution to the problem of moral distress.  It is treating only the symptoms of a serious problem that needs to be treated at the root, not just the periphery.  As an old man on 60 Minutes said one time in a meeting where savings and loan officials told customers that all their savings had been lost and that free counseling was being made available to them, ‘Son, we want you to give us our money back, not make us feel good that you stole it.’  He wasn’t seeking moral resilience, but moral remedy.  Nurses (and others who suffer moral distress) need remedy, not just resilience.  Making, or being able to make, the best of a bad situation does not make it right to create or permit bad situations.

The best way to point to problems with the concepts and ideas involved is to do a “close reading” of papers about it such as the recent review paper, by advocates of moral resilience, extolling moral distress as an opportunity for developing it: “Moral Distress: A Catalyst in Building Moral Resilience”, by Cynda Hilton Rushton, Meredith Caldwell, and Melissa Kurtz in AJN [American Journal of Nursing], July 2016, Vol. 116, No. 7  (http://www.nursingcenter.com/JournalArticle?Article_ID=3579853&Journal_ID=54030&Issue_ID=3579740).  I had intended to just place responses in their appropriate places in the paper to show that I was not misrepresenting their points in any way, and to make it easy for the reader to follow their arguments and mine.

However in my own test of moral distress, AJN’s policy is not to allow their articles to be anywhere else, even though this one is available free on their web site, and they don’t accept rebuttal articles.  So what I am going to do is to summarize and/or paraphrase points I am responding to in blue font below, and quote (in black font) the statements or parts of statements, where my responses belong.  I must say here, in the spirit of what the authors below seem to think is a component of moral resilience, and I do not, that I do not understand journals, whose business it is to seek truth, that will not even consider rebuttal articles to ones they have already published.  They do accept letters of 300 or fewer words that state objections, but that hardly does justice to explaining numerous problems in an article which represents flawed emerging thinking likely to become conventional because of prevalence in the literature. 

The article begins with an example problem that caused moral distress for a nurse: a patient rushed to the facility with stomach pains was diagnosed with a peptic ulcer and admitted for monitoring.  Her nurse had a large patient load already.  The woman’s condition seemed to be worsening, but the physician would not heed the nurse’s report and request for a follow-up exam.   

The patient “was becoming diaphoretic, her blood pressure was rising, and her oxygen saturation level was dropping.” The nurse’s “intuition told her something was wrong… She made several calls to the admitting physician but was unable to convince him that [the patient] needed further evaluation.” She should not have had to “convince” him beyond giving him the facts she did.  He should have been concerned enough about the patient, given those facts to further evaluate the patient. “She informed the charge nurse and the nursing supervisor of the situation and documented her assessment in the patient’s electronic medical record.” Documentation “covers” her liability minimally if the patient were to suffer from the lack of follow-up care by the doctor, but it doesn’t help the patient.  And if neither the charge nurse nor the nursing supervisor do anything to help the patient directly or by making the doctor (or another doctor) tend to her, again, none of that solves the medical problem for the patient.

The nurse had more patients in need of attentive care than she could reasonably give. “She felt that she was ‘spread so thin’ that she couldn’t provide safe, high-quality care to any of her patients, and she also felt that she was failing as [the patient’s] advocate.”  These were not just “feelings” but reasonable assessment of the work environment.  Calling them feelings makes it incorrectly sound as though this is an abnormal or overly sensitive response to an acceptable circumstance that should be part of the job.  It is not an acceptable circumstance; it should not be part of the job.

