Our Spring 2018 workshop, ‘Moral Distress and Powerlessness’, took place at the Wivenhoe Sailing Club on Friday 23rd February 2018.
Moral distress is a key concept in nursing and more generally in the context of health care practices. It is the distress experienced by agents who know what the right course of action is but are prevented from taking it by external constraints (material, hierarchical or institutional, for example). Moral distress differs from moral conflict in that there is no dilemma about what to do, but a sense of being powerless to do what one thinks is right. In this workshop, we sought to understand the experience of moral distress, to determine whether/when it is ethically appropriate, and whether faith, hope and love might be of help in dealing with moral distress.
- Dr Matt Bennett (University of Essex)
- Dr Karen Chumbley (St Helena Hospice)
- Professor Elizabeth Epstein (University of Virginia)
- Dr Alex Georgiadis (University of Cambridge)
- Professor John Lippitt (University of Hertfordshire)
Wivenhoe Sailing Club, Wivenhoe
9.15: Registration (Refreshments Provided)
09.30-11.00: Elizabeth Epstein ‘The work that hurts us as persons: Exploring dimensions of moral distress and opportunities for empowerment. ’
11.00-11.15: Break (Refreshments Provided)
11.15-12.00: Alex Giorgiadis ‘Frontline Healthcare Staffs’ Experience of Organising Complex Hospital Discharges: An Ethnographic Study.’
12.00-13:30: Lunch Break
13.30 – 14.10: Karen Chumbley ‘Moral Distress in Primary Care.’
14.10 – 14.20: Break
14.20 – 15.35: Matt Bennett ‘More responsibility than autonomy.’
15.35 – 15.45: Break
15.45 – 17.00: John Lippitt ‘Forgiveness, resentment and moral distress.’
Matt Bennett is a postdoctoral researcher in moral and political philosophy, specialising in moral emotions, responsibility, bioethics, and post-Kantian European philosophy. He completed his PhD at the University of Essex in 2013 and has published papers on guilt, health and social care, Nietzsche, and Derrida. Matt is currently working on theoretical and applied issues concerning responsibility, with a specific interest in the prospect of a non-moralised concept of responsibility suggested in Nietzsche’s work. He is also Virtual Library Editor for the University Bioethics Program at Univerisdad Nacional Autónoma de México, and Research Impact Manager at the University of Essex.
Dr Karen Chumbley has been the Clinical Director of St Helena Hospice since 2015. A GP by background, Karen developed an interest in end of life care planning and palliative care, becoming the North-East Essex CCG Clinical Lead for End of Life Care in 2013. Karen has worked in collaboration with the Gold Standards Framework to gain accreditation in their Primary Care Programme for local practices.
Karen led a two-year primary care project to support the identification of people approaching the end of life in collaboration with St Helena Hospice which resulted in a significant decrease in the proportion of people who died in hospital. Karen continues to work in primary care alongside her hospice role.
Dr. Epstein received her BS in biochemistry from the University of Rochester and her BSN, MS in Pharmacology, and PhD in nursing from the University of Virginia (UVA). She worked in maternal-child health and neonatal intensive care for 10 years before joining the UVA School of Nursing faculty in 2007. She currently serves as Chair of the Acute and Specialty Care Department, is an active member of the UVA Health System’s Ethics Consult Service, and directs the health system’s Moral Distress Consult Service. Dr. Epstein is active in research regarding ethical issues in acute and critical care settings and also studies parent engagement in the neonatal intensive care unit. She teaches ethics and pharmacology at the graduate and undergraduate levels and is a member of the Board of Directors of the American Society for Bioethics and Humanities.
Alex has a background in psychology (University of Ioannina, Greece) and holds an MSc degree in Psychology and Counselling from the University of Sheffield, and a PGDiploma in Counselling from Strathclyde University. Alex completed his PhD degree (funded by the National Institute of Health Research) at Peninsula College of Medicine and Dentistry (Institute of Health Services Research, Universities of Exeter and Plymouth). Alex is a post-doctoral research associate working at THIS Institute (The Healthcare Improvement Studies), the centre of a nationwide partnership that aims to strengthen the evidence base for improving the quality and safety of healthcare. Before joining the THIS Institute, Alex was working as a Research and Commissioner Manager at Healthwatch Essex, a charity organisation that aims to collect and represent peoples’ experiences of health, illness and care. In addition to his research work, Alex has worked as a counsellor in academic and NHS settings. Alex’s main work is focused on care quality and patient safety research. He is also interested in exploring the role and function of information and communication technologies in healthcare and how such technologies can improve the quality of care that patients receive.
