Moral disequilibrium comprises a spectrum of moral experiences from moral unease to moral distress, injury and decline. It is an increasing phenomenon amongst health care professionals who feel constrained from doing what they believe is the morally right action. In contrast, moral equilibrium can be defined as:
[A] dynamic state of equilibrium whereby health professionals’ motivations, intentions, judgements, and actions are coherent with their moral values. When in moral equilibrium health professionals’ moral integrity, identity and moral agency are maintained or intact. It is a dynamic state as there is a constant flux of conditions that can disrupt the equilibrium, such as varying moral residue, personal and workplace stressors, and moral challenges.[1]
There is a sense that healthcare professionals’ moral disequilibrium and especially moral distress is growing within health systems in crisis in many countries, including Australia. Demands for services have long outgrown resources available, and funding has long been inadequate. The phenomenon of moral disequilibrium may be significant in a particular way within organisations that have a particular vision, mission and ethos, such as Catholic healthcare organisations. I offer the following reflection on some of Martha’s[2] struggles as a non-Catholic health professional working within a Catholic hospital in Australia. Martha wrestled with three questions: “What sustains me and keeps me going in continuing to work in a Catholic hospital?”; “What challenges me?” and “What gives me hope?”. I offer this to affirm and encourage further dialogue in the ‘doing of theology at the margins’ as in Pope Francis’ Ad theologiam promovendam[3], and to do this through encounter.[4]
“What sustains me and keeps me going?”
Martha chose to work in a public-funded Catholic hospital because her values in practising medicine generally aligned with the values of the organisation, especially those of compassion, justice, hospitality and excellence of care. Passionate about providing innovative, excellent care, she also enjoyed working with a specialist team that has the patient as the highest priority. She valued the cordial collegiality that she could always depend upon for support and care; “We get each other,” she remarked with regards to decision-making in the care of patients, adding, “the senior clinicians are very willing to share their wisdom and always have time for us young ones.” She spoke of this environment as different from other hospitals that espoused similar values, though she was unable to define the differences.
Martha recognised that, as an employee of a Catholic organisation, she had a fiduciary responsibility to follow the hospital’s policies, mission, values, and practices and to follow professional codes and the Code of Ethical Standards[5]. Fortunately, most of these were in keeping with her own professional and personal values. Martha recognised too the importance of nurturing a conscience based on factual knowledge, reasoning and experiences as well as an inner knowing that she believed was more than cognition. She especially liked the concept of practising according to her conscience and that no one could force her to do otherwise.
“What challenges me?”
Moral disequilibrium resulting from differences in perspectives of colleagues and the hospital’s policies was not new to her:
There are lots of things that do bother me like tubal ligation for a multigravida patient who really doesn’t and can’t manage any more kids. I accept that I work in a Catholic hospital that doesn’t offer this service for purely contraception purposes and the reason behind it being that it contradicts the vision of an ideal concept of marriage and family—union and procreation etc. But life is not contextually ‘ideal’ all the time. And some can’t do natural family planning for a variety of reasons. Most of our patients do not have “ideal” relationships. Sure I can refer her elsewhere for tubal ligation solely for contraception purposes, but I feel I’m not offering her the best and most efficient care I can. I keep hoping that one day the hospital admin (sic) will change its perspective and reconsider broadening their services according to the circumstances. I must admit, where appropriate I do what I believe is the right thing to do by my patients. Sometimes with difficult cases I’d seek the advice of senior staff or the ethicist/ethics committee to help me and the team decide the morally right course of management. Some of them do accept that each patient is different, and more and more they are considering the patient’s circumstances… and considering the whole person including their broader social context that importantly influences their health. Someone mentioned the Principle of Totality here, you know, to consider the whole person—mind, body, spirit, social and others—not just the physical, and how each aspect influences the other. You know what’s strange? When it comes to the crunch, it’s often subjective—the advice offered is often dependent on who you ask! Some are more liberal, some more risk adverse and afraid of scandal.
