Moral distress or moral comfort

Moral distress in healthcare results from a professional's inability to provide compassionate care to patients because of individual, organizational, or societal barriers. Research suggests that moral distress is a growing concern among nurses, and may be a major reason why nurses leave one job for another or abandon the profession of nursing. Some professionals, however, have identified strategies that help them work through their moral distress toward an experience of moral comfort. These strategies may be individual, organizational, or societal. The focus of this paper is to identify examples of strategies professionals have used to alleviate distressful feelings and enhance moral comfort.     

The balancing of virtues—Muslim perspectives on palliative and end of life care: Empirical research analysing the perspectives of service users and providers

In this paper, I will share findings from a qualitative study that offers a thematic analysis of 76 interviews with Muslim patients and families as well as doctors, nurses, allied health professionals, chaplains and community faith leaders across the United Kingdom. The data show that for many Muslims, Islam—its texts and lived practice—is of central importance when they are deliberating about death and dying . Central to these deliberations are virtues rooted within Islamic theology and ethics, the traditions of adab (virtue) and aqhlaq (proper conduct). Themes analysed include theological and moral understandings around the virtues of hope and acceptance. The study provides an analysis of these themes in relation to the experiences of Muslim patients and families arriving at meaning making around death and dying and how this interfaces with their interaction with biomedicine and healthcare. The study shows that the juxtaposition of different values and moral frameworks require careful negotiation when Muslim patients and families encounter the healthcare system. The study also describes how healthcare professionals and staff of other faiths and no faith encounter Muslim beliefs and practices, and the challenges they face in interpreting virtues and values rooted in faith, especially when these are perceived to be mutually opposed or inconsistent.     

Parental refusal of life-saving treatments for adolescents: Chinese familism in medical decision-making re-visited

This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the 'AP-physician-family-relationship' and the dominant role Chinese families play in medical decision-making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives 'weak' family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re-interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its 'parens patriae' power to defend the defenseless in society and the integrity of the medical profession.     

Ethics and Rationing Access to Dialysis in Resource‐Limited Settings: The Consequences of Refusing a Renal Transplant in the South African State Sector

Resource constraints in developing countries compel policy makers to ration the provision of healthcare services. This article examines one such set of Guidelines: A patient dialysing in the state sector in South Africa may not refuse renal transplantation when a kidney becomes available. Refusal of transplantation can lead to exclusion from the state‐funded dialysis programme. This Guideline is legally acceptable as related to Constitutional stipulations which allow for rationing healthcare resources in South Africa. Evaluating the ethical merit of the Guideline, and exploring the ethical dilemma it poses, proves a more complex task. We examine the actions of healthcare professionals as constrained by the Guideline. From a best interests framework, we argue that in these circumstances directing patient decision making (pressurising a patient to undergo renal transplantation) is not necessarily unethical or unacceptably paternalistic. We then scrutinise the guideline itself through several different ethical ‘lenses’. Here, we argue that bioethics does not provide a definitive answer as to the moral merit of rationing dialysis under these circumstances, however it can be considered just in this context. We conclude by examining a potential pitfall of the Guideline: Unwilling transplant recipients may not comply with immunosuppressive medication, which raises questions for policies based on resource management and rationing.     

Facing decisions about life and death--communication with parents

How can healthcare professionals, most of whom have never personally been confronted with such tragic situations, best help parents and their children make decisions about life and death that will minimize the suffering of children and their parents? Research studies and the professional experience of those attuned to these problems can be instructive. This paper reviews and gives advice about the communication between healthcare professionals and parents and children facing life and death.     

Health Professionals “Make Their Choice”: Pharmaceutical Industry Leaders’ Understandings of Conflict of Interest

Conflicts of interest, stemming from relationships between health professionals and the pharmaceutical industry, remain a highly divisive and inflammatory issue in healthcare. Given that most jurisdictions rely on industry to self-regulate with respect to its interactions with health professionals, it is surprising that little research has explored industry leaders’ understandings of conflicts of interest. Drawing from in-depth interviews with ten pharmaceutical industry leaders based in Australia, we explore the normalized and structural management of conflicts of interest within pharmaceutical companies. We contrast this with participants’ unanimous belief that the antidote to conflicts of interest with health professionals were “informed consumers.” It is, thus, unlikely that a self-regulatory approach will be successful in ensuring ethical interactions with health professionals. However, the pharmaceutical industry’s routine and accepted practices for disclosing and managing employees’ conflicts of interest could, paradoxically, serve as an excellent model for healthcare.     

