writing

Bioethics. 2019;33:601–608. wileyonlinelibrary.com/journal/bioe  |  601© 2019 John Wiley & Sons Ltd

1  | INTRODUC TION

The idea of moral distress in healthcare has been an increasingly prevalent topic of discussion. Ever since Andrew Jameton's seemingly casual intro‐ duction of the term, empirical studies have been carried out, while re‐ searchers and a variety of healthcare professionals have offered disparate conceptual understandings of the phenomenon.1 Only in recent works have some explicitly called into question the nature of moral distress and the range of its harmful effects.2 Such efforts are often an attempt to broaden the set of causal circumstances thought to bring about the expe‐ rience.3 Very few authors, however, have questioned its value. Indeed, moral distress is almost unanimously characterized in a negative light.4

To some extent, these judgments are quite natural. Moral dis‐ tress has been found to be closely correlated with medical practi‐ tioner burnout (often known as ‘compassion fatigue’), high turnover rates and staffing shortages, which, in turn, contribute to a greater likelihood of patients receiving inadequate attention.5 Still, moral distress appears to be much more than a purely negative experience. Despite its ostensibly negative effects and prima facie objectionable quality for those who endure it, as I argue, moral distress can reveal and affirm some of our most important concerns as moral agents. Indeed, the experience of it under some circumstances appears to be partly constitutive of an honorable character and can allow one to undergo a crucial life process of moral maturation. In other words, the potentially positive value of moral distress is twofold: moral dis‐ tress carries both aretaic value as well as instrumental value.6

In order to support the aretaic value, I will first rely upon an anal‐ ysis of established definitions of moral distress. Here, also, I will briefly consider recent critiques of the established notions and argue that, by all accounts, the experience of moral distress often gives us

1Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice‐Hall. 2Kälvemark, S., Höglund, A. T., Hansson, M. G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts: Ethical dilemmas and moral distress in the health care system. Social Science & Medicine, 58(6), 1075–1084; McCarthy, J., & Deady, R. (2008). Moral distress reconsid‐ ered. Nursing Ethics, 15(2), 254 –262; Musto, L., & Rodney, P. (2016). Moving from concep‐ tual ambiguity to knowledgeable action: Using a critical realist approach to studying moral distress. Nursing Philosophy, 17(2), 75–87; Tigard, D. W. (2018). Rethinking moral distress: Conceptual demands for a troubling phenomenon affecting health care profession‐ als. Medicine, Health Care and Philosophy, 21(4), 479–488. 3See, for example, Fourie, C. (2015). Moral distress and moral conflict in clinical ethics. Bioethics, 29(2), 91–97; Campell, S. M., Ulrich, C. M., & Grady, C. (2016). A broader under‐ standing of moral distress. The American Journal of Bioethics, 16(12), 2–9. 4Among the few exceptions are Benner, P. (1991). The role of experience, narrative, and community in skilled ethical comportment. Advances in Nursing Science, 14(2), 1–21; Rushton, C. H. (1992). Care‐giver suffering in critical care nursing. Heart & Lung: The Journal of Critical Care, 21(3), 303–306; Tigard, D. W. (2018). Moral distress as a symptom of dirty hands. Res Publica. https://doi.org/10.1007/s11158‐018‐9403‐8.

5Wilkinson, J. (1987/88). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16–29; Corley, M. (2002). Nurse moral distress: A proposed theory and re‐ search agenda. Nursing Ethics, 9(6), 636–650; Whitehead, P. B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., & Fisher, J. M. (2015). Moral distress among healthcare professionals: Report of an institution‐wide survey. Journal of Nursing Scholarship, 47(2), 117–125. 6With my use of the term ‘aretaic’ I refer to considerations of character, following Watson, G. (1996). Two faces of responsibility. In G. Watson (Ed.), (2004). Agency and answerability (pp. 260–288). Oxford, UK: Oxford University Press.

Received: 31 December 2017  |  Revised: 24 October 2018  |  Accepted: 27 November 2018 DOI: 10.1111/bioe.12564

O R I G I N A L A R T I C L E

The positive value of moral distress

Daniel W. Tigard

RWTH Aachen University – Human Technology Center, Aachen, Germany

Correspondence Daniel W. Tigard, RWTH Aachen University – Human Technology Center, Theaterplatz 14, Aachen 52062, Germany. Email: [email protected]

Abstract Moral distress in healthcare has been an increasingly prevalent topic of discussion. Most authors characterize it as a negative phenomenon, while few have considered its poten‐ tially positive value. In this essay, I argue that moral distress can reveal and affirm some of our most important concerns as moral agents. Indeed, the experience of it under some circumstances appears to be partly constitutive of an honorable character and can allow for crucial moral maturation. The potentially positive value, then, is twofold; moral distress carries both aretaic and instrumental value. Granted, this position is not without its caveats, but by making these clear, I provide a novel framework for policy recom‐ mendations regarding when, if ever, we should work to reduce moral distress.

K E Y W O R D S

moral agency, moral distress, moral psychology, moral responsibility

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reason to think favorably of the agent who undergoes it.7 In support of the instrumental value, I will then invoke a consequential argu‐ ment that depicts moral distress as a personally edifying good. Granted, my position on the positive value of moral distress is not without critical caveats. After all, many effects of moral distress are often undeniably negative: again, consider the correlations with compassion fatigue and staffing shortages among healthcare work‐ ers.8 Nevertheless, by leaving room for certain decisive qualifica‐ tions, my arguments will provide a novel framework for policy recommendations regarding when, if ever, we should work to re‐ duce the experience of moral distress. To begin, I will set out some of the most widely cited definitions to which my arguments will respond.

