Moral distress affects a significant proportion of clinicians who have received requests and participated in euthanasia or physician-assisted suicide (E/PAS) globally. It has been reported that personal and professional support needs are often unaddressed, with only a minority of those reporting adverse impacts seeking support.

This study aimed to review studies from 2017 to 2023 for the perceived risks, harms, and benefits to doctors of administering E/PAS and the ethical implications for the profession of medicine resulting from this practice.

The search explored original research papers published in peer-reviewed English language literature between June 2017 and December 2023 to extend prior reviews. This included both studies reporting quantitative and qualitative data, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. The quantitative review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The qualitative review used the Critical Appraisal Skills Programme to assess whether studies were valid, reliable, and trustworthy.

Thirty studies (quantitative n = 5, qualitative n = 22, mixed methods n = 3) were identified and fulfilled acceptable research assessment criteria. The following 5 themes arose from the synthesis of qualitative studies: (1) experience of the request prior to administration; (2) the doctor’s role and agency in the death of a patient; (3) moral distress post-administration; (4) workload and burnout; and (5) professional guidance and support. Both quantitative and qualitative studies showed a significant proportion of clinicians (45.8–80%) have been adversely affected by their involvement in E/PAS, with only a minority of those reporting adverse impacts seeking support.

Participation in E/PAS can reward some and cause moral distress in others. For many clinicians, this can include significant adverse personal and professional consequences, thereby impacting the medical profession as a whole.

Young people are increasingly distressed by the climate and ecological crises (eco-distress). This has been associated with the failure of people in power to act appropriately, which may cause moral distress and moral injury. We examined this hypothesis by interviewing 13 young adults (19–25 years) in the UK about their climate concerns and perceptions of how State actors and authorities are responding to climate change. Using reflexive thematic analysis, four themes were developed: (1) Climate change is a wicked problem, (2) Moral distress is associated with witnessing acts of omission and commission, (3) Moral distress drives eco-distress, and (4) Opportunities for moral repair. Climate concerns extended to broader concerns about ecological degradation (eco-distress), linked to feelings of moral distress arising from repeatedly witnessing powerful people failing to act on climate change. Eco-distress was also exacerbated by (a) witnessing others in society failing to take appropriate responsibility, (b) realising the limitations of individual action, and (c) being embedded within a culture where personal contribution to climate change is inescapable. In contrast, eco-distress was lessened by seeing authorities engage with the issues morally, and further mitigated by collective, ethical, pro-environmental action. This adds empirical evidence to support the hypothesis that eco-distress involves moral distress and injury arising when State authorities and other powerful bodies engage in wrongful acts and omissions on climate change. We argue that this is affecting the wellbeing of young people and supports the argument that such wrongful (in)action infringes human rights. Clinical implications are discussed.

1. (1) To understand how and why moral distress and moral injury relate to the distress that young people feel about climate change (eco-distress).

2. (2) To consider the clinical implications of formulating eco-distress in a way that includes reference to the violation of core moral codes.

3. (3) To explore what opportunities exist that could reduce moral distress and support young people.

4. (4) To understand how research into moral distress and moral injury in relation to climate change can offer important insight into the relevance of eco-distress to human rights infringements and justice-oriented care.

5. (5) To discuss practical solutions that might support moral repair, both in psychotherapy settings and in broader social policy.

The aim of this work was to determine the impact of Moral Distress (MD) in emergency physicians, nurses, and emergency medical service staff at the Rand Memorial Hospital (RMH) in the Bahamas, and the impact of Hurricane Dorian and the COVID-19 pandemic on Moral Distress.

A cross-sectional study utilizing a 3-part survey, which collected sociodemographic information, Hurricane Dorian and COVID-19 experiences, as well as responses to a validated modified Moral Distress Scale (MDS).

Participants with 2 negatively impactful experiences from COVID-19 had statistically significantly increased MD compared to participants with only 1 negatively impactful experience (40.4 vs. 23.6, P = 0.014). Losing a loved one due to COVID-19 was associated with significantly decreased MD (B = - 0.42, 95% CI -19.70 to -0.88, P = 0.03). Losing a loved one due to Hurricane Dorian had a non-statistically significant trend towards higher MD scores (B = 0.34, 95% CI -1.23 to 28.75, P = 0.07).

The emergency medical staff at the RMH reported having mild - moderate MD. This is one of the first studies to look at the impact of concurrent disasters on MD in emergency medical providers in the Bahamas.

This study examined the relationship between moral distress, individual and professional values in oncology nurses.

Employing structural equation modeling, a descriptive-correlational study was conducted among 116 oncology nurses. Data were collected using the Moral Distress Scale-Revised Adult Nurses, the Nursing Professional Values Scale, and the Values Scale.

