By Stacey Kusterbeck
Residents experience moral distress just as other clinicians do, raising some unique ethical concerns. “Moral distress is especially harmful for residents, as it inhibits their ability to develop effective clinical reasoning and a sense of autonomy in training,” according to Benjamin Frush, MD, a McDonald-Agape fellow at the Kennedy Institute of Ethics.
Residents carry out much of the day-to-day clinical operations of academic medical centers and often are the ones who interface most directly with patients. “Yet this direct exposure is often paired with an attenuated sense of agency. Residents may disagree with the decision-making of attending physicians, but often must not only accede to such decisions, but serve as the ones who enact these decisions in the form of placing orders or communicating with patients,” says Frush. Residents may perceive that institutional priorities for efficiency or financial concerns conflict with what is best for individual patients. In contrast, clinicians higher up in the hierarchy are shielded from this direct experience. “Moreover, because residents are constantly evaluated in their performance, they may be disinclined to voice disagreement with decisions or care they object to. This introduces a tension between what they think is right and their sense of self-preservation in the competitive environment of medical training,” says Frush.
Ethicists can serve an important role in helping to mitigate residents’ moral distress by simply introducing the concept to them. “By providing a conceptual framework for this often inchoate, very common feeling, residents might learn that they are not alone in this experience and that the discomfort is not pathological and may in fact signal a problem with the system rather than themselves,” says Frush. Additionally, ethicists can help remind residents of their moral agency and their critical role as moral actors in the care of patients. “Medical education and training too often inculcate the idea that residents are primarily those who perform interventions or make technical decisions — or, at worst, serve as ‘cogs’ within a massive institution that fails to recognize their individual contributions,” warns Frush.
Ethicists can support residents by affirming that medicine is not merely a technical undertaking, but an ethical obligation. “Ethicists might remind residents of the central role that conscience plays in medical care and decision-making, and seek to embolden residents to develop virtues like courage and truthfulness in their care for patients,” says Frush.
Some previous studies have explored moral distress among medical students.1-3 “But there has been no prior work documenting moral distress occurring during the surgical clerkship, nor characterizing the type of moral distress experienced by medical students,” says Cara Humphrey, BSE. Humphrey and colleagues analyzed 180 narrative essays written by three cohorts of medical students (2018-2019, 2019-2020, and 2020-2021) at the University of Michigan.4 Medical students described four subtypes of moral distress during surgical clerkships: uncertainty-distress, dilemma-distress, tension-distress, and constraint-distress.
Conflict-distress is the type of moral distress most frequently experienced by nurses, according to prior research.5 This occurs when an individual is engaged in conflict with another individual about what they think is the most ethically supportable action. This type of moral distress was not experienced by medical students in the study sample. This difference may be the result of the varied roles and responsibilities between medical students and nurses, the authors suggested. “Consideration of an individual’s unique role on the healthcare team should be considered when developing interventions to mitigate harmful effects of moral distress,” advises Humphrey.
When medical students encountered events discordant with their moral beliefs, they hesitated to raise concerns. Students feared negative implications for their future career and also cited their position in the medical hierarchy and their perceived lack of experience as reasons for being reluctant to report concerns.
Medical students may be particularly vulnerable to moral distress, concluded the authors, because of a lack of training in managing distressing clinical scenarios and their position in the medical hierarchy. “Further, the surgical clerkship presents medical students with a host of unique moral dilemmas, including ‘healing’ that may require inflicting new wounds,” says Humphrey. Nasogastric tube placement or other bedside procedures performed by the student, pain management, and physical exam maneuvers that elicited pain were the scenarios medical students reported most frequently that precipitated moral distress. “For institutions that participate in proactive ethics rounds, involving medical students in real-time ethical discussions is highly valuable. It provides important opportunities for medical student professional identity development,” offers Humphrey.
By hearing discussions between care team members and ethicists, medical students learn valuable strategies to manage future ethical dilemmas. Small group case-based reflection discussions about ethical dilemmas also can be beneficial to students after morally distressing events. “Some clinical clerkships host these discussions as part of the clerkship with medical school faculty facilitators. If possible, involvement of ethicists in these existing small group discussions would provide additional valuable expertise and guidance,” says Humphrey.
References
1. Ong RSR, Wong RSM, Chee RCH, et al. A systematic scoping review moral distress amongst medical students. BMC Med Educ. 2022;22(1):466.
2. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: Development of a web-based survey. Acad Med. 2010;85(1):111-117.
3. Thurn T, Anneser J. Medical students’ experiences of moral distress in end-of-life care. J Palliat Med. 2020;23(1):116-120.
4. Humphrey CA, Aslanian RE, Bradley SE, et al. “Do no harm?” Moral distress among medical students during the surgical clerkship. J Surg Educ. 2025;82(1):103340.
5. Morley G, Bena JF, Morrison SL, Albert NM. Sub-categories of moral distress among nurses: A descriptive longitudinal study. Nursing Ethics. 2023;30(6):885-903.
Residents experience moral distress just as other clinicians do, raising some unique ethical concerns.
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