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Root Causes of Moral Distress Vary; Ethicists Can Help
July 1, 2025 7 minutes read
By Stacey Kusterbeck
Clinicians commonly contact ethicists for help determining the correct surrogate decision-maker for a patient who is incapacitated. On the surface, it seems like a purely legal question related to guardianship. As ethicists dig deeper into the case and conduct conversations with the family and medical team, it becomes apparent that moral distress also is a factor. The clinical team may be concerned that the surrogate is not making decisions in the patient’s best interest, for example.
“This can be morally distressing due to the powerlessness to make a decision that the healthcare team perceives to be right and just,” explains Adam T. Booth, PhD, manager of University of Louisville Health’s clinical research program.
In such cases, ethicists are obligated to address both the ethical concern and the clinicians’ moral distress. “Given how pervasive moral distress is, it’s important to use the ethics consultation process as a teachable moment. Leverage the value that an ethics committee can bring to a situation like moral distress,” urges Booth.
For ethicists, simply considering the possibility of moral distress is an important first step. “You can begin to parse out these issues. Is there an ethical issue with this case — or is this an ethical issue that is morally distressing?” asks Booth. The more ethicists know about the underlying causes of moral distress, the more effectively they can respond. To learn more, Booth and a colleague analyzed 282 free text responses from The Measure of Moral Distress — Healthcare Professionals, a survey that quantifies moral distress.1 Healthcare providers responded to a question asking about their own experiences with morally distressing situations. The researchers identified three themes in the responses about the causes of moral distress: Compromised quality of care, hostile work environment, and ineffective leadership. Respondents talked about moral distress adversely affecting patient care and described feeling powerless to act.
Some healthcare systems are investing considerable resources in combatting moral distress in an effort to combat burnout and turnover. Yet, in Booth’s experience, simply talking with colleagues quite possibly is the most effective way to mitigate the harm of moral distress. “It’s not always your loved one or partner [who] is most helpful. More often, it’s your coworkers, the people you experience it with the most,” says Booth. Ethicists can facilitate conversations between colleagues during ethics consults, and raise the issue by asking questions such as, “Why does this bother you so much?” “It’s a very inexpensive way to begin to put a name to this,” says Booth.
Although moral distress is known to be common in settings such as intensive care units, where end-of-life conflicts are common, it also is a frequent occurrence in other settings. One group of researchers looked at moral distress in the field of radiology.2 The researchers surveyed 126 academic radiologists at five institutions in five states. Moral distress was higher in radiologists working more than 60 hours per week. The radiologists reported four primary sources of moral distress:
- Feeling pressured to perform unsafe numbers of studies. “Ideally, safe workloads in radiology would have to be defined and adhered to. However, determining this number is challenging,” says Bettina Siewert, MD, executive vice chair of quality and safety in radiology at Beth Israel Deaconess Medical Center. The safe workload for radiologists is dependent on other obligations during the workday, such as teaching, multidisciplinary conferences, and live consults. It also varies depending on case complexity at the institution. “There is also likely variation among radiologists and subspecialties in radiology that would need to be taken into account. Further study is needed in this area,” says Siewert.
- High workloads that prevented radiologists from teaching residents.
- Perceiving lack of support from hospital administrators for patient care issues.
- Being pressured to perform unnecessary imaging.
“Ethicists can play an important role in cases when a family insists on further treatment of a patient and the patient refuses it,” says Siewert. A recent case involved a family who insisted on a patient receiving a feeding tube. The patient had altered mental status and was unable to give consent at that point in time. However, when the patient arrived for the procedure with improved mental status, the patient refused the feeding tube. After discussion with the patient, the radiology team thought that the patient was oriented and able to give consent. The team decided to respect the patientʼs wishes and declined feeding tube placement.
Ethics consults take time, though, and are not practical for all of the ethically complex cases encountered by radiologists. “This is particularly true when it comes to diagnostic imaging where incentives are misaligned,” says Siewert. “Institutional policies would need to be developed that referring physicians would have to adhere to. Ethicists could be extremely helpful in this area.”
Moral distress was strongly linked to radiologists’ past job changes or job turnover intentions, with 44% stating that they intended to leave their job or had left a previous job, the study found. In a previous study, 98% of 93 radiologists surveyed reported having experienced some amount of moral distress.3 “Moral distress is ubiquitous in medicine — it leads to radiologists leaving their positions and is important to address for retention,” says Siewert.
