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Trainees are reporting moral distress more frequently, according to bioethicists interviewed by Medical Ethics Advisor. Some approaches include the following:
• provide education on ethical principles behind hospital practices;
• routinely ask about moral distress during supervisory meetings;
• be open to the possibility that unethical practices are occurring.
"Medicine is changing me into a doctor I am not proud to be.” Unfortunately, residents are voicing such sentiments more frequently to Julie M. Aultman, PhD, director of the medical ethics and humanities program at Northeast Ohio Medical University in Rootstown.
“Having the privilege to follow trainees from undergraduate premedical education through their residency reveals the genuine struggles they face,” says Aultman.
Many residents are disheartened by lack of time to build relationships with patients. Sometimes, the inability to resolve serious ethical infractions is the problem. Residents occasionally report witnessing forced resuscitation of patients with DNR status, or withholding of medical mistakes from patients.
“Trainees often feel as though they lack the moral courage to report unethical behaviors,” says Aultman. During small group discussions, medical students and residents admit that they fear being viewed as a “whistleblower” and losing respect of peers and colleagues.
Fostering a “culture of ethics” is what’s needed, says Aultman: “Open and honest communication that is welcomed, rather than ignored or ridiculed, decreases the frequency and intensity of moral distress.”
Teaching the foundations of ethical theories and principles also is important. This allows trainees to justify their opinions, and prompts them to look at multiple perspectives before making a moral judgment.
“Patient autonomy, for example, when better understood, can guide trainees to understand the importance of patient decisions,” says Aultman.
Before trainees actually report moral distress to their supervisors, Aultman advises them to collect relevant facts, ask questions, and seek the advice of peers and mentors. “For trainees that take on leadership roles, I advise them to bring morally distressing situations to open forums for discussion,” says Aultman.
Medical educators are hearing from students about moral distress more frequently, reports M. Sara Rosenthal, PhD, professor and founding director of University of Kentucky’s program for bioethics and chair of the hospital ethics committee.
In a review of past resident case conference presentations, the issue of moral distress emerged as a recurring theme.
“We need to treat moral distress like an occupational hazard that is to be expected, and not something that happens out of the blue,” says Rosenthal. A recent paper reviewed the literature on best practices for reducing moral distress of trainees exposed to end-of-life cases, focusing on medical education and organizational ethics programs.1
Provider burnout has been a recent focus for bioethicists at East Carolina University in Greenville, NC, including its prevalence and causes. In conversations with providers, Maria Clay, PhD, realized that many symptoms of burnout were similar to the residual effects of moral distress. These include anger, lack of empathy, and moral and physical fatigue.
“Several experts expressed the concern that provider burnout could not be addressed without first addressing the lingering effects of moral distress,” says Clay, chair of the department of bioethics and interdisciplinary studies at East Carolina University in Greenville, NC.
Addressing medical trainees’ moral distress can provide insights for how to address moral distress experienced by attendings, adds Rosenthal: “We need to pay greater attention to mentors and medical educators.”
Efforts to address moral distress should not be isolated by discipline, says Clay: “Moral distress is a team phenomenon. Programs must include all members of the healthcare teams.”
Moral distress and what it means is “a very important early discussion that needs to be had” between trainees and supervisors, according to Celia B. Fisher, PhD, director of the Center for Ethics Education and professor of psychology at Fordham University in Bronx, NY.
Trainees may believe that they are prevented from doing what is morally right by limitations in their institutional setting. This sometimes stems from simple misunderstandings.
“Various rules and procedures in the hospital setting are based on ethical values. But these are typically not articulated to the trainee,” says Fisher.
For example, trainees may openly discuss a patient’s condition with colleagues, unaware that hospitals must adhere to very specific procedures for protecting the confidentiality of medical records — including which hospital staff should have access to patient information.
“These may differ from the trainee’s personal values. Some things we might do as a person for a loved one might be professionally unacceptable from a physician,” notes Fisher. To relieve patient distress, trainees may disclose their own personal medical history, inadvertently committing professional boundary violations that can cause patient harm.
If the distinction between personal and professional values is not made clear to trainees, moral distress is more likely to be reported. Another obligation for supervisors: Be clear that the topic of moral distress is open for discussion.
“When you are meeting every week, or whatever the supervisory situation is, you should be asking questions about moral distress,” says Fisher.
The professional appropriateness of discussing such issues should be made clear at the beginning of the supervisory relationship. The trainee understands that addressing moral quandaries is a part of his or her professional development.
If moral distress isn’t aired and addressed, it puts trainees at risk for unethical practices themselves. “They may do what they believe is a moral action that may actually be harmful to the patient,” says Fisher. Some examples include the following:
• overprescribing pain medication because they believe it’s a beneficent way to act;
• underestimating the level of disease to alleviate distress;
• disclosing information to a patient about his or her medical condition prematurely. “It may be perceived as a definitive diagnosis, but it’s just speculation until it’s confirmed,” says Fisher.
On the other hand, trainees sometimes have valid ethical concerns about hospital policies and procedures, or clinical practices. “There may be something going on that is not consistent with the ethical values of the field, but supervisors just weren’t aware of it,” says Fisher.
For instance, trainees may observe that the initial intake conducted by other staff did not include appropriate informed consent, or that a medical history was not adequately completed to ensure appropriate follow-up care. Trainees may also discover that a staff member is responding to patients in a manner that reflects harmful stereotyping or biases. “Those kinds of behaviors are very important to discuss with supervisors to help rectify patient care,” says Fisher.
1. Rosenthal MS, Clay M. Initiatives for responding to medical trainees’ moral distress about end-of-life cases. AMA J Ethics 2017; 19(6):585-594.
• Julie M. Aultman, PhD, Director, Medical Ethics and Humanities Program/Professor, Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown. Phone: (330) 325-6113. Email: firstname.lastname@example.org.
• Maria Clay, PhD, Chair, Department of Bioethics and Interdisciplinary Studies, East Carolina University, Greenville, NC. Phone: (252) 744-1290. Email: email@example.com.
• Celia B. Fisher, PhD, Director, Center for Ethics Education/Professor of Psychology, Fordham University, Bronx, NY. Phone: (718) 817-0926. Email: firstname.lastname@example.org.
• M. Sara Rosenthal, PhD, Professor and Founding Director, Program for Bioethics/Chair, Hospital Ethics Committee, University of Kentucky, Lexington. Phone: (859) 257-9474. Email: email@example.com.
Financial Disclosure: Consulting Editor Arthur R. Derse, MD, JD, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Author Stacey Kusterbeck report no consultant, stockholder, speakers’ bureau, research, or other financial relationships with companies having ties to this field of study.