A philosophical reconstruction of moral distress: Its paradox and significance in healthcare practice

The constraint model

Andrew Jameton introduced the concept of moral distress in his 1984 book Nursing Practice: The Ethical Issues. ¹ Jameton defined moral distress as the psychological distress that arises when one knows what the right action is but cannot carry it out because of institutional constraints. ⁵ In a later article, he distinguished between initial distress, which arises in direct response to institutional obstacles and conflicts with others about values, and reactive distress, which is felt when people do not act upon their initial distress. ⁶ These two formulations established the structural core of the constraint model: moral distress presupposes an agent’s moral judgement about what ought to be done, and what produces it is institutional obstruction of action that would accord with that judgement.

The constraint model made at least two important contributions. First, it distinguished moral distress from adjacent but different phenomena. In a moral dilemma, multiple competing obligations pull the agent in different directions, and the agent faces a genuine choice. By contrast, moral distress in Jameton’s sense arises precisely where there is no such choice: the agent already grasps what ought to be done but cannot do it. ¹ Second, by identifying institutional constraint as the crucial factor, the model provided a perspective that does not reduce distress to mere personal weakness or emotional fragility.

Yet, the constraint model leaves an important problem unresolved: the mechanism of moral perception – how one comes to know the right action – remains insufficiently examined. Campbell et al. explicitly criticise Jameton’s definition on the grounds that “the restriction to knowledge is too strong” (p. 9). ⁴ Morley et al., moreover, show that the notion of “moral judgement” presupposed by Jameton has remained ambiguous, with belief, judgement, and awareness often treated as interchangeable without epistemological distinction. ⁷ They further argue that distinguishing these notions in a moral-philosophical context could alter the conditions under which moral distress is said to arise. ⁷ Kolbe and de Melo-Martin further argue that existing moral distress measures often fail to determine whether distress reflects an accurate assessment of clinical circumstances, whether it is genuinely moral in character, or whether it constitutes an appropriate target for intervention. ⁸ This limitation illustrates how epistemological ambiguity in moral distress research generates not only definitional problems but also methodological difficulties in empirical studies.

The moral residue model

The second major development in moral distress theory came with the introduction of the moral residue model. Epstein and Hamric, while inheriting Jameton’s distinction between initial and reactive distress, ⁶ reformulated the latter as “moral residue.” ⁹ Their crescendo effect model depicts a structure in which, even after moral distress subsides, residue remains if it is not adequately resolved, and unresolved moral residue gradually accumulates over time. ⁹

Moral residue is initially defined by Webster and Bayliss as that which each of us carries with us from episodes in which we have seriously compromised ourselves, or been compromised, in the face of moral distress. ¹⁰ The moral residue model marked theoretical progress in at least two respects. First, it introduced a temporal dimension, recognising that the moral distress of healthcare professionals is shaped not only by the present situation but also by the history of ethical involvement and compromise. Second, it helped explain the mechanisms by which repeated experiences of moral distress can lead to burnout, withdrawal from patients, and similar consequences.^11–14

However, by focusing on the psychological aftereffects of repeated moral compromise, the moral residue model tends to shift the centre of analysis away from the normative structure of moral distress itself and towards the explanation of its psychological consequences. As a result, it risks leaving insufficiently examined the institutional conditions and normative structures that generate moral residue. From the standpoint of the present argument, the epistemological and normative questions left unanswered in the constraint model therefore persist in another form within the moral residue model.

The moral agency model

Of the three models, the moral agency model offers a comparatively more philosophically refined formulation. On this model, moral distress is understood not simply as the obstruction of action but as the restriction of professional moral agency – the capacity to deliberate, judge, and act in accordance with one’s moral commitments. A key transition towards this model is provided by Fourie’s critique of Jameton’s narrow definition. Fourie criticises Jameton’s narrow definition as overly restrictive and proposes a broader redefinition of moral distress as a psychological response to morally challenging situations involving moral constraint, moral conflict, or both. ³ Although Fourie’s discussion is not primarily framed in terms of moral agency, her broader formulation opens the way for later accounts that place moral agency more explicitly at the centre of the concept.