… “Every day, under a wide variety of circumstances, nurses in all roles and specialties are confronted with complex ethical questions that challenge their integrity.” This is not a complex ethical question; the right act is not in doubt nor difficult to decide; the patient was in fairly clearly abnormal distress and the physician should have checked on her or got someone else to check on her, or at least explained to the nurse why it was not a problematic situation, and how he could know that (which seems highly unlikely).  And the nurse’s integrity is not what is being challenged; it is her autonomy and liberty to do her job properly.  She is not being tempted to do what she knows is wrong but wants to do and get away with; that would be a challenge to her integrity.  Instead, she is being prevented by a wrong policy of authority from doing what she wants to and what she knows is right and best for the patient.  Furthermore, she has a responsibility for a task she is not granted the authority to do.  That is not only morally frustrating, but morally wrong and shameful.  And primarily developing the skill not to be professionally or personally troubled or incapacitated by it is not the right or a sufficient response.   “They struggle to balance competing obligations to their patients and families, their colleagues on the health care team, the organization where they practice, the surrounding community, society—and themselves.”  That is an entirely different kind of ethical problem or dilemma.  Moral dilemmas, which are often vexing and difficult, can arise from conflicting moral principles or elements within a principle or from conflicting prima facie obligations until they can be resolved as to the most reasonable priority.  And even then they can be emotionally troublesome because choosing the least bad or least flawed option is not particularly satisfying, nor is having to override one ethical obligation because of a conflicting one that is stronger, which incorrectly makes a conscientious person feel they have violated the weaker obligation.  But making right moral decisions, even if difficult and emotionally painful is not what moral distress is, according to the standard definition used later by the authors.   “Often working within health care systems that are driven by cost concerns, external metrics, and organizational expectations that undermine person-centered care,” -- no, not just that; they undermine doing the right thing for the patient, not just because it is not person-centered in the sense of being personal, but in the sense of being the wrong treatment or wrong thing to do to the patient (in this case, withholding of follow-up diagnosis and treatment by the physician).  Cost effectiveness in health care, while important, is not the central ethical feature of taking care of patients.  And pandering to whimsical patient “satisfaction” at the expense of proper medical treatment for all is not a valid policy either.  It is not right to do as little as possible to avoid work or liability. Patients deserve the proper care insofar as it can be reasonably provided, not unreasonably withheld to save physicians time or hospitals money for unnecessary and merely greedy profit at the expense of the health of the patient.  If we are going to make money the sole purpose of ethics, then we should allow theft, fraud, and extortion, as well as withholding proper treatment solely on the basis of cost.  We should also allow unsafe products on the market if they are cheaper to produce.  When Ford Motor Company did not recall Pintos to remedy the exploding gas tank problem for even low speed rear end collisions because it was calculated to cost more than losses of wrongful death lawsuits, the jury found out about saving money being their rationale for risking lives, and awarded plaintiffs the largest amount of money up to that time to make sure Ford (and other manufacturers) knew that if all they cared about was profit, profit would have to be made to extrinsically reflect, incorporate, and foster morally correct behavior in some way for those devoid of intrinsic moral sensitivity and understanding, at least in cases like this involving known safety defects that cost little to remedy.  …“many nurses despair at their inability to maintain their personal and professional integrity” – no; they despair at arbitrarily and wrongfully being prevented from doing what is right for their patients.  “When they’re unable to translate their moral beliefs into ethically grounded actions, moral distress ensues.”  While that is true it is like saying that when someone beats you, rapes you, and then shoots you and leaves you for dead, it makes you sad, which may also be true, but is the least important part of the problem, and is in a sense a secondary or peripheral response to clear wrongdoing.

…“moral distress … describe[s] the negative feelings that arise when one decides on a morally correct action in a given situation, but is constrained from taking that action.” But that is not the only salient feature in these kinds of cases.  The other salient feature is that the restraint is arbitrarily imposed by some sort of wrongful authority, policy, law, or regulation, which apart from being simply a conflicting prima facie obligation is actually wrong and could easily be remedied if there was the proper will to do it.  Moreover, there will usually be a severe penalty for doing the right thing, in an attempt to coerce the wrong choice by extrinsic harmful consequences to the agent (in this case, the nurse).  Constraints which are beyond anyone’s control to overcome (see below) cause emotional frustration and distress, but not “moral” distress of the sort that the usual examples of moral distress involve.  There are “two distinct components of moral distress: initial distress, experienced in real time as the situation unfolds; and reactive distress, which arises after the situation has passed and involves lingering feelings about one’s failure to act [in the way one knows is right] on the initial distress. This reactive distress [is] also known as moral residue”  “Reactive distress” can come from second guessing oneself, particularly in the hindsight of a bad outcome (or even a realized fluke, lucky good outcome), from figuring out later how one might have handled it better (though that may not have worked either), and/or from feeling later, when rested, that one could have done more because one forgets the energy one has later was not available at the time of the problem.  And it can involve a feeling of guilt (even if unjustified) for not having done more at the time, or known how, to avert the outcome that one thought should be averted.  “Specifically, moral distress occurs when one recognizes one’s moral responsibility in a situation […] but is then prevented from following through.”  But prevented by arbitrary policies or authority, etc., not by just natural obstacles.  E.g., the inability to save patients in the New Orleans hospital after Hurricane Katrina left it in sweltering heat with no power and insufficient resources was traumatic, but not a case of moral distress.  It was frustrating and difficult in a number of ways, some of which were moral, but it was not a case of moral distress in the sense that providers were arbitrarily prevented in the name of some wrongful moral policy or unreasonable regulation. “Moral distress is distinct in that it involves the violation of one’s core moral values” – no; it is caused by the violation of one’s autonomy and liberty to do what one knows is right; one’s values are not being violated, and one is not violating one’s own values; one is simply being prevented from acting upon them by an arbitrary obstacle, “has the capacity to erode personal integrity, and may undermine moral identity.”  -- again, all secondary effects of being arbitrarily prevented from doing what one knows one should.  At its heart, moral distress is a type of suffering that arises in response to wrongful, (easily) preventable, and arbitrary “challenges to, threats to, or violations of professional and individual integrity.”

