Moral Distress and Powerlessness – 23rd February 2018

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.

Speakers

  • 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)

Programme

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 – 15.35Matt Bennett ‘More responsibility than autonomy.’

15.35 – 15.45: Break

15.45 – 17.00: John Lippitt ‘Forgiveness, resentment and moral distress.’

Green Paper

‘What is Moral Distress? Experiences and Responses’Available to read online or as a PDF download.

Biographies

MATT BENNETT

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.

KAREN CHUMBLEY

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.

ELIZABETH EPSTEIN

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.

ALEXANDROS GIORGIADIS

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

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
Matt Bennett

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
Karen Chumbley

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.
Elizabeth Epstein

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.
Alexandros Giorgiadis

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
John Lippitt

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?

Addiction, Powerlessness and 12 Step Programmes – 24th November 2017

Our Autumn 2017 workshop, ‘Addiction, Powerlessness and 12 Step Programmes’, took place at the University of Essex, in room 1.1 of the Essex Business School, on Friday 24th November 2017.

Addiction is a paradigmatic case of powerlessness. Conversely, powerlessness and the acknowledgement of powerlessness are central to the twelve-step programs, as are references to faith, love and hope. Yet many balk at these programmes’ reliance on trust in a ‘higher power’ and more generally at the crypto-theology they seem to involve. In this workshop, we sought to understand the experiences of powerlessness involved in addiction, to explore the limits of the helpfulness of the twelve-step programs, and to see whether a secular version would be workable.

Speakers

  • Dr David Batho (University of Essex)
  • Dr Matt Burch (University of Essex )
  • Lisa Caulfield (Independent Researcher)
  • Professor David McNeill (Deep Springs College)
  • Professor Gabriel Segal (Kings College London)
  • Dr Sarah Senker (ATD Research & Consultancy)
  • Dr Bhags Sharma (NHS Fife)

Programme

Room 1.1, Essex Business School, University of Essex

9.00: Registration (Refreshments Provided)

9.10: Welcome

09.15-10.30: Gabriel Segal ‘Powerlessness, Spirituality and Science’

10.30-10.45: Break (Refreshments Provided)

10.45-11.15: Bhags Sharma ‘A day in the life of the Addictions Psychiatrist – who is powerless?’

11.15-11.45: Lisa Caulfield My Experience of Recovering from Alcoholism’

11.45-12.00: Break

12.00-12.30: Sarah Senker ‘“It’s definitely a choice, but it’s a choice you can’t understand”’

12.30-13.30: Lunch Break

13.30-14.45: David McNeill ‘St. Augustine, Desire and Addiction’

14.45-16.00: David Batho ‘Addiction and the Recovery From Identity’

16.00-16.15: Break (Refreshments Provided)

16.15-17.30: Matt Burch ‘A Phenomenological Approach to Addiction’

Green Paper

‘Addiction as Powerlessness? Choice, Compulsion and 12-Step Programmes’Available to read online, or as a PDF download.

Biographies

DAVID BATHO

David Batho is the Senior Research officer for The Ethics of Powerlessness: The Theological Virtues today. He has published on phenomenology and moral psychology and is the lead author of each Green Paper report produced by the project.

MATT BURCH

Matt Burch completed a PhD in philosophy at Rice University in 2009, spent a posdoctoral year at Bergische Universität, Wuppertal, and taught at the University of Arkansas for five years before coming to Essex in 2013. He works on issues at the intersection of phenomenology, action theory, and research in the cognitive and social sciences. At the moment, his research is focused in particular on the stance of objectivity, the phenomenology of risk, and, his favorite topic, the quintessentially human failure to act on one’s better judgment. He also has interests in applied philosophy, and has done such work on several projects with the Essex Autonomy Project (EAP), including an AHRC-funded project on the compliance of the Mental Capacity Act (2005) and the UN Convention on the Rights of Persons with Disabilities, and the Wellcome Trust-funded Mental Health and Justice project. In September 2018, he will begin an Early Career Research Fellowship awarded by the Independent Social Research Foundation. That project, which will also be associated with the EAP, will focus on risk decisions in the care professions.

