Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare

Health Care Analysis (2019) 27:185–201 https://doi.org/10.1007/s10728-019-00376-8 ORIGINAL ARTICLE Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare Georgina Morley1 · Jonathan Ives2 · Caroline Bradbury‑Jones3 Published online: 17 July 2019 © The Author(s) 2019 Abstract Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. Keywords Austerity · Moral distress · Bioethics · Nursing · Phenomenology · Empirical bioethics · Feminist empirical bioethics · Resilience · Moral resilience · Critical resilience * Georgina Morley 1 Department of Bioethics, Heart and Vascular Institute, Cleveland Clinic, Main Campus, 9500 Euclid Avenue, Cleveland, OH 44195, USA 2 Centre for Ethics in Medicine, University of Bristol, Bristol, UK 3 School of Nursing, University of Birmingham, Birmingham, UK 13 Vol.:(0123456789) 186 Health Care Analysis (2019) 27:185–201 Introduction Austerity, by its very nature, imposes constraints. It does so by limiting the options available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals (HCPs) must ration the time they make available to each patient. These constraints create and exacerbate ethical challenges in healthcare. As austerity has taken hold across the United Kingdom (UK) and Europe, it is important to consider the wider effects that these constraints impose on healthcare. The effects are multifactorial, as evidenced by this special edition, but in this paper, we focus specifically on one theorised effect—moral distress (MD). In this paper, we draw on data gathered and analysed as part of a larger project exploring MD in UK nursing. The purpose of the original study was to explore the concept of MD as experienced by critical care nurses and the first author (GM) provided a reconceptualisation and redefinition of MD in her Ph.D. thesis. Consequently, much of our discussion originates from a nursing perspective, but the underlying ethical challenges are applicable to all HCPs. We are applying our analysis of the empirical data to the context of austerity and to the responses to austerity. In particular, to the response that healthcare staff should be more resilient to overcome the additional challenges that have arisen because of austerity measures and resource restrictions [70]. Ethical challenges created by austerity should, we argue, be considered avoidable because they are the product of contingent, rather than necessary, features of healthcare work. They create burdens and ethical challenges for HCPs that go beyond the inevitable ethical considerations of balancing harms and benefits of different treatment options, patient suffering and end-of-life decision-making. Ethical questions regarding withholding or withdrawing life-sustaining treatments (LST) are unavoidable and will likely always be a cause of moral distress (MD). Even with infinite resources, clinicians would still need to ask whether it is ethically permissible to provide or continue LST and balance this with quality of life considerations. As some scholars have suggested, MD in these situations could be considered a natural response to morally troubling situations [23, 45, 69], and no amount of resources could mitigate the nature of these decisions. This is not to say we should ignore the MD that occurs due to unavoidable ethical challenges but rather that avoidable and unavoidable ethical challenges require different responses. We will discuss these different responses towards the end of the paper. We first outline the concept of MD before describing the larger study and presenting data that challenges the idea that MD is caused only by constraint. We explore the way that various examples of MD might be linked to austerity and consider how an appropriate response to MD and austerity might be interconnected through the concept of resilience, drawing on a distinction between moral resilience [54] and critical resilience [70]. We conclude that moral resilience is 13 Health Care Analysis (2019) 27:185–201 187 a useful response to the ‘unavoidable ethical challenges’ that arise in healthcare, but critical resilience is a more useful response towards the ‘avoidable ethical challenges’ that arise as result of austerity. The Moral Distress Debate The term ‘moral distress’ was first coined by Jameton [25] who observed amongst nurses a tendency to feel distressed when they were forced to act, because of institutional constraints, in way that was contrary to their beliefs. Jameton consequently suggested that MD arises when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6) [25]. Subsequent research, predominantly in the United States (US), but increasingly in Europe [11, 14, 47] has supported this conception of MD, showing that feelings of distress amongst HCPs are associated with being constrained in this way. Due to the presence and effects of austerity, it seems coherent to suggest there will follow an increase in the prevalence of MD amongst HCPs who will be forced to act in ways they feel are ethically sub-optimal. This will, subsequently, amplify the negative effects of austerity on patient care, given that MD is associated with increased rates of compassion fatigue, burnout and intention to leave the profession [22, 36, 46]. If we accept this, then the simple way to reduce MD in the HCP wo (...truncated)