… “ moral distress is a widespread problem in health care, occurring not only among nurses but also among physicians, pharmacists, therapists, social workers, and others.”  It occurs in any field where one is prevented by wrong policies, rules, or authority from doing what is right.  One of my students had been a soldier in Afghanistan whose duty was to accompany and protect convoys between their base and the airport, on a road that was in a valley where the mountains allowed the enemy to attack.  The policy was that no convoys should travel the road without air support.  On a morning when a number of the troops were to head to the airport to go home now that they had finished their tour of duty, the fog was pea soup thick.  Nevertheless the commanding officer was given the all-clear by the air base saying they would be flying cover.  My student pointed to the fog and said that had to be some kind of mistake – that visibility was clearly zero and there could not be air support.  The officer said the order was clear and that the convoy was to embark.  Of course, there was no air cover, the convoy was sharply attacked, and many of the people died, including members of his unit, along with many of the soldiers who were still getting to finish their tour and go home, but not upright.  The military, the corporate world, and basically any institution or bureaucracy provides ample evidence and examples, usually on a daily basis, of moral distress.  And in this soldier’s case there was ample moral “residue”, feelings of guilt, error, conflict, second-guessing, and lack of courage to stand up to his commanding officer – feelings of moral failure and inadequacy, even though he still wasn’t sure it would have been right for him to disobey a direct order or challenge the authority of a superior officer.  I did ask him which option was worse, being disciplined or even put in the brig or dishonorably discharged or losing all those lives, particularly of his close friends and fellow soldiers.

Teachers forced to teach in ways which they know thwart or diminish student learning also suffer moral distress, as does anyone not allowed to do anything properly because of artificial constraints such as bureaucracy, red tape, and ill-conceived rules.  The television series M*A*S*H pretty much each week showed such problems but they were only morally distressing momentarily for the characters in the program who were not averse to breaking and/or circumventing rules in all kinds of clever, amusing, and sometimes poignant ways – ways much easier to pull off and get away with in fiction than in real life – in order to do what was right, and, again in fiction, more clearly right.   

In regard to not putting (or being allowed to put) patients’ care and rights first,    “nurses face situa­tions that threaten their core values and integrity and put them at risk for not adhering to the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements.” While that is true, it is not totally accurate, for a couple of reasons:  

1) Nurses have obligations within their institutions and the field of medicine to follow directives of physicians, supervisors, and hospital rules and policies.  These people are supposed to have superior knowledge, experience, and wisdom, and so a nurse may feel that her diagnosis of the patient’s needs is mistaken.  So there is a genuine moral quandary rather than simply moral distress at that point.   Moral distress is only the problem of not being allowed to do what one knows is right, not just being caught between conflicting directives.  So-called ‘moral residue’ occurs later when it is clear that the authority that was obeyed was mistaken and the patient suffered harm or death, or would have, had someone else with greater authority or medical judgment not intervened and pointed out the error. 

If the authority was not mistaken, but the nurse’s diagnosis was, and that had become clear in time and/or after consultation with other physicians who were more explanatory about the actually harmless causes of what the nurse perceived in the patient, there would have been no moral residue because there would have been no moral error.  Moral residue only occurs where the belief remains that the agent made the wrong moral choice, particularly if they feel they did not show the proper moral fiber, resolve, courage, backbone, responsibility to do what they thought was right. 

2) While nursing codes of ethics have right principles in requiring nurses to consider patient safety and rights paramount, they have little teeth and are rarely enforced in the nurse’s favor.  A few recent lawsuits are some of the first to be successful, at least so far in the judicial process, but few nurses have the time or resources to fight such battles, and even when one wins, it can be at the cost of nursing for years, if not for the rest of their lives.  In that regard the nursing code of ethics is a sham because it is not really supported by nursing associations.  Instead of helping nurses do the right thing by their patients, it merely makes them feel even more guilty for not be willing to jeopardize their career over doing the right thing.  Nursing codes of ethics are like someone saying “Go ahead and charge the shooter, I’ll cover you” when you know they are not going to cover you.  Nursing association codes of ethics provide encouragement for martyrdom, not protective support for morality.  Instead of removing the need for exceptional courage to do what is right for patients, they make it require even more heroism and potential sacrifice than is fair to expect from any agent while merely unrealistically hoping and disingenuously imagining that every agent will rise to the occasion.  They put nurses in an even more morally untenable situation and then blame them for not doing the right thing, while allowing them to be punished for doing what is right and what they say they require.

