What is ‘moral distress’? A narrative synthesis of the literature

Georgina Morley, Jonathan Ives, Caroline Bradbury-Jones, & Fiona Irvine

Nursing Ethics

First Published October 8, 2017 Review Article  

https://doi.org/10.1177/0969733017724354

Introduction

The concept of moral distress (MD) was introduced to nursing by Jameton who defined MD as arising, ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. MD has subsequently gained increasing attention in nursing research, the majority of which conducted in North America but now emerging in South America, Europe, the Middle East and Asia. Studies have highlighted the deleterious effects of MD, with correlations between higher levels of MD, negative perceptions of ethical climate and increased levels of compassion fatigue among nurses. Consensus is that MD can negatively impact patient care, causing nurses to avoid certain clinical situations and ultimately leave the profession. MD is therefore a significant problem within nursing, requiring investigation, understanding, clarification and responses. The growing body of MD research, however, is arguably failing to bring the required clarification but rather has complicated attempts to study it. The increasing number of cited causes and effects of MD means the term has expanded to the point that according to Hanna and McCarthy and Deady, it is becoming an ‘umbrella term’ that lacks conceptual clarity referring unhelpfully to a wide range of phenomena and causes. Without, however, a coherent and consistent conceptual understanding, empirical studies of MD’s prevalence, effects, and possible responses are likely to be confused and contradictory.

A useful starting point is a systematic exploration of existing literature to critically examine definitions and understandings currently available, interrogating their similarities, differences, conceptual strengths and weaknesses. This article presents a narrative synthesis that explored proposed necessary and sufficient conditions for MD, and in doing so, this article also identifies areas of conceptual tension and agreement.

The research is here.

Don’t Want to Fall for Fake News? Don’t Be Lazy

Robbie Gonzalez
www.wired.com
Originally posted November 9, 2018

Here are two excerpts:

Misinformation researchers have proposed two competing hypotheses for why people fall for fake news on social media. The popular assumption—supported by research on apathy over climate change and the denial of its existence—is that people are blinded by partisanship, and will leverage their critical-thinking skills to ram the square pegs of misinformation into the round holes of their particular ideologies. According to this theory, fake news doesn't so much evade critical thinking as weaponize it, preying on partiality to produce a feedback loop in which people become worse and worse at detecting misinformation.

The other hypothesis is that reasoning and critical thinking are, in fact, what enable people to distinguish truth from falsehood, no matter where they fall on the political spectrum. (If this sounds less like a hypothesis and more like the definitions of reasoning and critical thinking, that's because they are.)

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All of which suggests susceptibility to fake news is driven more by lazy thinking than by partisan bias. Which on one hand sounds—let's be honest—pretty bad. But it also implies that getting people to be more discerning isn't a lost cause. Changing people's ideologies, which are closely bound to their sense of identity and self, is notoriously difficult. Getting people to think more critically about what they're reading could be a lot easier, by comparison.

Then again, maybe not. "I think social media makes it particularly hard, because a lot of the features of social media are designed to encourage non-rational thinking." Rand says. Anyone who has sat and stared vacantly at their phone while thumb-thumb-thumbing to refresh their Twitter feed, or closed out of Instagram only to re-open it reflexively, has experienced firsthand what it means to browse in such a brain-dead, ouroboric state. Default settings like push notifications, autoplaying videos, algorithmic news feeds—they all cater to humans' inclination to consume things passively instead of actively, to be swept up by momentum rather than resist it.

The info is here.

Why Health Professionals Should Speak Out Against False Beliefs on the Internet

Joel T. Wu and Jennifer B. McCormick
AMA J Ethics. 2018;20(11):E1052-1058.
doi: 10.1001/amajethics.2018.1052.

Abstract

Broad dissemination and consumption of false or misleading health information, amplified by the internet, poses risks to public health and problems for both the health care enterprise and the government. In this article, we review government power for, and constitutional limits on, regulating health-related speech, particularly on the internet. We suggest that government regulation can only partially address false or misleading health information dissemination. Drawing on the American Medical Association’s Code of Medical Ethics, we argue that health care professionals have responsibilities to convey truthful information to patients, peers, and communities. Finally, we suggest that all health care professionals have essential roles in helping patients and fellow citizens obtain reliable, evidence-based health information.

Here is an excerpt:

We would suggest that health care professionals have an ethical obligation to correct false or misleading health information, share truthful health information, and direct people to reliable sources of health information within their communities and spheres of influence. After all, health and well-being are values shared by almost everyone. Principle V of the AMA Principles of Ethics states: “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated” (italics added). And Principle VII states: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health” (italics added). Taken together, these principles articulate an ethical obligation to make relevant information available to the public to improve community and public health. In the modern information age, wherein the unconstrained and largely unregulated proliferation of false health information is enabled by the internet and medical knowledge is no longer privileged, these 2 principles have a special weight and relevance.

Does deciding among morally relevant options feel like making a choice? How morality constrains people’s sense of choice

Kouchaki, M., Smith, I. H., & Savani, K. (2018).
Journal of Personality and Social Psychology, 115(5), 788-804.
http://dx.doi.org/10.1037/pspa0000128

Abstract

We demonstrate that a difference exists between objectively having and psychologically perceiving multiple-choice options of a given decision, showing that morality serves as a constraint on people’s perceptions of choice. Across 8 studies (N = 2,217), using both experimental and correlational methods, we find that people deciding among options they view as moral in nature experience a lower sense of choice than people deciding among the same options but who do not view them as morally relevant. Moreover, this lower sense of choice is evident in people’s attentional patterns. When deciding among morally relevant options displayed on a computer screen, people devote less visual attention to the option that they ultimately reject, suggesting that when they perceive that there is a morally correct option, they are less likely to even consider immoral options as viable alternatives in their decision-making process. Furthermore, we find that experiencing a lower sense of choice because of moral considerations can have downstream behavioral consequences: after deciding among moral (but not nonmoral) options, people (in Western cultures) tend to choose more variety in an unrelated task, likely because choosing more variety helps them reassert their sense of choice. Taken together, our findings suggest that morality is an important factor that constrains people’s perceptions of choice, creating a disjunction between objectively having a choice and subjectively perceiving that one has a choice.