2  | DEFINING MOR AL DISTRESS

Moral distress is most often understood as a negative phenomenon, as an objectionable psychological response to morally troubling de‐ cisions or situations. Yet, this common perception appears to result from a persistent focus on the causes and the effects of moral dis‐ tress, with far less attention given to the experience itself. In a recent effort to deploy a ‘moral distress map’, Denise Dudzinski aptly states that the ‘symptom of moral distress should not be confused with the source’.9 Likewise, it seems, the symptoms should not be confused with the downstream effects. So, what exactly is moral distress and how might the experience of it be positively valuable? In this section, I provide a brief survey of the most widely cited definitions and, be‐ cause of the relative shortage of works addressing an agent's symp‐ toms, I pay special attention to both the systemic and psychological features of the troubling phenomenon.

In his popularized inauguration of the term, Jameton claimed that ‘Moral distress arises when one knows the right thing to do, but insti‐ tutional constraints make it nearly impossible to pursue the right course of action.’10 Consider, as Jameton envisioned, a nurse who is forced to comply with a hospital policy requiring blood sampling for all incoming patients. Given that the procedure is unnecessary for many patients and thereby places some at an undue risk of harm, the nurse sees this practice as morally wrong. To be sure, nursing – among perhaps only a handful of professions – is often thought to entail morally significant goals; thus, when professional goals are im‐ peded, moral goals are equally inhibited.11 In this scenario, the nurse is powerless to do otherwise, presumably also powerless to change the existing policy. As a result he sees himself as complicit in the

wrongdoing.12 This, we can grant, is an exemplary case of moral dis‐ tress. But what more can be said of the nurse in Jameton's example?

Imagine that, although the nurse knows the right thing to do and is forced to do otherwise due to institutional constraints, he loses no sleep over the discrepancy and, in time, he comes to abide willingly by the policy. On the one hand, we might think, by definition the case is still one of moral distress – at least, the circumstances are exem‐ plary causes of the phenomenon and they should be treated as such. That is, we should take the nurse's initial perception of moral wrong‐ doing as a possible indication that the hospital is not functioning as well as it could to protect the interests of its intended beneficiaries. As some authors have acknowledged, moral distress is an ‘ethical canary’ that warns us of something significant being amiss and de‐ manding systematic reform.13

On the other hand, as Jameton had in mind, imagine that the nurse is among many who feel guilt and related emotional discom‐ fort as a result of performing ‘procedures that they feel are morally wrong’.14 As a great deal of the literature has conveyed, moral dis‐ tress describes much more than an objectively determined set of circumstances. Here we see one of Jameton's motivations to specify – with the term ‘initial distress’ – an agent's feelings of ‘frustration, anger, and anxiety…when faced with institutional obstacles and con‐ flicts with others about values’.15 Indeed, on the definition suggested by Judith Wilkinson's early empirical studies, moral distress is ‘the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision’.16

Naturally, we might wonder why moral distress could not result from taking action, or whether or not a morally distressed agent must be faced with an institutional constraint. For it may seem that one could plausibly experience the discomfort characteristic of moral distress, but as a result of various decisions or actions, and without being subjected to any sort of constraint.17 Nevertheless, while we might call into ques‐ tion the range of causes distinctive of moral distress, my present pur‐ poses span beyond recent concerns over the proper definition. Instead, what I wish to show is that we can grant the most widely established accounts and, in doing so, find that an agent's experience of moral

7Note my emphasis on the ‘experience’ of moral distress. I take it that, for purposes of conceptual clarity, it will be important to distinguish between the causes and the phenom‐ enon itself. See Tigard, op. cit. note 2. I expand upon this further, below. 8Here, again, I emphasize ‘effects’ in order to highlight that my primary focus will be on the experience itself. I am extremely grateful for an anonymous reviewer's comments, which helped me to make this focus explicit throughout the present work. 9Dudzinski, D. M. (2016). Navigating moral distress using the moral distress map. Journal of Medical Ethics, 42, 321–324. 10Jameton, op. cit. note 1, p. 6. 11See, for example, Corley, op. cit. note 5.

12For a persuasive account of complicity and shared responsibility, see Gardner, J. (2007). Complicity and causality. In J. Gardner (Ed.), Offenses and defences: Selected essays in the philosophy of criminal law (pp. 57–76). New York, NY: Oxford University Press. 13Somerville, M. (2004). The ethical canary: Science, society, and the human spirit. Montreal, Canada: McGill‐Queen's University Press; Austin, W. (2012). Moral distress and the con‐ temporary plight of health professionals. HEC Forum, 24, 27–38. On this point, I am grate‐ ful for conversations with Lori Bruce. 14Jameton, op. cit. note 1, p. 283. 15Jameton, A. (1993). Dilemmas of moral distress: moral responsibility and nursing prac‐ tice. AWHONN's Clinical Issues in Perinatal and Women's Health Nursing, 4(4), 542–551. Jameton also established ‘reactive distress’ as ‘the distress that people feel when they do not act upon their initial distress’. While the distinction between initial and reactive dis‐ tress provides useful nuances, it will be largely inconsequential here. 16Wilkinson, op. cit. note 5, p. 16. 17See Fourie, op. cit. note 3; Campbell et al., op. cit. note 3; also Fourie, C. (2017). Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of moral distress. AMA Journal of Ethics, 19(6), 578–584.