Later in the article, the authors write about moral distress being a catalyst for moral resilience, essentially developing moral strength, courage, and resolve, but it is the near miss cases that are better for that because in those, no irremediable harm is done in teaching the lesson.  It is better to regret not having been more forceful (or manipulative) in making one’s case, learn from the error, and resolve to do better in the future over an instance that resulted in no significant harm, than to learn that lesson from one where harm was done and one then has to bear the responsibility and guilt for the disastrous consequences along with the shame of lack of sufficient resolve and moral courage.

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“For the individual, moral distress can result in debil­itating frustration, anger, and guilt. Unacknowl­edged or unjustifiable moral compromises can lead to the deterioration of one’s moral integrity and possi­bly of one’s moral agency, which has been defined as “having the capacity to make moral judgments and to act upon them” despite personal or institutional con­straints.”  This is convoluted.  Moral distress doesn’t “lead to” deterioration of one’s capacity to act on one’s moral judgments; as defined in their article, it is the result of not having the capacity to act in accord with one’s moral judgment.  Moral distress is the result of unnecessary and wrongful conflicts that make fulfilling normal moral obligations require unnecessary moral courage and willingness to be a self-sacrificing martyr.  While that may make someone feel they are guilty and feel they have lost their integrity, it really instead causes an anxiety that feels like guilt for not being able to meet an unfair and unrealistic expectation which cannot by its nature then be a real duty, but is transformed into a saintly or heroic act – what philosophers call a “supererogatory” act that is one over and above the call of duty.  You cannot reasonably, realistically, and morally give nurses a responsibility without the accompanying authority and protection from punishment and penalty for doing what is right.  Yet that is what the system does.  And nurses are supposed to cope with that and develop resilience?  (“The beatings will continue until morale improves.” “Walk it off; grow up.”)  “Guilt” is not the appropriate word for not being a martyr in an unnecessarily unfair situation – one in which one is, by definition, constrained from doing what is right – and in the kinds of cases at issue, constrained to the extent one is essentially prevented from doing what is right.  Anger, frustration, righteous indignation are understandable and reasonable.  Anxiety, sorrow, and regret for being put into an untenable situation are most reasonable, but anxiety, sorrow, and regret of that sort should not be confused with guilt.   “Long-term psychological consequences can include withdrawal, emotional exhaustion, deperson­alization toward patients, and burnout.” Those are natural reactions to being unnecessarily and repeatedly forced into terrible and avoidable situations, which is why the remedy should be to prevent such situations, not train nurses to adjust to them and try to cope. “Repeated or prolonged experiences of moral distress and moral res­idue can interact, resulting in what Epstein and Ham­ric call the crescendo effect, in which ‘new situations evoke stronger reactions as a clinician is reminded of earlier distressing situations.’” One would think that prolonged or repeated stress on its own weakens anyone or anything, whether it invokes memories or not. 

“Because moral distress affects such a wide range of health care professionals, it stands to reason that it may be a factor in teamwork erosion, decreased qual­ity of patient care, and poor patient outcomes.” No, it is not the distress that causes this; it is the behavior that causes the distress which also causes this! If a physician or administrator won’t let a nurse do what s/he knows is right for the patient, it is not the nurse’s distress that causes the breakdown in respect or cohesion, it is the physician’s or administrator’s actions that causes it; and the disrespect is justified.  

 … “Moral distress has been associated with perceived failure to meet pa­tients’ and families’ needs and perceived decreases in the quality of patient care.  It also increases nurses’ risk of burnout, decreased job satisfaction, and even departure from the nursing profession.”  Again, no!  It is not the nurse’s distress at being prevented from best serving the patient that causes these things; it is the nurse’s unnecessarily and repeatedly being prevented from doing his/her job right that causes the moral distress and the emotional withdrawal, etc.  It is not about a “perceived” failure to meet patients’ and families’ needs but about an actual, unnecessary, forced failure to do so.  Experienced care providers know there are limitations to their being able to prevent patients from dying or in some cases, suffering, and they have various healthy ways to try to cope with the sadness, disappointment, and frustration of that and to feel, accurately, they have done everything they could.  But the kinds of cases that cause moral distress, withdrawal from patients and other avoidance reactions, burnout, job dissatisfaction, quitting nursing  are ones where the limitations are imposed on them in a morally wrong way by people with authority over them.  It is bad policies and the bad actions of (likely bad) people in authority that make it very difficult, and in some cases impossible, for nurses to do their jobs properly and take care of patients in a caring way they know is best.  If you are not allowed to take care of patients in a caring way, but still need to take care of patients, you are bound to have to relinquish at least some of the caring way, and then mistakes can more easily happen.  Nurses are unnecessarily put into an untenable position and then blamed for the results of it.