Rushton develops this line of thought more directly by characterising moral agency as something that exceeds mere cognitive judgement and explicitly identifying moral sensitivity, perception, and imagination as its components. ¹⁵ Rushton and colleagues further define moral sensitivity as acute perception of morally salient features of a situation – including the interests and values of those involved, as well as options and courses of action relevant to ethical questions, conflicts, and dilemmas – and treat it as inseparable from moral perception and attunement. ¹⁶

The moral agency model represents an important advance over the previous two by shifting the focus from the obstruction of action to the restriction of professional moral agency itself, with moral sensitivity and perception recognised as its constitutive components. Yet, this model too fails fully to explain the perceptual and educational conditions presupposed by moral agency – namely, how healthcare professionals come to perceive ethical situations, recognise moral reasons, and thereby acquire moral agency in the first place.

A common unresolved question: The theoretical absence of moral perception

Across the three models, one finds that although the occurrence of moral distress presupposes some form of moral perception, the character and formation of that very capacity remain insufficiently theorised. In one model it is described as moral knowledge; in another as moral sensitivity or moral agency. In every case, however, the question of how an agent comes to “see” morally salient features recedes into the background. The theoretical confusion in moral distress research therefore arises not only from definitional disagreement but also from the epistemological gap that underlies it.

It is precisely this gap that the present paper addresses. The aim is to use McDowell’s arguments to provide an epistemological foundation for the moral perception presupposed by existing moral distress research. The point is not merely to introduce the arguments of McDowell. Rather, it is to reconstruct – guided by the question of how healthcare professionals perceive the ethical demands of their practice and are moved by them – the understanding of moral judgement presupposed in the constraint model, the temporal dimension addressed in the moral residue model, and the focus on agency in the moral agency model. This diagnosis is also consistent with McCarthy and Gastmans’s review of the argument-based nursing ethics literature, which shows that the concept of moral distress has been deployed in multiple ways and remains in need of greater conceptual clarification within nursing ethics itself. ² It is further reinforced by Deschenes et al.’s concept clarification, which shows that moral distress has been variously defined in the nursing literature and remains in need of greater conceptual coherence. ¹⁷

At this point, it is important to distinguish moral distress from psychological distress more generally. Psychological distress refers broadly to experiences of emotional suffering, anxiety, frustration, or burnout and may arise from a wide range of personal, interpersonal, or organisational factors. Moral distress, by contrast, is specifically connected to an agent’s perception of moral reasons and the inability to respond adequately to them. Although moral distress may be accompanied by psychological symptoms, its defining feature is not the intensity of emotional suffering itself but its relation to ethically significant considerations. This distinction suggests that an adequate account of moral distress requires not only a description of psychological states but also an explanation of how healthcare professionals come to perceive moral reasons in the first place.

McDowell’s argument in “Virtue and Reason”

In his 1979 essay “Virtue and Reason,” John McDowell offers a contemporary reinterpretation of Aristotle’s virtue ethics and addresses how a virtuous person recognises what is morally required in a given situation. According to McDowell, the virtuous person has a “reliable sensitivity” to the sorts of requirements that situations impose on action, and this sensitivity may be described as “a sort of perceptual capacity” (p. 51). ¹⁹ More generally, virtue itself is “an ability to recognize requirements which situations impose on one’s behaviour” (p. 53). ¹⁹ Although McDowell uses terms such as “sensitivity” and “perceptual capacity,” he does not present “moral sensitivity” as a technical term in the later sense used in healthcare ethics. What this paper takes from McDowell is rather the claim that moral perception is not simply the result of rule-application or propositional inference, but rather a perception through which trained healthcare professionals can see what a situation calls for.

Particularly important here is McDowell’s notion of “silencing.” When the virtuous agent perceives a situation, “some aspect of the situation is seen as constituting a reason for acting in some way” (pp. 55–56), and that reason is understood not merely as outweighing or overriding competing considerations but as silencing them. ¹⁹ By “silencing,” McDowell does not mean that one reason simply defeats another through a process of deliberative comparison. Rather, a morally salient feature of the situation is perceived as so normatively significant that alternative considerations cease to function as genuine reasons for action. In this sense, the agent does not experience a balance of competing reasons but sees the situation itself as calling for a particular response. This notion shows that moral perception is not merely an external comparison of reasons; rather, the ethical meaning of the situation as a whole presents itself to the agent with a certain priority. The presupposition that one already knows what the right action is can thus be recaptured as a result of moral perception.

