Does moral action depend on reasoning?

I chuckled when I read the preliminary answers from scientists and scholars. They ranged from "No, it does not!" to "Not so much" to "Yes, within limits" to "Yes, by nature," and finally, "Yes and no." Seeing such answers, I felt that many people would lose interest in exploring the issue because this interchange may seem too theoretical and confusing to help guide them to meet the ethical responsibilities and demands of their daily lives.

As someone who serves as an ethics specialist and a resource to busy frontline health care workers, what insights can I provide from this academic discussion? Let's say a nurse or addiction therapist asks me, "How can I know I'm acting morally?" or "When are my actions moral enough?"

There is more than one legitimate answer to these questions, but the one I want to delve into here involves moral distress. Accordingly, my initial response to the nurse or addiction therapist is, "When the moral distress you experience has been resolved." The ethics community and the nursing community have done a lot of good work identifying and understanding this important experiential component of everyday work in health care settings.

A favoured explanation of moral distress comes from George Webster, a Winnipeg-based bioethicist, and Françoise Baylis, a philosopher in Dalhousie University's bioethics department. In an article called "Moral Residue," published in Margin of Error: The Ethics of Mistakes in the Practice of Medicine, they explain that moral distress occurs when there is incoherence between one's beliefs and one's actions and possibly also outcomes -- that is, between what one sincerely believes to be right, what one actually does and what eventually transpires.

This distress can be in the form of self-doubt, guilt, fear or worry. When this negative psycho-emotional experience endures and influences the person's future actions, it qualifies as "moral residue."

When I work with clinicians on an ethically vexing or worrisome question or situation, I often ask them if their initial preference for one option over another is being influenced by past situations they've been in; in other words, whether they are trying to avoid re-creating past "cases that haunt them." Given the immense impact of health problems on people's lives, identities and relationships and the differing values at play with different therapies and clinical settings, it's to be expected that clinicians will be involved in situations with conflicting meanings and priorities. Certainly every situation can become a learning opportunity that increases the quality of future treatment and care. But every situation does not actually have such a positive outcome.

Sometimes a health care worker who is involved in the situation is left feeling distressed morally. And it's not uncommon for more than one person involved in the case to feel this type of distress. If no opportunities or resources are available for them to express their distress and reflectively examine its causes, they may continue to live with it.

To try to reduce these negative feelings, a clinician may succeed in "pushing it out of my mind." Pushing it away can be an understandable response, especially when the next day, he or she must return to work, ready to help patients still in the hospital or help new clients in the waiting room. Relevant here is a book written for corporate America. Its relevance is apparent in the first five words of its title: The Muted Conscience: Moral Silence and the Practice of Ethics in Business.

The author, F.B. Bird, is puzzled by the all-too-real phenomenon of employees who are well educated and advantaged and who have moral convictions. These people, according to the author's experience, appear to neither see nor hear frequent violations of business ethics' principles and values. And even when they are aware of violations, too often they refrain from voicing concern. This is one reason why I put little weight on people's common sense and good intentions, both of which are extolled frequently as valid guides for moral action: They do not ensure awareness, imagination, tenacity, humility or courage in complex, ambiguous or novel situations.

It has always concerned me when health care workers state they never encounter ethical quandaries or that they haven't since their first few years after graduating from university or college. Bird would concur with me, I think, in applauding those who do experience moral distress because they are at least able to identify actual or predictable ethical mistakes, transgressions and slippages. The next step is figuring out the appropriate action, rather than resorting to "it's someone else's responsibility," or what Bird characterizes as moral silence. Key here is the word "appropriate." Yes, there are practical, timely and nuanced ways to do this thinking and reasoning ... I leave that to my next column.

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Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that may arise in the mental health and addiction fields. Barbara is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. Barbara is also a contributing editor to the Journal of Ethics in Mental Health.

Submit your ethics questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.