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“A lack of self-confidence may cause nurses to hes­itate in voicing their concerns or to withdraw from conversations altogether.   In some settings, nurses may fear retaliation, such as job termination, if they make their moral stance known.”  Lack of self-confidence is not the same thing as reasonable fear of punishment. “The sense of being ‘voiceless’ during morally complex conversations can lead to feelings of powerlessness and can ham­per the ability to bring one’s perspective to the dis­cussion.”  Being prevented from speaking up through disdain or punishment makes one actually be powerless and unable to bring one’s perspective to the discussion.  This is not about “feelings” of powerlessness but about powerlessness.   

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Moral distress is also associated with moral sensi­tivity, Of course it is, because moral sensitivity is what helps one see what is right and want to do it; so if you either do not know or do not care what is right, you are not likely going to be distressed by not being able to do what you know is right and want to do  

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“The relationship between moral sensitivity and moral distress is unclear. It’s possible that clinicians with diminished moral sensitivity experience higher levels of moral distress, either because they fail to recognize and explore the ethical aspects of a case, or because they retreat to self-defensive actions and a ‘cover your tracks’ mindset.“  That does not fit the definition the authors use of moral distress, since it does not involve constraints upon doing what they know is right.  “Covering your tracks” to avoid punishment is not moral distress; it is a wrongful response to having done what was wrong in the first place and now trying not to be caught and punished.  And remorse and regret over being caught, and/or suffering from being punished are not moral distress either.

Moreover, many conscientious nurses know of lazy co-workers whose patients they had to assist in order for the patients not to suffer.  Conscientious nurses often have to do their own work and the work of their insensitive colleagues.  It is not just nursing shortages, but the shortage of good, caring, sensitive, responsible nurses, that can cause persistent untenable conditions involving moral stress when managers or administrators will not remedy the problem.

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“One common team factor that can trigger moral dis­tress is intra-team conflict.” It is only moral conflict caused by clearly wrong policies or bad authority that triggers moral distress.  Distress from difficulties beyond anyone’s control causes emotional distress, frustration, or disappointment and sadness, of a different sort.  Even reasonable moral disagreement does not necessarily or likely cause moral distress.  If one sees the rationale for a particular requirement is at least reasonable, and possibly right, even if one thinks it wrong, that doesn’t tend to cause moral distress even if it may be disappointing in some way.  

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“A culture characterized by intra-team conflict, excessive workloads, and con­tentious power dynamics can prevent individuals from acting as moral agents.” That just means that those factors prevent people from doing the right thing.   “It’s worth noting that such factors make it harder for nurses to adhere to Provision  of the ANA’s Code of Ethics, which states that ‘the nurse, through individual and collec­tive effort, establishes, maintains, and improves the ethical environment of the work setting and condi­tions of employment that are conducive to safe, qual­ity health care.’” Of course; no individual can be responsible for the bad behavior of others who will not listen to or heed them.  It is necessary for any given individual to be cooperative and decent in order to have cohesive teamwork, but it is not sufficient.  A cooperative nurse thwarted by bad supervisors or policies is not reasonably accountable for the conflict, workload, power dynamic, or the “ethical environment” of the workplace or the conditions of employment that are conducive to safety and quality.

“Other system-based sources of moral distress in­clude … limited human and material resources.” No; only when limited human and material resources are caused by wrong decisions by people who will not listen to reason about them.  Again, it is not moral distress that is caused by losing a patient through lack of knowledge or lack of resources that could not be reasonably expected to be available, such as a suitable healthy organ or a transplant surgeon in some remote area, etc.  

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“Despite its many negative effects, moral distress can precipitate positive, growth-producing experi­ences” as can many other forms of suffering, but that doesn’t make suffering a good thing, particularly unnecessary suffering.  … “For example, in recently pub­lished narratives, Pniewski and Hallett described experiences characterized by high moral stakes and challenges. Pniewski, a hospice nurse, was a caregiver for a dying patient whose views were racist and misog­ynist; Hallett, a psychologist, found herself involved in a death row case.  Though each struggled with com­plex ethical issues, each retained her sense of integrity and exercised effective moral agency.”  Distress over having to do what is morally right but repugnant, or in having to decide what is right between conflicting values, is not moral distress in the sense defined; it is just the necessity of performing an unpleasant moral duty or resolving a difficult moral dilemma to know what is right.  Moral distress is distress over being forced to do what you know is wrong or not being able to do what you know or believe is right because of some wrong arbitrary constraint.

