Reflections on How We Teach Ethics: Moral Failure in Critical Care.

Abstract

Critical care is one of the most ethically complex health care specialties. Nurses working in this highly intense setting face additional stressors of high-tech interventions, resource scarcity, and increased workloads. Evidence from the United Kingdom and the United States suggests that these stressors are affecting patient safety and mortality, and nurses are feeling dissatisfied with their job and are burning out.1–4 Although we are able to keep patients alive longer, a growing body of research suggests that in many cases the life-sustaining treatments carried out in critical care settings are perceived by health care professionals to conflict with the patient’s best interests, creating moral distress among health care professionals.5,6 Nurses are often left out of decision-making processes, yet they are responsible for enacting the decisions made. This situation, according to Liaschenko,7 reduces nurses to artificial persons—persons who speak or act for others but whose priorities and concerns are subordinate to others. To navigate this complex environment, nurses need to be taught how to recognize and respond to a range of challenging ethical situations.Whereas ethics training for nurses can vary widely depending on the institution (and country), in this article we explore a common approach to clinical ethics education used in the United Kingdom. We do so because this method promotes a particular approach to understanding and framing ethical issues that arguably engenders misunderstanding about expected solutions, as we will discuss. Toby’s case, describing an ethical issue arising in critical care, is used to exemplify this argument and is referred to throughout the article to illustrate key points.Ethics education in nursing tends to be practical: the focus is on the identification of challenging ethical situations and developing and defending a resolution. Our experience of clinical ethics education (in the United Kingdom) reflects this focus; the aim is to enable the student and/or clinician to use ethical theory to identify and understand the ethical issues, begin to resolve the issues, and find acceptable solutions. In the process, students develop as competent moral agents and effective advocates. The development of the moral agent tends to be described in terms of developing an appropriate character, enabling students and/or clinicians to challenge the “silent curriculum” that might habituate clinicians into unethical practice. Rhodes and Cohen8(p50) argue thatA common pedagogic approach is to teach some theory (eg, consequentialist, deontological, virtue, principlist approaches) and then encourage students and clinicians to identify cases from their own practice, apply their theoretical knowledge, and develop their practical ethical skills through reflection. As described by Roff and Preece,9(p487)For students, assessment of this style of learning typically will comprise some form of written case study (given to them or drawn from their own experience) in which students identify the key ethical issues drawing on theory and then show, in a limited number of words, how they would resolve the case—justifying their resolution with reference to ethical theory. Our assumption is that how clinical students, excepting those who go on to specialist study in ethics, are taught about ethics will frame their approach to ethical deliberation throughout their clinical careers.Many practicing clinicians are encouraged to document discussions of ethical issues, agreed solutions, and supporting reasons in their clinical notes—something that the models of assessment they encountered as students seem to have prepared them for. Whereas there are advantages to this approach, one risk is that this strategy encourages students and clinicians to equate their development as competent moral agents with their ability to reduce a complex ethical problem to a series of concisely articulated ethical issues and tidy, theoretically neat, solutions—leading to a single satisfactory solution.The problem with this model in clinical ethics education (both before and after certification) is that it risks encouraging a simplistic understanding of ethical analysis and offers little scope to explore complexity and uncertainty. This approach does not prepare students for dealing with real-life ethical problems; instead, it primes students to believe that identifying and resolving an ethical issue should be easy and encourages the belief that (1) if they cannot articulate and resolve a problem concisely and neatly, then they are doing something wrong and may lack the apposite moral character; and (2) there is a correct resolution that, if found, ought to be satisfying. Promoting these beliefs has substantial problems, which we will discuss briefly.Ethical reflection permeates everyday clinical practice; for example, deciding whether to follow protocol and reposition a patient now or delay for half an hour to take a much-needed lunch break requires such reflection. A person might overlook the ethical nature of this sort of decision because no complex ethical reflection is required. The challenge lies in finding the motivation to do the right thing—to put one’s hunger aside for a few more minutes and reposition the patient. This sort of ethical issue can be articulated and resolved neatly and concisely because it is a simple case; although we might want to do one thing, we clearly ought to do another.The everyday nature of ethics—the microethics10 woven into the fabric of all our personal and professional interactions—is important and should not be ignored; however, we want to focus on more challenging and complex situations involving dilemmas, restricted options, or disagreement (sometimes referred to as conflicts) among moral agents that cannot be articulated or resolved simply or concisely.A dilemma occurs when one must choose between 2 mutually incompatible and similarly weighted obligations (eg, a perceived obligation to save and preserve Toby’s life vs a perceived obligation to minimize his suffering when the only way to do so is not compatible with preserving life).A restricted option problem occurs when one feels there is a right course of action, but for some reason that course of action is not available and is a nonoption. Thus, the range of options left to choose from are less desirable, and none seem morally optimal (eg, the health care team ideally would like to offer Toby a heart transplant but due to his necrotic lung he is not eligible).A disagreement problem occurs when 2 or more agents who have a stake in the decision disagree over the right course of action, and action cannot be taken until a resolution is found. In Toby’s case, the medical team does not want to offer VV-ECMO if he shows signs