Principled Moral Outrage

Critical care clinicians commonly find themselves in situations that challenge their integrity as individuals and as professionals. In response to these situations, many clinicians experience moral distress.When moral distress cannot be relieved and integrity cannot be restored, moral or ethical outrage may ensue. This column explores the contours of moral outrage, offers a definition of principled moral outrage, and suggests strategies for working more skillfully with the inevitable challenges to integrity that occur in the critical care environment.Moral outrage has been described broadly as anger provoked by a real or perceived violation of an ethical standard such as fairness, respect, or beneficence.2,3 Pike4(p351) describes moral outrage as “characterized by energy-draining frustration, anger, disgust, and powerlessness.” The psychological processes that affect the intensity of moral outrage may be activated by threats to personal or professional role, identity, self-worth, or integrity; by beliefs or customs that are different from one’s own; or challenges to the beliefs or values that are integral to personal or professional identity.5 In the context of critical care, nurses may, for example, perceive that their nursing identity is irrevocably tarnished when they participate in actions that result in unrelieved suffering or when their efforts to advocate for their patients fail, resulting in unjust treatment allocation. Such actions threaten nurses’ ability to uphold the core values of the nursing profession to provide respectful, nondiscriminatory care to all persons and to avoid harm to their patients.6Moral outrage, perceived as justified anger, is primarily directed toward another individual or group, rarely toward oneself.5 This orientation calls for greater awareness of the sources and responses to moral outrage so that it can be distinguished from other strong emotional responses that may involve projection, rationalization, displacement, or reaction formation.5 Critical care clinicians, for example, may feel frustrated at not being able to achieve the desired outcome for a patient and blame other clinicians or specialists for their inability to achieve their goals. Similarly, in some instances, the anger or outrage is directed toward the administration of the institution, the government, or the policy maker. These sources of strong reactions need to be differentiated to determine whether moral outrage is, in fact, the source of the response.Moral outrage may be the initiator of action or inaction and likewise can remain as a painful residue of morally distressing situations. When confronted with conflicts among ethical principles, one cannot prioritize one value or principle without abandoning another. Any decision will result in the loss of something important and highly valued. As clinicians, we must acknowledge, however, that even when we are able to preserve or restore our integrity, a moral residue may persist in response to the ethical values that were not fully upheld but are highly valued.Critical care clinicians should distinguish between moral outrage that is grounded in principled discernment and action from an impulsive, unreflected emotional reaction that lacks sufficient grounding in ethical values or standards.Marva Stephens, 47 years old, was diagnosed with stage 4 ovarian cancer 18 months ago. She is the mother of 2 daughters, Sarah, 6, and Ruth, 8. After several rounds of aggressive treatment, she was admitted with fungal sepsis, respiratory failure, and renal insufficiency to the intensive care unit (ICU). Prior to her admission, Marva executed an advance directive designating her husband, Mark, as her health care agent. She indicated that she wanted “everything done” to keep her alive. Over the next few weeks, her condition continued to decline despite dialysis, high-pressure ventilation that necessitated a tracheostomy, and myriad medications and treatments. She developed a sacral decubitus ulcer and experienced pain, despite aggressive treatment. She would often mouth words that the nurses interpreted as requests to end her suffering.On day 63 in the ICU, she experienced another bout of sepsis and hemodynamic instability. The ICU team members felt that they were already providing maximal pharmacological support and that resuscitation, given the advanced stage of her cancer, would be futile. When they approached Mark about their concerns, he adamantly replied that he wanted everything done, including cardiopulmonary resuscitation (CPR). Several nurses felt that to resuscitate Marva would cause unjustified harm and disproportionate suffering, would not change her ultimate outcome, and would, perhaps, undermine her preferences. In giving CPR, they would violate their personal and professional integrity. They reasoned that participating in CPR would justify an act that they believed was wrong. Later that evening, Marva went into cardiac arrest and CPR was initiated. After 25 minutes of resuscitation, they were able to reestablish a cardiac rhythm. She is now unresponsive, receiving maximal pharmacological support, and venous access is depleted. Mark continues to request that everything be done to sustain