Moral Distress and Autonomy

In Ian McEwan’s book 'The Children’s Act' we have a clear example of moral distress. A judge has to make a decision which is in a child’s best interests when these conflict with his parent’s autonomous wishes. This posting will consider moral distress. What do we mean by moral distress? Moral distress was defined by Jameton as a phenomenon in which someone knows the right action to take, but is constrained from taking it. (1) Moral distress is usually considered in a medical setting but can occur in other areas. For instance a soldier might feel moral distress when carrying out an order which she believes to be morally wrong. It is important to clearly differentiate between distress in general and moral distress. For instance a nurse might be distressed because she feels empathy for a patient’s suffering. However her distress isn’t moral distress. It is also important to be clear about difference between distress caused by moral dilemmas and moral distress. For instance someone might feel distressed because she must either lie to a friend or cause her friend to suffer. She doesn’t know the right thing to do and is experiencing a moral dilemma but not moral distress as defined above. A nurse helping to resuscitate a terminally ill patient suffering great pain might become distressed because she feels she is carrying out an action which she believes is wrong, is suffering moral distress. Moral dilemmas are self-imposed. Moral distress is imposed on the sufferer by others. Both moral dilemmas and moral distress can cause moral injury which can be harmful but in this posting I will only be concerned with moral distress.

What sort of others can cause moral distress? I would suggest moral distress can be caused by two sorts of others. Firstly it can be caused by some authority. This might happen when there is a difference between what someone believes is the right thing to do and what some authority with power over her wants her to do. For example a soldier might suffer moral distress when ordered by her superiors to shell a village which she believes contains a large number of civilians. In a healthcare setting if systems are set up to provide good ethical guidance for healthcare workers this form of moral distress might be reduced. Such guidance might be particularly important during health care emergencies such as the covid-19 outbreak. Secondly moral distress can be caused by respecting someone’s autonomy. For instance a nurse who continues to give a competent patient treatment, which she believes is futile and causes suffering, because the patient requests that her treatment continues.

Most work on moral distress focusses on distress caused by authority. In this posting I want to consider moral distress caused by respecting someone’s autonomy. I will argue that sometimes such distress is sometimes inevitable and difficult to reduce. Someone suffering from moral distress believes she is being asked to do something she believes is wrong. This wrong can take two forms. Firstly respecting someone’s autonomy means that she is asked to do something which conflicts with her beliefs. Secondly respecting someone’s autonomy forces someone to do something wrong by preventing her from acting beneficently. It might be suggested that one way of averting moral distress is for the person suffering the distress to opt out from carrying out the action which is causing the distress. However opting out isn’t easy for someone who believes in respecting autonomy. I would suggest that if you care about someone then you must care about what they care about to some degree even when what they care about conflicts with your beliefs. Caring about someone makes opting out of helping an autonomous person achieve her goals difficult. Caring about differs from caring for. I can care for someone whilst ignoring her wishes but this form of caring is caring in much the same way as someone cares for a child or even a dog. Caring about someone means that the cared about person’s autonomous decisions must carry some weight to the carer and cannot be easily dismissed by the carer. I would further suggest that someone cannot feel genuine empathy for someone if she doesn’t care about what the person she feels empathy for cares about.

