REASONS TO REDEFINE MORAL DISTRESS: A FEMINIST EMPIRICAL BIOETHICS ANALYSIS

Abstract There has been increasing debate in recent years about the conceptualization of moral distress. Broadly speaking, two groups of scholars have emerged: those who agree with Jameton’s ‘narrow definition’ that focuses on constraint and those who argue that Jameton’s definition is insufficient and needs to be broadened. Using feminist empirical bioethics, we interviewed critical care nurses in the United Kingdom about their experiences and conceptualizations of moral distress. We provide our broader definition of moral distress and examples of data that both challenge and support our conceptualization. We pre‐empt and overcome three key challenges that could be levelled at our account and argue that there are good reasons to adopt our broader definition of moral distress when exploring prevalence of, and management strategies for, moral distress.


| ME THODOLOGY
The theoretical underpinning of the project was feminist empirical bioethics because feminist ethical theory was combined with empirical data to inform conceptual development and normative recommendations. Feminist interpretive phenomenology was the methodology used to collect and analyse the empirical data which is presented and described in a different paper. 9 Ives' 10 method of 'reflexive balancing' (RBL) was used to inform the ethical analysis and enables us to clearly articulate the relationship between the empirical, theoretical, and normative in bioethics research. RBL was selected partly because it can accommodate commitment to the feminist ideals that underpinned this project from its inception, and partly because its theoretical foundations of sceptical pragmatism, modest moral foundationalism, coherence and compromise resonate strongly with the critique of current thinking on MD, in particular the need to agree upon a concept that is relevant to clinical nurses' everyday experiences, coherent and rigorous.
RBL employs a quasi-moral foundationalism which accommodates both the benefits of a coherentist framework of moral justification-it remains broadly egalitarian as sets of beliefs can be introduced/ rejected based on coherence-and the benefits of foundationalism, enabling a foundation from which to build our coherent belief set. Beliefs can therefore be treated as epistemically privileged and posited as true for the purposes of moral enquiry.
Importantly these beliefs are only treated as though they are epistemically privileged, they are not actually epistemically privileged and so they can still be altered, moved or replaced. In Ives' 11 original method, these epistemically privileged beliefs are derived from empirical data and are labelled 'boundary principles'. Ives 12 suggests that by deriving the boundary principles from the empirical data, this guards against researcher bias. However, we deviate slightly from this, also treating our commitment to 'core feminism' as a boundary principle: the commitment to seek and 'eradicate traces of sexism and other oppressions wherever they may be found'. 13 'Core feminism' unites feminist theorists and commits them to the normative mandate of eradicating oppression. 14 We justify this deviation on the basis that this principle is widely accepted and uncontroversial. It would be difficult to argue that it is ethically justifiable to continue the oppression of women and marginalized individuals.
Further, although using this core feminist commitment as a boundary principle may introduce theoretical bias, we suggest it is a positive bias that aims for greater justice and equality, and is therefore coherent with feminist ideals.  The data supported the idea that MD is conceptualized in UK nursing practice in broad terms, giving prima facie reason to consider a broader definition of MD as most appropriate. At this point in the project, we have a working account of MD that appears to be conceptually coherent and consistent with the lived experiences of UK nurses as we interpreted it.
However, this account is still susceptible to conceptual challenges and these challenges need exploring before we can expect others to accept our account of MD. What follows is a discussion of three key pre-emptive challenges to our account. This discussion is taken from the final stage of the RBL process, where we expose our working account to systematic challenge, and either revise it in light of that challenge, or provide a reasoned account of why it does not work.

| Challenge 1: Conceptual concerns
In this section, we will present four potential criticisms of our account based upon concerns that our definition of MD is too broad.
We will present ethical justifications and a defence of our definition.

| The 'term of art' objection
The first proposed objection against our account is that MD is a term of art coined to capture the specific phenomenon of constrained

| The 'constraint is the only cause' objection
The second, and indeed stronger argument, is that constraint simply is the only morally relevant cause of MD and therefore we have no need to broaden Jameton's original definition. There is much empiri- Here, Wocial is conceding that MD occurred whilst the surgeon feels morally uncertain but, she argues, because his experience already fulfils Jameton's constraint criteria, there is no need for a new definition. However, in her theoretical paper, Fourie warns: 'if we limit distress to cases of constraint we may be dismissing the real-life experiences of many nurses'. 28 We do not contest that constraint is an important cause of MD and indeed this is supported by empirical data, but we agree with Fourie that if there is sufficient evidence to suggest there are other causes of MD then we should not dismiss these experiences.
However, is there good enough justification to broaden the definition of MD to include non-constraint experiences? Considering the boundary principles upon which our account must cohere and the commitment to attributing epistemic value to these accounts, we argue that disregarding these experiences or suggesting they are mistaken would be an act of testimonial injustice and would contribute to the oppression of these individuals. By denying that these experiences fall within the lexicon of MD, we are preventing them from making sense of their own moral experiences and associated emo- We suggest that there are good reasons to recognize these additional causes of distress and subsequently broaden our understanding of MD to accommodate them. There remain two more criticisms of this definition on the basis of historical and conceptual concerns.

