The Mary Dilemma - A Case Study on Moral Distress
Newborn infant starved to death in Toronto hospital
One of the nurses who was caring for her today looked at me
with tears in her eyes and said "this is not right - if they took
her home and didn't feed her they would be charged - why is it okay
for us to do this?"
of Catholic Scholars (Canada) Journal, Summer/Fall, 2013
Reproduced with permission
This paper begins with a case study describing the
perspective of a Catholic nurse who experienced moral distress while
observing the tragic death of a newborn infant named Baby Mary. The purpose
of this paper is to raise awareness and educate readers about the concept of
moral distress and promote a greater understanding of the lived experience
of Catholic health care providers who undergo this trauma. It also provides
an analysis and some recommendations for practice that can help health care
professionals make good ethical choices in difficult situations based on
Case Study Background
The new doctor's order written in the chart says "no stimulation" i.e. no cuddling or holding and "phenobarb for comfort".
The following case study and journal entries reveal an attempt by one
nurse to understand and describe the interior process of moral distress
utilizing the concept of conscious reflexivity as defined by Wojtyla ( 1981)
in which consciousness " ... enables us to have an internal view of our acts
and their connection with the personal 'I' (p. 20). "Reflexive
thinking is an important element in the creation of all understanding .. .it
is also an important element in the creation of knowledge about the self
... " (Wojtyla, 1981, p. 21).
The concept of conscious reflexivity or reflective thinking is
demonstrated in the following journal entries written by a registered nurse
working in a neonatal intensive care unit (NICU) in a tertiary hospital in
Toronto, Canada. This nurse identifies herself as a Roman Catholic with a
strong faith in God and supportive of the teachings of the Church on life
issues. The names of those involved and location of the following case study
are omitted for reasons of confidentiality. The case study and journal
entries depict the nurse's experience with moral distress.
A baby girl from immigrant parents was delivered in a peripheral hospital
- the labour was difficult and the baby experienced hypoxia at delivery. The
baby required resuscitation and ventilation to assist with poor respiratory
effort. She was transferred to a NICU in a tertiary hospital where a head
ultrasound and other tests revealed that there was some damage to the brain
although the degree of damage could not be determined. The movement in her
right arm was limited but movement in her other limbs was normal; she
responded appropriately to stimulation. She was born on October 27th at
almost 35 weeks gestation weighing 2760 grams -an appropriate size for
her gestational age. A few days after birth the parents decided they wanted
to withdraw care; at this point the health care team believed that when she
was removed from the ventilator she would stop breathing, however after
extubation, she started to breathe on her own and did not require any
assistance or increased oxygen to maintain normal oxygen levels in her
It is significant to note she did not have any seizures, no blood glucose
issues, she was able to maintain her blood pressure and she did not have
cerebral edema nor was she diagnosed with a disease or a syndrome. Her
condition was considered stable. In this case the NICU protocol would be to
slowly introduce feeds. If the baby did not have a strong suck reflex, which
is common for an infant at 35 weeks gestation that has experienced a
traumatic birth, then a nasogastric feeding tube is used until the baby
is able to take full feeds on her own. When feeding is established and the
baby is gaining weight, common practice would be to discharge the infant
home to her parents with close monitoring in a neonatal follow-up clinic.
Instead, the parents instructed the doctors that they wanted to leave her
to die; they did not want a handicapped child and did not want to bring her
home. Since she was stable and did not require level three care, the
doctors transferred the baby to the level two nursery and the nurses placed
her in the corner with a screen around her crib. The order was to "withdraw
care". Her parents rarely came to visit her and they did not give her a
first name. The baby was left for hours without being held or loved.
Tuesday November 4
I woke up in the middle of the night last night and the question that
came to me was "what are you going to do about it?" For hours I lay awake
thinking about it and knew that I had to try to bring this baby home. My
commitments to my work and my students made it difficult and I knew I
would need help. In the morning I called my friend and told her the story -
I said this baby has no name and my friend said her name is Mary of course.
