By David Lichter
This issue of Vision is dedicated to the theme of moral distress and spiritual care. If we have been around healthcare for some decades, we might recall that the term moral distress was named such in 1984 by Andrew Jameton in Nursing Practice, Ethical Issues, where he identified moral distress occurring “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.’’ (p. 6). Over the past three decades, research has continued to refine the term and the methods to study it.
The best presentation I have heard on moral distress was given by Cynda Rushton, Ph.D., RN, an ethics professor at Johns Hopkins University. At the Supportive Care Coalition’s 2013 Congress, she spoke on “Transforming Moral Distress into Healing and Resilience.” Much of that presentation was published later in 2013 in an article she co-authored with Alfred W. Kaszniak, Ph.D., and Joan S. Halifax, Ph.D., in the Journal of Palliative Medicine. She also cites the work of Webster and Bayliss in defining moral residue as “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised.”
I appreciated her exploration of moral distress and moral residue as types of suffering a clinician can experience in her or his work setting. She explains that suffering for and with those we care for (whether one is a physician, nurse, social worker, or chaplain) is an integral part of our profession as we attend to the needs of that other person. However, she notes the danger of suffering that impinges on and wounds our sense of well-being.
She offered the helpful distinction between healthy empathy, which stays focused on the well-being of another, and personal distress, which can become a self-focused emotion that one wants to alleviate because of the discomfort it causes. The healthy motivator of empathic emotional arousal can reach such heightened levels that it can become a negative emotion that we want to distance ourselves from.
Over time, our conscience and sense of moral responsibility advance. We come to recognize and make decisions about daily situations of our profession, and thereafter we carry the weight of those decisions. When they go against our identity and integrity, moral distress follows.
I found valuable her further suggestions for developing resiliency by tending thoughtfully and intentionally to one’s own basic physical, emotional, social, spiritual, and intellectual needs. Most of us might say, “Yes, I work at staying attuned to those needs and incorporating practices to tend to them.” However, Dr. Rushton spent further time on the importance of cultivating mindfulness. She noted the value of distinguishing between oneself and the one we are caring for, being alert to what triggers personal distress, and recognizing when our empathy is pushed to limits that become personally draining. We should cultivate personal capacities “that are conducive to compassion,” she said.
She concluded that moral distress is “an inevitable dimension of clinical practice,” but how we respond to it is part of our control. We need to cultivate the capacity to be present to suffering without being overwhelmed by it, transforming personal and moral distress that can leave us feeling powerless and tempting us to despair, and offer us an invitation to reclaim our identity, integrity, and compassion.
This was a brief summary of her presentation, but I invite you to read the article for yourself. The lines that provide me good food for thought this Lenten season are cultivating personal capacities that are conducive to compassion and being present to suffering but not overwhelmed by it. I think about our Christian heritage, the call to stand by the cross with other believers, the invitation to reflect on the sufferings of Christ in the many forms and people we encounter every day, and the verse from Luke’s Gospel 22:28: “It is you who have stood by me in my trials.” Does this Lenten journey help me, as a Christian believer, to cultivate our personal capacities that are conducive to compassion? I hope so.
I conclude with two quotes from Etty Hillesum’s An Interrupted Life (p. 225) that hold in tension both the desire to be with others in their suffering and the practice of not being overwhelmed by suffering. Perhaps she provides here a model for us as well.
“I believe that I know and share the many sorrows and sad circumstances that a human being can experience, but I do not cling to them, I do not prolong such moments of agony. They pass through me, like life itself, as a broad, eternal stream, they become part of that great stream, and life continues. And as a result all my strength is preserved, does not become tagged on a futile sorrow or rebelliousness.”