Elsevier

Social Science & Medicine

Volume 58, Issue 6, March 2004, Pages 1075-1084
Social Science & Medicine

Living with conflicts-ethical dilemmas and moral distress in the health care system

https://doi.org/10.1016/S0277-9536(03)00279-XGet rights and content

Abstract

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as “moral distress”. The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies.

The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas.

Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

Introduction

During the last decade, the Swedish health care system has undergone fundamental changes. New evidence based medicine and health care quality certification programs have been implemented alongside the development of advanced biomedical techniques. Organizational reforms have been carried out in order to make health care more efficient, often including elements of competitive inducements between health care providers. A more educated population and changes in values have increased the consumer demand on health care services (Forsberg, 2001).

The changes have made health care more complex and ethics1 has increasingly become a required component of clinical practice. Demands on first-line professionals, i.e. doctors, nurses and auxiliary nurses, to make decisions concerning priority-setting in their everyday work have resulted. Not only do they have to consider what is best for the present patient, but also consider the future patient's needs and questions of social economics.

Despite the increasing demands for qualified ethical judgements the health care organization often lacks standardized policies for guidelines as well as systematic education in ethics and structures of ethical support for their staff members who are to carry out the decisions. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Several studies have shown how fundamental changes in the health care organization have added new stressors to the medical profession. Arnetz (2001) has identified several stressors facing physicians as part of their medical practice. Most stressors identified are psychosocial in their origin, such as workload, unsatisfying tasks, lack of skill development and lack of clear work directives from the immediate supervisor. According to recent studies ethical dilemmas can also cause stress-related disorders among health care professionals (van der Arend & Remmers-van den Hurk, 1999; Raines, 2000; Corley, Elswick, Gorman, & Clor, 2001). Stress related to ethical dilemmas is usually referred to as “moral distress”. A well-established definition of moral distress is that it “occurs when one knows the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action” (Raines, 2000, p. 30).

In this article, the results of an investigation concerning the views of health care professionals themselves on what kinds of situations involve ethical dilemmas are presented. Building on Andrew Jameton's definition of moral distress (Jameton (1984), Jameton (1992), Jameton (1993)), an analysis of whether these ethical dilemmas could also be considered as creating moral distress among health care professionals of different categories is undertaken. Unlike previous studies on moral distress, which have often focused upon the work situation of the nurse, this study covers health care in a broad perspective and includes both hospital clinics and pharmacies.

Section snippets

Background

Stress related to ethical dilemmas, or moral distress, has been discussed particularly in relation to nurses. According to Raines (2000) the impact of ethical issues in nursing practice in the United States has increased tremendously during the last decade. Nurses in almost every practice setting spend increasing amounts of their time resolving ethical dilemmas, as well as experience more stress in dealing with ethical conflicts. The trend has continued despite efforts by health care

Theoretical framework

The present research derives from Jameton (1984), Jameton (1992), Jameton (1993) concept of moral distress in nursing. A basic assumption is that health care professionals hold values in their work and strive to deal with ethical dilemmas when they arise in their work environment. The principle starting point is that moral distress could not be studied adequately without taking philosophical concerns, concerning the concept of moral distress, seriously. Moral distress is therefore studied from

Method

To identify situations of ethical dilemmas and moral distress focus group interviews were carried out. The idea that group processes can help people explore and clarify their views in new ways seems to lay behind every definition of the method. All definitions centre on the use of interaction among participants as a way of accessing data that would not emerge if other methods were used (Webb & Kevern, 2000).

There are also difficulties associated with the focus group method. It involves group

Results

Below the results of the focus group interviews are presented and categorized. The statements were analysed and categorized from the point of view of the interviewees. The categories were deduced from statements dealing with ethical questions and particularly those that are associated with stress. Many of the situations that are described could be assigned to more than one category.

  • Resources:

    • Lack of time/staff: The present patient versus the future patient.

    • Lack of time/staff: The patients

Discussion

The results show several situations where ethical dilemmas caused frustration and distress among all staff categories studied. The dilemma generally arises through the staff's experience of conflicting goals, primarily the interests of the organization versus the interests of a particular patient. The dilemma is often due to the shortage of resources and the relation between the care provider's own conscience and a complex health care reality.

Concerning the conflict between the time and work

Conclusion

The conclusions are threefold: first, all categories of staff interviewed express experiences of moral distress. Therefore, the definition of Jameton and followers was revised, to make it clear at the conceptual level that this phenomenon is not related to one specific category of health care professionals.

Second, moral distress does not only occur as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations. There are situations

Acknowledgements

The authors would like to thank all the health care personnel who participated in the interviews within this project. Thanks are also due to the Swedish Council for Work Life Research (FAS) for their providing of founding of the study, which is part of an interdisciplinary project on “Organization of work, moral values and prioritization in health care”.

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