Freda is a thirty-two-year old woman in an advanced fixed stage of multiple sclerosis. She is no longer able to move independently or feed herself. She is able to speak with great difficulty. Her decisional capacity is intact.
Freda's inability to swallow has caused her to lose weight to the point that she is clinically malnourished. Three decubitus ulcers have developed and are not responding to treatment. In conversation with long-term care nursing staff, social workers, and her attending physician, she has made it clear that she does not want a gastric feeding tube. In conference with staff, her mother, and an aunt, she has declared that she wants her two young children to be in the care of their father (who is not her husband), and that she ought to be allowed to die as peacefully and gracefully as possible.
Her mother takes her to a neurologist at a nearby teaching hospital where she has been followed in the past. The neurologist is persuaded by the mother and arranges the insertion of a gastric feeding tube.
When the patient returns to the long-term care facility, the nursing staff is in a high state of moral distress. They view the feeding tube as a flagrant violation of the patient's clear statement of preferences. They lash out at the mother and accuse her of manipulating the patient. Freda is frozen in a catatonic state and cannot, or will not, communicate with staff or family. The attending physician shows no willingness to try to reverse the decision to maintain the patient on the feeding tube. The nursing staff morale sinks very low as they see no way to avoid doing to the patient what she very clearly did not want done. They finally confront the attending physician and demand that something be done to relieve the patient's suffering and their moral distress.
Reflecting on Cases involving Moral Distress
Each case should be analyzed according to its particular merits and context. The following questions, however, will help individuals or ethics committees clarify the nature of the conflict, the impasse, and the sort of moral distress that characterizes each situation.
The following questions test whether adequate attempts have been made to deal with the moral distress created by the conflicting goods:
These questions are important elements in all ethical deliberation.