Martha also described the increasing moral residue of holding this disequilibrium—some days being better than others. Her moral distress was more evident when she went on to describe situations whereby patients had to be referred elsewhere for time sensitive care. These situations prove difficult, as other hospitals are often unable to accept patients immediately given that demands for these services, including terminations of pregnancy, far exceed resources. “Sometimes to get the services needed patients have to go private at great cost to themselves, and some can’t afford to do so.” Martha understands that this is a health-system-in-crisis situation where there are not enough resources to meet the increasing demands of healthcare, but it does not help her distress for the patient before her. She questioned why a hospital receiving public funds could choose what services they provided and not others. “I really struggled with this. I did attend a ‘moral deliberation session’ that tried to address this issue with a whole lot of other people: colleagues, admin and ethicists.” She heard that not all hospitals provide all services and that funding was given with the understanding that certain services would not be offered: “Well then the government has a responsibility to ensure such services are available even if it means building other specialist hospitals that do offer these services and make it available to everyone regardless of where they live!”
Martha continued to struggle with the frustration of balancing the fact that the hospital provided services according to their beliefs, values, ethics, and identity, and that there are patients who do not share these perspectives and struggle to find the help they need. This struggle was compounded by: the fact that the services not provided by the hospital were in accordance with professional guidelines; that the hospital she worked in was a tertiary hospital and so theoretically should provide all care; and that there were instances when the medical procedures were provided for different reasons. “I wish they would explain the nuances of this better. It may help me with my moral (disequilibrium) issues. There needs to be more opportunities for us to nut all this out.” Martha continued, “I struggle also with the instruction that I can only refer patients for ‘ongoing care’ and not for termination of pregnancy which I know is the best treatment for this patient at risk of mental anguish and complications.” She added, “I know I can’t dictate what the other hospital does to manage the patient’s care, but I feel, rightly or wrongly, I’m being undermined, not being able to express my professional opinion… and that I am compromising my professional integrity!”
“What gives me hope?”
“What gives me hope is the fact that the hospital is beginning to take more seriously the experiences of moral disequilibrium and distress that we clinicians are experiencing.” More opportunities have arisen for formal moral deliberation and formation in moral discernment and decision-making involving clinicians, ethicists, moral theologians, those in governance and perhaps even lawyers—though not enough. Martha noted, “it seems that Australia is catching up with other countries where Clinical Ethics Consultation availability is the norm and Ethics Departments are essential elements of governance structures.” She adds, “These opportunities need to be available to everyone who works here, including cleaners and ward clerks, not just clinicians.” Martha commented that the Catholic health sector was increasingly recognising and respecting the significance of the therapeutic and trust relationship between the clinician and the patient and family:
We used to perceive the Ethics Committee as policing and deciding what we can and can’t do. Now we are recognising that their role is predominantly in assisting us with our moral deliberation of patient management. After all, we know more about our patients than they ever could, and nothing is ever black and white. And that’s the same with the Code—it assists us in our moral deliberations.
Throughout these struggles, Martha is not ignorant of her fiduciary responsibility to the organisation, its identity and ethos. Another reflection Martha offered:
The other thing that gives me hope is that the Church’s perspective and teachings under Pope Francis is changing. The foundational message is the same, but the interpretation and expressions are evolving, some are becoming more relevant to the realities of today and in meeting the changing values of society. It often feels as if it’s still lagging behind. Perhaps more and more they are putting on the lens of ‘what would Jesus do?’ (WWJD)… at least my perception of WWJD. I know it’s a whole lot more complex than that… but I am a simple philosopher and moral agent who believes in enabling the other to be the best they can be and flourish. I am not a Catholic, but I believe in compassion, justice, extravagant hospitality and the loving of my neighbour as I understand Jesus was teaching. Jesus always put the person first rather than rules and regulations that constrain us from doing what is right and best for the other. That is my signpost too, like the Good Samaritan. I especially liked what I read in Pope Francis’ (sic) Declaration of Dignitas Infinita[6]”… the first part anyway. The second part at times seems to contradict the first… perhaps this is where further explanations would be helpful.