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distress reveals favorable qualities of his or her character. Upon con‐ cluding this argument, I will show that my observations regarding the positive aretaic value of moral distress generalize to the wider defini‐ tions proposed more recently.

3  | THE ARETAIC VALUE

As I noted at the outset, my use of the term ‘aretaic’ follows Gary Watson's famed essay ‘Two faces of responsibility’.18 With this ground‐ breaking work, Watson aimed to make sense of our ambivalence to‐ wards those whom we see as having a bad character yet, for some reason, do not deserve other, more overt forms of blame. For many of us (or perhaps for all of us) who we are and what we care about are due to factors largely beyond our awareness or control.19 When one per‐ forms an action that seems clearly wrong, we are likely to attribute the conduct to the agent – that is, we make aretaic appraisals which ‘impli‐ cate one's practical identity’, what it is they value or stand for.20 Beyond making assessments of character, however, we might or might not hold agents accountable for their conduct, for example, by communicating the offense or imposing punishment, for in some cases it seems unfair to do so. In this way, moral responsibility can be divided into assess‐ ments of an agent's character, on the one hand, and our accountability practices, on the other.

Putting aside our practices of holding each other accountable, I want to focus on the appraisals – both the negative and the positive judgments – that we make of agents’ characters, of who they are and what they care about. According to David Shoemaker's notion of agency, it is the things we care about that motivate us to act in some way or other, at least in situations that matter.21 Our caring renders us susceptible to various emotional responses and ultimately makes up who we are.22 When we succeed in supporting something we judge to be valuable, naturally, we feel a sense of satisfaction, like pride. When we betray our values, we likely feel a sense of shame or guilt. Importantly, our emotional reactions toward the successes and failures of a given object are indicative of the cares we maintain. As Shoemaker eloquently states, ‘caring is simply a way of referring to the range of emotional reactions one is expected to have with respect to the for‐ tunes of the cared‐for object’.23

Turning to the experience of moral distress, I can grant here that it is usually, perhaps even always, an extremely adverse phenome‐ non. As I have surveyed, it is often related to or assumed to be partly constituted by some negative emotional response. Nonetheless, I

want to acknowledge four general points about the value of moral distress as it pertains to an agent's character. Taken together, the following observations point to a view of moral distress which merits serious consideration by stakeholders ranging from bioethicists and policy makers to healthcare administrators and patients.

First, it appears widely accepted that the morally distressed agent often undergoes some sort of ‘negative’ emotional experience. Where one faces an obstacle to what is seen as morally appropriate action, it should come as no surprise that one feels something akin to frustration or anger, as Jameton first posited. In other cases, one likely experiences moral distress as a feeling of guilt or regret, say, where practitioners are constrained from doing the right thing and thereby wish they could have acted differently.24 Given that moral distress might involve a variety of negative responses, we see good reason to accept Wilkinson's helpful proposal, a more general de‐ scription of moral distress as a form of psychological disequilibrium and negative feeling resulting from moral decisions which cannot be fulfilled.25

Second, these sorts of reactions are naturally undesirable. It may be difficult to say exactly why we desire to avoid such feelings. For the moment, I will posit that they are phenomenologically objec‐ tionable; they constitute a sort of pain. Nevertheless, it remains to be seen why these sorts of pain – understood on their own or as instances of moral distress – must be characterized only as objec‐ tionable. Surely, we can imagine a young adult learning and growing, say, from the pains of heartbreak. And, granted, it might sound crass or plainly absurd to liken the pains of moral distress – a response to system‐wide problems that may well demand resolution – to a meaningful rite of passage. Still, the key point to be made is simply that while the pains of anger and frustration, guilt and regret are cer‐ tainly undesirable, there is much more to them than their negative phenomenology.

The third point, following Shoemaker's notion of agency, is that our emotional responses tell us something very important about the things we care about and the ways in which we care about them. Some of the most commonly experienced emotional states – indeed, what are thought by some to be universal human experiences26 – serve as key indications that something we care about has been harmed or benefited, or otherwise noticeably affected. As Justin D'Arms and Daniel Jacobson explain, psychological states like anger, envy, pride, fear, joy, guilt, and regret ‘both descry and circumscribe a distinctive realm of human values’.27 Consider again Jameton's case of the nurse who is forced to comply with a gratuitous hospital admission policy. As it appeared, the nurse might experience a sort

18Watson, op. cit. note 6. 19Consider, for example, some of the recent work on responsibility and implicit biases: Doris, J. (2015). Talking to our selves: Reflection, ignorance, and agency. Oxford, UK: Oxford University Press; Levy, N. (2017). Implicit bias and moral responsibility: Probing the data. Philosophy and Phenomenological Research, 94(1), 3–26; Vargas, M. (2017). Implicit bias, responsibility, and moral ecology. In D. Shoemaker (Ed.), Oxford studies in agency and re- sponsibility, Vol. 4. Oxford, UK: Oxford University Press. 20Watson, op. cit. note 6, p. 271. 21Shoemaker, D. (2003). Caring, identification, and agency. Ethics, 114(1), 88–118. 22Ibid: 94. 23Ibid.

