That Powerlessness You Feel Is Called ‘Moral Distress’
This article was authored by guest writer Michele DeMarco, who is an award-winning writer and published author in the fields of psychology, trauma, health, and spirituality, and is a professionally trained therapist, clinical ethicist, and researcher, specializing in moral injury and resilience. Michele's writing has been featured in numerous publications; when she is not writing, she works helping individuals, families, and groups to navigate change, transform conflict, and rebuild lives in the wake of crisis or transition.
“See no evil, hear no evil, speak no evil” is a centuries-old proverb inspired by a Japanese carving that depicts three monkeys, each with a hand covering eyes, ears, and mouth, respectively. In the West, the phrase has come to be associated with turning a blind eye to something that is legally or morally wrong, but the original meaning was that a person should always avoid evil, including in deed.
But what do we do when we find ourselves in a situation where “evil” is unavoidable? When we can’t stop seeing or hearing it, or else are powerless to prevent it? What do we do when speaking up or acting against evil is inadvisable because doing so poses a direct threat to ourselves or to something or someone we love? What happens when life forces us to choose between two “wrongs,” or bad situations, either one compromising our core values, obligations, and commitments? How do these so-called “choices” live inside us? Better yet, how does “wrong” live inside us, whether it’s our own or something others have done?
The concept of “moral distress”
“Moral distress” is a term coined in 1984 by philosopher Andrew Jameton to describe the suffering nurses experience when institutional or systemic barriers prevent them from acting with integrity, particularly when it comes to fundamental moral principles and ethical responsibilities. With Covid-19, the weight of moral distress on health care workers and first responders has been unprecedented. But they are not alone. Both the widespread injurious effects of the pandemic on public health and the social, political, and economic unrest of 2020 have forced many people to confront morally distressing situations. At times, actions deemed to be ethical are different from the ones a person would naturally choose or reach for if otherwise available.
Examples include:
Parents caught between homeschooling and sending children to in-person classes.
Individuals whose values and beliefs are in conflict with state and federal safety guidelines (or lack thereof).
Small businesses having to close their doors, despite feeling a fiduciary responsibility to their employees and their own families.
Families needing the security of a home, but because of unemployment or financial issues no longer being able to afford it.
People desperate to spend time with elderly or solitary family members, or those who are sick or dying, but being unable to because of health dangers.
People caught within sociocultural grievances or injustices, and the impending sense that nothing will ever change.
Tectonic shifts in what is considered acceptable “civic” and “civil” behavior, and not having those values respected — individually or collectively.
The sense that the “other side” of the sociopolitical divide is wreaking existential harm and feeling powerless to do anything about it.
Powerlessness is at the heart of moral distress. It is the feeling that we have had to, or must seriously, compromise ourselves or something we hold dear due to external forces seemingly beyond our control. It is also the sense that others don’t grasp a moral significance or moral imperative that is clear to us. Moral distress is what results from repeatedly not having our values respected, either individually or collectively.
When we are morally distressed, we often feel muzzled, restricted, devalued, unheard, or dismissed. We easily become fueled by anger, disgust, fear, and frustration. Over time, these emotions can fill us with anxiety, depletion, or depression. A sense of being fragmented can set in, leaving us to question who we or others are at their core and what the world is, generally. Research also shows that moral distress has long-term consequences, such as burnout, exhaustion, numbness, disconnection, and diminished moral sensitivity (also called “compassion fatigue”).
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In health care or social service settings, the damaging effects of moral distress aren’t limited to clinicians. Patients can also be negatively impacted, due to changes in a providers’ actions or attitudes toward care. In our day-to-day lives, this type of calcification can take a serious toll on relationships and affiliations. In its extreme form, it can result in “otherizing.”
Powerlessness is at the heart of moral distress. It is the feeling that we have had to, or must seriously, compromise ourselves or something we hold dear due to external forces seemingly beyond our control.
How moral distress lives inside us
Human beings are hardwired to detect and respond to threats. Like physical threats, psychological and existential or “soul” threats (like those to our integrity) can activate the body’s nervous system, shifting it from a calm, regulated state into survival mode. The most primitive part of the brain — the reptilian brain — goes on high alert, scouring the environment for other potential threats, and readying the body for action.