I think the Church and Catholic hospitals can do more in this age and time. They can listen more to those of us at the coal face and work together to come up with creative solutions. I think Francis called it being workers in the ‘field hospital’—to assist and not constrain. We clinicians need to know that the hospital will always have our back… and that we are valued and respected. We can only do this if we have lines of open communication and people who are open and true listeners, and as Francis says, open to encounter.
Conclusion
Advancement in medical technologies, changing societal values, and relevance of Church teachings in everyday healthcare have highlighted the differences in moral perspectives in the provision of healthcare. The crisis in healthcare provision with very limited resources and funding has compounded the resulting increase in moral disequilibrium amongst healthcare professionals. The solution to this problem is complex and requires contributions of government, the healthcare sector and policymakers, all seeking solutions at the grassroots level. However, Martha has highlighted some immediate pathways to assist in addressing health professionals’ moral disequilibrium.
Organisations can prioritise and provide moral deliberation opportunities, both formal and informal, to address complex, everyday moral challenges, especially where there are differences of perspectives and values. Participants in these deliberations could be colleagues, ethicists, executives, lawyers and other experts in the relevant fields, even all staff.
Prioritising formation or professional development opportunities in understanding and applying the principles and methodologies underpinning Catholic moral decision-making outlined in the Code and Catholic teachings is another way forward. This may contribute to further informing of conscience and clinicians’ own decision-making.
It is vital that we support healthcare professionals in their decision-making, practice, daily challenges, and well-being. Ensuring open lines of communication and transparency would also engender mutual respect and address false assumptions, which in turn allows for and encourages creative solutions. For people like Martha, this may foster greater hope and ‘keep them going’ even more.
These suggestions are not new; implementing them so that they become the norm seems to be too slow a process, according to Martha. Much, much more can be done to address the moral disequilibrium in our health professionals.[7]The way forward must encompass this critical aspect of where we find ourselves today. We are, after all, called to be pilgrims of hope.
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[1] Ong, Caroline Gaik-Gim. 2020. “Moral distress, moral equilibrium and the moral equilibrium framework: health professionals’ well-being in the face of daily challenges to moral values and integrity.” p. 94. University of Melbourne.
[2] Martha is a fictional character whose reflections capture those of a number of non-Catholic health professionals working in a public funded Catholic hospital in Australia. There is of course a much broader spectrum of experiences not captured but just as significant.
[3] Francis, Ad theologiam promovendam, Apostolic Letter motu propio, Nov 1, 2023. https://www.vatican.va/content/francesco/it/motu_proprio/documents/20231101-motu-proprio-ad-theologiam-promovendam.html
[4] Francis, For a Culture of Encounter, Morning meditation in the chapel of the Domus Danctae Marthae, September 13, 2016 https://www.vatican.va/content/francesco/en/cotidie/2016/documents/papa-francesco-cotidie_20160913_for-a-culture-of-encounter.html
[5] Catholic Health Australia. 2001. Code of Ethical Standards for Catholic Health and Aged Care Services in Australia. First ed. ACT, Australia: Catholic Health Australia. https://cha.org.au/wp-content/uploads/2021/06/Code-of-ethicsfullcopy.pdf
[6] Dicastery for the Doctrine of Faith. “Declaration ‘Dignitas Infinita’ on Human Dignity” Mar 25, 2024. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_ddf_doc_20240402_dignitas-infinita_en.html
[7] Phoenix Australia-Centre for Posttraumatic Mental Health, and Canadian Centre of Excellence-PTSD. 2020. Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury; American Association of Critical Care Nurses. 2004. “The 4A’s to Rise Above Moral Distress”; Ong, Caroline Gaik-Gim. 2020. “Moral distress, moral equilibrium and the moral equilibrium framework: health professionals’ well-being in the face of daily challenges to moral values and integrity.” University of Melbourne.