Within the hour I had many compassionate and loving pro-life friends
willing to come to my home to help care for Baby Mary. I then called the
social worker assigned to this case thinking she was going to laugh at me
but she said she had been thinking about the baby as well. I told her that I
would be willing to foster this baby in my home and she informed me that she
would offer this option to the parents - she never got back to me. When I
called her again she spoke to me about respecting the parent's wishes. I
believe there are a lot of factors here.
I truly believe that if Baby Mary's mother came and visited her often
she would have asked to feed her. No mother could see her baby rooting for
food and not want to feed her. I don't know all the reasons for her actions
but I know this mother is grieving for her baby.
Saturday November 8
Her chart entry says that she took a bottle and drank 40 mls quickly
today - this is the last time she is to be fed. When I went to the L2 to
hold her during my break the nurse wouldn't let me near her. She said she
had "no religious hang-ups" and had no problem doing as the parents
wished. The new doctor's order written in the chart says "no stimulation"
i.e. no cuddling or holding and "phenobarb for comfort". I can't tell you
how upset I was today.
I was working that day in an office by myself and there was-no one to
talk to - no support. One of the nurses I was working on the project with
came by - I thought I would feel her out about the no cuddle order and her
response was: "it's too bad that we couldn't give something to hasten the
death." I couldn't believe the words that I heard. I felt so alone, I felt
fear, deep sadness, anger and helplessness. It is difficult to be a prolife
nurse - the distress I have felt this past week is more than I thought it
Wednesday November 12
Baby Mary is still alive - a bit dusky today - no food since Friday -
she pees only tiny amounts and the nurse found blood in her diaper - she
responds to sucrose and then settles back to sleep - she only lost 200 grams
in 3 days and her face still looks full - not wizened and sunken like a
starving person yet.
Sunday November 16
I called to see if she had passed yet and her nurse said to me on the
phone "This is not right - I cried when I changed her at noon".
Wednesday November 19
Baby Mary cried out today when I was there - her eyes were wide open
and she was rooting for food. One of the nurses who was caring for her today
looked at me with tears in her eyes and said "this is not right - if they
took her home and didn't feed her they would be charged - why is it okay for
us to do this?"
Friday November 21
Baby Mary is still alive - I can't believe that it takes so long for
a baby to starve to death - her parents gave her a name 2 days ago probably
because they had to fill out the birth certificate and health insurance
forms so the hospital and doctors can get paid - she now weighs 1950 grams
and she looks like a starving infant - like the ones I saw in Africa. Unlike
in Africa however - there is lots of good formula barely 10 feet away from
I was working in the level 3 today and it was very unusual for them
to ask me if I would be willing to change assignments and move to level 2
because one of the nurses had to go on a transfer. Of course I said yes.
When I asked her if she would mind if I picked up Baby Mary the nurse who
was team leading responded: "I told them I didn't want to take care of this
baby - I can't take it." As I held Baby Mary close, I prayed for her and her
parents. She was very quiet and still and her breathing was shallow but I
knew that it was a graced moment. The next day she died - she lived
for 27 days. God gave me consolation by providing the opportunity to give
her my love.
In the wake of Baby Mary's death, many complex questions arise which need
to be answered, especially by the Catholic health care provider. Moral
theologians and medical experts, for example, can debate important ethical
- Was Baby Mary's death murder?
- Was Baby Mary starved to death or was it the result of following a
- Was this a case of non-voluntary passive euthanasia or was it an
informed and collective decision in accordance with standard procedure?
But there are other profound questions that go beyond the academic or
medical inquiries and emerge in an alarming way within the hearts of the
health care providers some of whom may be experiencing an awakening of their
conscience. Agonizing questions like:
- Could I or should I have done more?
- Did I participate in an abortion?
- Am I complicit in murder?
