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What happens when morally iffy work becomes part of your job?

Unthinkable: Moral distress is a workplace problem we ignore at our peril

Have you ever had to do something at work that you felt was morally iffy? Now imagine having to do that over and over again so it becomes part of your daily routine.

The result is what is called moral distress. If the term sounds familiar you may have heard nurses speaking powerfully of their experiences at the height of the hospital overcrowding crisis this month.

Explaining why staff might strategically avoid eye contact with patients as they juggled their workload, Karen McGowan, president of the Irish Nurses’ and Midwives’ Organisation told RTÉ's Today with Claire Byrne show: “It’s that constant internal dilemma that we have faced, and that is having a huge moral distress on us. We all go home exhausted. We might fall asleep on the sofa and then we wake up in the middle of the night and we’re thinking: Oh my god, what did I do today; what did I not do?”

Moral distress should not be confused with burnout, although one can follow the other, says Dr Sarah Otten, a lecturer in philosophy and social care at Carlow College. Along with fellow academic Francis Gahan, she has been researching the phenomenon in Irish work settings. “Theoretically, it could arise in any workplace, thought it appears to be more acute in the caring professions,” she says.


Moral distress has implications not just for employers but for all of us, Otten points out, as it raises deep questions about societal values and what it means to be human.

Modern societies focus on individual freedom and autonomy, “which is very much an inheritance from the Enlightenment”, says Otten, who did her PhD on the 18th-century thinker Adam Smith.

“But a second aspect of being human is relationality. We all have to have had relationships because we wouldn’t be alive if we hadn’t. Somebody had to have a relationship with you at least as a child, which accounts for you being here, and our focus on autonomy has kind of obliterated or hidden that aspect of our humanity.

“We have built our institutions – our schools, our businesses, our politics – to facilitate our autonomous aspect. So I can be a teacher, a student or a politician on the assumption I can freely become these things. But if you have a baby, or an elderly parent who is dependent on you out of ill-health, you can’t do those things easily; you have to find someone to offload that work onto, or hide it, and then walk out as if you are autonomous.”

Acknowledging that we are social animals – something Aristotle believed was self-evident – has revolutionary implications. “What will it mean if we didn’t take autonomy as the fundamental characteristic of being a citizen?” Otten asks. “If we took dependency and relationality as the fundamental characteristic of being a citizen, how would politics have to change, how would business have to change?”

She explains further as this week’s Unthinkable guest.

What causes moral distress?

Sarah Otten: “Moral tension is when a conflict arises between ‘what is the right thing to do’ and what organisational structures, culture and policy allow or enable the individual to do within their workplace. If this is ongoing or cannot be resolved, it leads to moral distress.”

Is it the price for participating in the labour market?

“Not inevitably, I believe. Some of us are lucky enough to be in jobs that are in sync with our moral values; or that, if there is something wrong, we feel we have the power to alter the practice or policy we believe is morally wrong. But not everyone is so lucky. And this raises larger issues about our economic system.

“Does capitalism force some groups into the kinds of jobs where moral tension is more likely and the worker is not in a position to change the condition or leave the job? Or given our suspicion that our economic system has contributed to the climate and environmental catastrophe, perhaps all of us who participate in it feel uneasy – or conflicted – to the extent that we feel forced to engage in a system that is damaging our planet because we can see no alternative way to make a living.”

How does the healthcare model in Ireland contribute to moral distress?

“It has a very rights-based focus, for historical reasons obviously, which has its benefits but also has its drawbacks – and that is it becomes very bureaucratic and very managerial.

“Social care’s main mode of working is relationship-based – you have to have a relationship with the person you’re working with, and you have to work at that. An individualistic, right-based framework doesn’t see that… There are tick-boxes in all the nursing homes for [different standards] but the relationship is invisible.”

What are care workers saying to you?

“There has been quite strong feedback from practitioners on the ground: yes, this is what I recognise and, more so, the notion that relationality and dependency are being defined as bad things. They feel bad about that because a lot of their clients will never be any other way.”

Is there a way of changing this?

“The question is: How can we make the public sphere facilitate relationality? It’s going to be messy. A box-ticking exercise won’t work.

“What it’ll mean is far more flexible workplaces – and I think this is where hybrid working, or working from home, comes into its own… So when you ask ‘Is there a fix?’ there is but it’s going to have to mean a culture shift, so [for example] having a child isn’t going to be seen as a private burden to manage outside of the public space.”

And how would healthcare organisations have to change?

“It would mean some practical things such as hire more people. Relationships require time… You’ll also need security of contracts. Unfortunately, particularly in private companies that provide care, there is often a high turnover.

“So it comes down to more time, more attractive contracts and more people.”

Looking at workers across the labour market, would you recommend someone should quit their job if they felt moral distress?

“It would obviously depend on a person’s circumstances – and if they had duties and responsibilities to others and whether they can afford to give up the job. People have to make their own judgments. But the important thing is for people to deal with it, you can’t ignore it.

“I do think it often gets misdiagnosed as burnout. That is what it can lead to but I think you have to recognise it’s a moral issue you’re feeling – ‘I feel bad about this’ – and you owe it to yourself as a human to acknowledge that…

“There is this thing: our conscience… and if we don’t pay attention to it we are diminishing a fundamental aspect of ourselves.”

Ask a sage

Misogynistic social media influencers like Andrew Tate claim to speak for men. But what is true masculinity?

Adam Smith replies: “Man naturally desires, not only to be loved, but to be lovely; or to be that thing which is the natural and proper object of love. He naturally dreads, not only to be hated, but to be hateful; or to be that thing which is the natural and proper object of hatred.”