What is an ethical dilemma and how is it different from ethical distress?
To answer this question, it is important to understand the difference between an ethical dilemma and a clinical dilemma. Clinical dilemmas are challenges or factors related to a patient’s diagnosis or prognosis. For example, cultural background, belief systems, cognitive abilities, etc. help us choose a clinical approach and clinical recommendations for a patient. An ethical dilemma is choosing between two or more options; sometimes they can be two good options, but more often, they are two bad options. However, we are thinking about what the right approach is for a patient.
How is this different from moral distress or ethical distress? There are many times when we face true ethical dilemmas, but more often, the feeling of concern we have for a particular situation is defined as “moral distress”. Moral distress is not uncommon when we have a team-based approach, because each team member will approach a situation different due to the type of relationship they have with the patient, as well as the different responsibilities, different scopes of practice, different licensure, different educational backgrounds, and differing knowledge about the facts of the situation. We have distress when we are in a situation where we feel like we know that the right action or right course is not happening. For example, a decision has been made for a patient and we do not feel it is the right one, but we do not have the locus of authority in that situation to make those decisions. This often causes a scenario called moral distress. Hamrick, who is an ethicist and nurse in Virginia, has written about this and indicates that ethical distress often affects nurses and resident physicians. Being in a position of carrying out the orders of the primary provider on the team and not agreeing with the particular approach can create moral distress. It is important that we recognize that, and figure out how to manage those situations.
Lynne Brady Wagner is the Program Director of Stroke Rehabilitation and the Chair of the Ethics Advisory Committee at Spaulding Rehabilitation Hospital in Boston, Massachusetts.