John Lippitt is Professor of Ethics and Philosophy of Religion at the University of Hertfordshire, UK and Honorary Professor of Philosophy at Deakin University, Australia. He is the author of the Routledge Guidebook to Kierkegaard’s Fear and Trembling (second edition, 2016), Kierkegaard and the Problem of Self-Love (2013) and Humour and Irony in Kierkegaard’s Thought (2000). He is also co-editor of Narrative, Identity and the Kierkegaardian Self (2015, with Patrick Stokes) and The Oxford Handbook of Kierkegaard (2013, with George Pattison). He is currently working on a project entitled ‘Love’s Forgiveness’, which will be supported by a Leverhulme Trust Major Research Fellowship for two years from September 2018. He also serves as an advisor to Hertfordshire Constabulary on matters pertaining to the ethics of policing.
Titles and Abstracts
MORE RESPONSIBILITY THAN AUTONOMY
According to much of the literature moral distress is felt when someone is involved in a situation that prompts a moral judgement but cannot act on that judgement. But in what way is someone who experiences moral distress “involved in” the situation that provokes this response? The details of many recorded cases suggest that health professionals experiencing moral distress take themselves to be responsible for a patient being mistreated; indeed, Moti Gorin has recently suggested we add a “responsibility condition” to our definitions of moral distress. However, this perceived responsibility sits uneasily with the powerlessness integral to moral distress. We might say that if moral distress is by definition felt when one is prevented from doing the right thing, then those who suffer moral distress should not feel responsible when a patient is wronged. How are we to make sense of an emotion or set of emotions that register the prima facie paradoxical state in which a health worker has, as Mary Corley puts it, “more responsibility than autonomy”? I hope to find an answer to this question by exploring two areas of moral philosophy: freedom-determinism compatibilism and analysis of moral luck.
MORAL DISTRESS IN PRIMARY CARE
The pressures on General Practice are frequently discussed in the British media. In an age of medicalisation and longevity General Practice is busier than ever before. A significant proportion of General Practitioners are planning retirement and resignation and levels of dissatisfaction are high. In such a context is moral distress relevant? Is their discomforture stress, distress or moral distress?
THE WORK THAT HURTS US AS PERSONS: EXPLORING DIMENSIONS OF MORAL DISTRESS AND OPPORTUNITIES FOR EMPOWERMENT.
Moral distress occurs when providers believe they are doing something ethically wrong but have little power to act differently or to change the situation. As a result, they feel that they are compromising their own moral integrity as well as their ability to protect patients and care for them appropriately. In today’s session, we will explore the concept of moral distress at three levels: patient, unit/team, and system. We will evaluate connections between moral distress and power and will strategize opportunities for empowerment.
FRONTLINE HEALTHCARE STAFFS’ EXPERIENCE OF ORGANISING COMPLEX HOSPITAL DISCHARGES: AN ETHNOGRAPHIC STUDY.
Existing studies show that nurses often experience moral distress when the care they deliver to patients does not meet their professional values. We draw on ethnographic data collected in June 2015 from one acute care trust in England and present how frontline healthcare staff experience organising complex hospital discharges. Our findings demonstrate how problems with the panel responsible for allocating funding for NHS continuing healthcare cases contributed to healthcare staff experiencing moral distress. Our findings offer a basis for further research on how other aspects of the complex hospital discharge planning process may contribute to nurses’ experiencing moral distress.
FORGIVENESS, RESENTMENT AND MORAL DISTRESS
One major source of moral distress can be a hierarchical institutional context in which the individual worker’s sense of the good conflicts, in a non-trivial way, with the perceived goals of the organisation as understood by an institutional superior. Taking my lead from the context of policing, I shall suggest that this is an environment in which forgiveness – and self-forgiveness – have important roles to play. In doing so, however, I shall offer a partial defence of a reactive attitude often dismissed too quickly in the forgiveness literature: resentment. Drawing on an unorthodox account thereof, I shall argue that negotiating the competing claims of resentment and forgiveness can be key to dealing with moral distress. As well as saying a little about the roles of love and hope in forgiveness, I shall raise the question of how both forgiveness and resentment relate to medio-passive agency. Could both forgiveness and resentment be different ways of expressing one’s power in a situation of apparent powerlessness?