Second nature, the space of reasons, and Bildung

In Mind and World (1994), McDowell develops the epistemological basis of this kind of moral perception in a more systematic way. Here, we focus on three key notions: the space of reasons, second nature, and Bildung.

The starting point for the “space of reasons” is Wilfrid Sellars’s critique of the Myth of the Given. Classical empiricism tended to assume that knowledge is grounded in “the given” – mere sensory stimulations or observational data that are prior to concepts. Against this, Sellars writes: “in characterizing an episode or a state as that of knowing, we are not giving an empirical description of that episode or state; we are placing it in the logical space of reasons, of justifying and being able to justify what one says” (pp. 298–299). ²⁰ Justification thus belongs to the realm of concepts, and preconceptual sensory stimuli cannot, by themselves, count as reasons.

McDowell inherits this insight. ²¹ However, he does not conclude that because experience is sensory it must therefore lie outside the space of reasons. His central claim is rather that conceptual capacities are already operative not only at the stage of judgement but at the stage of perception itself. Experience does not have a two-stage structure of “nonconceptual sensation plus subsequent interpretation”; instead, it is conceptually structured from the outset. “Conceptual capacities, whose interrelations belong in the sui generis logical space of reasons, can be operative not only in judgements […] but already in the transactions in nature that are constituted by the world’s impacts on the receptive capacities of a suitable subject” (p. xx, Introduction). ²¹ In this way, the subject can be “open to the way things manifestly are” (p. xx). ²¹

This argument is connected to McDowell’s critique of “bald naturalism,” which attempts to reduce the space of reasons to the explanatory space of natural science. ²¹ The structure of the space of reasons, McDowell argues, has a “sui generis” character irreducible to the descriptive space of natural science. ²¹ At the same time, he rejects “rampant platonism,” which pictures the space of reasons as an autonomous structure constituted independently of anything specifically human. ²¹ The key concept here is “second nature”: “The mistake here is to forget that nature includes second nature. Human beings acquire a second nature in part by being initiated into conceptual capacities, whose interrelations belong in the logical space of reasons” (p. xx). ²¹

In the ethical context, this point is concretised through Bildung. McDowell writes that when “decent upbringing” initiates us into the relevant modes of thought, “our eyes are opened to the very existence of this tract of the space of reasons” (p. 82). ²¹ He further notes that if we generalise Aristotle’s conception of ethical character formation, we arrive at the idea that by acquiring a second nature one’s eyes are opened to reasons in general – an idea that appears in German philosophy as Bildung. ²¹ Meaning is not “a mysterious gift from outside nature” (p. 88) ²¹; rather, the second nature acquired through Bildung is a “capacity to resonate to the structure of the space of reasons” (p. 109). ²¹ Importantly, McDowell does not treat “decent upbringing” as a foundational criterion for moral truth. Elsewhere, McDowell clarifies that the notion of proper upbringing is introduced not as a foundation for ethical theory but as a way of explaining how individuals acquire a mode of ethical perception through habituation and enculturation. ¹⁹ In this sense, it refers to a process of initiation into the space of reasons through which individuals acquire the conceptual capacities necessary for ethical perception. Accordingly, McDowell explicitly acknowledges that inherited forms of understanding may be distorted by parochialism or prejudice and therefore remain open to critical reflection and revision. ²¹

The upshot of McDowell’s argument is that the capacity to see what is ethically important can be reduced neither to preconceptual perceptual data (the Given) nor to mere after-the-fact inference. Through Bildung, human beings acquire a second nature and thereby become open to part of the space of reasons. This openness is not merely cognitive but also practical, shaping how agents perceive and respond to ethically significant situations. Moral sensitivity in clinical practice should accordingly be understood not as something merely subjective or as the outcome of rule-application, but as a trained perceptual capacity.

Moral sensitivity reconsidered

Against the background of McDowell’s framework, the concept of moral sensitivity used in clinical ethics can be reformulated more carefully. Rushton and colleagues define moral sensitivity as an acute perception of morally salient features of a situation and discuss it as inseparable from moral perception. ¹⁶ This paper connects that notion with what McDowell calls the ability to recognise requirements imposed by situations, ¹⁹ and understands it as the expression of a second nature trained to respond to the structure of the space of reasons. In other words, moral sensitivity in this paper refers to the capacity, formed through professional education and ethical formation (Bildung), to perceive morally significant features of a situation as reasons.

