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Working through moral anguishBy Patricia Angelucci, RN, CCRN, CNA, CHE, MS,

and Shannon Carefoot, RN, CCRN, BSN

WWhether healthcare providersare treating patients in a criticalcare setting or in a home healthenvironment, ethical dilemmaspose significant challenges tothose providing care. Althoughwe all have our own thoughts asto proper care protocols, it’simportant to maintain a respect-ful stance toward a patient’swishes—even if we might notagree. By having the appropriateinformation, the nurse managercan effectively assist staff mem-bers in addressing the varyingdegrees of moral anguish theymight encounter.

Clashing principlesConsider the following example:

Mr. Smith is a patient in yourcritical care unit. He’s hemorrhag-ing, and without intervention, he’lllikely die. Based on his beliefs,Mr. Smith won’t accept any bloodproducts, even though he under-stands that such interventionscould save his life. Mary, one ofthe nurses in the critical care unit,is visibly upset and struggling asshe anticipates the outcome.Finally, Mary approaches thenurse manager and insists that thehealthcare team intervene.

The intense moral anguishMary is experiencing stemsfrom internal conflict; her ethi-cal framework clashes with the

ethical beliefs of the patient.She doesn’t agree with what’shappening with Mr. Smith andfeels badly, but can’t articulateher position. It’s obvious thatMary’s operating from a person-al ethical framework thatrevolves around several princi-ples, the first of which involvesfidelity to her profession.

The principle of fidelity inferskeeping promises, honoring con-tracts and commitments, andtruth-telling.1 By virtue of herrole as a nurse, Mary has animplicit contract with thepatient to provide him with thebest care possible. She’s alsodriven in her thoughts andactions by the closely intermin-gled principles of beneficence,benevolence, and nonmalefi-cence. Beneficence, in its sim-plest sense, means to “do good,”and the partner of this is non-maleficence, or “do no harm.”Benevolence goes one step fur-ther than beneficence, in that itobligates us to act when weknow an individual has a need.2

Mary believes strongly thatby giving blood products, thehealthcare team can “do good”for the patient and preventmore harm. Further, Mary feelsthat because it’s evident thatadministering blood productscan help save the patient’s life,

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the healthcare team is obligatedto do so.

Patient autonomyWhen talking with Mary, thenurse manager should help herarticulate and name her feelingsas ethical principles. Also, thenurse manager points out thatwe must sometimes put asidepersonal convictions or thehealthcare provider’s perceptionthat we know what’s best forthe patient. The patient hasmade clear his wishes, and hispersonal ethical framework iswell known. Like Mary, thepatient is driven by beneficenceand nonmaleficence, but thepatient’s perspective varies dra-matically. He believes that ablood transfusion will cause himharm, as well as grievous moraland spiritual distress.

Healthcare professionals mustconsider the principle of autono-my—the right to self-determina-tion—which directs us to abideby the patient’s wishes, unlessthe principle of justice comesinto play. Mr. Smith has clearlyarticulated that he won’t acceptblood products and that heunderstands the dire conse-quences. As Mary develops anunderstanding of her feelingsand a working knowledge ofethical principles, her view ofthe ethical world will expand.She’ll eventually experience less moral anguish and greateracceptance of these types of situations.

Promote understandingClinical ethics is a practical dis-cipline that provides a struc-tured approach for identifying,analyzing, and resolving ethical

issues in clinical practice. Exer-cising good clinical medicineand nursing practice requires aworking knowledge about ethi-cal issues and principles. Clini-cal ethics concerns both the eth-ical features present in everyclinical encounter and the ethi-cal problems that occasionallyoccur in those encounters. Theprinciples rely on the convictionthat even when perplexity runshigh, nurses, physicians, pa-tients, and families can workconstructively to identify, ana-lyze, and resolve many of theethical problems that appear inclinical practice. Our actions orjudgments about what should orshouldn’t be done in particularsituations are justified by moralrules grounded in ethical princi-ples, which in turn flow fromethical theories.

Being involved in ethicaldilemmas involving patients andtheir families can be a stressfulprocess. These experiences cancause moral anguish and burn-out, or a state of emotional andphysical exhaustion. By under-standing the drive underlyingone’s feelings, moral anguish—and the accompanying emotion-al and/or physical exhaustion—will be lessened when conflictoccurs. Examining one’s person-al ethical framework promotesgreater acceptance and under-standing of another ethicalframework when divergenceexists. Nurse managers need toprovide staff members with thetools to help them identify theirindividual personal ethicalframework. The nurse managershould:• listen mindfully as staff mem-bers discuss troubling moral

dilemmas as they happen.• clarify the aspect of carethat’s most troubling. • facilitate informal debriefingswith individual nurses and for-mal debriefings with staff asneeded.• research parallel ethical situa-tions for background informa-tion.• consult bioethics committeesfor issues that are appropriate.• educate staff on ethical theo-ries and principles. • encourage staff to communi-cate directly in an open mannerwith other members of thehealthcare team regarding ethi-cal issues.

Know your frameworkNurse managers must seekways to alleviate the anguishthat can occur when healthcareproviders are unaware orunclear of their own personalmoral framework. It becomes aleadership imperative to assiststaff toward greater ethical clarity, which may decreaseepisodes of moral anguish andreduce the resulting physicaland emotional exhaustion.Perhaps then, Mary will faceher next Mr. Smith with awhole new approach—onethat’s couched in knowledge,awareness, and acceptance.3 v

REFERENCES

1. Mappes T, DeGrazia D. BiomedicalEthics. 4th ed. New York, NY: McGraw-Hill; 1996.

2. Frankena W. Ethics. 2nd ed. EnglewoodCliffs: Prentice-Hall; 1973.

3. Angelucci P, Carefoot S. Workingthrough moral anguish. Nurs Manage.2007;38(9):10,12.

At Willamette Valley Medical Center, McMinnville,Ore., Patricia Angelucci is chief nurse officer, andShannon Carefoot is manager, intensive careunit.

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