Her gaze drifted over to our patient. “What can I do?” she asked.

Moral distress  knowing what is ethically appropriate but being unable to act on it because of obstacles inherent in a situation  was first described in 1984 in a book on nursing ethics. Subsequent researchers focused primarily on the experiences of nurses and found that those who suffered from moral distress often became reluctant to interact with patients and other providers. In one recent study, 15 percent of nurses left their jobs because of moral distress.

It now appears that doctors  caught between obligations to patients and the demands of insurance companies, administrators and even, occasionally, patients’ families  are feeling increasingly “trapped” and unable to do what they believe is ethically right. Researchers from the University of Virginia recently studied I.C.U. physicians and nurses and found that while doctors on average are less frustrated than nurses, they can also suffer from intense moral distress.

This finding doesn’t surprise me. It is profoundly disheartening to haggle with disembodied voices over the phone over insurance approval for operations to remove cancers, to struggle to do everything that should be done for the rising numbers of patients a single doctor must see, and to follow the wishes of estranged relatives who swoop into the hospital during the last days of life and demand aggressive treatment.

What can we do?

I spoke with Ann B. Hamric, a registered nurse and the lead author of the study on I.C.U. physicians and nurses.

“There are many different reasons why a clinician may feel that he or she is not able to do the ethically appropriate thing,” Dr. Hamric said over the phone. “A lot of the reasons for moral distress come from the environments where we work. Are we working as respectful partners or are we afraid? Doctors feel that the risk managers or the lawyers are telling them what they can and cannot do for patients, and that affects physicians.”

We discussed the implications of moral distress for the current nursing shortage and the impending primary care shortage. I asked her if there might be some way to change the work environment.

“Part of what we have to do,” Dr. Hamric answered, “is to start recognizing moral distress and deliberately talking about it in health care settings. Otherwise, we will fail to recognize the damage to the integrity of the provider. We can’t expect people to work in this kind of highly intense, emotional, intimate space and then expect them to tolerate threats to their professional integrity.”

She added, “No one’s going to stay otherwise. It’s just too heartbreaking.”

Join the discussion on the Well blog, “Medicine and Moral Distress”