What happens when students and clinicians feel a conflict between their deeply held values and the demands of an event unfolding before them—and feel powerless to intervene? Research about this set of experiences, first documented years ago in nurses as moral distress, has evolved in important ways and has now been prominently explored in other health professions’ ethics literatures.

However, there has been less attention to moral distress among medical students and resident physicians—despite the fact that they are particularly vulnerable to moral distress given the hierarchical nature of their training.

This month’s AMA Journal of Ethics® distinguishes different types of moral distress and considers how clinicians, organizations, and educators can identify and acknowledge moral distress and respond with care for patients and for each other.

Take a moment to consider this question: A student is distressed when her resident asks her to perform a lumbar puncture on a reluctant patient. How should she respond?

Tell the patient, “This is a teaching facility.”

Engage with the patient about the patient’s concerns.

Privately explain her concerns to her resident physician.

Refuse to perform the procedure.

Give your answer and find responses to this question in the June issue of the AMA Journal of Ethics, which explores moral distress and medicine.

Articles include:

“How Should Integrity Preservation and Professional Growth Be Balanced during Trainees’ Professionalization?” Experiences of moral distress are not uncommon for medical trainees, who are still in the process of forming their professional identities. This article examines how health professions-training programs can incorporate case-based ethics education sessions to identify and alleviate trainees’ moral distress, especially in cases where the beliefs that give rise to moral distress may be underdeveloped.

“What Is the Role of Ethics Consultation in the Moral Habitability of Health Care Environments?” Ethics consultation has traditionally focused on the provision of expert guidance to health professionals when challenging quandaries arise in clinical cases. This article contends that ethics consultation, more broadly conceived, can be a major asset in ensuring that ethical practice is meaningfully supported, that moral distress is mitigated, and that the organizational environment is morally habitable.

“Strategies for Promoting High-Quality Care and Personal Resilience in Palliative Care.” Palliative care clinicians are faced with ever-expanding pressures, which can make it difficult to fulfill their duties to self and others and can lead to moral distress. This article highlights recommendations related to two promising pathways for supporting palliative care clinicians: improving systemic palliative-care delivery and strategies to promote ethical practice environments and individual resilience.

“Culture and Moral Distress: What’s the Connection and Why Does It Matter?” Culture is the learned behavior shared among members of a group and from generation to generation within that group. In health care work, references to “culture” may also function as code for ethical uncertainty or moral distress concerning patients, families or populations. This article analyzes how culture can be a factor in patient-care situations that produce moral distress and addresses common situations where “culture” can mask more complex problems concerning family dynamics or implicit bias.

In the journal’s June podcast, Elizabeth Epstein, MD, discusses practical steps that can be implemented to alleviate moral distress, using her home.

Submit manuscripts and artwork

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

The Conley Art of Medicine and Ethics Essay contests for medical students, residents, and fellows is now open through Sept. 25, with $3,000 prizes for winning entries and up to two $1,000 honorable mentions.

A look ahead

Upcoming issues of the AMA Journal of Ethics will focus on quality of life in Dementia and iatrogenesis in pediatrics. Sign up to receive email alerts when new issues are published.

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