When this happens, a deluge of stress chemicals are released, which leads to physical, emotional, and cognitive changes. Our heart rate and blood pressure rise. Our muscles tighten. All nonessential functions become dormant. Negative emotions are activated. Articulating and appropriately expressing feelings or desires can become difficult or exhausting. Our attention narrows and becomes biased to potential threats. Our capacity for empathy lessens, which interferes with prosocial behavior, and we rely on instinctual defensive default patterns of thinking and behavior.
The way we inherently manage this stress response is, generally, in one of three ways: fight (trying to regain control by disarming the source of the threat and displaying power over it); flight (disengaging with the threat by quitting or, in cases of moral distress, placating the situation); and freeze (inaction or paralysis; numbing ourselves by “going through the motions”; as well as distraction, denial, or dissociation from the cause of the distress altogether).
Ongoing dysregulation, caused by repeated experiences of unprocessed moral distress, can build up at an embodied level — quite literally, in our tissues. In other words, it leaves “moral residue” or “ethical plaque” (also known as the “crescendo effect”) that lodges itself in our being, even after any one crisis is over. Like an occluded artery, this moral occlusion can threaten our very existence.
Cultivating moral resilience
Resilience is generally considered to be the ability to recover or adapt well to stress, adversity, or trauma; it ensures that change and challenge improve, rather than hurt our lives, and fortifies rather than weakens our spirit. Resilience helps us to see that difficulties need not leave us eternally damaged; only temporarily challenged.
Moral resilience, while still a nascent concept, is related to psychological resilience but distinct in three ways. Cynda Hylton Rushton, a leading scholar in the field of clinical ethics and a professor of nursing and pediatrics at the John Hopkins School of Nursing, says, “Moral resilience focuses on the moral aspects of human experience; the moral complexity of the decisions, obligations and relationships; and the inevitable moral challenges that ignite conscience, confusion, and moral distress.” Because the moral domain is connected with all dimensions of human resources — biological, psychological, cognitive, spiritual, and relational — building moral resilience can benefit us at a whole person or embodied level.
As 2021 continues to unfold in challenging ways, the following practices can help you cultivate moral resilience whenever you’re feeling boxed in by a morally distressing situation and struggling to hold onto your integrity.
Self-mastery: The art of learning to self-regulate
Self-mastery is the present-focused realization that we can always be in command of ourselves — body, mind, and spirit — even while accepting that we may not be able to control all situations or outcomes. It’s about learning how to struggle well, starting by turning our attention inward or engaging in interoceptive awareness. Interoception helps us to be mindful of what is happening below the surface that might be fueling our feelings, thoughts, and actions.
In going into ourselves, we don’t try to quash unpleasant emotions or judge them as wrong or weak. We give them space to tell us something new about what’s going on. We observe and get curious about what moral values, obligations, or responsibilities are not getting met; what this says about the distressing situation and us; and how we might find other ways to satisfy them.
Doing so allows us to regain a sense of calm and perspective that is necessary to stay in our “window of tolerance,” which is key for self-mastery. In this way, in any moment, no matter how difficult, we can make an intentional choice to honor our core values, make principled choices, and take wise, ethically grounded action. Mindfulness practices and titration are two ways to explore this internal space.
Self-awareness: “To thine own self be true.”
Rushton says that moral resilience is grounded in moral conscientiousness. “It reflects a vigilance to live in ways that are aligned with who we are and what we stand for in the midst of situations that appear to be incommensurate with integrity.” This vigilance or desire to be moral requires that we are fundamentally aware of what values, commitments, and imperatives actually comprise our moral core — and this means regularly examining these things, otherwise, we run the risk of becoming complacent or losing our moral sensitivity. At the same time, we want to avoid becoming rigid or dogmatic.
Being self-aware is an intentional embodied dance that requires continually exploring our feelings, thoughts, and desires — and to do so humbly, carefully, and courageously, with, what I call, “benevolent honesty.” We also must do so with transparency, that is being willing to both acknowledge when our convictions have become biased, distorted, shortsighted, or incorrect; likewise, being open to possible change, revision, or alternative outcomes. The ability to be self-aware makes room for us to discover possibilities for responding to morally distressing situations with our head held high, eyes wide open, shoulders relaxed, and grounded confidence in our core, with the least personal cost.