Attitudes towards carrier testing in minors: a systematic review

The objective of this article is to review the attitudes of the different stakeholders (minors, healthcare professionals, parents and relatives of affected individuals) towards carrier testing in minors. The databases Pubmed, Google Scholar, Psychinfo, Biological Abstracts, Francis, Anthropological Index online, Web of Science, and Sociological Abstracts were searched using key words for the period 1990-2004. Studies were included if they were published in a peer reviewed journal in English and described the attitudes of minors, parents or healthcare professionals towards carrier testing in minors in a family context. The results were presented in a summary form. In total 20 relevant studies were retrieved (2 studies reported the attitudes of two stakeholders). Only one study reported the attitudes of adolescents, two studies reported the attitudes of adults who had undergone carrier testing in childhood. In total six studies have been retrieved discussing the parental attitudes towards carrier testing in their children. Over all studies, most parents showed interest in detecting their children's carrier status and responded they wanted their child tested before the age of majority: some parents even before 12 years. Eight studies were retrieved that reported the attitudes of relatives of affected individuals. Most were in favor of carrier testing before 18 years. The studies retrieved suggest that most parents are interested in the carrier status of their children and want their children to be tested before they reach legal majority (and some even in childhood). This can lead to tensions between parents and healthcare professionals regarding carrier testing in minors. Guidelines of healthcare professionals advise to defer carrier testing on the grounds that children should be able to decide for themselves later in life to request a carrier test or not.     

Current trends in teaching ethics of healthcare practices

The unprecedented progress in bio-medical sciences and technology during the last few decades has resulted in great transformations in the concepts of health and disease, health systems and healthcare organisation and practices. Those changes have been accompanied by the emergence of a broad range of ethical dilemmas that confront health professionals more frequently. The classical Hippocratic ethical principles, though still retaining their relevance and validity, have become insufficiently adequate in an increasing range of problems and situations. Healthcare that has been practised for centuries on the basis of a direct doctor-patient relationship has been increasingly transformed into a more complex process integrating the health-team, the patient (healthcare seeker) and the community. Systematic review of the specialised literatures revealed that Healthcare Ethics education has become a basic requirement for any training programme for health professionals, and should cover the different stages of undergraduate, postgraduate and continuing education. Both theoretical foundations and practical skills are required for the appropriate ethical reasoning, ethical attitude and decision-making abilities. There is growing evidence that physicians' professional and moral development is not only determined by the formal curriculum of ethics; rather more, it is determined by the moral environment of the professional practice, the 'hidden curriculum' which deserves serious consideration by medical education.     

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.     

Parental Moral Distress and Moral Schism in the Neonatal ICU

Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept—that parents may experience “moral schism”—a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and “moral schism” for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental “moral schism” and moral distress.     

Moral Distress Reexamined: A Feminist Interpretation of Nurses’ Identities, Relationships, and Responsibilites

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life.     

Virtue,foible, and practice--medicine's arduous moral triad

Moral distress is often discussed as a response to the moral dilemmas that professional and other caregivers encounter in their effort to balance competing moral principles, or to provide care in difficult cases, to difficult patients, in spite of difficult institutional requirements or policy. In this essay, a reforming ER clinician and teaching physician, offers a personal approach to moral distress. Assuming that a clinician's own foibles may sometimes contribute to another's distress, and that attempting to rationalize or subvert these foibles causes moral fatigue, he offers personal guidelines for healthcare providers--four strategies that less-than-perfect practitioners may use while striving to attain the ideal of the competent, compassionate, altruistic, calm, and wise clinician.     

The emotions of oncologists

Emotions are parts of organizational reality to an ever increasing extent. Importantly, they are not just tools in the hand of healthcare workers to achieve better physician / healthcare professional-to-patient interactions but intrinsic processes and characteristics with psychic, cognitive and somatic actions. For a thorough investigation of the issue, a PANAS-X questionnaire was used to examine the emotions of 187 physicians and other healthcare professionals, all engaged in oncology, in 2009. The research succeeded in exploring the overall emotional state oncology professionals had assumed in relation with their job as well as enabled the authors of this study to draw the respondents' emotional map and assess their fundamental emotional attitudes. Furthermore, the authors managed to identify groups of respondents that had felt more intense positive, and/or less intense negative emotions that are socially accepted than others. They included those of senior experienced oncologists, males, individuals with families, childless individuals, ward workers, and skilled professionals. According to the findings, the range of emotions an oncologist experiences / feels intently during his everyday work is dependent upon a great number of factors.     