And the question especially distressing to those affiliated with a
Church; am I excommunicated?
Searching for answers to these questions in order to gain some
understanding and meaning is particularly traumatic to a growing number of
health care professionals who may or may not be prepared to grapple with the
psychological and emotional anguish and/ or grave moral implications that
these questions contain. In struggling with these and other moral dilemmas,
more and more health care professionals are experiencing acute anxiety which
has come to be identified as a condition known as moral distress.
What is Moral Distress?
While moral distress is pervasive, it is seldom recognized and is poorly
understood (Cavaliere, Daly, Dowling and Montgomery,
2010). The study of understanding the exact nature of moral distress is
at its beginning stages (Thibeault, 2001), (Corley,
2002) and is confirmed by the fact that early references to moral
distress (Cavaliere et al. 2010) offer only
incomplete definitions. In reviewing the literature it is apparent that the
first definition of moral distress given by Jameton
(1984) lacked reference to the spiritual and physical aspects; for him
moral distress is the:
" ... painful feelings and/or the psychological
disequilibrium that occurs when nurses are conscious of the morally
appropriate action a situation requires, but cannot carry out that action
because of institutional obstacles; lack of time, lack of supervisory
support, exercise of medical power, institutional policy, or legal limits."
Pendry's more recent study (2007) expanded the definition to include the
interior challenges, defining moral distress as "the physical or emotional
suffering that is experienced when constraints (internal or external)
prevent one from following the course of action that one believes is right."
(p. 217). In Hanna's (2005) phenomenological study of nurses who assisted
with legal, elective, and surgically induced abortions is noteworthy because
it attempted to articulate a universal definition of the concept of moral
distress. She seems to get at the underlying essence of moral distress when
she defines it as "an act of interior aversion that occurs when some harm to
an objective good is perceived." (p. 105).
Despite the fact that many people who suffer from moral distress are not
familiar with the term, and despite how few studies have been conducted on
what constitutes moral distress, it is cited in many medical codes of
ethics. In Canada, for example, the Canadian Nurses
Association (CNA, 2008) Code of Ethics defines moral distress
(derived from Jameton, 1984) in the following way:
"Moral distress arises in situations where nurses know
or believe they know the right thing to do, but for various reasons
(including fear or circumstances beyond their control) do not or cannot take
the right action or prevent a particular harm. When values and commitments
are compromised in this way, nurses' identity and integrity as moral agents
are affected and they feel moral distress."
Who experiences moral distress?
Today, health care teams commonly need to make decisions to sustain a
life not considered viable twenty years ago and as a result, the number of
those experiencing moral distress has increased. Although moral distress
can affect all health care professionals, the intimacy of the relationship
between a nurse and a patient can make nurses more vulnerable.
It is not surprising that studies indicate that nurses, whose work is
essentially a "moral endeavour," experience moral distress more frequently
than physicians. (Janvier, Nadeau, Deschenes, Couture
and Barrington, 2007; Rittenmeyer and Huffman,
Nurses working in a NICU setting, for example, are at an increased risk
of experiencing moral distress due to the frequency with which their patient
population encounters life issues. While there are a limited number of
studies in the NICU setting, neonatal nurses, who care for patients who are
extremely vulnerable, work in an "emotionally and ethically sensitive area"
every day (Cavaliere et al, 2010, p. 146) and confront many difficult
decisions. In these cases, which involve questions of life and death, the
long-term outcomes of premature infants must be considered and weighed
against the considerable pain and suffering these tiny patients must endure.