Self-mastery is the present-focused realization that we can always be in command of ourselves — body, mind, and spirit — even while accepting that we may not be able to control all situations or outcomes.
Self-expression: Choose and contribute in ethically clear and competent ways
There are many ways to express ourselves, but when it comes to moral resilience, two ways can be particularly helpful: developing ethical competence and speaking with clarity and confidence.
Ethical competence involves what Rushton refers to as ethical embodiment, that is living the values that we espouse by making sure that what we hold to be true and sacred is reflected in our actions. It is about immersing ourselves in the “moral” world by cultivating a moral vocabulary, imagination, attitude, and coherent character, as well as a dynamic moral posture — being patient with, and open and flexible to, others’ values, desires, hopes, and fears.
Speaking with clarity and confidence means giving voice to our concerns by bringing distressing issues to the attention of invested others. Rather than seeing moral distress as an end in itself, consider it an opening to a broader and more substantive conversation about the dynamics of the situation. Speaking with clarity and confidence also includes knowing when to excuse ourselves from a situation, system, or relationship, whether it be for a short time or else permanently because that situation could irreparably harm our conscience.
Meaning-making: Don’t demand it. Create it.
Meaning-making is the process of how we perceive, interpret, and make sense of events in life, relationships, and ourselves. It gives us a way to organize memories and shape the narrative of an experience. Meaning also helps us to reconcile incongruities in our values, beliefs, and expectations and in our attitude toward life. This is especially important in times of moral adversity.
Senseless suffering is a big theme in moral resilience. We often think to ourselves, “Why am I continuing to do ‘this’ when nothing changes?” Or, “I’m doing everything I can to make things better, but nothing I ever do is enough.” And, “I’m fighting against a system that is inherently flawed or damaging.” These umbrages can either fuel a disempowering, dead-end narrative or they can become the foundation for principled and embodied action.
One way to create meaning is to consider alternatives that may not appear obvious or that you have previously rejected. Consider, is there information you have overlooked or misconstrued? Are your grievances cloaking relevant information? How can you look at the situation in a more nuanced way and from multiple stakeholders’ perspectives?
Also, consider how this situation is asking you to grow. What new insights about yourself, others, and life have come to light? What core strengths have you relied on? What weaknesses have reared their head? What values, responsibilities, or moral imperatives have remained constant — and are there any that have shifted? How is all this meaning living inside you?
A mistake often made when it comes to meaning-making is thinking it is a lesson to be learned or the “moral of the story.” Not so. Meaning-making is not trying to put a happy spin on pain, nor is it necessarily trying to teach us cautionary realities. Meaning-making simply helps us to broaden our thinking and feeling about a morally difficult situation and keeps us moving forward with integrity and principled action.
Connectedness: Engage with others
Being connected is one of the realities of life; in fact, recent neuroscience research shows that we’re hardwired for it: When we talk to other people, mirror neurons in our brains light up to mimic the emotions and behaviors the other person is conveying. Matthew Lieberman, director of UCLA’s Social Cognitive Neuroscience lab, suggests that human beings’ need for connection is even more basic than food and shelter and is the primary motivation of a person’s behavior.
Reaching out and letting trusted others in is an absolute must when it comes to cultivating moral resilience. And note here the word “trusted.” This is also key. Sharing challenges, difficult emotions, and frustrations can make us feel vulnerable. Being in the midst of moral distress is not necessarily the time to test the waters with those who can’t be counted on to be present, to listen and to hear, to have empathy and show compassion, and to offer benevolent honesty and, at the same time, grounded hope. Knowing that you are not alone in your moral struggle can go a long way to alleviating a sense of isolation and despair.
We never want to seize control more than when we don’t have it — and when we’re morally distressed, it can really feel as though we don’t have it. Shifting the narrative from one of powerlessness, hopelessness, and helplessness to one defined by possibility and principled choice will help to both assuage the effects of moral distress and cultivate moral resilience.