AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. June 2017, Volume 19, Number 6: 585-594.
doi: 10.1001/journalofethics.2017.19.06.stas1-1706.

State of the Art and Science

  • Print
  • |
  • View PDF

Initiatives for Responding to Medical Trainees’ Moral Distress about End-of-Life Cases

Medical students’ moral distress about end-of-life cases can be reduced through ethics consultation and ethics rounds, narrative reflection, and mentoring.

M. Sara Rosenthal, PhD, and Maria Clay, PhD


Moral distress frequently arises for medical trainees exposed to end-of-life cases. We review the small literature on best practices for reducing moral distress in such cases and propose two areas to target for moral distress reduction: medical education and organizational ethics programs. Students require training in end-of-life dialogues and truthful prognostication, which are not generally available without skilled mentors. But physician-mentors and teachers can suffer from lingering moral residue themselves, which can affect the teaching culture and student expectations. Finally, reducing unit moral distress that affects learners requires formal educational opportunities to debrief about difficult end-of-life cases and formal institutional mechanisms for effective clinical ethics consultation.


Moral distress, initially defined by Andrew Jameton [1, 2], occurs in situations in which a person recognizes a moral problem but is constrained from acting on it or resolving it. In the case of medical students facing such a problem, internal constraints (e.g., feelings of powerlessness or insecurity from perceived low level on a team or in a hierarchy) as well as external constraints (e.g., legal or patient rights-based) prevent their taking action, resulting in moral distress and moral residue. Moral distress is not the same as feeling “sad” about a case or being vicariously traumatized by another’s tragedy; rather, it occurs when the right action is identified but cannot be carried out. This is different than the limits of beneficence in patient care, in which all treatments for a patient at the end of life have been exhausted, leaving students feeling sad about a patient’s death. Moral residue is a term initially defined by George C. Webster and Françoise E. Baylis as “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised” [3]. Moral residue thus refers to the “lingering feelings” after the morally distressing event has passed [2].

Our analysis focuses on an emerging, yet critical problem facing medical education: moral distress in medical students unprepared for end-of-life cases and patient care dilemmas in the adult setting [4]. Reducing moral distress for students in the end-of-life patient care context involves attending to two groups whose deficits contribute to a perfect storm: medical students who may feel powerless, insecure, and ill-prepared to navigate a difficult environment and role models and mentors who could have unresolved moral residue or who are unknowledgeable about how to help medical students address moral distress. So the first questions we must address are these: Who are the students? Who are their mentors? And, finally, who are the dying patients, and why might how they’re treated trigger moral distress? We argue that failure to reduce rates of moral distress can lead to a variety of consequences and may even trigger or exacerbate depression, a recognized problem in medical school [5, 6].

Demographics: Students and Mentors

The incoming medical students for fall 2017 will be graduating in 2020. The vast majority of them will be admitted because of their academic performance and grades in the sciences [7]. Although in recent years there has been much more variety in medical school admissions criteria and openness to humanities majors, the typical applicant is still a science major [7-13].

In 2003, women comprised 50.8 percent of medical school applicants, but that figure had fallen to 47.3 percent by 2011 [14]; during the same period, the percentage of female medical school graduates rose from 45 percent to 48-49 percent [15]. It has even been suggested that there are “too many” women in medicine [16] because they tend to choose more family-friendly subspecialties (e.g., family medicine, internal medicine), leaving vacuums in more demanding specialties such as surgery. This pattern appears to reflect lifestyle choices that are not affected by health care systems, as the same trends are found in the United Kingdom [16], Canada [17], and Japan [18] as in the US. We know of no studies demonstrating whether women students are better equipped than male students to handle the end-of-life patient care context, although one study found they experienced less moral distress [4]. However, given that female medical students may not be seeing enough women in medical leadership roles due to a lag in organizational ethics policies surrounding promotion of females to leadership positions [19, 20], their moral distress may be exacerbated if they feel uncomfortable discussing it with male mentors.