LISA CAULFIELD

I am a 50-year-old single mother to 3 children; my youngest is 14 and lives with me. He has autism and has been out of education for a year. I am not in paid employment at the moment but in the past have worked mainly in legal advice. After many years of poor mental health and alcoholism, I began my journey of recovery 2 and a half years ago. Since then I have regularly attended AA and try to follow the 12 Steps in my daily life.

DAVID MCNEILL

David McNeill is the Robert B. Aird Professor of the Humanities at Deep Springs College.  He is the author of An Image of the Soul in Speech: Plato and the Problem of Socrates, and has published articles on Plato, Aristotle, Nietzsche, Sophocles and contemporary Critical Theory. His current research focuses on the role of ethical perplexity in Aristotle’s account of practical wisdom.

GABRIEL SEGAL

Segal has published extensively on Philosophy of Mind, Philosophy of Psychology, Philosophy of Language and cognitive science. He is co-author, with Richard Larson, of Knowledge of Meaning: An Introduction to Semantic Theory (MIT Press 1995), author of A Slim Book about Narrow Content, (MIT Press 2000) and Twelve Steps to Psychological Good Health and Serenity – A Guide, (Grosvenor House 2013) and co-editor, with Nick Heather, of Addiction and Choice: Rethinking the Relationship (OUP 2016) which was Highly Commended in the category of Public Health at the BMA Book Awards 2017.  Much of his recent published work focuses on addiction and recovery. He defends the disease model of addiction and is a proponent of Twelve-step programs.

SARAH SENKER

Dr Sarah Senker is a chartered psychologist with a background in Forensic Psychology.  Her doctoral thesis considered addiction and recovery in offenders with a history of heroin and crack use. Sarah has published findings from her thesis in Drugs and Alcohol Today and delivers workshops for the British Psychological Society on motivating offenders to change including presenting at the International Association for the Treatment of Sex Offenders in Denmark last year.  Since her thesis, Sarah has been working as a successful independent research consultant and has conducted multiple substance misuse needs assessments across the Country, ensuring that substance misuse services including community rehabilitation centres, are fit for purpose and meet the desires of service users. In addition to her research and academic background, Sarah has experience as a practitioner in both community and custody settings, delivering recovery programmes and one to one therapy.

BHAGS SHARMA

I would describe myself as a ‘Jobbing Consultant Psychiatrist in Addictions’. I have been in the NHS for over 20 years and working in this field for over 15 years, the last 10 of which have been in Essex. Recently I have moved to Scotland. A role of the Consultant has traditionally been to provide clinical leadership in the treatment of addictive disorders.

I am passionate about this field trying to reduce stigma to this patient group. Patients who are inflicted with these difficulties tend to have worse outcomes in terms of their health and wellbeing and I see my role not only to advocate and provide at an individual level, for evidence based treatments, but also to train a workforce to face future challenges.

I have recently stepped down as Chair of the East of England Addiction Forum. I am also a Fellow of the Royal College of Psychiatrists and an elected committee member to the national executive of the Faculty of Addictions at the Royal College of Psychiatrists.

Titles and Abstracts

ADDICTION AND THE RECOVERY FROM IDENTITY
David Batho

12 Step programmes often encourage members to identify as addicts. This has been controversial. Critics argue that, at the extreme, to identify oneself as an addict is to block the way to full recovery. These critics worry that the self-identifying addict’s life is made to revolve around recovery programmes, rather than being led into new possibilities and contexts outside of addiction. Despite such criticisms, however, there seems to be something right about the thought that ‘once an addict always an addict’. Even if there is reason to worry about over-dependence on recovery groups, it appears that it would be differently problematic to suppose that the addict can simply slough off the addiction, as easily as quitting a job. Whether or not it is problematic to encourage addicts to identify as such, however, depends both on what identification amounts to and the prospects for recovery from such an identity. In this paper, my aim is to describe a number of ways in which one might understand oneself to be an addict and to discuss what it would mean to recover from each.