Another study looked at whether the surge in pediatric mental health patients influenced pediatricians’ feelings of moral distress.4
“The number of children seeking mental healthcare from pediatricians has increased substantially,” observes JoAnna K. Leyenaar, MD, PhD, MPH, vice chair of research in the Department of Pediatrics at Dartmouth-Hitchcock Medical Center. Leyenaar and colleagues analyzed survey data from the 2022 American Board of Pediatrics Maintenance of Certification enrollment on pediatricians who cared for children with mental health disorders. Participating pediatricians were asked how frequently high-quality care was provided to children with mental health conditions. About one in five (22.7%) of 5,363 pediatricians reported perceived suboptimal care quality for children with mental health conditions. “This may contribute to burnout and job dissatisfaction, as well as challenges for children and their families,” says Leyenaar.
Pediatricians who work in acute care settings (such as emergency rooms and inpatient pediatric units) reported higher levels of moral distress. “This might be related to the growing numbers of children who go to their nearest hospital in times of crisis,” suggests Leyenaar. Pediatricians also were asked about some possible sources of moral distress and reported being required to care for patients but not feeling qualified. Pediatricians also reported a lack of administrative support and a feeling that patient care was compromised because of inadequate resources.“Ethicists may play a role in supporting pediatricians when they encounter particularly challenging situations, such as prolonged mental health boarding, challenges with discharge planning, or issues related to use of restraints in this population,” recommends Leyenaar.
As chief wellness officer at University of Utah Health, Amy B. Locke, MD, FAAFP, has seen too many physicians burn out from overwork. “The system is designed in such a way to drive overwork, which isn’t good for patients or providers,” says Locke. In a recent paper, Locke and colleagues propose these solutions to mitigate the harmful effects of moral distress on burnout in medicine: to acknowledge the presence of routinized stress injury in healthcare, to use available data on physician well-being to optimize care, and to foster connection and community.5 The hope is that individuals and healthcare systems can do a better job of recognizing the relationship between overwork and moral distress and how it contributes negatively to patient care and physicians’ leaving the profession. “Ethicists can help us better understand these relationships as ethical dilemmas, not as individual moral failings,” adds Locke.
Nurses, too, face unique issues contributing to moral distress. As the team members who enact providers’ orders, nurses may experience moral distress when there is poor team communication around treatment decisions and goals of care. “Knowledge about ethical issues in nursing can help nurses address moral issues when they arise, mitigating the potential for moral distress,” according to Margie Hodges Shaw, JD, PhD, HEC-C, director of clinical bioethics at the University of Rochester Medical Center.
Unacknowledged moral distress can lead to a continuation of the same circumstances that caused the distress in the first place. “Unmitigated moral distress leads to moral residue, which negatively impacts patient care, leads to burnout, and results in nurses leaving the profession,” says Shaw.
At the University of Rochester, nurses can attend regularly scheduled and ad hoc clinical ethics rounds and moral distress debriefings. Nurses also can participate in an ethics liaison program designed to help bedside nurses address moral distress. “Nurses and others accepted into the program are supported by their supervisors to attend the classes,” says Shaw. Nurses develop a capstone project to bring back to the unit. The content includes the foundations of clinical ethics through the lens of the biopsychosocial approach to medicine, which originated at the University of Rochester. “We integrate the health humanities, using the methods and materials to teach core ethical content and skills, including knowledge of ethical theories, critical thinking, ethical decision-making, and communication skills necessary for morally complex topics,” says Shaw.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Booth AT, Robinson KL. Factors influencing healthcare professionals’ moral distress: A descriptive qualitative analysis. Nurs Ethics. 2025; Feb 7. doi: 10.1177/09697330251317672. [Online ahead of print].
2. Dave P, Brook OR, Brook A, et al. Causes of moral distress in academic radiologists: Variation among institutions. J Am Coll Radiol. 2025; Apr 7. doi: 10.1016/j.jacr.2025.04.001. [Online ahead of print].
3. Dave P, Brook OR, Brook A, et al. Moral distress in radiology: Frequency, root causes, and countermeasures — results of a national survey. AJR Am J Roentgenol. 2023;221(2):249-257.
4. Leyenaar JK, Green CM, Turner A, Leslie LK. Perceived quality of care and pediatricians’ moral distress caring for children with mental health conditions. Acad Pediatr. 2025; Apr 7. doi: 10.1016/j.acap.2025.102825. [Online ahead of print].
5. Locke A, Rodgers TL, Dobson ML. Moral distress as a critical driver of burnout in medicine. Glob Adv Integr Med Health. 2025;14:27536130251325462.
Moral distress in clinicians stems from ethical dilemmas, hostile environments, and systemic failures. Ethicists play a crucial role in identifying causes, facilitating dialogue, and supporting clinicians in navigating distress, especially in high-stakes fields such as radiology and pediatrics.
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