Furthermore, nurses may be required to perform many painful procedures on
these infants while having limited influence on major treatment decisions
(Thibeault, 2001). When discussing whom the legitimate decision maker is
when making ethical decisions about a baby - the nurse often feels powerless
to influence the doctor or the family who sometimes make uninformed choices
or elect treatments that the nurses disagree with or may feel are
In one study in a NICU, almost all the nurses experiencing moral
distress told stories of a baby who died (Thibeault, 2001). The stress of
having to watch an infant suffer extreme pain while knowing the infant
cannot speak or make a choice is extremely difficult for anyone to
endure. For nurses, however, it is even more so as this feels contrary to
what is at the core of the caring profession - that of advocacy and
seeking the good of the patient as priority. Janvier et al. (2007) found
in a study conducted in Quebec that 35% of all nurses and 19% of the
residents experienced frequent ethical confrontations that were
stressful- the rates for NICU nurses in tertiary hospitals were higher at
56%. A systematic review of 39 qualitative studies on moral distress found
nurses in critical care settings experienced high levels of moral distress
which not only affected them psychologically and physically, but even
spiritually; thus negatively impacting their self-image and job satisfaction
(Rittemeyer and Huffman, 2009).
Situations that contribute to moral distress
There is a dichotomy between what nurses are trained to do and how they
actually perform in the clinical setting; in practice, ideals are
contradicted by realities. The Canadian Nurses'
Association (2008) Code of Ethics for Registered Nurses clearly
articulates the ideal in the following way: "Nurses intervene, and report
when necessary when others fail to respect the dignity of a person receiving
care, recognizing that to be silent and passive is to condone the
behaviour." (Code, 04). In addition the nursing baccalaureate programs teach
nursing students ethical principles - that of autonomy, beneficence,
non-maleficence, justice and fidelity. They are taught to respect all
persons and promote their independence, self-determination and selfreliance.
Nursing educators specifically teach students not to blindly follow medical
orders but to carefully assess patient needs and then to develop a plan of
care to meet these needs. Nurses are committed to caring and not
intentionally inflicting harm or injury - they are responsible for ensuring
safe and competent care.
In practice however, ethical or moral decision-making is not only
influenced by the ideals of personal values and the values of the profession
but by concrete factors in the particular system they work in. The question
is often not what is morally right or wrong but how can nurses act in a
moral way in a particular environment when some factors may prevent this.
The inability to follow their conscience is a major problem among nurses who
work in critical care areas of a hospital - especially with the critically
ill and dying and those with life prolonging treatments. Distress is
heightened for nurses who work in environments that are resource
constrained, have excessive workload assignments or experience problems
around resource allocation. Other unique challenges include: the fear of
facing adversity through whistle blowing, weak policies and the moral
distress experienced when nurses advocate for their patients but feel their
voices are not heard (Rittenmeyer and Huffman, 2009).
Rittenmeyer and Huffman's (2009) study on the experience of moral distress,
reported by nurses themselves using a variety of methodologies, uncovered
four syntheses that highlight the difficulty of moral orthopraxis. The four
a) the inability to advocate for the patient and
b) the patient's pain and suffering and the inability
to influence decisions about their care,
c) power hierarchies and lack of recognition for
d) perceived employment risk if they were to voice
What are the signs and symptoms of moral distress?
Nurses' reactions to moral distress contain a wide range of physical,
psychological, spiritual and stress responses. Thibeault' s (2001)
descriptive exploratory study of moral distress experienced by NICU
nurses attributed the complexity to several factors: an increase in
technology and the number of interventions as well as the fragile condition
of premature infants. Most literature describes similar themes where moral
distress was the result of needless pain and suffering inflicted on babies.
One prevailing theme was the feeling of powerlessness. Most organizations
have an unequal hierarchy in which doctors have the power to decide, despite
rhetoric about teamwork, inter-professional collaboration and shared
decision-making. Nurses often fear raising concerns because of possible
repercussions - they fear the doctors as well as the administrators. Nurses
experienced "profound disillusionment" when they were repeatedly unable to
practice their core values, especially when doctors and nurses differed
in opinion over the right treatment of a patient (Rittenmeyer and Huffman,
2009, p. 1242). When coping strategies are inadequate, nurses may get burned
out and/or leave the unit, the institution or even the profession. Some
nurses either distance themselves becoming callous and indifferent or
alternatively, they choose to act as advocates for patients and are
sometimes successful (Cavaliere et al., 2010).
