Ethics in a Pandemic

Laura Webster, DBE, RN, HEC-C, CEN; Lucia D. Wocial, PhD, RN, FAAN, HEC-C


Am Nurs Journal. 2020;15(9) 

In This Article

Moral Distress

A simple definition of moral distress is the feeling that occurs when we're prevented from doing what we believe is right. When we experience moral distress, we feel compromised in our ability to practice as moral agents according to professional values and standards. Anyone working in healthcare during the current COVID-19 pandemic should expect to experience moral distress.

Shifting standards of care, interrupted patient relationships, triaging limited resources, working in unfamiliar environments, and uncertainty about disease progression and transmission are only a few of the potential sources of moral distress during the pandemic. For many, the change in how we care for dying patients has been a significant contributor to our moral distress. In many instances, visitor restrictions prevent families from being present when their loved one dies. Compassion and respect for patients have inspired some workarounds and exceptions; some organizations use video technology to allow virtual presence and others have designated a staff member to support a limited number of family members who, at their own risk, are permitted to visit a dying patient. None of these options feel right, because under normal circumstances global visitor restrictions would be unacceptable. But doing our best with current resource limitations has to be good enough.

Addressing Moral Distress

Mapping your moral distress is an effective strategy for navigating the experience. (Click here for a visual image that illustrates how to map moral distress) Acknowledging and naming the emotions that define your distress is the first step to reflecting on it. Then challenge yourself to move beyond your immediate emotional response and apply ethical frameworks to the actions available to you. Although you may not agree with the options, seeking to understand the ethical rationale may help you understand the context of the constraints in the ethically permissible actions available. When possible, organizations may want to provide opportunities for staff to discuss ethical challenges, facilitated by someone trained in ethics. (See Self-care strategies and resources.)

ANA Code of Ethics

Turning to the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements during the pandemic may help nurses shift our focus and decrease moral distress. During a pandemic, we move away from a focus on relationship-centered care (Provision 2, Commitment to Patient) and adopt an outcome-based framework (Provision 8, Promotion of Community and World Health) with the two primary goals mentioned earlier: Use strategies to avoid entering crisis standards of care and, if crisis is unavoidable, work to fairly save the greatest number of people possible.

Despite this shift, Provisions 1 and 5—Compassion and Respect for Every Person and Equal Duty to Self—remain constant; we always practice with compassion and respect, and we owe the same duty to ourselves that we do to patients. These standards can be hard to accept, especially if it means self-protection compromises a response to a patient. It creates a tension between avoiding harm (nonmaleficence) to oneself and doing good (beneficence) for a patient. However, failing to protect ourselves compromises the patient in front of us and our ability to care for future patients.

Unfortunately, a code of ethics doesn't eliminate the challenges of making sound ethical decisions. Barriers to doing the "right thing" (such as not having sufficient supplies to care for patients) create ethical tensions in a pandemic. Internal and external constraints influence our actions, making us feel as though we're violating our professional integrity by not providing the care patients deserve and that we're capable of providing, if only we had more resources.