Ultimately, mentors in medical education need to acknowledge that the strengths that got students into medical school (aptitude in math, science, and memorization) are frequently not the same skills that students need to get through medical school and become physicians in their own right. Invariably, the skills required to succeed in the profession, including empathy and communication, will need to be both modeled and taught, which is the ongoing process of exercising clinical phronesis, or practical reasoning [21, 22].

Who Is Teaching Medical Students?

Mentors in charge of training the next generation of physicians were trained in an era in which palliative care and clinical ethics education were rare offerings in hospitals [23], and thus they may be ill-prepared to help students with moral distress—particularly if they are themselves unfamiliar with or habituated to the phenomenon. Female mentors who trained in the 1980s and 1990s had very different, often negative, experiences due to their gender and might have learned to repress moral distress, becoming more numb to the triggers for it over time [24, 25].

Some mentors grew up in an era in which the 1978 satirical book, House of God [26], was seen as reality rather than fiction [27, 28]. The book centers on the dehumanizing process of medical residency, based on the author’s own experiences as a resident at Beth Israel Hospital at Harvard Medical School in the 1970s, and became a “must read” because of its accurate descriptions of the grueling training environment. Many mid-career clinicians report increased burnout and increased emotional exhaustion [29], characteristics that have been associated with unresolved moral distress issues [30]. Moreover, mid-career mentors’ differences from their students can pose challenges in addressing students’ moral distress. The 1970s was an era in which diversity was virtually absent in medical schools; one report noted that minority students comprised 2.8 percent of total enrollment but 11-12 percent of the US population [31]. Baby boomer physicians also value complete dedication to work and “rigid approaches to patient care” [32], which might pose barriers to shared understanding and make it more difficult for students to discuss their moral distress with mentors. For all these reasons, there may be an insufficient number of appropriate mentors to help students with moral distress.

Who Are the Morally Distressing Patients in the End-of-Life Context?

When medical students have moral distress about end-of-life cases, it usually concerns the quality of life of the dying patient or the psychosocial circumstances surrounding the patient’s death. Delayed decision making and delayed truth telling are the most common triggers [2, 33]. The patient population is heterogeneous, as are the many causes of death. However, the literature supports that the most frequent triggers involve the following types of cases:

  1. Delayed end-of-life discussions. A common example in critical care involves patients on extracorporeal membrane oxygenation (ECMO) who are being “bridged to nowhere.” In these cases, health care clinicians’ reluctance to discuss death and dying leads to offering ECMO to poor patient candidates as a last resort. Families may consent to ECMO without really appreciating what it means. As a result, discussions about withdrawing from ECMO become delayed [34], creating moral distress in the unit.
  2. Delayed or poor decision making. A common example involves incapacitated, unrepresented (i.e., unbefriended) patients waiting for guardianship. In such patients, end-of-life options are often delayed due to an overburdened guardianship system, which in many states, does not routinely consent to comfort care [35]. Patients might also have inauthentic surrogate decision makers who may not respect known patient preferences concerning end-of-life care.
  3. Medically inaccessible or inappropriate care. Common examples involve families and patients requesting aggressive care that is either not financially feasible due to coverage problems or medically inappropriate because it does not offer benefit [36, 37].
  4. Poor communication during notification of death determined by neurologic criteria. In many such cases, there is very poor understanding of how to talk to families about brain death, and there may be chaos at the bedside [38].
  5. Codes gone bad. This involves misunderstanding about code status and what full code actually means [33, 39].
  6. Health disparity cases. Such cases include patients presenting with end-stage diseases that are clearly preventable with proper primary care access [4, 40].
  7. Patients with psychiatric problems, including end-stage addiction patients. Such patients can be violent towards nurses and health care professionals [41].
  8. Grieving family members. Grieving can occur in either the adult or pediatric setting; however, in the latter, moral distress is pronounced because of the age of the patient and the suffering of the parents.