24For Jameton's description of moral distress as related to feelings of guilt, see Jameton, op. cit. note 1, p. 283. 25Wilkinson, op. cit. note 5, p. 16. Here I am indebted to an anonymous reviewer for en‐ couraging me to maintain the more traditional conception as my primary target. 26See, for example, Frijda, N. (1986). The emotions. Cambridge, UK: Cambridge University Press; Eckman, P. (1992). Are there basic emotions? Psychological Review, 99(3), 550–553. 27D'Arms, J., & Jacobson, D. (2006). Anthropocentric constraints on human value. In R. Shafer‐Landau (Ed.), Oxford studies in metaethics, Vol. 1 (pp. 99–126). Oxford, UK: Clarendon Press, p. 107.

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of anger or frustration, and understandably so. He sees that the pol‐ icy is morally wrong, for it places patients at an unnecessary risk of being harmed. Importantly, what the nurse's anger or frustration ef‐ fectively reveals is that he cares about patients’ well‐being and that he is unfortunately unable to act in a way that promotes their best interests. Indeed, if moral distress is truly an ethical canary, we should hope that he and others will heed the call to systematically improve the harmful procedures in question. During the time in which he is morally distressed, his anger and frustration reveal to others, and likely affirm to himself, the degree and the ways in which he cares about his patients’ well‐being.

Fourth, and finally, because our susceptibility to various emo‐ tional responses is so intimately tied up with the things we care about, it seems that if we did not feel so frustrated or angered when seeing certain objects or persons harmed, it would indicate that we do not care. This point might be somewhat obvious or trite. However, consider that some of the most common accounts of moral distress recommend efforts to drastically reduce or even eliminate the expe‐ rience from the lives of healthcare professionals. For example, Mary Corley and others who worked to develop the so‐called ‘moral dis‐ tress scale’ suggest that ‘reducing moral distress is an important pri‐ ority’.28 Corley later called for ‘preventative solutions’.29 Similarly, Lynn Musto and Patricia Rodney cite the need for ‘comprehensive actions to prevent and ameliorate moral distress’.30

As I have granted, moral distress is undoubtedly a negative phe‐ nomenon for those who must suffer it. But imagine we somehow succeed in not only reducing moral distress but eliminating the expe‐ rience altogether. Certainly, this could not mean eliminating morally distressing situations, for it seems safe to assume that dealing with troubling moral circumstances is simply part and parcel of navigating occupations that directly impact sensitive interests and other lives. Perhaps, then, we should strive to eradicate the experience of moral distress. Here we begin to see an added complexity of the problem. What would it mean for healthcare professionals to not be frus‐ trated, angered, or anxious when forced to act against what they see as morally right action? How should we regard those who do not experience some degree of disequilibrium or a negative feeling when failing to fulfill morally significant decisions? For some, adopting a level of professional callousness or inurement is exactly what we want for good healthcare workers.31 After all, although they are per‐ sonally involved, practitioners do not bear moral responsibility for the difficulties and harms to be encountered.32 Nevertheless, we

occasionally think it quite appropriate for a person to feel terribly upset or even morally troubled where they were not morally respon‐ sible for the upsetting events.

Consider Bernard Williams's popularized case of the lorry driver who accidentally hits and kills a child.33 While the driver is not at fault, his uniquely terrible feeling for being causally involved – what Williams calls ‘agent‐regret’ – is seen as completely understandable. Of course, any bystanders to the tragedy should comfort him and counsel him away from his bad feelings. Still, such counseling should not succeed, at least not immediately. Should the driver's knowledge that he is not at fault allow him to shrug off the events without hes‐ itation, we would rightly question his sensitivity. To be sure, we would have significant reason to think poorly of the quality of his character.34 At the same time, the fact that he beats himself up over things he cannot control shows that he is sensitive to the morally relevant losses that were incurred. Granted, we would not want the driver to beat himself up too much. That being said, his guilt or regret (or agent‐regret) shows that he cares for the others affected and per‐ haps for the well‐being of persons, generally. Despite the fact that he did no wrong, his susceptibility to emotional discomfort and being morally troubled by the perceived hardships of others is surely the mark of an honorable character.

Before closing the present section, it should be noted that my observations – which point to a previously unacknowledged value – generalize to the wider definitions of moral distress. On the most traditional notion, moral distress entails knowing the right thing while facing insurmountable obstacles imposed at the systemic level. But what if, as some have recently suggested, moral distress is a response to a range of circumstances, including moral dilemmas, uncertainty, and bad moral luck?35 No doubt, these suggestions may well contribute more confusion than clarity to the discussion of moral distress.36 Still, whether or not ‘moral distress’ accurately de‐ scribes a range of morally troubling situations, our negative psycho‐ logical responses to such difficulties likewise give reasons to think favorably of the morally troubled agent. Consider again the reac‐ tions we expect of Williams's lorry driver, or the political actor who faces a tragic dilemma – where lives are sure to be lost – but feels appropriately tormented by the decision. In Michael Walzer's nota‐ ble words, it is because ‘he has scruples of this sort, [that] we know him to be a good man’.37

While many authors suggest efforts to reduce or eliminate moral distress, it seems that the reduction or elimination of it would risk discounting or obstructing important features of one's

28Corley, M., Elswick, R. K., Gorman, M., & Clor. T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250–256, p. 256. 29Corley, op. cit. note 5, p. 648. 30Musto and Rodney, op. cit. note 2, p. 81. 31See Rentmeester, C. A. (2007). Should a good healthcare professional be (at least a little) callous? Journal of Medicine and Philosophy, 32(1), 43–64. For pursuing this line in conver‐ sation, I am here indebted to Kevin Morris. 32That is, barring cases of medical error, where practitioners may indeed bear responsibil‐ ity for preventable or even inadvertent harms. For sake of brevity, this consideration must be set aside for a separate project. See Tigard, D. W. (2018). Taking the blame: Appropriate responses to medical error. Journal of Medical Ethics. https://doi.org/10.1136/ medethics‐2017‐104687.