“This outcome stands in stark contrast to the usual depiction of moral distress as inherently negative and disempowering.” A long section than follows that lumps together various kinds of moral issues or problems under moral distress as already explained above, and that also then goes on to confuse moral understanding, moral courage, moral limitations, moral responsibility or agency, integrity, and ability to resolve ethical problems in a reasonable way.  It also confuses being empowered to cope with moral distress with being empowered to prevent or eliminate it.  As such, it is about being empowered to cope with the symptoms not eradicate the root cause.  I am omitting most of that discussion but want to comment on one passage that really involves two different claims:  “Ethics education is a vital component in building an individual’s coping capacities and decreasing the intensity and frequency of moral distress. There is evidence that nurses who have had ethics education feel more confident in their ability to recognize and address morally distressing situations, and are more likely to access ethics resources (such as institutional ethics committees or consultation services) for sup­port when making ethically difficult decisions.”

The authors then detail disagreements about which sorts of ethics programs are more effective.  It is my contention that it is the quality of the ethics education that matters, not its format.  There are two things that need to be taught/learned no matter how that is achieved:

1) all the moral elements that need to be considered in any ethical issue, such as:

·         amount, intensity, duration, significance of the goods and harms an act will cause

·         fairness of the distribution of burdens and benefits

·         deservingness

·         fairness to the agent doing the act or expected or required to do it

·         risk of harm

and other elements as well, and how to prioritize them if and when they conflict.

This component of ethics involves addressing ethical issues correctly – knowing what is right and why.

2) the nature of personal responsibility is mainly the ability to choose and refrain from choosing an act from among options, and the ability to implement one’s choice even if the choice or the act was psychologically difficult, but not excusably or justifiably too unfairly difficult, to do.     

This component of ethics involves knowing that one needs to address what one considers to be an ethical issue or a wrong order in the first place, because one is responsible for choosing and acting as one does, as opposed to either shirking responsibility for them or not recognizing one has responsibility for them.

Therefore one is responsible and culpable for inexcusably doing something wrong or inexcusably omitting to do something right if one could, and should have known to, have chosen otherwise and could have acted upon that choice, even if the choice or the act was psychologically but not excusably or justifiably too difficult to do.

It was, for example, made clear at Nuremberg that “following orders” is not a valid moral defense, excuse, justification, or reason for clemency for committing a wrong act one should have known not to commit.  And my way of suggesting you think about this in regard to any order you are given which you think is wrong, is to ask yourself

“Imagine that orders you are given require you to do something wrong, with a penalty for not obeying the orders; and also imagine that someday someone else is in charge who will hold you personally accountable for what you did, who may or may not have the same view of what you should have done as your current supervisor or boss.  Would you rather be held accountable for doing what you thought was right or doing what you thought was wrong, given that you don’t know which choice will be punished?  If you are going to be punished, wouldn’t you prefer it to be for doing what you believed in, rather than for what you didn’t believe in?”

If we look at the case of the student who obeyed the order to take the convoy through the fog, he would clearly have chosen to be punished for disobeying the order than to have all those people killed that were lost that day.  He should have refused to obey the order.  He should have insisted the commander understand he was giving an order that was unnecessarily putting at risk the lives of all the people in the convoy just for expediency and that clearly there was no way the report of visibility that permitted effective air cover could possibly be true.  “May it please the colonel to look out the window, sir!”

Combining both of these components, it important to understand that being responsible for doing, or refraining from doing, an act does not tell you whether the act is right or wrong to do or to omit from doing or what reasons and conditions might excuse one from doing or omitting it.  There are two different questions: a) is the act or refraining from the act your responsibility, and b) which option of all your choices and possibilities is the right one.  Good ethics education, whatever its form, needs to teach how to determine both of these components.

Understanding the nature of personal responsibility helps people see that they need to and can address moral issues where they are being required to do something wrong.  That doesn’t mean their belief is the correct one, but it needs to be taken into account and acted upon in an ethical way in itself.  That may involve at least a reasonable policy for conscientious objection if the person’s position seems wrong even after consideration of it.  But all that is too involved to go into here.  It just needs to be seen to be part of helping nurses develop what might be considered the moral courage or resolve to stand up for their views.

The authors discuss helping nurses recognize moral distress, but I really do not think that is necessary.  It is readily apparent to nurses when moral distress occurs – whenever they are unreasonably required to do something they believe wrong or unreasonably constrained from doing something they believe right, particularly when it requires them to do what they have good reason to believe will cause or allow undeserved and unwarranted harm to patients.  They clearly know when that happens, even if they don’t know good ways or the best way in a particular situation to articulate or deal with it.

