The covid-19 pandemic has drawn our collective attention to the vulnerabilities of healthcare workers (HCWs). Currently, these vulnerabilities are largely couched in proximal terms of long working hours and shortages in appropriate personal protective equipment. Less attention has been paid to HCW vulnerability to moral distress: which occurs when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right action.” [1] Moral distress is well described amongst HCWs and leads to stress, burnout, and lack of resilience. We would thus emphasise the cumulative emotional toll that follows having to navigate frequent, and often nebulous, ethical dilemmas at the frontlines of the pandemic. Ethical dilemmas are commonplace in healthcare settings. But they are heightened in new and uncertain circumstances, and when faced with increased pressures and limited resources.

A recent survey investigating the experience of UK health professionals’ engagement with ethical issues found that only about half (54%) of the 562 respondees reported having no problem distinguishing a technical (i.e. empirical) from an ethical (i.e. normative) issue—with 7% reporting they were unsure how to distinguish a technical issue from an ethical issue. [2] When it came resolving ethical issues, the two most prominent methods reported were personal reflection and discussion with colleagues—which presumes both adequate ethics education/training and the time to engage with such activities. Finally, just over half (54%) of the 562 respondees reported feeling uncertain about whether they had dealt with an ethical issue in the best way. 

Feeling ill-prepared or unable to pursue ethically appropriate action—based on personal integrity or professional obligations—causes moral distress. Moral distress undermines functional competency and wellbeing in the face of strain and adversity, which adversely affects both worker resilience (leading to disconnection, loss of meaning, and lower physical/mental health) and workforce resilience (leading to higher rates of illness, poor morale, higher turn-over, and loss of institutional memory). [3-5] This is a problem of regular practice that is amplified when dealing with events like the covid-19 pandemic. We can do three things to help.

Manage Expectations—Unlike technical questions, ethical questions are less likely to admit to simple or certain answers. HCWs must be supported in identifying and resolving ethical issues, which must include preparation for the potential to operate in an environment of moral ambiguity where we cannot expect clear-cut resolutions to complex or contentious ethical questions. Responsive clinical ethics committees or ethical guidance can help provide, e.g. consistency and clarity around professional obligations in such circumstances.

Provide Practice-Relevant Ethical Guidance—While well-considered and agreed general ethical principles are helpful in guiding ethical decision-making, HCWs (especially in a pandemic and when time is of the essence) require more context-based, specified guidance concerning particular ethical issues. The equal status of lives and equity are important principles that should inform clinical judgement, but they are too abstract to provide sufficient operative guidance to help decide, for instance, who should be exempt from staffing cohort wards.

Improve Ethics Education, Preparedness, and Response—Examples of moral distress among HCWs are commonplace, as we see in the news and on social media. Individual-level ethics education and training and systems-level ethics preparedness and responses can be strengthened to help promote individual and workforce resilience. Institutions like the Royal Colleges and universities can play an important role in this respect.

Reducing moral distress and supporting HCWs’ ability to navigate ethical dilemmas, especially those that institutional and situational constraints make it impossible to satisfactorily resolve, will provide a more resilient workforce that is better able to weather the covid-19 storm and be in place, ready for the next one. 

A.M. Viens is an associate professor of Global Health Policy in the Faculty of Health and Investigator at the Global Strategy Lab at York University. He is an Honorary Member of the UK Faculty of Public Health and sits on its Ethics
Committee.

Catherine R. McGowan is an assistant professor at the London School of Hygiene & Tropical Medicine and Humanitarian Health Adviser at Save the Children UK.

Caroline M. Vass is a Consultant in Public Health, working as a Public Health England screening and immunisation lead. She is a member of the UK Faculty of Public Health’s Ethics Committee.

Competing interests: The authors have read and understood BMJ policy on declaration of interests and we do not have any conflicts of interests to declare.

References:

1. Jameton A. Nursing practice: The ethical issues. Prentice Hall, 1984.
2. Viens AM, Vass C, McGowan CR, Tahzib F. Education, training, and experience in public health ethics and law within the UK public health workforce. Journal of Public Health 2020; 42:208-215.
3. Wiegand DL, Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics 2012;19:479-487. 
4. Mitton C, Peacock S, Storch J, Smith N, Cornelissen E. Moral Distress among healthcare managers: Conditions, consequences and potential responses. Healthcare Policy 2010;6:99-112.
5. Wilkinson JM. Moral distress in nursing practice: Experience and effect. Nursing Forum 1987;23:16-29.