Reducing Moral Distress: Best Practices Solutions

Although the moral distress literature is still short on proven intervention strategies [42, 43], several strategies have been identified: discussion of issues and debriefing [44, 45]; an ethics consultation service and ethics rounds conducted by trained personnel to promote in-depth and personal conversations [44, 46, 47]; reflection, including mindfulness as a source of personal empowerment [30]; and peers and mentors to aid in the process of coping with moral distress [30]. The following organizational programs have been recommended to reduce moral distress within academic medical centers in which medical students are dealing with death and dying.

24/7 Clinical ethics consultation service. This model involves a 24/7 pager-responsive service in which trained clinical ethicists respond promptly to a request for consultation. Such services need to ensure that “anyone” can call a clinical ethics consult, and medical students should learn how to contact the service—in either their preclinical or their clinical years. In a typical ethics consultation, the ethicist reviews the case with relevant stakeholders; organizes multidisciplinary team meetings (e.g., huddles) or meetings, sometimes with families; and provides chart documentation and formal opinion notes in the chart with recommendations [48].

Preventative ethics rounding in targeted areas. Regular weekly rounding by either a clinical ethics team or a multidisciplinary team that includes pastoral care, social workers, and mental health care professionals should be done in ICUs or other units where end-of-life cases are common as a preventative ethics mechanism [49, 50]. Rounding permits early identification of potential dilemmas before they reach a crisis, planning goals of care discussions, identifying surrogates before a patient loses capacity, and so on. Chief beneficiaries of such rounding typically include nursing staff, residents, and medical students in their clinical years.

Moral distress debriefings. Some end-of-life cases leave the health care team with such profound moral distress and moral residue that there is a risk that the next similar case will have a “crescendo effect” [2], in which the moral distress intensifies with each repetitive situation. A debriefing involves a skilled facilitator (often a social worker or mental health care practitioner) who sits down with the team members and allows them to air frustrations and feelings [51]; medical students who were affected by such cases should be encouraged to participate.

Schwartz RoundsTM. This is a specific type of panel-based grand rounds that presents one difficult end-of-life case from the perspectives of the multidisciplinary team members looking after the patient and then invites audience feedback. The goal of such rounds is to discuss health care professionals’ emotions rather than focus on the case from a medical science perspective. These are specific types of rounds that involve training and accreditation through the Schwartz Center for Compassionate Healthcare [52], and medical students at all stages should be encouraged to attend as a way to sensitize them and prepare for difficult cases.

Medical Education Initiatives

Stewards of medical school curricula should ensure that all physician-educators have opportunities to debrief about moral residue [4, 53], thus preparing them to serve as mentors to medical students and residents. These are, effectively, “train the trainers” programs. Physician-mentors should attend faculty development programs specifically aimed at equipping them with strategies to reduce learner moral distress, including open-communication strategies, facilitation skills for learners to debrief about “difficult” patients [54], the use of narrative ethics for self-reflection [55], an enhanced ethics curriculum [56], and peer-support programs [57]. Such initiatives also allow mentors to identify their own current or past experiences of moral distress, which can enable greater empathy and better communication with students.


Reducing students’ moral distress in end-of-life cases is not of the “one solution fits all” variety. Strategies involve effective mentorship concerning end-of-life dialogues and management of difficult cases as well as responsive clinical ethics services and training to support students, hospital staff, other trainees, and faculty, including medical education faculty who mentor students.


