When Fulfilling a Professional Obligation Causes Moral Distress: A New Evaluative Approach.

PURPOSE: The term 'moral distress' was coined by Andrew Jameton to name the anguish that clinicians feel when they cannot pursue what they judge to be right because of institutional constraints. We argue that moral distress in critical care should also be addressed as a function of the constraints of ethics and propose an evaluative approach to the experience considering its implications for professional identity. METHOD: We build on a selective review of the literature and analyze a paradigmatic example of moral distress, namely, clinicians who feel compelled to perform procedures on patients that seem futile. Such cases are commonly cited by clinicians as among the most morally distressing. RESULTS: Our analysis shows that (1) physicians' experiences of moral distress can stem not only from toxic workplace cultures and institutional constraints on their time and resources for patient care but also from the limits of ethical reasoning and (2) an emotion-based evaluative approach to analyzing moral distress is needed to address its hazards for professional identity. CONCLUSION: We propose a new evaluative approach to moral distress with implications for professional identity and the need for institutional education and support.

Lack of Association Between Donor-Derived Cell-Free DNA and Cardiac Allograft Vasculopathy.

Cardiac allograft vasculopathy (CAV) is a leading cause of death after heart transplantation (HT). We evaluated donor-derived cell-free DNA (dd-cfDNA) as a noninvasive biomarker of CAV development after HT. The INSPIRE registry at the Intermountain Medical Center was queried for stored plasma samples from HT patients with and without CAV. At Stanford University, HT patients with CAV (cases) and without CAV (controls) were enrolled prospectively, and blood samples were collected. All the samples were analyzed for dd-cfDNA using the AlloSure assay (CareDx, Inc.). CAV was defined per the ISHLT 2010 standardized classification system. Univariate associations between patient demographics and clinical characteristics and their CAV grade were tested using chi-square and Wilcoxon rank sum tests. Associations between their dd-cfDNA levels and CAV grades were examined using a nonparametric Kruskal-Wallis test. A total of 69 pts were included, and 101 samples were analyzed for dd-cfDNA. The mean age at sample collection was 58.6 ± 13.7 years; 66.7% of the patients were male, and 81% were White. CAV 0, 1, 2, and 3 were present in 37.6%, 22.8%, 22.8%, and 16.8% of included samples, respectively. The median dd-cfDNA level was 0.13% (0.06, 0.33). The median dd-cfDNA level was not significantly different between CAV (-) and CAV (+): 0.09% (0.05%-0.32%) and 0.15% (0.07%-0.33%), respectively, p = 0.25 and with similar results across all CAV grades. In our study, dd-cfDNA levels did not correlate with the presence of CAV and did not differ across CAV grades. As such, dd-cfDNA does not appear to be a reliable noninvasive biomarker for CAV surveillance.

Clinician Moral Distress: Toward an Ethics of Agent-Regret.

Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well-understood in terms of what Bernard Williams calls "agent-regret." We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience.

Professional Identity Formation in Medical Education: Some Virtue-Based Insights.

Issue: In 2010, the Carnegie Foundation published a call to reorient medical education in terms of the formation of identities rather than mere competencies, and the medical education literature on professional identity formation (PIF) has since grown rapidly. As medical learners navigate a hectic clinical learning environment fraught with challenges to professionalism and ethics, they must simultaneously orient their skills, behaviors, and evolving sense of professional identity. The medical education literature on PIF describes the psychosocial dimensions of that identity formation well. However, in its conceptual formulations, the literature risks underappreciating the pedagogical significance of the moral basis of identity formation-that is, the developing moral agencies and aspirations of learners to be good physicians. Evidence: Our conceptual analysis and argument build on a critical review of the medical education literature on PIF and draw on relevant insights from virtue ethics to deepen the conceptualization of PIF in moral, and not just psychosocial, terms. We show that a narrowly psychosocial view risks perpetuating institutional perceptions that can conceive professionalism norms primarily as standards of discipline or social control. By drawing on the conceptual resources of virtue ethics, we highlight not just the psychosocial development of medical learners but also their self-reflective, critical development as particular moral agents aspiring to embody the excellences of a good physician and, ultimately, to exhibit those traits and behaviors in the practice of medicine. Implications: We consider the pedagogical relevance of this insight. We show that drawing on virtue theory can more adequately orient medical pedagogy to socialize learners into the medical community in ways that nurture their personal growth as moral agents-in terms of their particular, restless aspirations to be a good physician and to flourish as such.

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians.

Physician impairment, the inability to carry out patient care responsibilities safely and effectively, is a problem of functioning. However, the presence or treatment of a potentially impairing illness or other condition does not necessarily imply impairment. This American College of Physicians position paper examines the professional duties and principles that should guide the response of colleagues and the profession to physician impairment. The physician should be rehabilitated and reintegrated into medical practice whenever possible without compromising patient safety. At the same time, physicians have a duty to seek help when they are unable to provide safe care. When identifying and assisting colleagues who might be impaired, physicians should act on collegial concern as well as ethical and legal guidelines that require reporting of behavior that puts patients at risk. Health care institutions and the profession should support practice environments in which patient safety is prioritized and physician wellness and well-being are addressed. Physician health programs should be committed to best practices that safeguard patient safety and the rights of physician-patients.

Back to the future: The AMA and religion, 1961-1974.

U.S. medical scholarship and education regarding religion and spirituality has been growing rapidly in recent years. This rising interest, however, is not new; it is a renewal of significant interweavings that date back to the mid-20th century. In this Perspective, the authors draw attention to the little-known history of organized medicine's engagement with religion from 1961 to 1974. Relying on primary source documents, they recount the dramatic rise and fall of the Committee on Medicine and Religion (CMR) at the American Medical Association (AMA). At its height, there were state-level committees on medicine and religion in 49 states, the District of Columbia, and Puerto Rico, and there were county-level committees in over 800 county medical societies. Thousands of physicians attended annual conferences for clinicians and clergy, and direct outreach to patients included a film viewed by millions. The CMR arose in the context of rapid medical advances, the growth of professional chaplaincy, and concern for declining "humanism" in medicine-conditions with parallels in medicine today. The CMR was brought to a puzzling end in 1972 by the AMA's Board of Trustees. The authors argue that this termination was linked to the AMA's long and contentious debate on abortion. They conclude with the story's significance for today's explorations of the intersection of spirituality, religion, and medicine, focusing on the need for mutual respect, transparency, and dialogue around the needs of patients and physicians.