Dx: Moral Distress

Sig: Take Option One or Two PRN

Moral distress is a term used to describe the various psychological and emotional conflicts we feel when our actions don't live up to our own personal standards. Moral distress can happen for several reasons: legal and/or institutional constraints; conflict of interest, or; inability to recognize the link between cause and effect.

There are two ways to avoid moral distress:

  1. By ignoring your own personal standards or
  2. By modifying your actions to match your standards.

I'd like to take a moment to explore these options relative to the moral distress caused by legal constraints, conflict of interest and other tests of professional integrity.

Whether stopping for a red light on the way to work or releasing confidential medical records in response to a court order, legal and/or institutional constraints influence our daily behavior. The deontologists amongst us avoid moral distress by following the letter of the law, understanding that running a red light is wrong, even if breaking that law might accomplish some greater good. As a kid, I remember watching Batman on TV (starring Adam West) and laughing at how the caped crusader always stopped traffic lights, slamming the batbrakes, while the criminals escaped. Although Robin pitched a fit, Batman suffered no moral distress; instead, he took the opportunity to educate his young ward about the importance of following the law.

Students of medical ethics learn that society's laws may conflict with moral laws. Inevitably, most students recognize the need to surrender to legal or institutional authority, at least if they want to stay out of jail or keep their job. Some medical professionals, like the doctors in North Carolina who were ordered to release confidential patient records so that the local sheriff could flush out illegal aliens, suffer extreme moral distress.1 Unable to ignore ethical standards that define their professional duty to respect patient privacy and confidentiality, these doctors feared the threats to personal integrity and patient trust more than they feared the long arm of the law.

Moral distress can also occur when commercial and professional interests come into conflict. Rather than avoid conflict of interest, the latest trend in medicine is to publish a complete disclosure, suggesting that transparency will suffice, and that it is ultimately the patient's responsibility to do the research: in other words, "Buyer Beware.” These practitioners avoid moral distress simply by referring the patient to the fine print. World renowned child psychiatrist Joseph Biederman might have avoided moral (and legal) distress for pushing specific antipsychotic drugs had he simply reported the $1.6 million he earned from drug makers to his patients and his University and NIH employers.2

We are unlikely to suffer much moral distress by running a red light, unless harm is inflicted on an innocent bystander. Likewise, if we are unable to recognize the possible consequences of our actions as care providers, we are unlikely to feel any moral distress. The inability of some medical practitioners to link cause and effect has been used to defend cases of malpractice and negligence. That is why medical ethics educators encourage students to resolve sample case-studies by exploring all the options for action along with their potential consequences.3 Skeptics who claim that ethics cannot be "taught,” might be surprised at how effective these explorations can be for bringing about change in moral reasoning. In my online medical ethics classes, for example, it is not uncommon for students to broaden their own understanding of cause and effect from collaborative give-and-take and peer discussions. Sometimes the resultant self-reflection prompts expressions of moral distress, such as, "I am embarrassed to admit I never thought of that” or "Thanks for sharing your experience. It helped me sympathize with the patient's dilemma.”

The moral development of students should be every medical educator's goal. In today's complex medical environment it is unlikely that they will be able to avoid legal and institutional constraints, conflict of interest, and moments when the thread between cause and effect are lost. Instead of testing comprehension of ethical theories and moral principles, perhaps medical educators should test their students for signs of moral distress with the goal of making the classroom a safe haven for discussion. In conclusion, perhaps the goal is not to teach students how to avoid moral distress, but to teach them how they might use it as a compass.


  1. Collins, K. (2009). Illegal aliens may fear to seek care. News & Observer. http://www.newsobserver.com/2008/08/18/37485/illegal-aliens-may-fear-to-seek.html
  2. Levine, B.E. (2008). Harvard psychiatrist is paid stooge for big pharma. Psychiatric News. http://psychiatricnews.wordpress.com/2008/06/19/harvard-psychiatrist-paid-front-for-big-pharma/
  3. Gettman, D.A. & Arneson, D. (2003). Pharmacoethics: A problem-based approach. Boca Raton, FL; CRC Press.


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