  1. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.
  2. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.
  3. Webster GC, Baylis FE. Moral residue. In: Rubin SB, Zoloth L, eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown, MD: University Publishing Group; 2000:208.
  4. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: development of a web-based survey. Acad Med. 2010;85(1):111-117.
  5. Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 2016;50(4):456-468.
  6. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-2236.
  7. Witzburg RA, Sondheimer HM. Holistic review—shaping the medical profession one applicant at a time. N Engl J Med. 2013;368(17):1565-1567.
  8. Nova Southeastern University. Career development: myths about getting into medical school.
    getting_in.html. Accessed January 4, 2017.
  9. Harvard Medical School. Application requirements.
    requirements-admission. Accessed January 4, 2017.
  10. Dienstag JL. Relevance and rigor in premedical education. N Engl J Med. 2008;359(3):221-224.
  11. Chen PW. The changing face of medical school admissions. New York Times. May 2, 2013. Accessed January 4, 2017.
  12. Burkhardt JC, DesJardins SL, Teener CA, Gay SE, Santen SA. Enrollment management in medical school admissions: a novel evidence-based approach at one institution. Acad Med. 2016;91(11):1561-1567.
  13. O’Neill L, Vonsild MC, Wallstedt B, Dornan T. Admission criteria and diversity in medical school. Med Educ. 2013;47(6):557-561.
  14. Association of American Medical Colleges. The changing gender composition of US medical school applicants and matriculants. 2012;12(1). Accessed January 4, 2017.
  15. Kaiser Family Foundation. Distribution of medical school graduates by gender. Accessed January 4, 2017.
  16. McKinstry B. Are there too many female medical graduates? Yes. BMJ. 2008;336(7647):748. doi:
  17. Gill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical students’ choice of family medicine. Can Fam Physician. 2012;58(11):e649-e547.
  18. Kawamoto R, Ninomiya D, Kasai Y, et al. Gender difference in preference of specialty as a career choice among Japanese medical students. BMC Med Educ. 2016;16:288. Accessed April 28, 2017.
  19. Bauman MD, Howell LP, Villablanca AC. The Women in Medicine and Health Science program: an innovative initiative to support female faculty at the University of California Davis School of Medicine. Acad Med. 2014;89(11):1462-1466.
  20. Wietsma AC. Barriers to success for female physicians in academic medicine. J Community Hosp Intern Med Perspect. 2014;4(3). Accessed January 5, 2017.
  21. McGee G. Phronesis in clinical ethics. Theor Med. 1996;17(4):317-328.
  22. Davis FD. Phronesis, clinical reasoning, and Pellegrino’s philosophy of medicine. Theor Med. 1997;18(1-2):173-195.
  23. Morrison RS, Meier DE. America’s care of serious illness: 2015 state-by-state report card on access to palliative care in our nation’s hospitals. New York, NY: Center to Advance Palliative Care; 2015. Accessed January 5, 2017.
  24. Kirk J. Gender and inequality and medical education. In: Jacobs M, ed. Is Anyone Listening? Women, Work, and Society. Toronto, Ontario, Canada: Canadian Scholars’ Press; 1994:173-197.
  25. Zimmerman MK. The women’s health movement. In: Hess BB, Ferree MM, eds. Analyzing Gender: A Handbook of Social Science Research. Newbury Park, CA: Sage Publications; 1987:442-471.
  26. Shem S. The House of God. New York, NY: R. Marek Publishers; 1978.
  27. Markel H. A book doctors can’t close. New York Times. August 17, 2009. Accessed January 5, 2017.
  28. Shem S. Samuel Shem, 34 years after “The House of God.” Atlantic. November 28, 2012. Accessed January 5, 2017.
  29. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367.
  30. Rushton CH, Kaszniak AW, Halifax JS. A framework for understanding moral distress among palliative care clinicians. J Palliat Med. 2013;16(9):1074-1079.
  31. Association of American Medical Colleges. Report of the Association of American Medical Colleges Task Force to the Inter-association Committee on Expanding Educational Opportunities in Medicine for Blacks and Other Minority Students. Washington, DC: Association of American Medical Colleges; 1970. Accessed April 28, 2017.
  32. Smith LG. Medical professionalism and the generation gap. Am J Med. 2005;118(4):441.