Rittemeyer and Huffman (2009), found responses
to moral distress include feelings of: anger, loneliness, depression, guilt,
anxiety, powerlessness and emotional withdrawal as well biopsychosocial
responses. These symptoms include sleeplessness, headaches, nausea, dreaming
and fatigue. Lasting effects of moral distress include:
a) A profound sense of sadness - the feelings of
sadness were not correlated with either successful or unsuccessful coping -
they were just pervasive.
b) An increased sense of patient advocacy - many NICU
nurses felt the baby's voice needed to be heard and that "we forget that
babies are persons" (Thibeault, 2001, p. 53).
Moral distress is a subjective experience yet can be objectively observed
and measured to some extent. In an effort to describe the spiritual aspect
in a scientific way, Hanna (2005) used the Roy
Adaptation Model of nursing (a theory most RNs are familiar with) as the
conceptual basis for her study as well as the philosophy of Wojtyla. His
work is significant to qualitative inquiry because it focuses on the
phenomenological analysis of the moral/ethical nature of the human person.
Phenomenology is a scientific way to discover universal truths. Sr. Callista
Roy's philosophical assumption is derived from the view "that truth exists
and its fullness is found in the creator." (p. 98).
Not all health care professionals react in the same way when experiencing
an ethical dilemma; therefore, by studying their lived experience, we are
able to gain understanding in order to find ways of supporting others.
After Hanna analyzed her phenomenological data through four different
perspectives: the lived body, the lived space, the lived relationship and
the lived time, she added a fifth perspective derived from Wojtyla's
work- the concept of conscious reflexivity or lived consciousness. By
looking through this lens, Hanna (2005) sought to
analyze the data related to moral/ethical/spiritual self. The findings in
Hanna's qualitative study found that the nurses who utilized conscious
reflexivity were able to describe their values and were able to journey
interiorly in order to grow through their experience.
Hanna describes moral distress as an act of interior aversion that
usually begins with a pre-cognitive "physical" type of perception that is
experienced through the senses. Hanna later goes on to describe a second
level of perception that happens at the cognitive level. By consciously
reflecting on significant events in clinical practice we are able to
interiorize our internal view of our acts.
Hanna (2005) was able to classify three types of moral distress: shocked,
muted and suppressed. Nurses with shocked moral distress begin with a clear
perception of harm to an objective good that is matched with an immediate
interior rejection of that harm, and a "fight or flight reaction". These
nurses seek others they trust to listen to their stories
in order to receive support. It is possible that the nurse in this case
study experienced shocked moral distress. She was certain that Baby
Mary's lack of care was wrong and was facing grave harm. Her visceral
reaction as a result of her conscious awareness of her position on
euthanasia created an internal conflict. Her attempt to bring Baby Mary
home was her effort to "fight" what was happening - however her
inability to speak out was dominated by the fear of losing her job. The
communication of peers who openly shared their abhorrence was reassuring
and the support of her spiritual director and pro-life community helped
her to journey through this difficult time.
Nurses with muted moral distress avoid discussion with others while
interiorly dialoguing and through conscious reflexivity and they can be
lead to increased self-knowledge and healing. Nurses with suppressed
moral distress avoid selfconversations and rarely discuss their
experience with others; for these nurses the issues remain unresolved.