of deteriorating, but wants to continue other life-sustaining treatments such as continued invasive ventilation; the nursing team believes that they are prolonging Toby’s inevitable death, contributing to his continued suffering, and believes that all life-sustaining treatments are futile; whereas Jenna has requested VV-ECMO and wants to continue all life-sustaining treatments.These kinds of decisions are never simple, nor can their ethical complexity be summarized or resolved in a short piece of written work or by rote ethical analysis. By definition, a challenging ethical issue is complex and requires a great deal of thought and analysis. To assess competency as a moral agent and/or moral character based on a student’s or clinician’s ability to reduce and articulate a response in a short written assignment or verbal analysis sends the wrong message and communicates unrealistic success criteria.Most ethics educators likely are aware of this complexity and are aware that not all clinical ethics education follows this model. However, we are less sure that students or clinicians are aware of the shortcoming of this model; thus, their own measure of success in dealing with ethical issues becomes associated with a concise and relatively sanitized written summary or analysis that demonstrates understanding and clear resolution, which seems unrealistic. Furthermore, as clinical curricula become more crowded and resources become increasingly competitive, pressure increases to reduce ethics assessments to simple “pass or fail” and multiple-choice and short-answer questions to assess ethics competency. This pressure makes it important to reflect on the problems associated with this kind of assessment and to consolidate counterarguments so that such simple assessments might be resisted.Moral dilemmas, restricted options, and disagreement features include the following: (1) perhaps not having a clearly discernible correct course of action, and (2) even if a course of action is identified and morally preferable, moral residue may still be felt after taking the preferable path. These 2 points can be seen in Toby’s case because it illustrates a moral reason to withdraw treatment and a moral reason to continue treatment. What ought to be done for Toby is not clear, and no theoretical approach provides an answer. Arguments for either course of action could be made from any theoretical perspective—many courses of action could be argued as ethically defensible and reasonable. In a situation like Toby’s, no solution is unequivocally correct, and it seems unlikely that we can select a course of action without also feeling we have done something wrong.The term moral residue often is used to refer, in the context of moral distress, to the build-up of negative emotions that occurs after we allow ourselves to be morally compromised. Webster and Baylis11(p208) characterize moral residue asEpstein and Hamric12 describe moral residue as the painful feeling that remains after a morally distressing event that, unless satisfactorily resolved, builds up over time and amplifies negative responses to subsequent morally distressing events, creating a “moral residue crescendo.” Moral residue arises in these types of arguments when the agent feels a wrong has been done; thus, negative feelings are associated with a perceived moral failure and the logically necessary assumption that moral success was possible.We, however, will be using the term moral residue as it was used originally: to refer to the lingering feeling of having done wrong even when one has made a decision that feels right.13,14 This concept was used to argue for the existence of genuine moral dilemma—the special case of moral conflict in which an agent recognizes that (1) moral reason can be used to perform 2 or more actions, (2) not all actions can be performed, and (3) there is no reason to choose one action over another. In such a situation, avoiding moral failure seems impossible because by choosing one course of correct action we fail to perform another correct course of action.The term unavoidable moral failure15 derives from the fact that we must choose between 2 conflicting moral requirements, violating one for the sake of the other. The presence of moral residue after having made a moral decision could be evidence that the agent faced a genuine moral dilemma. Furthermore, this moral residue is an appropriate response to this situation.In Toby’s case, the health care team could feel justified making the decision to withdraw ECMO altogether and yet feel they have wronged Toby and his wife, especially if the decision results in Toby’s death. A wrong has been done, even though the wrong occurred during the process of doing something right. The same could be said of the decision to continue to treat Toby. The decision is ethically defensible and arguably correct, yet in making the decision to continue treatment a wrong seems to have been done because of the real possibility that it might only prolong Toby’s dying process and associated suffering.Debate continues over whether moral residue can be used as proof of the existence of genuine moral dilemmas. One might argue that it is nonsensical to suggest that someone can do wrong while doing right, since choosing option A over option B means that one has decided that A is the right course of action; thus, by definition, all other actions would be wrong.Feeling guilt after having made such a decision could be thought of as irrational.15 Tessman,15 however, argues that labeling this guilt irrational assumes that all perceived wrongs can be compensated for by having done right overall. This viewpoint requires a hyperrational agent who can endorse a conception of “the right” such that the perception of having done right renders any contributing action or consequence similarly “right,” thereby avoiding feeling any regret or loss because of unfulfilled values.People rarely, however, display that kind of rationality. Tessman15 argues that because we often encounter impossible, nonnegotiable moral requirements, we ought to accept that we will unavoidably experience moral failure. In a dilemmatic situation, ethically sensitive people will always be cognizant that in choosing one moral requirement they have failed to perform another. Even when a decision is made that is inclusive, fair, and considered, rarely can a person be certain that the decision was correct and may continue to have feelings of doubt or regret. Doubt is a constant feature of ethical decision making in complex cases. In fact, certainty in the face of ethical complexity may suggest a failure to understand that complexity and may indicate a lack of moral character.We need not resolve the debate about moral failure to learn something important from it. There are 3 key learning points that we can take away that should inform