her life. Several members of the team express anger and moral outrage at being asked to inflict a therapy, CPR, on a patient who is clearly not going to survive.Moral outrage may be an appropriate response to situations that compromise a person’s important ethical values or standards. The emotional responses to egregious situations can provide the fuel for discernment and action that arises from wisdom and compassionate action. Emotions can be a rich source of insight and information that one needs to discern the moral contours of a situation or issue, to evaluate the ethically permissible or ethically required actions to address the concern, and to motivate and sustain the courage needed to persevere despite resistance.Ungrounded moral outrage can be disturbing and detrimental to all parties involved. When deeply held values are at stake, absolutism, either/or thinking, power struggles, and blaming or disconnection can arise. In critical care settings, nurses and others may find themselves in intractable conflict with patients or surrogates or members of the interdisciplinary team. Likewise, individuals may justify their anger toward another group by giving their anger moral sanction. In contrast, some people will become morally deaf or silent by failing to speak up about violations of ethical values or to overlook or be inattentive to moral issues voiced by others.7 Critical care clinicians may experience intensified moral outrage, for instance, if their leaders fail to respond to their requests for guidance or intervention.Breaches of ethical values and principles affect a person’s whole being in varying degrees of intensity and consequence. The consequences to the persons who are mounting claims that are fueled by moral outrage of this sort often are overlooked. With the nervous system stuck on high alert, the chronic activation of the stress response can arguably lead to depletion of vital energy, physical and emotional symptoms, unprofessional behaviors, and erosion of teamwork and patient centeredness. It can also lead to apathy when the person shuts down and becomes numb and morally mute. Bird7(p2) says, “people are morally mute when they fail to defend their ideals and when they cave in too easily and do not bargain vigorously for positions they judge to be right.”The way that an individual relates to the real or perceived breach of a moral value or principle will inform the way he or she responds to it. Past experiences; the degree of physical, emotional, or moral attunement; and awareness of one’s vulnerabilities to emotional wounds or moral blindness can influence responses. At times, the narrative surrounding a clinical case involving moral distress includes the phrase “Why are we doing this?” and may include references to prior cases that have resulted in moral distress or have had ethically unsatisfactory outcomes. Similarly, how one perceives personal, professional, and collective responsibility to address the breach of ethical values can affect the response one pursues.Critical care clinicians can be vulnerable to the detrimental effects of unexamined and cumulative moral distress that leads to moral outrage. Moral outrage can become the glue that holds a group together in a sense of solidarity against those who threaten their personal or professional identities, values, beliefs, or integrity. The sense of moral outrage can become contagious and, if unexamined, can exacerbate differences and fuel separation rather than connection and cooperation.For moral outrage to be principled, one must cultivate the conditions for wisdom, empathy, and compassion to arise. The ability to perceive the situation and experience of the other and to attune to it allows us to experience moral outrage about our own circumstances and the circumstances of others, without being overwhelmed by it.8 Discernment, inquiry, and self-effacement are essential to determine the right and best response to these situations.9 Discerning the right response invites an appraisal of one’s mental and emotional stability to ground one’s responses on a foundation of clarity and nonreactivity. Each potential response may be justified on the basis of the circumstances of the situation, the moral viewpoint one takes, and a focused reasoning process.In response to situations or actions that violate ethical values or standards, principled moral outrage arises from a balanced stance of wisdom and compassion that informs actions that seek to reestablish a moral value or standard and preserves integrity. It is a creative space that is sourced from a place of honor, respect, peace, equity, and dignity (M. Sharma, personal oral communication, 2012). Principled moral outrage is grounded in a state of mental and emotional stability in which anger and distress are modulated and action is compassionate. In this sense, compassion is a rigorous, balanced stance of a “strong back” that allows one to be clear, nonreactive, courageous, and principled in the midst of the most challenging circumstances and a “soft front” of open heartedness, kindness, and empathy leading to compassion.10 As some may perceive, it is not an ungrounded tolerance of unacceptable conditions or passive inaction.The preservation