The study suggests that the nurses' health and sense of wholeness can
be affected if they resist the process of conscious reflexivity
Guidance from the Catholic Church
Human life is sacred from the very first moment it begins because it
involves a creative act of God and always remains in a special
relationship with the Creator, for whom all life is directed as its sole
end. Donum Vitae (1987) thus concludes: "No one can, in any circumstance,
claim for himself the right to destroy directly an innocent human being"
(p. 76-77). Catholic health care professionals can be guided and
consoled by this truth and by John Paul II's reminder in
Evangelium Vitae (1995) that emphasizes the "incomparable worth" and "inestimable value"
of the human person in regard to these or any issue that threatens or
opposes life: Even in the midst of difficulties and uncertainties, every
person sincerely open to truth and goodness can, by the light of reason
and the hidden action of grace, come to recognize in the natural law
written in the heart (cf. Rom 2: 14-15) the sacred value of human life from
its very beginning until its end, and can affirm the right of every human
being to have this primary good respected to the highest degree. (EV 2)
Nurses therefore need only trust and listen within themselves to the
voice of God that speaks to them in the interior of their heart. Gaudium
et Spes, as quoted in the Catechism (1994), affirms this same universal
and divine truth which echoes deep within the conscience of every person,
a voice "ever calling him to love and to do what is good and to avoid
evil" and that remarkably "sounds in his heart at the right moment." (CCC
Pope Francis (2013), however, alluded to a "widespread mentality" which
makes it difficult to hear this voice because it enslaves the hearts and
minds of so many, producing a "throw away culture" which seeks
to eliminate human beings, especially the physically and socially weak.
The Pope even stated that this "cultural disorientation has affected a
sphere that seemed unassailable", the medical profession. He continues
by saying, "Although being by their nature at the service of life, the
health professions are induced sometimes not to respect life itself." The
medical environment, conditioned by certain factors, can ironically
become a place in which "life is not always protected as a primary value
and a primordial right of every man," a place which not only prohibits
the exercise of our conscience but clouds it (Francis, 2013). The
consequence of this is summed up by John Paul II who concludes:
The end result of this is tragic: not only is the fact of the
destruction of so many human lives still to be born or in their final
stage extremely grave and disturbing, but no less grave and disturbing
is the fact that conscience itself, darkened as it were by such
widespread conditioning, is finding it increasingly difficult to
distinguish between good and evil in what concerns the basic value of
human life. (EV 4)
Benedict warns us of the danger in Caritas in Veritate (2009), which
affirms that openness to life is crucial to the development of society.
He explains that a society that moves towards the denial or suppression
of life ends up no longer finding the necessary motivation and energy to
strive for man's true good, resulting in the "withering away" of other
forms of acceptance that are valuable for society. On the other hand, he
confirms how the acceptance of life strengthens our moral fiber, promotes
virtuous action and engenders the capacity of people to mutually help one
another (CV 67). In cases like Baby Mary's, the Church clearly guides
moral decisions regarding the extubation and withdrawal of extensive
lifesaving interventions when the prognosis is poor as seen in the
Vatican's Declaration on Euthanasia (1980):
"It will be possible to make a correct judgment as to
the means by studying the type of treatment to be used, its degree of
complexity or risk, its cost and the possibilities of using it, and
comparing these elements with the result that can be expected, taking into
account the state of the sick person and his or her physical and moral
In focusing on these concrete circumstances, probabilities,
statistical analysis and research however, the key is not losing sight of
the totality of the human person. Francis points out, "The credibility of
a health care system is not measured only by efficiency but above all by
the care and love of persons, whose life is always sacred and
inviolable." (2013). One must not become distracted by the medical
complexities and so emphasize the case over the gift and dignity oflife
and be led into neglecting or omitting to do what is necessary. When
the ultimate end of medical action ceases to be the defense and promotion
of life, sin enters into the arena. This is in fact a grave sin of
omission, as proposed by Harrington and Keenan (2002) who define sin as
"our failure to bother to love" (p. 100). The health care environment
must become a place in which we always strive to love and thereby
transform the occupation into a mission (Benedict, 2012).