approaches to teaching and learning about clinical ethics: (1) resolution, (2) compromise, and (3) incorporation of concepts.Feelings of guilt, remorse, or regret may be unavoidable features of being in an ethically complex situation. Even when we feel we have done the right thing we still might have negative feelings about our decision; thus, finding an ethical resolution is not the same as finding personal satisfaction or personal resolution.Arriving at a solution that one is completely happy with is not a marker of ethical success or competency. Rather, accepting these feelings as part of being a moral agent may mitigate the feelings that are associated with the accumulation of negative emotions and moral distress. Whereas one may feel guilt or regret because of unavoidable moral failure, unless that person is culpable, he or she is not blameworthy.15 For example, culpability might flow from having failed to deliberate properly, listen to all relevant voices, or create spaces for respectful discussion.There are, then, 2 kinds of moral failure: culpable and nonculpable. Culpable moral failure might arise when one has reached a decision that one regrets or feels guilty about due to not deliberating properly. Moral residue, as defined in this article, is always non-culpable because moral residue follows from having engaged in proper deliberation but nonetheless feeling one has done wrong.When faced with having to choose a course of action in response to a complex and uncertain ethical problem, sometimes the only way to move forward may be to find principled (ie, integrity-preserving) compromise. As Huxtable16(p140,141) argues,Thus, even though the clinical team feels they should withdraw care from Toby, they might nonetheless try other options to enable them to meet their obligations of beneficence to his wife. Such a compromise may not represent a perfect solution, but may be the best arrangement that can be achieved; it might be too much to expect to find a perfect solution to such a complex problem.The problem with compromise, however, is that the concept often is used and understood in a pejorative sense; for example, when Webster and Baylis talk about moral residue occurring after allowing oneself to be “compromised.”11 Although compromise may not always be desirable, it may sometimes be necessary. According to Benjamin,17 compromise makes the “best of a bad situation.” Ives18(p310) also argues thatA potential problem arises from attempting to combine compromise with the goal of coherence. Both might focus on the value of the process of deliberation over the outcome such that (1) the compromise position might not matter as long as a compromise is achieved and all stakeholders are willing to sign up to the compromise, and/or (2) that knowledge of having undertaken a rigorous process of ethical deliberation might, in part or in total, alleviate feelings of moral residue, because participants in the decision can have confidence that they have done the best they could.We would be wary of a focus on process as a justification for outcome. Whereas process is important for many reasons, such as transparency, agency, and accountability, it is difficult to see how the process of ethical deliberation and agreement can confer justification for the decision. Huxtable’s endorsement of compromise is not just a call for decision makers to reach agreement16; the plea is for “principled compromise,” wherein agents are required to make compromises that can be justified by principles external to the process of compromise itself (ie, the compromise position is not legitimate just because it is agreed to).A person who is not part of a robust process of deliberation and has not experienced moral residue may have misplaced faith in the justificatory power of process. Moral residue would survive any feeling that the decision is justified, whether by process or principle. If, conversely, one is unsatisfied with the process, one is unlikely to feel the decision was correct, and so the conditions for moral residue would not have been met. For these reasons, we are wary of drawing the conclusion that a focus on robust processes might be a panacea. Although ethics education can and should facilitate learning about how ethical deliberation can occur, too much emphasis on process runs the risk of leading to empty proceduralism, wherein the process of deliberation comes to replace justification.However, process still has significant value, which is derived from being able to distinguish culpable moral failure (about which we ought to feel bad) and nonculpable moral failure (about which we have no need to berate ourselves). Having confidence in a robust process can help guide us in determining whether we are experiencing nonculpable moral residue or culpable guilt.Clinical ethics educators should incorporate the concepts of moral failure and moral residue into teaching and learning—not to encourage indifferent or immoral behavior, but to better prepare clinicians for the realities of the experience of having to make difficult ethical decisions in the face of the complex and challenging ethical situations and to better understand what a solution might look like.Real-life ethical decision making does not mimic the sanitized assessments clinicians are often required to undertake in a teaching environment, and that expectations of what success might look like need to be adjusted to something more realistic.As illustrated by Toby’s case, a complex, challenging clinical situation will often have multiple justifiable solutions; it is unlikely that any single solution will feel completely satisfactory. Whatever the outcome, the participants would likely experience some form of moral residue. Assuming that decision makers have deliberated properly and arrived at a solution they believe to be correct, they may still feel they have done something wrong. Health care clinicians need to understand that this feeling is moral residue, which is an unavoidable consequence of trying to manage the often-impossible demands of morality within critical care rather than a culpable moral failure. Moral residue is a failure to reconcile the irreconcilable and not a failure of moral character or a sign that one is an incompetent moral agent.We believe that clinical ethics education should prepare nurses and other clinicians for the experience of moral residue and such education should use this concept to distinguish between moral failures that are culpable and nonculpable. This learning strategy should better enable nurses and other clinicians to interpret and appropriately respond to negative feelings that occur after they have made a decision in an ethically challenging scenario. Using such a strategy, clinicians can better manage expectations about what an acceptable ethical solution might look and feel like.