This reformulation bears directly on the central hypothesis of the paper. If moral sensitivity is one form of second nature developed through Bildung, then healthcare professionals with greater moral sensitivity can perceive moral reasons more vividly; consequently, when their responses to those reasons are blocked by some external constraint, they may experience stronger moral distress. This is the philosophical basis of what we call “the paradox of moral distress,” which will be discussed later.

Connecting McDowell to moral distress research

McDowell’s framework provides at least three theoretical benefits for moral distress research. First, it offers an epistemological account of the state Jameton presupposes when he says that one “knows what the right action is.” This is not merely propositional knowledge but a capacity to perceive features of a situation as reasons that call for action. Second, it allows moral distress to be located not merely as a psychological reaction but as suffering that belongs to a subject in the space of reasons – in other words, as the normative aspect of moral distress. Third, it makes it possible to describe moral distress structurally as a rupture between trained perception and some external blockage. By drawing on McDowell in this way, one can provide a philosophical basis for the moral perception presupposed by moral distress research and thereby redefine moral distress with greater precision. The next section presents such a redefinition.

Reconsidering the limits of existing definitions

As the previous discussion has shown, the three dominant models originating in Jameton’s classical definition ¹ all fail fully to address the epistemological genesis of “moral judgement.” Fourie’s broader definition – moral distress as a psychological response to morally difficult situations involving moral constraint, moral conflict, or both ³ – is valuable as a conceptual expansion, but it still leaves its perceptual presuppositions insufficiently explicit. Rushton’s moral agency model explicitly mentions moral sensitivity, perception, and imagination, ¹⁵ yet does not enter into the mechanisms by which these are formed. As Morley et al. conclude, there is still little agreement concerning the conditions that cause moral distress and lingering uncertainty about what moral distress is and when and how it arises. ⁷ This is not unrelated to the epistemological deficit identified here.

Reformulation through a McDowellian model

On McDowell’s framework, the generation of moral distress can be described in three stages. First, through professional education (Bildung), healthcare professionals acquire a second nature that enables them to perceive features of a situation that call for action. In the vocabulary of clinical ethics, this paper calls that capacity moral sensitivity. Second, by means of this capacity, the agent perceives moral reasons in a situation. This perception is not merely the application of a rule or an after-the-fact inference, but a practical perception in which the ethical meaning of the situation as a whole comes to presence with a certain priority. Third, when the response to those perceived reasons is blocked by institutional, power-related, or environmental constraints, the agent experiences distress. This is the essential structure of moral distress.

Understood in this way, moral distress is not a merely retrospective description of psychological distress; it is a rupture between the practical perception of a subject in the space of reasons and the obstruction of response by institutions or other external conditions. The significance of introducing McDowell lies precisely in the fact that his account can explain the mechanism of the “perception” presupposed by that rupture.

A new definition

On the basis of this reformulation, this paper defines moral distress as follows:

Moral distress is the normative aspect of the distress experienced when a healthcare professional with moral sensitivity—understood as the cultivated capacity to perceive ethically significant features of a situation as reasons—is prevented by some external constraint from responding to those reasons.

This definition differs from the existing three models in at least three respects. First, unlike the Jameton model, it does not take “knowing” as a given, but explicitly incorporates the conditions of its formation – namely, the development of perceptual capacities through professional education and ethical formation. Second, unlike the moral residue model, it understands moral distress not primarily as a matter of accumulated psychological aftermath but as normative suffering belonging to a subject in the space of reasons. Third, unlike the moral agency model, it explains the epistemological basis of moral agency through the concepts of moral perception and second nature. Nor is this definition inconsistent with Fourie’s broad definition ³ : whether moral constraint or moral conflict serves as the occasion for moral distress, what is made explicit here is that the capacity to perceive a situation as ethically significant is presupposed in either case.