33Williams, B. (1981). Moral luck. In Moral luck (pp. 20–39). Cambridge, UK: Cambridge University Press. 34Shoemaker aptly states that an agent would be ‘quite callous’ to perk up upon being counseled away from feelings like regret. Shoemaker, D. (2015). Responsibility from the margins. New York, NY: Oxford University Press, p. 86. 35Fourie, op. cit. note 3; Campbell et al., op. cit. note 3; Fourie, op. cit. note 17. 36See Wocial, L. (2016). A misunderstanding of moral distress. American Journal of Bioethics, 16(12), 21–23. Here, also, I greatly appreciate an anonymous reviewer's helpful comments. 37Walzer, M. (1973). Political action: The problem of dirty hands. Philosophy and Public Affairs, 2(2), 160–180.

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character. Rather than working to prevent our natural affective responses, we should offer comfort or even praise to those who find themselves frustrated, angered, or in a general state of dis‐ equilibrium as a result of being constrained from doing the right thing. Of course, some of the most extreme instances will call for exceptions, to which I will return. First, however, I will show that along with its aretaic value, moral distress can be instrumentally valuable.

4  | THE INSTRUMENTAL VALUE

I claimed above that in being morally distressed, one's outward emo‐ tional responses reveal to others the degree and ways in which one cares for something or someone. Upon reflection, this process of revealing our cares may already indicate an instrumental good to be achieved. We want others to know that we care and, often, how much we care. Yet, if this feature alone was the extent of the instru‐ mental value, it seems that the best‐case scenario would be one in which a person successfully displays the appropriate emotional re‐ sponse, and thereby displays that they care, while in fact not suffer‐ ing the negative phenomenology of the state.38 While a case could be made, I think, for a truly effective display of an emotion being one where an agent actually experiences it, I will focus instead on the instrumental goods of moral distress to be realized by the agent alone. Doing so should help to make clear that it is the actual experi‐ ence of moral distress, and not merely the display of it, that bears potentially positive instrumental value.

First, a relatively straightforward comparative account can be offered in support of instrumentally valuable moral distress. The basic idea is that the experience of an undesirable, painful psycho‐ logical state can help one to understand and appreciate the more pleasurable experiences in life. A similar move has been made by theologians attempting to explain why evil would exist in a world created by an omnipotent and praiseworthy god.39 It may be that we need evil to know the good, or that we are better off in a world with both than we are in a world of pure pleasure. Still, as com‐ monly noted, this explanation fails to account for gratuitous suf‐ fering, that which is obviously excessive or has no apparent purpose whatsoever.40 Similarly, we might think, we can surely understand and appreciate pleasurable emotions – joy, pride, hap‐ piness – without ever experiencing something as troubling as moral distress. Perhaps just a bit of frustration or occasional anger would do the trick.41

Indeed, the experience of moral distress does not seem necessary for acquiring an understanding of and appreciation for pleasurable experiences. It may, however, be sufficient for this purpose, and this possibility alone reveals some minimal degree of instrumental value. Nonetheless, while the basic comparative account gives some reason to think moral distress might carry positive instrumental value, at least in a minimal sense, it appears that a stronger case can be made.

Along with seeing moral distress as helping one better to under‐ stand and appreciate pleasurable experiences, the troubling phe‐ nomenon can be seen as helping to develop a deeper understanding of oneself. That is, in being morally distressed, one may well affirm what one is emotionally invested in and realize the extent of one's investment. Given that our emotional responses directly implicate our cares, moral distress is equipped to help one understand the things we care about and the ways in which we care. But again, we might wonder, couldn't a simpler, less troubling experience of anger, frustration, guilt, or regret allow for the very same sort of personal development? If so, again, moral distress may be sufficient but not necessary for achieving this sort of instrumental value, namely an increased understanding of oneself.

What is important to notice here is that the experience of moral distress is phenomenologically distinct from the emotions thought to be closely related to or partly constitutive of it.42 Moral distress feels different from the more commonplace episodes of anger, frustration, and guilt. The ways of spelling out this difference vary, of course, but on the most widely accepted accounts, the morally distressed agent is said to know what is right while being incapable of acting accordingly. It is thought that the agent has made a decision – one that bears a great deal of moral significance – but cannot follow through with it.43 No doubt, those who face such dire situations experience something highly dis‐ tinctive and likely much more psychologically troubling than those who are simply angered or frustrated at any number of circumstances.