of integrity is the fundamental goal of responding to violations of ethical standards and moral outrage. McFall11(p9) suggests that “personal integrity requires that an agent subscribe to some consistent set of principles or commitments and in the face of temptation or challenge, uphold these principles or commitments, for what the agent takes to be the right reasons.” This perspective on personal integrity presumes a level of awareness and insight that is coupled with the cognitive skills and abilities to reason and deliberate about various options and to assess the impact of various actions. Cultivating these capacities and skills is necessary to move from ungrounded moral outrage to principled moral outrage.A person who is acting from principled moral outrage is able to make important distinctions, including being able to distinguish self from other and to recognize the inherent interconnection of all beings. Distinguishing what is happening to the patient or others as separate from one’s personal experience can help the clinician have greater perspective about violations of ethical values or standards and how different persons may or may not be affected. Likewise, if a person adopts a stance of objectifying others (such as patient, family member, colleague, or administrator) or intensifying separation by highlighting differences rather than similarities, his or her actions can become a vehicle for working out other related or nonrelated concerns or issues. In principled moral outrage, separation of self from other dissolves, and the interconnection among all beings becomes primary. Action arises from the recognition that harm to one being constitutes harm to all beings. From this space, our individual and collective responsibility to take reasoned steps to address the root causes and consequences of egregious patterns of behavior becomes clear.Similarly, moral outrage must be distinguished from frustration that produces anger that may not be ethical in nature. Focused or generalized anger invites inquiry in principled moral outrage to locate the source of one’s anger and frustration, which requires self-awareness and emotional intelligence to be able to intentionally make these important distinctions and to avoid the anger becoming unconsciously contagious among the persons involved.Principled moral outrage leverages ethically sound, modulated responses to address the injustices of situations, the violation of core ethical values or standards, and threats to integrity. Recognizing the time for action is foundational to integrity. Waiting until the situation has deteriorated beyond repair undermines the possibility for integrity-preserving action. If one overlooks or rejects such opportunities to act individually and collectively, one may be inadvertently participating in acts that are morally unjustified and in so doing give legitimacy to the act and contribute to individual and collective harms. Similarly, an insidious apathy and powerlessness can ultimately undermine individual and collective agency, integrity, and trust.A hallmark of principled moral outrage is an uncompromising commitment to uphold the highest ethical values and principles and to speak up about violations of these values and principles, which may involve executing unpopular decisions and, when appropriate, conscientiously objecting to ethically compromising situations despite resistance in a fair, respectful, and modulated manner. It does not imply apathy, disregard, or indifference to egregious situations. On the contrary, intentionally determining personal and collective thresholds of accommodation of morally distressing situations and defining norms governing when action is permissible or required are necessary steps.Violations of conscience can invite various responses, ranging from (1) finding a compromise that preserves integrity particularly when there is factual confusion, uncertainty, conceptual ambiguity, and moral complexity12; (2) raising a conscientious voice to bring awareness to or criticize a practice or violation of an ethical standard; (3) refusing to participate on the basis of conscience violations; (4) responsible whistleblowing arising from clarity, nonreaction, and ethical resolve rather than anger and retaliation; and (5) conscientious exiting from institutions or situations where efforts to address isolated or repeated instances that result in moral outrage are unaddressed, unresolved, or continue to compromise integrity.Undoubtedly, some of the clinicians caring for Marva are experiencing moral distress and/or moral outrage. They may perceive that their mandate to do no harm, to relieve suffering, and to benefit their patients has been violated by administering CPR. The understandable frustration and resultant anger could be directed at (1) the situation generally, (2) Marva and Mark for insisting that they “do everything,” (3) themselves for not being able to change the situation that resulted in their participation in acts that they believe are wrong, or (4) institutional or public policies or laws that they perceive forbid them from doing what they believe is ethically correct.If we were to apply a model of principled moral outrage to their experience, we may