Bala wāsṭa: aspirant professionals,class-making,and moral narratives of social mobility in Lebanon

While there is a growing anthropological interest in professionals as experts and powerful actors, there is little ethnographic inquiry into invocations of professionalism by less privileged communities. This article examines how professionalism in Lebanon was increasingly appropriated by low-income communities in ways not referring to any particular profession or occupational domain. As a locally defined category, professionalism indexed an urban middle-class subjectivity of performing specific sets of symbolic capital, moral dispositions, and cross-sectarian relationalities. Lebanese civil society, led by middle-class cultural elites, promoted professionalism as a moral alternative to reliance on wāsṭa (intermediary connections through family or kinship), a practice associated with a corrupt sectarian political system. What I call aspirant professionals – young, low-income, university-educated Lebanese – increasingly participated in empowerment NGOs to learn professionalism in pursuit of social mobility and respectability. Aspirant professionals did not simply emulate the middle-class culture of professionalism; rather, their class-making process generated its own moralities, subjectivities, and practices. Through a critical examination of aspirant professional subjectivity, this article contributes to anthropological studies on professionalism, NGOs, and class.     

Social Responsibility and the State's Duty to provide Healthcare: An Islamic Ethico‐Legal Perspective

The United Nations Educational, Scientific and Cultural Organization's (UNESCO) Declaration on Bioethics and Human Rights asserts that governments are morally obliged to promote health and to provide access to quality healthcare, essential medicines and adequate nutrition and water to all members of society. According to UNESCO, this obligation is grounded in a moral commitment to promoting fundamental human rights and emerges from the principle of social responsibility. Yet in an era of ethical pluralism and contentions over the universality of human rights conventions, the extent to which the UNESCO Declaration can motivate behaviors and policies rests, at least in part, upon accepting the moral arguments it makes. In this essay I reflect on a state's moral obligation to provide healthcare from the perspective of Islamic moral theology and law. I examine how Islamic ethico‐legal conceptual analogues for human rights and communal responsibility, ?uqūq al‐’ibād and far? al‐kifāyah and other related constructs might be used to advance a moral argument for healthcare provision by the state. Moving from theory to application, I next illustrate how notions of human rights and social responsibility were used by Muslim stakeholders to buttress moral arguments to support American healthcare reform. In this way, the paper advance discourses on a universal bioethics and common morality by bringing into view the concordances and discordances between Islamic ethico‐legal constructs and moral arguments advanced by transnational health policy advocates. It also provides insight into applied Islamic bioethics by demonstrating how Islamic ethico‐legal values might inform the discursive outputs of Muslim organizations.     

LGBT+ Individuals’ Perceptions of Healthcare Services in Turkey: A Cross-sectional Qualitative Study

When accessing healthcare services, LGBT+ individuals are often exposed to segregating and marginalizing discourses. Knowledge about how such experiences are reflected in the moral world of LGBT+ individuals living in Turkey is limited. This study examined LGBT+ individuals’ lived experiences when utilizing healthcare services. The findings are discussed in terms of moral discourses related to LGBT+ individuals’ gender identity and sexual orientation. A qualitative field study was conducted using semi-structured interviews with fifty-five LGBT+ individuals from Turkish cities who were in contact with various non-governmental organizations that conduct studies on gender identity and sexual orientation. A questionnaire was administered with items on participants’ demographic information, experiences, behavioural patterns, and knowledge regarding healthcare services. The data were analysed thematically. The findings were evaluated within the framework of “access to healthcare service” theme related to “healthcare service demand” context. Additionally, the “interaction with physicians” theme was addressed in the context of “physician–patient/counselee relationship.” LGBT+ individuals state that they are exposed to stigmatizing and segregating discourses by healthcare professionals, which might pose an obstacle for adaptive health-seeking behaviours. These results suggest that physicians’ professional approach has a considerable influence on LGBT+ individuals’ capacity for utilizing healthcare services.     