Moral distress is frequently associated with feelings of being powerless and, in this way, the experience of moral distress is cer‐ tainly unique for those who must suffer it.44 Nevertheless, the uniquely painful phenomenon can also serve as an extremely power‐ ful educational experience. Unlike those who are simply frustrated or angered upon seeing the objects of their cares harmed, the mor‐ ally distressed person comes to know exactly what it is like to care about something and to be helpless with respect to its fortunes. Unlike those who are ridden with guilt or regret upon acting against their values, the morally distressed person learns what it is like to

38For raising this potential worry, I thank David Shoemaker and Chad Van Schoelandt. 39See, for example, Hick, J. (1977). Evil and the God of love. New York, NY: Harper and Row. 40For a prominent example of this sort of response, see Rowe, W. (1979). The problem of evil and some varieties of atheism. American Philosophical Quarterly, 16(4), 335–341. 41Those with more Stoic or Buddhist inclinations would submit here that an appreciation for states like happiness is achievable without any degree of frustration or anger. Providing a reply to this line is well beyond the scope of this project. However, for arguments sup‐ porting the occasional fittingness of all sentimental states, see D'Arms and Jacobson, op. cit. note 27; and D'Arms, J., & Jacobson, D. (2000). Sentiment and value. Ethics, 110(4), 722–748.

42If it were not, it would be a wonder why so much effort has been spent on addressing a phenomenon that is utterly indistinguishable from other states. 43Again, here I am enormously grateful for an anonymous reviewer's suggestion to aim my arguments at moral distress as it is most commonly defined. By maintaining this target, my arguments serve to challenge both the academic research (e.g., Jameton, Wilkinson, and followers) as well as institutions that adopt the common notion, such as the North American Nursing Diagnosis Association (NANDA) and the American Nurses Association (ANA). (2015). Code of ethics for nurses. Silver Spring, MD: ANA). 44See, for example, McCarthy and Deady, op. cit. note 2; Wilkinson, op. cit. note 5; Dudzinski, op. cit. note 9; Burnston, A. S., & Tuckett, A. G. (2013). Moral distress in nursing: Contributing factors, outcomes and interventions. Nursing Ethics, 20(3), 312–324; Johnstone, M., & Hutchinson, A. (2015). ‘Moral distress’ – Time to abandon a flawed nurs‐ ing construct? Nursing Ethics, 22(1), 5–14.

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have done all one can do, despite the harms or losses that were in‐ curred. Acquiring such an intimate understanding of these ways of caring for something, and thereby to better understand oneself and what one would do in such circumstances, is surely an instru‐ mental good for those who are fortunate enough to suffer in this way.

Consider, for example, a palliative care physician who cannot le‐ gally administer a lethal dosage that would allow a dignified death for her long‐time patient who competently requested the treatment. Naturally, the physician may feel a sense of frustration or even guilt for not being able to honor her patient's wishes. Through this experi‐ ence, she might learn that she cares too much about patients’ dignity to let certain laws govern the duration of their lives. Perhaps she be‐ comes increasingly invested in the political debate as an outspoken advocate for the right to receive aid in dying. Despite the pain of her morally distressing experience, the physician undergoes a crucial life process of uncovering and affirming some of her most deeply held values. As we can imagine, without this experience, she might have never learned just how much, or in what ways, she cares about the causes she finds so dear to herself.

With the possibility of moral distress providing one with import‐ ant lessons concerning one's cares, we see ways of supplementing the common characterizations of moral distress as harmful. In a re‐ cent article appearing in this journal, Elijah Weber attempts to estab‐ lish what he takes to be an overlooked aspect of the discussion, namely the ‘intrinsic harm’ of moral distress.45 The extrinsic harms – the harmful events resulting from moral distress – are said to have received most of the attention, while the fact that moral distress is harmful ‘in itself’ is rarely acknowledged.46 In his first of two key ar‐ guments, Weber claims that moral distress is ‘a negatively‐valenced felt experience’ and relates the feeling to an experience of pain. ‘Usually,’ it is said, ‘a negatively‐valenced felt experience is regarded, almost by definition, as an intrinsically bad state.’47 Thus, it seems to follow that moral distress must be an intrinsically bad state. However, it is clear that there are exceptions to the generalizations presented here. There may well be, even on Weber's account, a variety of ‘neg‐ atively‐valenced’ experiences that are not intrinsically bad. These exceptions can be further exposed by noticing Weber's reliance upon the very general idea of pain as intrinsically bad. While we can easily grant that most pains are simply bad, in the sense that we can‐ not imagine any good coming about as a result (consider stubbing your toe), surely some pains are quite different. Emotional pain, spe‐ cifically, seems to bear important dissimilarities from simple physical pains. Being pained in an emotional sense, after all, can surely bring about some additional, possibly beneficial effect. As I suggested above, the pains of heartbreak are often seen not only as personally edifying, but also as a meaningful rite of passage in one's coming of age.

Given that the experience of moral distress is very much unlike the simple felt pains which admit of no further effect, it is hard to see how the two sorts of phenomena could be equally intrinsically bad. Of course, Weber might accept my argument for the positive instru‐ mental value of moral distress while maintaining that, consequences aside, it is a negative experience. What is needed, then, given the weakness of the pain‐based argument, is a stronger account of the supposed intrinsic harm.

In a second line of argumentation, Weber supports the intrinsic harmfulness of moral distress by starting from a definition he takes to be ‘extremely’ broad yet describes little more than Jameton's in‐ augural account. Moral distress, he states, ‘is a response to a per‐ ceived conflict between what one is expected to do and what morality requires’.48 With this notion, Weber draws an analogy be‐ tween moral distress and violations of one's integrity. Acting with integrity, he aptly describes, is to act in ways that accurately express ‘one's values, the commitments, concerns, and projects that one holds to be most important’.49 Violations of integrity, then, are where one acts in ways that do not cohere with one's values, commitments, and so on. Because such actions, or even the expectations to act in such ways, are supposedly intrinsically harmful, so too is moral dis‐ tress.50 And while there is a certain intuitive appeal to the analogy drawn here, Weber's reliance upon Bernard Williams proves to be self‐defeating. Allow me to explain.