Let us assume that respecting autonomy matters and that autonomy is a useful. First let us consider someone who is in moral distress because respecting someone’s autonomous decision means she feels she is prevented from acting beneficently. For instance the nurse in the example I have used above. I would suggest that if the nurse accepts that respecting her patient’s autonomy matters that her moral distress is inevitable. It might be objected that my suggestion depends on a particular account of autonomy and that if we adopted a different account her distress could be avoided. I am using a primitive or Millian account of autonomy. My objector might then suggest that if we adopted a substantive account of autonomy which requires that an autonomous decision must be in a patient’s best interests that the conflict between acting beneficently and respecting autonomy would disappear and with it the moral distress. In response to my objector I will now argue that if we accept a substantive account of autonomy that this account becomes redundant. Let us assume that an autonomous decision isn’t simply some decision made with only reference to what the maker cares about but must also concur with some substantive norms. An autonomous decision must be a good decision. However if we accept that an autonomous decision can’t be a bad decision then the whole idea of an autonomous decision isn’t really much use and we can simply replace all autonomous decisions by good decisions. Let us consider a nurse caring for a terminally ill patient who has one treatment option withdrawn, which the patient desires, because it is regarded as a futile option. If the nurse in question believes in a substantive account of autonomy then this option withdrawal against the patient’s wishes means she will feel no moral distress due to a failure to respect patient autonomy; the patient’s wishes weren’t good wishes because the treatment option was futile and hence weren’t autonomous wishes. If we accept a substantive account of autonomy then the idea of an autonomous decision becomes redundant and can be replaced by a good decision. If we accept that autonomy matters we must be prepared to accept that autonomous decisions can be bad decisions. We must be prepared to accept a primitive account of autonomy. Accepting that autonomous decisions can be bad decisions means that respecting autonomy and acting beneficently will sometimes clash causing inevitable moral distress. It might be argued that opting out of acting might combat this moral distress. I would argue that this option isn’t available in a caring setting. In a caring profession caring about what someone believes to be wrong way is better than not caring at all. It follows that respecting autonomy in a caring profession sometimes makes moral distress inevitable.

My objector might accept a primitive account of autonomy but still suggest that moral distress is not inevitable. She might suggest that autonomy is connected to of my “real self” as opposed to my empirical or actual self. She might proceed to suggest that if we did so my ‘real self’ wouldn’t make bad decisions and that respecting autonomy wouldn’t lead to moral distress. This might lead to the position where someone might think it right to ignore an agent’s intuitively autonomous decision because she believes it does not reflect his real self. I would reject my objector’s suggestion for two reasons. Firstly the world is populated by real people rather than idealised people. Secondly if we accept autonomy is only connected to idealised people who don’t make bad decisions then once again the concept of autonomy becomes redundant and can be replaced by good decision making,

Let us now consider cases where respecting someone’s autonomous decision causes moral distress because it conflicts with the distressed person’s beliefs. For instance a nurse’s religious beliefs might mean she believes we must do all we can to maintain life. Let us assume that she is nursing a terminally patient who isn’t in pain and is expected to continue enjoying a reasonable standard of life for some time. Let us also assume that this patient has made a last directive stating that if she goes into cardiac arrest that she isn’t to be resuscitated. The patient goes into cardiac arrest and the nurse suffers from moral distress because she can’t resuscitate her. Our nurse’s distress is caused by respecting her patient’s autonomy expressed in the last directive. I would suggest that in such scenarios respecting autonomy makes moral distress inevitable. Once again an objector might reject my suggestion. She might attempt to do so not by suggesting that we replace a primitive concept of autonomy by a substantive one but by limiting the domain of autonomous decision making. The domain of autonomous decisions is limited to those decisions which don’t clash with certain basic or religious beliefs. In the example used above the nurse might not suffer moral distress due to respecting autonomy because she believes the patient’s decision isn’t really an autonomous decision because it doesn’t belong in the domain of autonomous decisions. She may of course be forced to respect it by authority. Most hospitals have a policy to respect patients’ last directives. However the basic cause of her moral distress remains respecting patient autonomy. There are two arguments against accepting my objector’s suggestion. Firstly it might be argued that restricting the domain of autonomous decision making removes the importance of autonomy and makes it peripheral to our lives. Someone might end up in a situation in which she could autonomously decide to have an ice cream but couldn’t autonomously decide to have sex if she wasn’t married. Autonomy is about self-government and self-government must of necessity include those decisions which are central to our lives. If the nurse above suffers no moral distress due to respecting autonomy by adopting a limited domain of autonomy then her lack of distress is due to her adopting a deficient idea about the domain of autonomy. Secondly I would argue that any such limitation autonomy is really a surreptitious attempt to reintroduce a substantive concept of autonomy. The domain of autonomous decisions is limited because a larger domain would permit some people to make bad decisions. It is now possible to employ the argument used above against substantive accounts of autonomy. If autonomous decisions cannot be bad decisions then the concept becomes redundant. It follows that respecting someone’s autonomous decision inevitably causes moral distress when the decision conflicts with the respecter’s beliefs.