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”Direct attempts to im­prove an institution’s overall moral climate include implementing ethics committees, ethics rounds, and ethics-based forums, as well as strategies to im­prove the transparency of communication between administrators and practitioners.” This mistakenly presumes that people will act reasonably and in good faith on the information they have.  But the very example used, was one where the nurse pointedly and clearly told the physician the patient needed follow-up examination and he ignored her.  I think it highly unlikely that lack of clear communication is the main problem in most moral distress cases, particularly ones with a clear pattern, though it may be in some individual cases where one party has knowledge they don’t articulate clearly that would resolve the problem; but normally, particularly in cases that fit a prevalent pattern, it is lack of reasonable understanding and cooperation.  And also, while it is possible that a reasonable explanation would show that the practitioner’s beliefs are untrue as to what is right or needed in a given situation, and in such cases transparent communication might resolve an issue, that does not mean that a first excuse or rationale is sufficient, if a sensitive, conscientious moral person would find a means to overcome the condition that is the rationale.  ”Although the Joint Commission now mandates institutional ethics com­mittees for hospital accreditation, nursing presence on these committees varies from institution to institu­tion. … nurses … have unique perspectives, and are needed on ethics committees …”… So now that this is clearly and “transparently communicated”, is there any reason to believe it will therefore happen or be effective if it does – that sensitive, independent-thinking, medically and morally knowledgeable,  nurses will be place on ethics committees and that their ideas and evidence will be seriously and reasonably considered?  I would guess not in those cases where staff is not as appreciated as they should be.

The authors then explain other institutional ways to give nurses more voice and power.  However, those also depend for their success on their work and recommendations being heeded, which in the sorts of climates that cause systemic or repeated moral distress, is not likely.  

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“Several factors make practice environments in­creasingly likely to engender moral distress; these include nurse staffing shortages, increased patient acuity” – again, only when these problems are caused by entrenched bad judgment, policies, etc, not something like a terrible, unexpected disaster that could not reasonably be anticipated or prepared for in advance.  People tend to pitch in and work together when such a circumstance occurs, as in a natural disaster or intentionally caused mass casualty act.  And while such situations can be emotionally traumatic, again that is different from moral distress, which involves powerlessness to effect wrongful policies and orders.  … “Mitigating that will require significant political as well as organizational change.” – except that it is moral and legal change that is necessary, not just political change.  This is not just about what a majority wants, as if that were subject to whim, but about being able to do what is right for patients and workers – voluntarily whenever possible, but forcibly when it is not.

…   

Efforts to reduce moral distress might be best served by developing systems that [… involve] all stake­holders in establishing or changing the ethical rules by which institutional decisions are made.  Rule-based systems tend to fail for all kinds of reasons: 1) loopholes, 2) insufficient, inadequate, or bad rules, especially those overzealously and inflexibly enforced, 3) people who either ignore or twist or interpret the rules to their own advantage, 4) insufficient penalties to give the rules teeth, etc.  Congress and Wall Street are examples of what happens in rule-based systems operated by selfish people of bad faith.

… moral dilemmas and conflicts are an inevitable part of nursing practice; it’s unrealistic to believe they can be avoided.  But as pointed out repeatedly, it is not all moral dilemmas and conflicts that are the problem; just those which are caused by clearly wrongful recalcitrant policies, decisions, and orders.   Indeed, morally distressing situations offer opportunities for nurses to learn and to main­tain or restore their integrity and wellbeing. And being shot or stricken with ebola gives one the ‘opportunity’ for recovering from being shot or having ebola.  That is not the kind of opportunity anyone wants or should have to have.  Being able to make the best of a bad situation does not make it best to have bad situations, particularly ones that are avoidable.  Nurses should not be put into situations where they are not allowed to do what is right merely because of some wrong rule, order, authority, policy, or monetary restraint based solely or primarily on greed rather than reasonable lack of resources.  And nurses should particularly not be put into such situations in order to build character, resistance, or ‘resilience’ to being put into unnecessary, bad situations.  There are enough real problems in life to ‘help’ or force us to develop moral character, courage, and strength, without putting people into artificial situations that are more destructive than productive.

Let’s imagine how the opening case might have un­folded differently. When Ms. Keller [the nurse in the opening scenario] becomes aware of her moral distress, her next steps are to consider and appreciate the precipitating factors, name the eth­ical conflict, There is no ethical conflict!  And the cause of the problem is clear; the physician is not doing the right thing for the patient and is simply ignoring the nurse’s report and request.  The problem is not the nurse’s moral distress, but improper care of the patient by the physician.  Making the problem her moral distress is like saying that the problem with a person who just had a heart attack is that he is lying on the floor; it confuses the result of the problem for the problem. and examine why addressing it matters to her. She reconnects with her core values and in­tentions as a nurse, which serve to ground her in de­termining what the situation calls for and provide motivation for taking action. This is just jargon; the nurse cares about the well-being of the patient and thinks for good reason that the patient is in jeopardy and needs a follow-up examination.  This is not about the nurse’s well-being as somehow separate from or primary to the patient’s receiving proper medical attention and care.  … Ultimately, Ms. Keller determines which actions are best aligned with the profession’s values, as delineated in the ANA’s Code of Ethics --she had already easily done that with regard to the patient-- and takes those actions but that is where the problem arises, because she is restricted from taking those actions by other ethical, legal, formal, and powerfully punitive forces. This requires steadfast effort, courage, and ethical competence. But it takes much more than that if it not just going to be an exercise in futile martyrdom.  It did not take any particularly unusual ethical competence to recognize her duty to her patient, or even her own responsibility in trying to get the physician to re-check the patient.  What she lacked was either the power to force him to do what is right or the psychological skill and pressure point knowledge to manipulate him into doing it.   Ms. Keller further recognizes that she has an obligation to foster a culture of ethical practice in her workplace. Besides acting as a patient advocate for Ms. Dawkins, she bring her concerns about the case to the nursing leadership and contrib­utes to team efforts to address the root causes of her moral distress. Except that apparently nothing was done to get the patient, Ms. Dawkins, proper medical attention; it was just documented that the captain was warned of the approaching iceberg and the warning was duly noted in the ship’s log.

