Fixing Moral Distress Will Not Fix Your Burnout

Stay with me. I’m writing this as a human who witnesses suffering first, then a pediatric intensivist, and then a clinical ethicist. So, like this:

Human > Pediatric Intensivist > Clinical Ethicist

I’m writing this with the utmost respect for all the physicians, nurses, and ethicists who have researched this topic and are trying so hard to help us out of this burnout hole we find ourselves in. Speaking of, just to make sure we’re all thinking the same thing, the definition of moral

distress from Beth Epstein and Ann Hamric (two of the Grandmasters on the topic) is: “the presence of constraints, either internal (personal) or external (institutional) that prevent one from taking actions that one perceives to be morally right.” (Epstein 2009) While we’re on definitions, for I’ll use the definition from Jacobellis v. Ohio regarding obscenity: I know it when I see it. Whenever I’ve thought to ask myself the question, “Am I burned out?” and answering it has given me any length of pause, I’ve looked up a definition for “burnout,” and sure enough, I was burnt out.

We witness a lot of suffering in clinical practice. We see our patients suffer. In pediatrics, the suffering of our patients’ families is front and center (but it is also there in adult medicine, I’m sure). We witness the suffering of our colleagues: the division mate trying to find a way through for a gravely ill patient or the bedside nurse who physically carries out the frequently painful (and sometimes blatantly arduous) medical care. I have spent a lot of time in my (moderately short) career telling people that one of the ways to minimize moral distress is to develop a vocabulary around it. To use jargon like “autonomy,” “benefit,” “risk,” and “burden” to bring the concept from the bedside and into the academic space where it can feel more objective. Looking at something objectively can give us some distance from it.

I’ve been wrong.

In reality, distancing myself from the suffering isn’t what I want to do. Unknowingly, my definition of being a “good” person involves feeling sad when people are hurt, empathy when people are suffering, and anger when I see injustice. By trying to distance myself from suffering, I was (again, unknowingly) creating such cognitive dissonance that my brain (and heart, let’s be honest) would not let me NOT feel moral distress. So, not feeling moral distress makes me (in my definition) a bad person. And, barring the development of sociopathic tendencies, my brain cannot do what it thinks makes me a bad person. The alternative is to become so numb to the human condition that I shouldn’t be practicing medicine anymore. My definition of being a good doctor is knowing what medication to order and acting with empathy, compassion, and grace. See the issue? If I don’t suffer with my patients and colleagues, then I’m not only a bad doctor but also a bad human.

All this time I’ve spent trying to minimize my moral distress is futile. Describing my sadness with jargon does not actually fix my feeling sad; it just gives me a way to ignore the uncomfortable feeling of being sad for a time. My apologies to everybody I’ve taught that strategy to (and if it worked for you, keep on with it and stop reading right here!) So, here’s my big realization: “fixing” moral distress to ease burnout is futile and not worth my time. And I am using “time” as a surrogate for mental energy and emotional stability because they don’t lend themselves to easy, objective measurables like time has with hours, minutes, and seconds. If being “a good doctor” (or nurse, or physical therapist, or hospital housekeeper, or whatever vital role we play in medicine) involves feeling bad when people feel bad, then trying to “not feel bad” while practicing medicine is not worth my time. Suffering, injustice, and pain will happen. I cannot completely prevent them, and it does me no good to burn myself out trying to be okay with them.

So, if “fixing” moral distress is impossible, there must be a different way to fix burnout. There is, and it’s way easier to deal with. What is it, and how do we manage it? Just wait until my next email 🙂

References:
Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.