Our hope, then, lies in striving "to interpret the data of experience
and the signs of the times assisted by the virtue of prudence, by the
advice of competent people, and by the help of the Holy Spirit and his
gifts." (CCC, 1788). We as Catholics are mandated to be witnesses for the
"culture of life". We have a great responsibility to ourselves to live a
committed Christian vocation. We also have a responsibility toward our
culture, to recognize God's work in every human person; this sometimes
requires "going against the current" (Francis, 2013). The nurse in Baby
Mary's story faced this challenge; that of acting on her conscience and
speaking up knowing it could have jeopardized her professional career.
Although the CNA ensures that nurses who declare a conflict of conscience
receive fair treatment and not experience discrimination, few nurses are
aware of this provision and fewer exercise it. Taking note of the "tide
of popular culture and peer pressure that is indifferent, if not
hostile, to Christian morality",
John Paul II (1987), in his address
while visiting the United States said:
In a secularized world, to speak and act in the name of Jesus can
bring opposition and even ridicule. It often means being out of step with
majority opinion. Yet if we look at the New Testament, we find
encouragement everywhere for perseverance in this testing of our faith.
In the New Testament after Jesus, we find Mary the Mother of God is
the paragon who embodies all the virtues. In the face of confusion Mary
gives us a powerful example of how to ponder in our heart, to think about
something carefully and weigh it in our mind - it implies a serious
process of mental activity - a careful consideration of all the pertinent
factors involved. "Ponder" in the Greek implies not just considering
but an attempt to put things together. To ponder in our heart and mind is
a kind of holistic contemplative response or a type of reflexive
thinking. She helps the Church to discern the battle lines of the war and
helps to understand exactly what is at risk; that every human life is
always at the centre of a great struggle between good and evil, between
light and darkness (EV, 104). John Paul II (1995) points to the child in
Revelations 12:4, who is held by his mother, (a symbol of Mary, the
Mother of God), as "a figure of every person, every child, especially
every helpless baby whose life is threatened because as the Council
reminds us "by his Incarnation the Son of God has united himself in some
fashion with every person". (EV, 104)
Some Implications for Practice
Despite clear guidance from the Church supporting the rights of Baby
Mary to life, we find decisions that support a culture of death
quietly being made in our North American hospitals every day. The
question remains how else can nurses and other health care professionals
feel supported in order to continue to care for the sick and dying in a
system dominated by moral relativism? Implications for practice
include providing education on the effects of moral distress, by giving
nurses a voice in order to express their views and concerns and providing
an environment where nurses can practice without either being coerced
or violating their values. There is a need to raise awareness of the
moral nature of nursing work as well as the lived experience of moral
distress in Catholic nurses and other helping professions, particularly
those who are responsible for counseling persons experiencing ethical
dilemmas. Research is important in order to assess the effectiveness of
possible strategies to implement that can decrease the effects of moral
distress. (Rittenmeyer and Huffman, 2009). Also, Catholic nurses need to
advocate for policies that support those who stand firm in their own core
beliefs about good nursing care and patient advocacy.
(2001) identified several key strategies to help nurses who experience moral
distress. The most effective strategy was the importance of peer support,
this is especially important to pro-life nurses as many institutions
are not supportive of nurses with Catholic and prolife views. In her
study, Zuzelo (2007) found that while nurses identified various support
groups, most named nurse managers, ethics committee consultation and
chaplains as most helpful. Discussing ethical practice concerns in a safe
place will decrease the chances that she will experience the consequences
of using negative coping strategies (CNA, 2003). Nurses must be
encouraged to engage in self-reflective practices as mandated by their
College, as they are often active participants in care they feel is wrong
(CNO, 2002). If they do not participate in a reflective process to
facilitate moral growth they may be left with unresolved healing.
addition, as seen in the journal entries of the nurse who cared for Baby
Mary, telling and retelling our stories can make a contribution to the
understanding of this lived experience and also begin the process of
healing. For Catholic health care professionals, prayer, hospital
chaplains, good spiritual direction and conversation in confession can
be sources of great comfort and support, which foster the reflective
process. One of the most important aspects is the development and
education of the conscience. The Catechism of the Catholic Church
emphasizes that the education of the conscience is a lifelong task that
can prevent fear, guilt and feelings of complacency. The education of the
conscience guarantees freedom and engenders peace of heart(1784, 5).