It’s essential that nurses stop seeing themselves as powerless victims of moral distress. Instead, nurses can acknowledge that their moral distress arises from having a strong moral compass—their deeply held values and the commitment to relieve the suffering and promote the wellbeing of their patients.  That is not what is causing the moral distress.  It is powerlessness to overcome the physician’s refusal to do what is right and best for the patient.  “Covering herself” by noting the problem to the proper channels doesn’t solve the problem for the patient or relieve her moral stress, since the problem for the patient is not solved.  The nurse needs either the power to make sure someone competent attends to the patient (by calling another physician, for example) or having the ability to jeopardize the physician’s career in some way, or by having the psychological skill to manipulate the physician into compliance.  Her problem is not an ethical one but a lack of cooperation and compliance one. Nurses can step forward in a new way—one that reflects their moral agency and courage which does no good if it does not get results for the patient and is simply pointless self-sacrifice to assuage a mistakenly troubled but actually innocent conscience that has done no wrong. “See What Nurses Can Do to Address Moral Distress for some simple ways to begin to shift one’s relationship to moral distress and build moral resilience. The American Association of Critical-Care Nurses’ 2006 public policy statement on moral distress (www.aacn.org/wd/practice/docs/ moral_distress.pdf) further includes suggestions for how to engage one’s institution and its leaders in as­sessing and improving the handling of morally dis­tressing situations. Together, we can develop more robust notions of moral distress and devise strategies that allow us to meet morally distressing situations more effectively for all concerned.” 

It is my view that expecting or requiring nurses to risk their careers to stand up (often just futilely) for the well-being of patients (and themselves) and just buck up to the challenge and cope resiliently with the consequences, is unfair to nurses when nursing associations have much more power to effect the sorts of changes which are clearly needed to empower nurses to meet what the codes of ethics of nursing association, and what ethics in general, would say is right. 

I understand that medical professionals believe that strikes or work slowdowns are normally wrong because they put patients in jeopardy in a way that is not only counterproductive (in the short run at least) but hypocritical as a means of trying to achieve better patient safety and care.  But there are ways that nursing associations can get better laws and hospital policies without having to call for or permit general strikes or work slowdowns that jeopardize innocent patients.  They should be putting all kinds of moral and political pressure on lawmakers and hospitals to do better, reporting those that endanger their patients and how they do that. 

Nursing associations should be defending nurses in court who are in trouble for obeying the code of ethics and their consciences and doing the reasonable or right act.  They should be doing this not only to defend individual nurses, but to set powerful precedents.  The U.S. Constitution recognizes many civil rights and liberties, but it and the courts need work with regard to developing reasonable criteria and provisions for conscientious objection in areas other than avoiding compulsory military service in time of war.  Nursing associations can and should contribute to this effort; there are plenty of cases for them to work with.

Nursing associations should also insure nurses against some amount of financial loss from displaying moral courage in reasonable cases and meeting their code of ethics.

They should also threaten to treat doctors and hospital administrators who become hospitalized in compliance with their own policies and rules.  In 1971, a movie The Hospital starring George C. Scott was a murder mystery with an ingenious plot.  A person who had lost a loved one due to hospital ineptness and malfeasance caused the people responsible to become patients in their own hospital for minor conditions.  He then helped them be victimized by their own procedures and ineptness.  While the Golden Rule can never serve to tell us what is right or wrong (because what you want for yourself may not be what others want for themselves, and because even if you both want the same thing, it may still not be right for either of you), it often helps stir the soul to do what is right if one imagines being on the receiving end of one’s own acts and policies one should already know are wrong. 

Creative and compassionate minds should be able to find effective ways to overcome institutional and professional resistance to minimizing or eliminating moral stress in nursing, without simply doing a disservice to the problem and to nurses by telling, requiring, and relying on them, to develop moral resilience to abuses that should not be permitted to occur in the first place.