I have argued that the moral distress caused by respecting autonomy is sometimes inevitable and must simply be accepted by us as the price we pay for viewing other people as the sort of creatures who can decide how to live their lives. We may of course try to get someone to change her mind but if we can’t then respecting her as a particular person and not some idealised person means accepting her decisions and sometimes that means accepting moral distress.

1. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall

Honour in a Cosmopolitan Society

In the western world the idea of honour seems to be becoming less important. Politicians make promises and feel no shame when they break them, others offer apologies without feeling any sense of shame. In a new book Tamler Sommers argues that honour matters. Let us accept that honour matters. Sommers argues that in our cosmopolitan culture we have replaced honour by dignity and that this replacement damages society. In this posting I will argue that some of the goods honour delivers can be outweighed by other goods delivered by a dignity based culture. I will then argue that honour can matter in a dignity culture albeit in a modified form.

Why does honour matter? Sommers lists three main disadvantages of living in a culture without honour. Firstly he argues that such a culture makes us fearful. Secondly he argues that the rampant individuality of contemporary western leaves us without a sense of solidarity. Lastly that such a society diminishes the power of shame. Honour matters to Sommer because it gives us courage to combat fear, it helps to form our identity and it gives us a stronger disposition to feel shame. Honour matters because these goods are valuable.

Let us accept that courage is valuable, Martha Nussbaum like Sommers argues that we are damaged by living in a fear driven culture (2). However it might be argued that in a cosmopolitan society courage has diminished because the need for courage has diminished. For herders or hunter gatherers courage helped them to survive in a harsh environment. For a citizen in ancient Greece or Rome courage helped flourish in brutal times. However most of us no longer need courage to survive even if we might need it to flourish. Perhaps as the need for courage diminishes so does its value. It might be concluded that in a cosmopolitan society because we have less need for courage that this is on balance a good thing. It might be objected that some inner city dwellers live in a harsh and brutal environment which means that the need for courage remains. Perhaps this is one of the reasons why gangs persist in these areas. I would suggest what this objection shows is not that there is still an undiminished need for courage in a cosmopolitan society but rather that the domain of such a society is limited. A truly cosmopolitan society must address the needs of all of its citizens. I would further suggest that in an efficient cosmopolitan society which addresses the needs of all its citizens that there is less need for courage and that as a result the value of courage diminishes.

However even if it is accepted that there is less need for courage in a cosmopolitan society this does not imply we have no need for courage. It is sometimes remarked lose it or use it. If there is less need for courage in such a society does this damage our capacity to display courage when needed? I am prepared to accept it does but would suggest that any harm done by a lack of courage in a dignity based society is more than offset by living in a more peaceful society which protects its citizens. Perhaps the harm done by living in a fearful society might be better addressed by hope supported by faith as suggested by Nussbaum (3). In this context faith might regarded as the realistic optimism of Tiberius. Nonetheless I still believe courage should be fostered. Our educational systems seem to be becoming solely concerned with preparing people for work rather than life perhaps with more emphasis on sport and perhaps even the teaching of philosophy might foster courage.