A pdf can be found here.

A choice may not feel like a choice when morality is at play

Susan Kelley
Cornell Chronicle
Originally posted November 15, 2018

Here is an excerpt:

People who viewed the issues as moral – regardless of which side of the debate they stood on – felt less of a sense of choice when faced with the decisions. “In contrast, people who made a decision that was not imbued with morality were more likely to view it as a choice,” Smith said.

The researchers saw this weaker sense of choice play out in the participants’ attention patterns. When deciding among morally relevant options displayed on a computer screen, they devoted less visual attention to the option that they ultimately rejected, suggesting they were less likely to even consider immoral options as viable alternatives in their decision-making, the study said.

Moreover, participants who felt they had fewer options tended to choose more variety later on. After deciding among moral options, the participants tended to opt for more variety when given the choice of seven different types of chocolate in an unrelated task. “It’s a very subtle effect but it’s indicative that people are trying to reassert their sense of autonomy,” Smith said.

Understanding the way that people make morally relevant decisions has implications for business ethics, he said: “If we can figure out what influences people to behave ethically or not, we can better empower managers with tools that might help them reduce unethical behavior in the workplace.”

The info is here.

The original research is here.

Social relationships more important than hard evidence in partisan politics

phys.org
Dartmouth College
Originally posted November 13, 2018

Here is an excerpt:

Three factors drive the formation of social and political groups according to the research: social pressure to have stronger opinions, the relationship of an individual's opinions to those of their social neighbors, and the benefits of having social connections.

A key idea studied in the paper is that people choose their opinions and their connections to avoid differences of opinion with their social neighbors. By joining like-minded groups, individuals also prevent the psychological stress, or "cognitive dissonance," of considering opinions that do not match their own.

"Human social tendencies are what form the foundation of that political behavior," said Tucker Evans, a senior at Dartmouth who led the study. "Ultimately, strong relationships can have more value than hard evidence, even for things that some would take as proven fact."

The information is here.

The original research is here.

Why Are Doctors Killing Themselves?

The Practical Professional in Healthcare
October/November 2018

Here is an excerpt:

The nation loses 300 to 400 physicians each year, the equivalent of two large medical school classes, and more than a million patients lose their doctor.  According to a new research study encompassing data from the past ten years, physicians are committing suicide at a rate that’s more than twice as high as the average population—higher even than for veterans.

With a critical shortage of physicians looming and advocates like Pamela Wible calling attention to the problem, the increasingly urgent question remains: Why are doctors killing themselves? And what can be done to help?  In response, researchers are ramping up their efforts to understand the causes of
physician suicide; leading hospitals, medical schools and professional organizations are pioneering new programs and interventions; and regulators are reconsidering how they might revise the licensing/renewal process to support their efforts.

The info is here.

There are several other articles on physician self-care, which applies to other helping professions.

Beyond the Boundaries: Ethical Issues in the Practice of Indirect Personality Assessment in Non-Health-Service Psychology

Marvin W. Acklin
Journal of Personality Assessment
https://doi.org/10.1080/00223891.2018.1522639

Abstract

This article focuses on ethical quandaries in the practice of indirect personality assessment in non-health-service psychology. Indirect personality assessment methods do not involve face-to-face interaction. Personality assessment at a distance is a methodological development of personality and social psychology, psychobiography, and psychohistory. Indirect personality methods are used in clinical, forensic, law enforcement, public safety, and national security settings. Psychology practice in non-health-service settings creates tensions between principles of beneficence and duty to society. This article defines methods of indirect personality assessment and some ethical ramifications. Their application in non-health-service settings occurs in the context of intense controversy over the ethics of psychologists’ participation in work settings where there are third-party loyalties, absence of voluntary informed consent, presence of nonstipulated harms, and absence of legal and ethical accountability. A hypothetical case example illustrates typical quandaries encountered in a national security assessment. This article provides a framework for critically examining ethical quandaries, a contemporary conceptual and process model for integrative moral cognition, and parameters for ethical reasoning by the individual practitioner under the exigencies of real-world practice.

Is It Ethical to Use Prognostic Estimates from Machine Learning to Treat Psychosis?

Nicole Martinez-Martin, Laura B. Dunn, and Laura Weiss Roberts
AMA J Ethics. 2018;20(9):E804-811.
doi: 10.1001/amajethics.2018.804.

Abstract

Machine learning is a method for predicting clinically relevant variables, such as opportunities for early intervention, potential treatment response, prognosis, and health outcomes. This commentary examines the following ethical questions about machine learning in a case of a patient with new onset psychosis: (1) When is clinical innovation ethically acceptable? (2) How should clinicians communicate with patients about the ethical issues raised by a machine learning predictive model?

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Conclusion

In order to implement the predictive tool in an ethical manner, Dr K will need to carefully consider how to give appropriate information—in an understandable manner—to patients and families regarding use of the predictive model. In order to maximize benefits from the predictive model and minimize risks, Dr K and the institution as a whole will need to formulate ethically appropriate procedures and protocols surrounding the instrument. For example, implementation of the predictive tool should consider the ability of a physician to override the predictive model in support of ethically or clinically important variables or values, such as beneficence. Such measures could help realize the clinical application potential of machine learning tools, such as this psychosis prediction model, to improve the lives of patients.