Moral distress and injury in social work

by

Frederic G. Reamer

• LAST REVIEWED: 22 September 2021
• LAST MODIFIED: 22 September 2021
• DOI: 10.1093/obo/9780195389678-0304

Introduction

Among the most challenging ethical dilemmas in social work is what has become known as moral injury. Moral injury is ordinarily defined as the sort of harm that results when someone has perpetrated, failed to prevent, or witnessed acts that transgress deeply held moral beliefs. What these phenomena have in common are instances when social workers must decide how to handle work-related circumstances that are deeply troubling because they have caused, or have the potential to cause, harm. It is important for social workers to understand the nature of moral injury, the diverse causes of moral injury and the moral distress that often results, meaningful responses, and prevention strategies.

The Nature of Moral Distress and Injury

Moral distress and injury in social work can arise in a variety of circumstances and practice settings. Several publications—including Campbell, et al. 2016; Clarke and Kissane 2002; Epstein and Hamric 2009; Fourie 2017; Griffin, et al. 2019; Jinkerson 2016; and Shay 2014—provide a general overview of moral distress and injury. Other publications focus more narrowly on moral distress and injury in specific professions. Austin, et al. 2003 discusses moral distress in nursing. Austin, et al. 2005 discusses moral distress in the psychology profession. Brazil, et al. 2010 explores moral distress experienced by palliative care professionals. Currier, et al. 2015 discusses moral injury involved in work with veterans.

• Austin, Wendy, Vangie Bergum, and Lisa Goldberg. 2003. Unable to answer the call of our patients: Mental health nurses’ experience of moral distress. Nursing Inquiry 10:177–183.

  DOI: 10.1046/j.1440-1800.2003.00181.x

  This article describes the experience of moral distress reported by nurses working in mental health care settings who believed that insufficient resources lead to dispiritedness, lack of respect, and absence of recognition (for both patients and staff), which severely diminishes their ability to provide quality care.

• Austin, Wendy, Marlene Rankel, Leon Kagan, Vangie Bergum, and Gillian Lemermeyer. 2005. To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior 15:197–212.

  DOI: 10.1207/s15327019eb1503_1

  This article reports on specific incidents in which psychologists reported feeling their integrity had been compromised by such factors as institutional and inter-institutional demands, team conflicts, and interdisciplinary disputes.

• Brazil, Kevin, Sharon Kassalainen, Jenny Ploeg, and Denise Marshall. 2010. Moral distress experienced by health care professionals who provide home-based palliative care. Social Science & Medicine 71:1687–1691.

  DOI: 10.1016/j.socscimed.2010.07.032

  The authors summarize the results of a study that examined the experience of moral distress in a broad range of health-care occupations that provide home-based palliative care.

• Campbell, Stephen, Connie Ulrich, and Christine Grady. 2016. A broader understanding of moral distress. American Journal of Bioethics 16:2–9.

  DOI: 10.1080/15265161.2016.1248579

  The authors discuss six types of distress that fall outside the bounds of the traditional definition of moral distress and explain why they should be recognized as forms of moral distress. They propose a more expansive definition of moral distress and examine how it can enable the development of a taxonomy of moral distress.

• Clarke, David, and David Kissane. 2002. Demoralization: Its phenomenology and importance. Australian and New Zealand Journal of Psychiatry 36:733–742

  DOI: 10.1046/j.1440-1614.2002.01086.x

  The authors review and summarize the literature on the concept of demoralization in order to examine the validity of the construct.

• Currier, Joseph, Wesley McCormick, and Kent Drescher. 2015. How do morally injurious events occur? A qualitative analysis of perspectives of veterans with PTSD. Traumatology 21:106–116.

  DOI: 10.1037/trm0000027

  The authors report on the results of interviews with veterans about morally injurious events that occurred during respondents’ war-zone deployments.

• Epstein, Elizabeth, and Ann Hamric. 2009. Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics 20:330–342.

  The authors propose a model that describes the complex interrelationship between the concepts of moral distress and moral residue.

• Fourie, Carina. 2017. Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of moral distress. AMA Journal of Ethics 19:578–584.

  DOI: 10.1001/journalofethics.2017.19.6.nlit1-1706

  The author differentiates between categories of distress and between groups of health professionals who might experience moral distress. She argues that these distinctions should influence the analysis, measurement, and amelioration of moral distress in clinical settings.

• Griffin, Brandon, Natalie Purcell, Kristine Burkman, et al. 2019. Moral injury: An integrative review. Journal of Traumatic Stress 32:350–362.

  DOI: 10.1002/jts.22362

  The authors provide a comprehensive overview of research studies that focus on the concept and nature of moral injury.

• Jinkerson, Jeremy. 2016. Defining and assessing moral injury: A syndrome perspective. Traumatology 22:122–130.

  DOI: 10.1037/trm0000069

  This article reviews descriptions, incidence, etiology, and symptoms of moral injury. The author offers recommendations for quantitative assessment of moral injury and an updated conceptual definition.

• Shay, Jonathan. 2014. Moral injury. Psychoanalytic Psychology 31:182–191.

  DOI: 10.1037/a0036090

  This article discusses the concept of moral injury and identifies clinical challenges faced by people who witnessed atrocities. The author explores clinicians’ countertransference emotions and judgments of self and others.