The paradox of moral distress

The first implication of this definition is what we call “the paradox of moral distress.” To experience moral distress is also a sign that the healthcare professional is, in some way, accurately perceiving the ethical situation. Moral distress, in other words, is not only an indicator of suffering; it can also be a by-product of sensitivity to moral reasons. Here lies the paradox: healthcare professionals with greater moral sensitivity can perceive moral reasons more vividly, and therefore may experience stronger moral distress when their responses to those reasons are blocked. This provides the theoretical basis for the paper’s central hypothesis: the higher one’s moral sensitivity, the more likely one is, under certain conditions, to experience moral distress. This claim does not entail the simplistic conclusion that those who do not experience moral distress lack moral capacity. In clinical settings, the presence and intensity of distress are shaped by many factors, including institutional environment, scope of authority, years of experience, and systems of support. What we claim, rather, is the structural relation that, at least in theory, higher moral sensitivity can increase the possibility that moral distress will arise under certain conditions.

This paradox also poses an important question for intervention strategies aimed at reducing moral distress. If reducing moral distress is conceived, even implicitly, as involving the dulling of moral sensitivity itself, then from the perspective of this paper it risks sanctioning the deterioration of moral capacity. What ought to be asked, therefore, is not the simple reduction of distress, but how to build institutional conditions under which healthcare professionals with moral sensitivity can respond to the reasons they perceive – and, alongside this, how to cultivate the agent’s moral resilience and provide care from others.

Implications for professional education and organisational ethics

This definition foregrounds the formation of moral sensitivity, that is, the role of professional education (Bildung). For McDowell, when “decent upbringing” initiates us into the relevant modes of thought, “our eyes are opened to the very existence of this tract of the space of reasons” (p. 82) ²¹; by acquiring a second nature, one arrives at “the notion of having one’s eyes opened to reasons at large” (p. 84). ²¹ From this perspective, nursing and healthcare education should be understood not merely as the teaching of ethical rules or principles, but as the formation of the capacity to perceive ethically significant features of situations.

At least three implications follow:

First, the aim of ethics education should not be just the memorisation of rules and principles but the cultivation of the ability to discern features of situations that call for action. If moral sensitivity is understood as a cultivated second nature, ethics education should be concerned not only with the transmission of ethical knowledge but also with the formation of perceptual capacities. Educational practices such as ethics case discussions, reflective practice, narrative reflection, ethics rounds, mentorship, and supervised clinical experience may contribute to this process by helping healthcare professionals learn to recognise morally salient features of clinical situations as reasons for action and to respond appropriately to them.

Second, the experience of moral distress should not be understood as straightforward evidence of the failure of ethics education, but as an experience that can arise within the formation and enactment of moral sensitivity. The issue is not distress as such, but whether institutions secure opportunities to reflect upon it, support it, and connect it to future practice.

Third, moral resilience should be understood not as the capacity never to experience moral distress, but as the capacity to sustain or restore one’s integrity in response to moral adversity. ¹⁵ In this sense, the task of professional education is not to eliminate or reduce moral distress as such, but to cultivate the ability to reflect on it within ethical practice, endure it, and preserve responsiveness. Such integrity is sustained not only through individual reflection but also through relational and institutional support that enables healthcare professionals to deliberate with others, articulate ethical concerns, and remain responsive to moral reasons even under conditions of adversity.

Accordingly, reducing moral distress to a matter of individual coping or resilience risks rendering invisible the institutional conditions that sustain it. Support for individual healthcare professionals and resilience-building may be necessary, but they are not sufficient. What must be asked is how to establish institutional conditions in which healthcare professionals with moral sensitivity can act in accordance with the reasons they perceive. From the standpoint of organisational ethics, this raises issues such as mechanisms by which the views of healthcare professionals who raise ethical concerns are substantively reflected in decision-making, team cultures in which ethical conflicts can be discussed safely, and reforms of power structures and resource constraints that obstruct attempts to respond to what healthcare professionals recognise as ethically wrong. It also highlights the importance of effective access to clinical ethics consultation and other clinical ethics support services, including moral case deliberation and ethics rounds, as well as mentorship structures, supportive organisational leadership, and institutional ethics structures that enable healthcare professionals to sustain ethical responsiveness in practice.^22–24 Such support may help healthcare professionals articulate ethical concerns, deliberate collectively about morally challenging situations, and remain responsive to moral reasons under conditions of adversity.^22–24