find that some clinicians would be able to see their actions from a different vantage point, others would conclude that the value of helping Mark live with his wife’s death superseded their own distress, and still others may conclude that CPR was ethically unjustified. What would individuals who felt that ethical values and their integrity are compromised do differently? Would the outcome be different?The outcome could be different or the same but arrived at from a different vantage point and awareness. Ideally, the tenor and internal would be different. Instead of a contentious, angry, and blaming stance, a ground of neutrality, insight, understanding, and wisdom could be created. Engaging with each other with the intention to understand, rather than convince the other of their viewpoint, has the potential to shift both parties to greater respect and understanding. Each of the ethically justifiable options would be arrived at from a stable, nonreactive foundation that allows individuals to discern the ethical conflicts and possible responses and determine the best course of action. Action in Marva’s case might include exploring more fully the meaning Mark ascribes to doing “everything.” Quill et al13(p345) suggest exploring the “balance of treatment burden and benefit, the emotional, cognitive, spiritual, and family factors that underlie their request, proposing a philosophy of treatment and making recommendations that capture the patient’s values and preferences.” They go on to advocate for directly responding to the emotional reactions and disagreements and strategies to address instances in which the patient or family continues to request treatment that is or action would be grounded in a that that the was and clear, and that there had been sufficient to avoid the to into a space of and when confronted with In Marva’s both Mark and the clinicians caring for her will where their values their would continue to a of that allows for and decision making for treatment and a of and in instances, the patient or family when violations of conscience have a where individuals must take steps to preserve their integrity. with principled moral outrage, such are without threats of or and a for care or other of The of principled moral outrage allows clinicians to the integrity of all to the of their and to avoid responses, and to have the courage to act with ethical despite or a of ethically permissible options is in cases such as this Quill et suggest options such as (1) even if it of (2) a of options that include different thresholds of patient burden that is balanced with the benefit of or (3) or that are not desired by the patient or his or her these treatment options are the team can a on a treatment that of such as of to another of an institutional or action of this can distress or help it and the consequences steps to respond to value conflicts are is another way to support an in which principled moral outrage is In Marva’s for example, that value conflicts and disagreements were in place that address these concerns, such as clinical family and patient care can opportunities for concerns and as an of this case and others critical care clinicians would ethical in discernment and with the patient, and team and how to in about ethically challenging with patients and that include ethically justifiable and and and In the some clinicians may not in their that CPR is ethically wrong, but what may be different is the way they their a grounding that them to bring the issues surrounding the case to the their and arguably to policy in a way that the of action important ethical values and must also that in some best efforts do not and integrity cannot be and the detrimental effects of moral outrage cannot be These cases also an for and toward others and the of our efforts with compassion and can help us from the inevitable moral residue that and the suffering that it. processes to address these is essential in an ethical practice care clinicians are not to the detrimental effects of moral distress and moral outrage. to the detrimental effects of moral outrage that can help critical care clinicians to their responses, ground themselves in their commitments and ethical values, discern the right action to and those actions with clarity, and care clinicians have a responsibility to speak up about situations that cause them moral outrage, of the outcome of their Ideally, the outcome of being able to moral distress and moral outrage is a state of integrity, and that allows clinicians to restore their integrity and their resolve to their patients and from the highest ethical values and standards. the ability to to a of in the midst of challenging from focused awareness and of emotional, spiritual, and moral a of stability and distressing situations that cause moral outrage are to be suggests that the of may not the intensity of situations that result in moral outrage may not result in detrimental In clinicians have the to blame something or for the injustices that in critical care practice or to to how they feel and act in the of their moral outrage and to make the to from a stance of principled moral outrage and Sharma, and the team of With for their wisdom, and support in the of this