Nursing Ethics Program, Center for Bioethics, Stanley S. Zielony Institute for Nursing Excellence, Cleveland Clinic, Cleveland, Ohio, USA.
Neuroethics Program, Center for Bioethics, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Nurs Philos. 2024 Jan;25(1):e12419. doi: 10.1111/nup.12419. Epub 2023 Feb 7.
In recent years, the phenomenon of moral distress has been critically examined-and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re-examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re-centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of 'narrow' moral distress and the value of re-considering moral distress. Finally, we provide an action-oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency.
近年来，道德困境现象受到了批判性的审视——这是有充分理由的。已经提出了许多不同的定义，其中一些声称与原始定义一致，但实际上指的是不同的认识论状态。在本文中，我们通过探讨道德困境与道德代理的关系来重新审视道德困境。我们批判性地审查了道德代理的三个概念，并认为其中两个概念存在将护士的价值观置于道德行动中心的风险，而应该是患者的价值观来塑造护士的义务。我们提出，Aimee Milliken 提出的道德代理概念重新将患者的价值观置于中心位置，应该在护理领域得到更广泛的认可。我们利用一个案例来演示患者父母（代理人）的价值观合理限制护士道德代理的情况，从而产生道德困境。通过对这种情况下护士代理的限制的考察，我们说明了“狭义”道德困境的问题性质以及重新考虑道德困境的价值。最后，我们提供了一个面向行动的建议，确定了调解步骤，我们认为这些步骤对于护士（和其他医疗保健专业人员）在狭义道德困境和道德代理的行使之间具有实用价值。