Williams helps us to see, in his objections to utilitarianism, that the violation of one's integrity is undoubtedly disagreeable.51 The principle of utility, whereby one must maximize the good for all per‐ sons and projects, fails to account for the uniqueness of our individ‐ ual characters and our relationships. As a utilitarian agent, Williams explains, ‘I am just the representative of the satisfaction system who happens to be near certain causal levers at a certain time’.52 Whenever there is a conflict between promoting the good of all and promoting our own projects (the desires and concerns that help make up who we are), the principle of utility will demand that we act against our personal projects.53 In this way, utilitarianism will often violate our integrity.

However, what it important to note about the integrity violations prompted by the principle of utility is that the demands are alienat‐ ing.54 That is, they cause harm, extrinsically, in the sense of leaving our own projects unfulfilled and requiring that we act against the concerns that make up who we are. In other words, it is not yet clear how violations of integrity are intrinsically harmful. As a result, even

45Weber, E. (2016). Moral distress, workplace health, and intrinsic harm. Bioethics, 30(4), 244–250. 46Ibid: 248–249. 47Ibid: 249 (italics added).

48Ibid. 49Ibid. 50I am extremely grateful to an anonymous reviewer for encouraging me to clarify this argument. 51Here, Weber appeals to Williams's work in Smart, J. J. C., & Williams, B. (1973). Utilitarianism: For and against. Cambridge, UK: Cambridge University Press. 52Williams, B. (1981). Persons, character and morality. In Moral luck (pp. 1–19). Cambridge, UK: Cambridge University Press, p. 4. 53Ibid: 14. 54Weber himself cites Williams's claim that demanding that a person act against his per‐ sonal projects is ‘to alienate him in a real sense from his actions and the source of his ac‐ tion’. Smart & Williams, op. cit. note 51, p. 116.

     |  607TIGARD

if we grant Weber's analogy between moral distress and violations of integrity, it is unclear how exactly an experience of moral distress might constitute an intrinsic harm.

I have accepted that moral distress often brings about negative effects; it may be extrinsically harmful. In the following section I will address these considerations, as they undoubtedly merit further dis‐ cussion. In concluding the present, however, it must be reiterated that although moral distress may have negative effects, it can also serve as a personally edifying good. We can and often do learn and grow when our cares are put to the test. We can come better to understand and appreciate the contrasting, pleasurable experiences in life. But moreover, morally troubling experiences may well help us to develop a deep awareness and affirmation of the things we care about and, indeed, of who we are.

5  | C AVE ATS AND A FR AME WORK FOR POLICY

Certainly, some instances of moral distress are simply too much for one to handle. They may often be nothing but painful, with no fore‐ seeable good to come about as a result. These recognitions allow for several rudimentary but important qualifications to the account I have offered here. Further, with the following qualifications, we see the beginnings of a novel framework for policy recommendations on how we might effectively address moral distress among a range of practitioners.

First, although the experience of moral distress under various circumstances is closely aligned with what it means to have an hon‐ orable character, to be sensitive to morally significant circumstances and moral losses, surely we can imagine a duration of distress or degree of sensitivity beyond that which speaks favorably of one's character. Consider, once again, Williams's lorry driver, who under‐ standably beats himself up over what happened and should not be immediately consolable. While we know him to be a good person by his sincere emotional reaction, however irrational it is for him to feel guilt or regret, there comes a point when we expect him to move forward. Dwelling on and on about tragedies from long ago, even if one were morally responsible, seems to show that one is excessively sensitive or disturbed. In such cases, it is only natural that we work to help someone away from their prolonged negative experience.

As several recent studies have shown, there are ‘statistically sig‐ nificant correlations between moral distress [and] compassion fa‐ tigue’.55 A phenomenon studied most often in critical care nursing or psychiatric contexts, compassion fatigue is typically seen as a form of burnout or traumatic stress, wherein caregivers have given too much. As a result, the excessive degree or duration of their caring

has exhausted their ability to provide additional care, either for their patients, family and friends, or even for themselves.56 In some of the most troubling cases, we see caregivers who become emotionally exhausted, intellectually impaired, and susceptible to compulsive be‐ haviors like overeating, overspending, or the abuse of alcohol and drugs.57 No doubt, in the formation of much‐needed policies ad‐ dressing the health and well‐being of various healthcare practi‐ tioners, we must make every effort to guard against such devastating and very real consequences. Indeed, for the morally distressed among us who display symptoms of burnout, we will need to invoke substantial precautionary measures, such as leaves of absence, well‐ ness regimens, and support networks.58

The point to be emphasized here is that for some practitioners, and for some cases, moral distress does not (yet) indicate the pres‐ ence of these more severe downstream effects. It may be that one is frustrated or angered as a result of knowing the right action while facing obstacles traced back to system‐wide regulations. Still, as I discussed at the outset, in many situations moral distress will serve as an ethical canary, warning us that systematic reform is urgently needed. In other words, it is not necessarily the case that moral dis‐ tress demands reformation of system‐wide policies and of individu‐ als’ responses within the system. For where moral distress is not an indication of severe individual turmoil but serves to alert us to sys‐ temic troubles that in fact demand attention, why silence the ca‐ nary? If moral distress can occur where one is appropriately sensitive to others’ interests and values or to morally significant losses, we should be hesitant at suggestions calling for its elimination. Indeed, very often we should recognize and encourage practitioners’ contin‐ ued sensitivity to morally troubling circumstances.59