- Note: On 18 March, 2014, the Project Administrator
sent this information to the Toronto Police Service homicide section
using the email form provided on the Toronto Police Service website.
Not having received a response, on 25 March, 2014, the Administrator
faxed a letter and the information to Toronto Chief of Police William
Blair. Toronto Police acknowledged receipt of the information in a
letter dated 27 March, 2014, stating that someone would contact the
Administrator. A member of the Homicide Squad contacted the Project
Administrator on 15 August, 2014, requesting any further available
information. The Administrator replied the same day. On 14 April, 2015,
in response to an enquiry from the Administrator, the member of the
Homicide Squad advised that the journal article above disclosed "no
criminal offence" and that "the circumstances surrounding this death would fall
under acceptable medical protocols that are followed by medical
practitioners in neonatal care facilities." That being the case,
the Toronto Police did not begin a homicide investigation.
Benedict XVI, (2009).
Caritas in Veritate.
Canadian Nurses Association (CNA), (2008).
Code of Ethics for Registered Nurses,
Canadian Nurses Association (CNA), (2003).
Ethical distress in health care environments. Ethics in
Practice for Registered Nurses.
Catechism of the Catholic Church. (1992).
Cavaliere, T., Daly, B., Dowling, D. &
Montgomery, K. (2010). Moral distress in neonatal Intensive care unit RNs.
Advances in Neonatal Care, 10 (3), p. 145 - 156.
College of Nurses of Ontario (CNO), (2002).
Professional Standards. p. 1-13.
Congregation for the Doctrine of the Faith. (1987).
Corley, M. (2002). Nurse moral distress: A proposed
theory and research agenda. Nursing Ethics. 9(6), p. 636 - 650.
Hanna, D. (2005). The lived experience of moral
distress: nurses who assisted with elective abortions. Research and
Theory for Nursing Practice: An lnternational Journal, 19 (1), p. 95 -
Harrington, D. & Keenan, J. (2002). Jesus
and virtue ethics: Building bridges between new testament studies and moral
theology. Lanham, Maryland Chicago Illinois.
Jameton, A. (1984). Nursing practice: The
ethical issues . Englewood Cliffs, NJ: Prentice-Hall.
Janvier, A., Nadeau, S. , Deschenes, M., Couture,
E., & Barrington, K. (2007). Moral distress in the neonatal intensive care
unit: caregiver's experience. Journal of Perinatology. 2 7,
John Paul II, (September 15,
Address of His Holiness John Paul II Apostolic Journey to the United
States and Canada, Visit to the Cathedral of Saint Vibiana.
John Paul II, (1995).
Pendry, P. (2007). Moral distress: Recognizing it to
retain nurses. Nursing Economics. 25(4), p. 217 - 221.
Pope Francis. (September 20, 2013).
Address at a meeting of the International Federation of Catholic Medical
Pope Benedict XVI, (May 3, 2012).
Address to the Catholic University of the Sacred Heart of Rome.
Rirtenmeyer, L., Huffman, D. (2009). How
professional nurses working in hospital environments experience moral
distress: a systematic review. Journal of Advanced Nursing. 7 (28),
p. 1233 - 1290.
Thibeault, M. (2001). The experience of moral
distress in neonatal nurses. Unpublished master's thesis, Dalhousie
University, Halifax, Nova Scotia, Canada.
Wojtyla, K. (1981). Toward a philosophy of
praxis: An anthology. A. Bloch & G.T. Czuczka (Eds.). New York:
Zuzelo, P. (2007). Exploring the moral distress of
registered nurses. Nursing ethics. 14 (3), p. 344 - 359.