  33. University of Kentucky Program for Bioethics Moral Distress Education Project. Common origins of moral distress. Accessed April 24, 2017, 2017.
  34. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523-530.
  35. Khan T, Lesandrini J, Subramanian A. A review of the DNR decision making process for unbefriended patients at an urban public hospital. Crit Care Med. 2015;43(12):90.
  36. Piers RD, Van den Eynde M, Steeman E, Vlerick P, Benoit DD, Van Den Noortgate NJ. End-of-life care of the geriatric patient and nurses’ moral distress. J Am Med Dir Assoc. 2012;13(1):80.e7-80.e13.
  37. Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson JS. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Crit Care Nurs. 2007;23(5):256-263.
  38. Youngner SJ. How to communicate clearly about brain death and first-person consent to donate. AMA J Ethics. 2016;18(2):108-114.
  39. Moral Distress Education Project. Moral distress arising from end of life cases. Accessed April 24, 2017.
  40. Loomis KD, Carpenter RO, Miller BM. Moral distress in the third year of medical school; a descriptive review of student case reflections. Am J Surg. 2009;97(1):107-112.
  41. Campbell AF. Why violence against nurses has spiked in the last decade. Atlantic. December 1, 2016. Accessed January 5, 2017.
  42. Moffat M. Reducing moral distress in case managers. Prof Case Manag. 2014;19(4):173-186.
  43. Oh Y, Gastmans C. Moral distress experienced by nurses: a quantitative literature review. Nurs Ethics. 2015;22(1):15-31.
  44. Wilson MA, Goettemoeller DM, Bevan NA, McCord JM. Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses. J Clin Nurs. 2013;22(9-10):1455-1466.
  45. de Veer AJ, Francke AL, Struijs A, Willems DL. Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. Int J Nurs Stud. 2013;50(1):100-108.
  46. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics. 2007;14(3):344-359.
  47. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care. 2004;13(3):202-208.
  48. Fins JJ. Understanding and utilizing the convening power of ethics consultation. AMA J Ethics. 2016;18(5):540-545.
  49. Appelbaum PS, Reiser SJ. Ethics rounds: a model for teaching ethics in the psychiatric setting. Hosp Community Psychiatry. 1981;32(8):555-560.
  50. Libow LS, Olson E, Neufeld RR. Ethics rounds at the nursing home: an alternative to an ethics committee. J Am Geriatr Soc. 1992;40(1):95-97.
  51. Moral Distress Education Project. Preventing moral distress and solutions. Accessed April 24, 2017.
  52. Schwartz Center for Compassionate Care homepage. Accessed April 13, 2017.
  53. Hamric AB, Davis WS, Childress MD. Moral distress in health care professionals. Pharos Alpha Omega Alpha Honor Med Soc. 2006;69(1):16-23.
  54. Rosenthal S, Howard B, Schlussel YR, et al. Humanism at heart: preserving empathy in third-year medical students. Acad Med. 2011;86(3):350-358.
  55. Aultman J, Wurzel R. Recognizing and alleviating moral distress among obstetrics and gynecology residents. J Grad Med Educ. 2014;6(3):457-462.
  56. Berger JT. Moral distress in medical education and training. J Gen Intern Med. 2014;29(2):395-398.
  57. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622.

M. Sara Rosenthal, PhD, is a professor in the Departments of Internal Medicine, Pediatrics, and Behavioral Science at the University of Kentucky in Lexington, where she is also founding director of the Program for Bioethics and chair of the healthcare ethics committee. She is also a co-creator of the novel self-guided documentary, The Moral Distress Education Project.

Maria Clay, PhD, is chair of the Department of Bioethics and Interdisciplinary Studies at East Carolina University’s Brody School of Medicine in Greenville, North Carolina, where she is also director of the Office of Clinical Skills Assessment and Education and an adjunct professor in the College of Education. She is a co-creator of the novel self-guided documentary, The Moral Distress Education Project.

Antecedents and Consequences of Medical Students’ Moral Decision Making during Professionalism Dilemmas, June 2017

End-of-Life Care and the Goals of Medicine, June 2007

The Medical Student and Care at the End of Life, August 2013

Strategies for Promoting High-Quality Care and Personal Resilience in Palliative Care, June 2017

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.