The mean moral distress frequency was evaluated as low (1.6 ± 0.7) and the intensity as moderate (1.9 ± 0.8). Both the Nursing Professional Values Scale and Values Scale subdimension mean scores were at levels evaluated as high. There was no specific value that stood out from the others. Structural equation modeling analysis showed that individual values were found to have a direct and negative significant effect on moral distress intensity (β = −0.70, p < 0.01) and frequency (β = −0.58, p <0.01) and professional values had a direct positive and significant effect on moral distress intensity (β = 0.37, p < 0.05) and frequency (β = 0.25, p < 0.05).

It is believed that more national and international studies need to be conducted to examine the relationship between the moral distress concept and values. While individual values were found to have a direct and negative significant effect on moral distress, professional values had a direct positive and significant effect on moral distress.

Moral distress is associated with adverse outcomes contributing to health-care professionals’ worsened mental and physical well-being. Medical social workers have been frontline care providers throughout the COVID-19 pandemic, and those specializing in palliative and hospice care have been particularly affected by the overwhelming numbers of those seriously ill and dying. The main objectives of this study were (1) to assess palliative and hospice social workers’ experiences of moral distress during COVID-19 and (2) to identify and describe participants’ most morally distressing scenarios.

Using a mixed-methods approach, participants completed an online survey consisting of the Moral Distress Thermometer (MDT) and open-ended text responses.

A total of 120 social work participants responded to the study, and the majority of participants (81.4%) had experienced moral distress with an average MDT score of 6.16. COVID-19 restrictions emerged as the main source of moral distress, and an overlap between the clinical and system levels was observed. Primary sources of moral distress were grounded in strict visitation policies and system-level standards that impacted best practices and personal obligations in navigating both work responsibilities and safety.

In the first year of the COVID-19 pandemic, palliative and hospice social work participants indicated high levels of moral distress. Qualitative findings from this study promote awareness of the kinds of distressing situations palliative and hospice social workers may experience. This knowledge can have education, practice, and policy implications and supports the need for research to explore this aspect of professional social work.

This study aimed to examine the impact of COVID-19 on hospice Interdisciplinary team (IDT) members’ self-reported stress and identify possible sources of moral distress.

A cross-sectional survey was conducted using Qualtrics to understand the impact of COVID-19 on quality improvement initiative implementation and hospice IDT members’ general and dementia-specific care provision. Directed qualitative content analysis was used to analyze hospice IDT members’ responses from five open-ended survey questions that were indicative of stress and possible moral distress.

The final sample consisted of 101 unique respondents and 175 comments analyzed. Three categories related to sources of moral distress based on hospice IDT member survey responses were identified: (1) impact of telehealth, personal protective equipment (PPE), and visit restrictions on relationships; (2) lack of COVID-19-specific skills; and (3) organizational climate. Sources of moral distress were categorized in 40% of all responses analyzed.

This study is one of the first to document and confirm evidence of potential stress and moral distress amongst hospice IDT members during COVID-19. It is imperative given the possible negative impact on patient care and clinician well-being, that future research and interventions incorporate mechanisms to support clinicians’ emotional and ethical attunement and support organizations to actively engage in practices that address clinician moral distress resulting from restrictive environments, such as the one necessitated by COVID-19.

Parents of seriously ill children worry about their vulnerable child contracting COVID-19, whether their child's palliative care providers will be able to continue to provide the same quality of care to their child, and who can be with the child to provide comfort. For providers, shifts in healthcare provision, communication formats, and support offerings for families facing distress or loss during the pandemic may promote providers’ moral distress. This study aimed to define the ways that the COVID-19 pandemic has impacted end-of-life care and approach to bereavement care in pediatric palliative care (PPC).

The Palliative Assessment of Needed DEvelopments and Modifications In the Era of Coronavirus (PANDEMIC) survey was developed to learn about the PPC experience during COVID-19 in the United States. The survey was posted with permission on seven nationally focused Listservs.

A total of 207 PPC team members from 80 cities within 39 states and the District of Columbia participated. In the majority of hospitals, admitted pediatric patients were only allowed one parent as a visitor with the exception of both parents or nuclear family at end of life. Creative alternatives to grief support and traditional funeral services were described. The high incidence of respondents’ depicted moral distress was often focused on an inability to provide a desired level of care due to existing rules and policies and bearing witness to patient and family suffering enhanced by the pandemic.

The COVID-19 pandemic has had a profound impact on the provision of end-of-life care and bereavement for children, family caregivers, and PPC providers. Our results identify tangible limitations of restricted personal contact and the pain of watching families stumble through a stunted grieving process. It is imperative that we find solutions for future global challenges and to foster solidarity in PPC.