Traversing the moral distress minefield

Dr Noel was in a spot of bother. On the consulting table was a 3 year old black, heavily pregnant German Shepherd bitch. Her puppies had died inside her and she had a purulent vaginal discharge. Despite being flat and weak, the dog’s character was revealed in her effort to wag her tail at the anxious vet.

The vet’s anxiety was caused by the dog’s owner, a puppy-farm breeder, who was at this moment insisting that he euthanise the dog. Dr Noel explained to the breeder that Valentine – Valentine was the name the breeder had given the dog – could probably be saved if she was speyed without delay. She could then lead a normal life, albeit not one in which she had two or more litters year after year.

But the breeder would have none of it. Couldn’t Dr Noel see, he argued, that the bitch had an economic function, namely to produce litters of puppies for sale? What purpose could she serve him now? Better, then, to save the money from the suggested surgery and buy new breeding stock.

Feeling that he might save this dog, Dr Noel, with considerable discomfort, tried again. He would lower substantially the cost of the operation. It was, he said to the breeder, in the interests of the dog to have the operation rather than to lose her life. And furthermore, he explained, it was a central motivation of his job and vocation to restore animals to healthy life. Still the breeder held firm.

Actually, the situation for Dr Noel was not so much a “spot of bother” as a case of what has been called moral distress. Now, the Christmas period is perhaps not the best time to talk about things traumatising and distressing. A vet’s life is already stressful enough! Nevertheless, I think the concept is interesting enough to subject you to it.

The study of moral distress is a new and undeveloped one. Much of the discussion about it emerges from human nursing. It’s important to be clear that moral distress differs from the idea of a “moral dilemma”. A moral dilemma involves a situation in which the agent judges that the options open to her are in conflict and of equal moral force. This generates genuine uncertainty in the agent’s mind about what is morally the best or the right thing to do in those circumstances.

In contrast, moral distress results when a person feels morally confident or certain about the best or right thing to do but is constrained from pursuing that course. In the above example, Dr Noel strongly believes it is right to operate on Valentine the German Shepherd. To kill her for the convenience of the puppy farmer strikes him as a far less morally desirable option. Hence his feeling of distress. The anxiety he feels is brought about through his ethical beliefs.

Nurses in medicine face a number of scenarios in which moral distress has been known to occur. These scenarios include: continued life support against the interest of the patient; inadequate communication about end of life care between providers, patients and families; inadequate staffing or staff who are not adequately trained; inadequate pain relief provided to patients; and false hope given to patients and families (Epstein and Delgardo, 2010).

The same authors relate this scenario:

Mr. Anderson, a 92 year old man living in a nursing home and suffering with Alzheimer’s disease for over 10 years, reaches the stage where he is no longer able to swallow food effectively. He has been hospitalized with aspiration pneumonia four times in the last year. The man’s eldest child, who lives in the same town, has a durable power of attorney, and visits regularly, insists that a feeding tube be inserted. He has the support of his two siblings. The staff feels that a feeding tube would be distressing to the patient. Besides, they say, “He swats away our hands when we try to hold him down to insert the tube, and he always pulls the tube out”.

The prospect of having to accede to the family’s wishes rather than act in what was perceived as the patient’s best interests created moral distress for the nursing staff.

Although the distress is moral in nature, it can have further emotional repercussions for the individual. According to the literature, these effects include anger, fear, self-doubt and frustration. It can lead to a sense of isolation and distance. In addition, a feeling of powerlessness can result from the person’s inability to address the situation in the way that they deem important or necessary.

Serious cases of moral distress may even threaten a person’s moral integrity. The scenario Dr Noel confronted was for him a relatively rare one. But if he had to face this scenario time and again the pressure would grow. He may then feel that his self-worth and identity had been severely compromised.
It has been suggested that nurses in medicine who are under this kind of moral pressure can suffer burnout, lose moral sensitivity, and even lose their careers. The reality of moral distress and its potentially damaging consequences, some members of the nursing profession have realised, require the profession’s interest and assistance. Possibilities for addressing moral distress include correctly recognising it, seeking and receiving the support of professional fellows, and formulating plans to change the conditions that lead to it.

Perhaps this applies to the veterinary profession. Some researchers (e.g. Verrinder and Phillips) have begun to examine these issues. Identifying the extent of moral distress and appropriate ways to address it may be something that is recognised as important in the future.

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