A PHENOMENOLOGICAL APPROACH TO ADDICTION
Matt Burch

Paradox permeates the discourse on addiction: addiction is a disease but quitting is a choice; we pity addicts for their condition but we blame them for their indiscretions; addicts can’t control themselves but they respond to normal behavioral incentives. The list goes on. My presentation will argue that these apparent contradictions in large part stem not from addiction itself but from the way we conceptualize the addicted agent. To put it simply, there is a tendency in philosophy and the cognitive sciences to split the agent into discrete faculties – such as reason and desire – and then to think of addiction as a battle between these faculties, e.g., reason knows better, but desire drives the agent to act against her better judgment. Although this combat model is in many ways intuitive and compelling, I argue that it gets us into trouble when thinking about self-undermining behavior like addiction. As an alternative, I recommend a phenomenological approach that does not divide the agent into discrete faculties but rather attempts to provide a unified description of her experience. This approach, I contend, can i) help us resolve some of the apparent paradoxes associated with addiction and ii) point to promising ways to understand why and how addicts recover.

MY EXPERIENCE OF RECOVERING FROM ALCOHOLISM
Lisa Caulfield

I plan to talk about my personal experiences as an alcoholic. The starting point will be my background and early years, progressing through adulthood with an increasingly challenging relationship with alcohol and intermittent crises of mental health. I will go on to describe my experience of “hitting rock bottom”, the start of my journey into recovery. I will talk about my experiences of the AA fellowship and what I have learnt from the 12 Steps, concluding with where I am today and the action I need to take on a daily basis to help to ensure my ongoing sobriety.

ST. AUGUSTINE, DESIRE AND ADDICTION
David McNeill

In the past decade researchers such as Gene Hayman and Marc Lewis have argued against understanding addiction as a chronic relapsing brain disease, a view now dominant in academic and therapeutic contexts, and in favor of understanding addiction as a learned behavior, albeit a commonly self-destructive one. These researchers want to reject both the disease model of addiction and the account of addiction as a moral failing which the disease model has largely displaced.  Instead they emphasize the continuity between the neurological changes that occur in addicts’ brains and those that occur in any learned behavior that becomes deeply habitual. In my paper I will argue that while these accounts of addictive behavior are largely persuasive, they need to be supplemented by a richer account of the phenomenology of specific character addictive desire. I will try to take a few steps in that direction looking to an unexpected source for aid: St. Augustine’s account of his conversion in Confession VIII.

POWERLESSNESS, SPIRITUALITY AND SCIENCE
Gabriel Segal

“The fact is that most alcoholics, for reasons yet obscure, have lost the power of choice in drink” (Alcoholics Anonymous p 24).  I will explain the way in which an addict’s power of choice is lost. An addict’s choice-making apparatus is severely impaired so that their desires or felt needs to use can easily overcome and even obliterate their will to refrain from using. I will show how Twelve-Step programs solve this problem and restore the addict’s ability to choose in line with their wills. Alcoholics Anonymous offers a conception of addiction as involving a ‘physical allergy’, a ‘mental obsession’ and a ‘spiritual malady’. I shall argue that this conception is correct and largely vindicated by contemporary neuroscience.

“IT’S DEFINITELY A CHOICE, BUT IT’S A CHOICE YOU CAN’T UNDERSTAND”
Sarah Senker

The focus of this talk will be to present findings from a doctoral thesis, which, in part, explored the concept of choice and disease models within addiction. Offenders with heroin and crack misuse considered the role of choice in their behaviour. Correlations were found with those who were more ‘recovered’; who were more likely to acknowledge the role of choice in their drug-taking even if they had benefitted from a 12 step programme. The aim of this talk is to consider the findings and open the conversation about whether true addiction can ever be defined as a choice.

A LIFE IN THE DAY OF THE ADDICTIONS PSYCHIATRIST – WHO IS POWERLESS?
Bhags Sharma

I will talk about a typical day as a consultant in Addictions to demonstrate the variety and challenges that are faced in treating Addictions. I hope that the theme of ‘Powerlessness’ is captured.

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