Not the doctor’s business: Privacy,personal responsibility and data rights in medical settings

This paper argues that assessing personal responsibility in healthcare settings for the allocation of medical resources would be too privacy-invasive to be morally justifiable. In addition to being an inappropriate and moralizing intrusion into the private lives of patients, it would put patients’ sensitive data at risk, making data subjects vulnerable to a variety of privacy-related harms. Even though we allow privacy-invasive investigations to take place in legal trials, the justice and healthcare systems are not analogous. The duty of doctors and healthcare professionals is to help patients as best they can—not to judge them. Patients should not be forced into giving up any more personal information than what is strictly necessary to receive an adequate treatment, and their medical data should only be used for appropriate purposes. Medical ethics codes should reflect these data rights. When a doctor asks personal questions that are irrelevant to diagnose or treat a patient, the appropriate response from the patient is: ‘none of your business’.     

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial

Implementation of evidence-based practice (EBP) is regarded as core competence to improve healthcare quality. In the current study, we investigated the EBP of six groups of professionals: physicians, nurses, pharmacists, physical therapists, technicians, and other allied healthcare personnel. A structured questionnaire survey of regional hospitals throughout Taiwan was conducted by post in 2011. Questionnaires were mailed to all healthcare workers of 11 randomly selected hospitals. Linear and logistic regression models were used to examine predictors for implementing EBP. In total, 6,160 returned questionnaires, including 645 from physicians, 4,206 from nurses, 430 from pharmacists, 179 from physical therapists, 537 from technicians, and 163 from other allied healthcare professionals, were valid for the analysis. Physicians and pharmacists were more aware of EBP than were the other professional groups (p < 0.001). Positive attitudes toward and beliefs in EBP were significantly lower among nurses than in the other groups (p < 0.001). Physicians had more sufficient knowledge and skills of EBP than did the other professionals (p < 0.001); in addition, they implemented EBP for clinical decision-making more often and perceived fewer personal barriers to EBP (p < 0.001). Multivariate logistic regression analyses showed that EBP implementation was associated with the following characteristics of participants: EBP training, having a faculty position, academic degree, one's profession, and perceptions (beliefs, attitudes, knowledge, skills and barriers). This study depicts various levels of EBP implementation among medical, nursing, pharmacological, and allied healthcare personnel. There were significant differences in their implementation of EBP. We observed that certain factors were associated with EBP implementation, including personal backgrounds and perceptions toward EBP. The data suggest that strategies for enhancing EBP implementation should differ for various groups of professionals.     

Patients and borders, money and mission: responding to medically needy persons from other countries who lack financial resources

When financially impoverished persons from resource-poor countries travel to resource-rich countries to seek medical treatment, health-care professionals and hospital administrators must decide how to respond. These financially impoverished "medical travelers" are medically no different from financially impoverished citizens or immigrants, but their national residence and purpose of travel may cause them to be seen as having a lower degree of standing within the communities that hospitals are expected to serve. In responding to such persons, health-care professionals and administrators encounter tension between the mission-driven intention to provide care and a budget-driven intention to protect operating margins. Responses require practical wisdom and a readiness to wrestle with tensions related to objectives (charitable versus financial), role-specific obligations (clinicians versus administrators), and contrasting moral frameworks. There are also challenges of reconciling plural moral values, setting moral priorities, and considering whether national borders should constrain our view of persons as neighbors. Finding a way forward amidst many tensions is hard moral work, but it may be facilitated by granting a moral imperative to physical proximity, respecting role-fidelity among clinicians and administrators, furthering candid moral dialogue, and promoting a presumption to treat whenever it is feasible to do so.     

Misunderstanding death on a respirator

As Tom Tomlinson's study indicates, there is considerable misunderstanding and confusion among physicians and nurses working in the area. Brain death is often not well-understood by healthcare professionals and hence inadequately explained to relatives, leaving them confused as to whether their loved-one is alive or dead. Whilst these healthcare professionals are using whole-brain death as the criterion of death, they have no clear understanding of the definition of death which underpins the brain-death criterion. Lack of this philosophical rationale makes the use of the brain-death criterion a mere technicality, rather than the expression of a well-grounded conceptual and ethical understanding. The other difficulty is that a brain-dead respirator patient just does not look dead. This appearance of life, Tomlinson suggests, can trigger deep emotions in caregivers and family members which will compound the intellectual perplexity already felt by them.