Moral distress—easier said than solved

We have all had times when working in healthcare was difficult and distressing, and it feels good sometimes to admit it. We need to share responsibility and look out for one another

To quote Woody Allen: “Life is full of misery, loneliness and suffering, and it’s over much too soon.” The point, presumably, is that everyone is living their struggles, alongside their joys. In fact, it is one thing that unites us. Obviously, being a patient is usually the tougher gig compared to being the practitioner. However, that doesn’t mean it’s always easy to be a doctor or a nurse: especially when you have nagging concerns about the state of the medical industrial complex, but feel little choice but to soldier on. Whether recipient or provider, we should all expect our fair share of distress, doubt, even despair. It’s simply part of the deal. When these nagging emotions rear up we also need time and bandwidth to contemplate what it all means. Distress could be a foe that needs to be chased away, and or a friend that needs to be invited in. After all, adversity can be a terrible thing to waste. 

Emotions are difficult to pinpoint and cannot just be wished away. Regardless, “distress” likely sits in the same unpleasant waiting room as anxiety, sorrow, and pain. Because healthcare workers are witness to all that life and death throws at us, this means that doctors and nurses and administrators—privileged as we are—may get a double dose of distress: one from ourselves and one from our work. If we receive still more from our employers, or even from the general public, then there is a real and present danger that we could become less humane. It takes strength to ask for help, and step one, whether patient or provider or politician, is to cut yourself some slack. [1,2] However, we feel the need to dig deeper, and to understand what we mean when we claim “workplace distress”. After all, if you want to re-find your happiness you may have to look in the very place you lost it. 

Other terms such as “burnout” and “resilience” are relatively new in healthcare, but already, they risk becoming old. Despite a laudable call to arms (“it’s time we did something”), and a call to alms (it’s time we focused on humans in need), there are times when resilience is fallaciously portrayed as a personal failing, something you must address alone, or something that just needs a commercial fix. This state of affairs is neatly summarized by Ronald Purser in his 2019 book, McMindfulness. [3] It is also why new expressions such as “moral distress” and “moral injury” are gaining momentum. [4] Being content at work, or at least not being toxic, matters because there are substantial implications for recruitment, innovation, safety, and quality. The solution is not to merely download the problem from organizations to individuals. Instead, we should share responsibility and prioritize practical action.  

“Moral distress” is usually defined as the reaction of any sane human if they feel responsible, but disempowered. In other words, we know what to do, but do not believe we have the authority or agency to do it. It can be extremely unpleasant because you feel compromised instead of empowered, and pressured into acting against your code. This makes us all feel inauthentic and conflicted and disconnected. In other words, we lose the humanity that our vulnerable patients need, and we “burnout” in order to self-preserve. Like so many people, healthcare workers are finding the world a tough place to navigate. We are being asked to do more with less, our expertise is both challenged and ignored, and each day still only contains 24 hours. 

This issue of moral injury in healthcare is encompassed in a powerful viral video. [4] Its proponent, Zuban Damania, rightly points out, we are forced to simultaneously serve three task masters: ourselves, our patients, and our employers. Worse still, these three are often at odds. For example, we want to deliver our A-game to every patient, but by hour-70 something has to give. We want to ensure our patient is 100% safe, but perhaps the next patient needs their bed even more. We want to be present, but what about endless meetings and inexhaustible bureaucracy. 

In the past we would not have talked about distress in “moral” terms. Stoicism, and even denial, would have ruled the day. We would have highlighted the need to work harder and longer, and would have accepted that this is why we receive salary and benefits. However, we would still have emphasized a shared responsibility and mutual aid. We would have briefly acknowledged that this job challenges our emotions, but then reminded ourselves that we knew that when we signed up. The mantra of old would have been that personal growth often comes from finding a way to carry on nevertheless, not in squabbling over who is more virtuous. Like most things in medicine, the way forward is about balance and shared responsibility.

Morals encompass personal characteristics whereas ethics stress the social system in which morals are applied. In other words, ethics point to standards or group expectations. As such, while a person’s moral compass should not change, the way we act will be modulated by larger forces. To borrow from the legal profession, a criminal defence lawyer should always find murder morally abhorrent. However, their ethics demand that they vigorously defend the accused, even at the risk of setting them free. Just as in medicine, this is how we create a system from which we can all benefit. To those in distress, this may seem like semantics but it matters mightily. We have all had times when working in healthcare was difficult and distressing, and it feels good sometimes to admit it. We need to share responsibility and look out for one another. With that said we now wish to get back to work.  

See also: Autonomy, mastery, respect, and fulfillment are key to avoiding moral injury in physicians

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter @docpgb
Competing interests: None declared

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Jeffrey P Kerrie, General Internal Medicine and Medical Ethics, Island Health, Victoria, Canada
Competing interests: None declared


  1. Sara Gray. Voices in My Head.
  2. Kristin Neff. Self Compassion.
  3. Ronald Purser. McMindfulness: How mindfulness became the new capitalist spirituality Penguin Randon House 2019. 
  4. Zubin Damania. It’s Not Burnout, It’s Moral Injury.