A second, fundamental caveat can be seen in response to the in‐ strumental value I suggested. That is, while the experience of moral distress carries the possibility of allowing one to learn about one‐ self and to grow in terms of moral maturity, these are speculative prospects among a host of possibilities. It is of the utmost impor‐ tance that we account for them in our efforts to implement insti‐ tutional policies aimed at addressing moral distress. For it may be that one's distressing experience effectively reveals to others and affirms to oneself what one truly cares about and to what extent. Nevertheless, it cannot be denied that some experiences of moral

55Maiden, J., Georges, J. M., & Connelly, C. D. (2011). Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses. Dimensions of Critical Care Nursing, 30(6), 339–345. See also Mason, V. M., Leslie, G., Clark, K., Lyons, P., Walke, E., Butler, C., & Griffin, M. (2014). Compassion fatigue, moral distress, and work engagement in surgical intensive care unit trauma nurses: A pilot study. Dimensions of Critical Care Nursing, 33(4), 215–225.

56See, especially, Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel. For a re‐ view of the extensive literature, see Najjar, N., Davis, L. W., Beck‐Coon, K., & Carney Doebbeling, C. (2009). Compassion fatigue: A review of the research to date and relevance to cancer‐care providers. Journal of Health Psychology, 14(2), 267–277. 57Payne, N. (2001). Occupational stressors and coping as determinants of burnout in fe‐ male hospice nurses. Journal of Advanced Nursing, 33(3), 396–405; Gentry, J. E. (2002). Compassion fatigue: A crucible of transformation. Journal of Trauma Practice, 1(3‐4), 37–61. 58Such recommendations can be found in Gentry, op. cit. note 57; Abendroth, M., & Flannery, J. (2006). Predicting the risk of compassion fatigue: A study of hospice nurses. Journal of Hospice and Palliative Nursing, 8(6), 346–356; Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 12, 235–243. 59Elsewhere, I argue that often we should praise those who face extremely difficult deci‐ sions and blame themselves nonetheless, despite self‐blame being largely inappropriate. Tigard, op. cit. note 4; Tigard, op. cit. note 32.

608  |     TIGARD

distress have either no instrumental value, or are such that the good to be achieved is not worth the cost of the pain. Again, in these sorts of cases, it is a natural and humane response for individuals and insti‐ tutions to carry out efforts to mitigate the genuine moral difficulties we encounter.

Where moral distress has no instrumental value, such as foster‐ ing moral growth or alerting us to systemic troubles, it will be im‐ portant to consider relief efforts like discussion forums, ethics‐based education, or perhaps a form of professional mentoring.60 Notably, unlike most accounts that have recommended these strategies, my appeal to such policy measures does not entail the need to reduce or eliminate moral distress. Indeed, if I am right about the potentially positive value of the phenomenon, we should not engage in efforts to reduce or eliminate it, except in the most severe circumstances.

6  | CONCLUSION

What I have said here is surely not the end of the story to be told about moral distress. Much more remains to be said, and indeed more remains to be seen, regarding the value of the troubling expe‐ rience, in both its negative and positive lights. Still, with the consid‐ erations offered here, I hope to have shown several ways in which we might at least call into question the prevailing assumptions con‐ cerning this peculiar phenomenon. The experience of moral distress may well be a painful one, but under certain circumstances it can in part constitute an honorable character and to suffer the experience can allow one to undergo a crucial life process of moral maturation. In these ways, moral distress bears significant positive value, both aretaically and instrumentally. No doubt, the mere recognition of these possibilities calls for new ways of thinking about how we can and should respond to moral distress within and beyond healthcare settings.

ACKNOWLEDG MENTS

This project progressed through many stages, and there are many people who helped with its development. First, I am extremely

grateful to my matchless dissertation committee: David Shoemaker, Alison Denham, and Chad Van Schoelandt. Next, for their comrad‐ ery and ruthlessness, I thank the ‘Shoe Crew’: Nathan Biebel, Eric Brown, Jesse Hill, Nick Sars, and Nathan Stout. For invigorating conversations, I am indebted to Lori Bruce, Katharina Hammler, Georgina Morley, and Kevin Morris. I also want to thank participants in the 10th Postgraduate Bioethics Conference, at the University of Bristol (particularly Jonathan Ives), and the 2017 Pacific Division Meeting of the American Philosophical Association (especially my commentator, Ryan Nelson, and session chair, Bonnie Steinbock). Finally, I am grateful to my anonymous reviewers and to the editors at Bioethics.

CONFLIC T OF INTERE S T

The author declares no conflict of interest.

ORCID

Daniel W. Tigard https://orcid.org/0000‐0003‐3633‐3563

How to cite this article: Tigard DW. The positive value of moral distress. Bioethics. 2019;33:601–608. https://doi.org/10.1111/ bioe.12564

60Kälvemark et al., op. cit. note 2; Corley, op. cit. note 5; Hamric, A. (2000). Moral distress in everyday ethics. Nursing Outlook, 48(5), 199–201.

Daniel TigarD is a postdoctoral research fellow in applied ethics at the Human Technology Center, RWTH Aachen University. His current work addresses issues of moral responsibility in emerging technology.

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