Is Sommers right when he suggests that the rampant individuality of contemporary western leaves us without a sense of solidarity? It might be argued that a dignity culture means that all are valued. Perhaps all being valued gives all of us a basic sense of solidarity. However this is a very basic sense of solidarity and I accept Sommers is right and that rampant individualism can damage solidarity. A sense of solidarity can have various roots. It might be rooted in a profession, a religion, class, a nation or even a tribe. However even if a sense of solidarity has benefits it might have shallow roots. Let us accept our identity is linked to solidarity. We identify with those who are similar to us. If our sense of identity is rooted in some class, nation or tribe then our identity is passively determined and our sense of solidarity is easily acquired. Such a sense of dignity might increase solidarity with our own in group but lessen our sense of solidarity with others and lead to a decrease in toleration. Perhaps these harms outweigh the solidarity an honour culture fosters. Can a dignity based culture deliver a sense of solidarity other than a very basic form? In a dignity based cosmopolitan society we determine our identity to some degree. We might do so explicitly by choosing profession, such as joining the police force, or choosing a religion, perhaps by becoming a Buddhist. We might also do so implicitly by the actions we choose. I would suggest that if we choose our identity, even if our choice is implicit rather explicit, that we are more authentic than if are identity is acquired passively by being, born in some particular place or class. I would argue that even if solidarity is of value that the loss of solidarity in a cosmopolitan society might be more than offset by the value of authenticity. However at this point courage re-enters our discussions for someone wants to be true to himself must have the courage of his convictions. Does someone in this situation really need raw courage or would fortitude be more useful? I would also argue that a cosmopolitan society might increase a stronger sense solidarity in some cases. I have suggested above if we passively acquire our sense of solidarity that this is easily acquired. I have suggested that identity and solidarity are linked. If our sense of identity is based on partly on the choices we make we might feel a stronger sense of solidarity with those who have made a similar choice rather than those who are simply members of our class, nation or tribe.

Sommers argues that we are less likely to experience shame in a dignity culture than in an honour culture. I agree with Sommers that the ability to feel some form of shame is valuable but what form of shame? What do we mean by shame? I have previously argued that there are two types of shame. Firstly David Velleman defines shame as “anxiety about social disqualification” (4). This seems to be the sort of same fostered by an honour based culture. Secondly shame might be defined as someone’s anxiety about harming the things he cares about or loves and is linked to character. If we accept Velleman’s account of shame then a cosmopolitan society does indeed damage our ability to feel shame. A cosmopolitan dignity based culture seeks to include rather than exclude. But is Velleman’s type of shame really valuable? Consider a high caste Brahmin in India who has come into contact with something unclean and feels no shame. Has he done anything wrong and would social disqualification ever be valuable in this scenario? Shame is valuable but I would suggest that the type of shame which is valuable is linked to character. But shame linked to character is linked to authenticity which is perhaps best fostered in a cosmopolitan society than an honour culture. If we accept the above then shame matters and the shame that matters is connected to character. Such shame is not the shame fostered by an honour basis.

Let us accept that Sommers is right and that a loss of a sense of honour damages society. He argues honour is connected to being a member of some organisation such as a profession, a religion, class, a nation or even a tribe. If honour is only connected to some social group then in a dignity based society honour becomes irrelevant and fades away. I have argued if honour depends on the above bases that the goods delivered by a cosmopolitan outweigh the damage done by losing our sense of honour. Sommers argues that honour is damaged by an excessive focus on dignity. Perhaps it’s not our excessive focus on dignity but our excessive focus on rights, rather what it means to be a good person, which damages our sense of honour. I would suggest being a virtuous person is connected to being a good person. I would further suggest that being virtuous is not incompatible with living in a dignity or rights based society. I would still further suggest honour can be based on acting virtuously. Indeed it might be argued that virtue based ethics is impossible without some idea of honour. Moreover acting virtuously sometimes requires courage, gives us a sense of identity and if we fail a sense of shame. Such thoughts might have pleased Jane Austin. If we accept the above that being honourable means acting virtuously then honour is possible in in a dignity based or rights based society. Perhaps to promote honour we don’t need to encourage a greater sense of solidarity in our cosmopolitan society as suggested by Sommers but rather by encouraging people to be good persons by acting virtuously.

1. Tamler Sommers, 2018, Why Honor Matters, Basic Books, chapter 2
2. Martha Nussbaum, 2018. The Monarchy of Fear, Oxford University Press
3. Nussbaum , chapter 7
4. David Velleman, 2009, How We Get Along, Cambridge University Press, page 95