| The 'constraint is most common' objection
The third objection is that the most common and most distressing cause of MD is constraint and the term should be reserved only for those experiences. Indeed, moral constraint was a common cause of MD discussed by participants and, through extensive use of the MDS and MDS-R, we have evidence to suggest that constraint causes MD in many other settings. However, we cannot say with certainty that it is the most common because other causes have not been widely accepted and thus have not been explored or measured to the same extent.
Regarding whether constraint causes the most distress, attempting to characterize MD based on severity level again disregards a great deal of moral experiences. Not only is it arbitrary to determine an MD experience based upon the severity of the distress, but it is also very difficult to measure and compare emotional experiences. Individuals react to and express their emotions in a variety of ways and it would be unfair to discount an experience of MD on the basis that it is not distressing enough to constitute MD 'proper'.

| The 'broadening makes it meaningless' objection
The fourth criticism that we suggest could be levelled at this broader

| Challenge 2: Epistemological concerns
Jameton's and subsequent conceptions of MD have been built upon the assertion that MD only occurs when one has made a moral judgement but is constrained. 42 In this section, we address what we anticipate to be the second substantial challenge to our broad definition-that moral judgement ought to be regarded as a necessary condition of MD. To respond to this, we first need to establish what is meant by the term 'moral judgement' because the terminology within the literature is currently ambiguous.
In this section, we argue that 'moral judgement' should be understood in a weak sense and should not be regarded as a necessary or sufficient condition of MD. The first reason for this is the variation and ambiguity regarding the way participants framed their moral judgements within their narratives. Below, we provide six excerpts from the data. In each of these excerpts, participants articulate their moral judgement in different ways:  In the first quotation, Beth suggests she knew the right thing concerning the practical issue but expressed uncertainty about the ethical issue. In the second and third quotations, Joyce and Rachel both suggested thinking they knew and in the fourth Elizabeth discussed feeling she knew. In the fifth, Holly articulates feeling tormented and conflicted, and seems to be uncertain; and lastly, Amelia says that her feelings and opinions do not even matter. Participants most commonly expressed their judgements in terms of empathetic feeling rather than rules or judgements, which Jaggar suggests may reflect a more feminist approach to ethics. 43 Participants described a 'feeling of knowing' more akin to a moral intuition than a judgement, and they do not indicate certainty, which suggests MD can occur in a variety of epistemic states.
This variation in expression mirrors the variation in the existing definitions of MD (these can be found in. 44 The variation and subsequent ambiguity seems to suggest that we should not take 'moral judgement' in its strongest sense but rather accept that MD occurs along a spectrum of epistemic strength.
The second reason we suggest moral judgement should be understood in its weakest sense is because of the complexity of clin-  Finally, in a recent green paper, Batho and Pitton argue that 'knowledge of the right course of action' sets an 'epistemic threshold' that is too high for MD. 59 They suggest that it is entirely plausible that the moral agent experiencing MD may feel indeterminate about the morally appropriate action, or even fail to even see the options available to her. Indeed, the moral agent may not recognize the cause of their distress, or even be able to identify the moral options available to her but, nonetheless, it still seems plausible to suggest that she feels MD.
Batho and Pitton suggest that an account of MD should avoid both this 'epistemic threshold' and the 'objectivity constraint': that the agent must be aware of all the options available to her. They suggest that many previous accounts of MD fail to recognize that MD 'is primarily a function of how the world appears to the individual, which may be different from how the world objectively happens to be' and that MD should not depend on 'the world actually being as she understands it to be'. 60 Indeed, MD is a unique phenomenon, caused and experienced differently by individuals. We ought to trust individual experiences of MD to inform the concept, as only they can provide an account of how the world appears to be to them: only a broad definition can capture these unique, individual experiences.

| Challenge 3: Ideological concerns
Some authors have attempted to explain the concept of MD by suggesting that it occurs when one's moral integrity is violated. 61 Suggesting that compromised integrity is the defining feature of MD allows authors to avoid the conclusion that the moral agent knows with certainty the right thing to do, because the terminology is vague enough to capture a breadth of situations; it also allows authors to retain the spirit of Jameton's original conception by suggesting constrained moral agency is central. However, we are reluctant to use an ill-defined concept such as integrity to try and bring conceptual clarity because, we suggest, it only defers the problem of definition.
Batho and Pitton suggest that the notion of integrity is unclear.
To gain clarity, they analysed seven accounts of MD in the existing workers who want to provide the best care for their patients without violating their own personal and professional integrity'. 63 Case study 7 is taken from a paper by Hardingham 64 who also frames MD in terms of moral integrity, and three cases were taken from a special issue of a bioethics journal edited by a prominent US MD scholar who also frames MD in terms of compromised moral integrity.
Therefore, their method of case analysis is not the naïve phenomenological inquiry they suggest it is. Instead, the case studies appear to have been cherry-picked to support a pre-analytic understanding of the centrality of integrity to MD. Batho and Pitton 65 have not provided a convincing argument regarding how a 'feeling of being compromised' clarifies MD and instead seem to have again deferred the problem.
Our secondary reason for not including integrity into our suggested definition is because the participants did not frame their experiences in this way and therefore the data did not provide any mandate to frame MD in these terms. By reframing compromise in this way, it can be seen as a positive by-product of moral decision making rather than inevitably causing distress. Again, this could also help to encourage moral communities to grow. Rather than HCPs engaging in conflict with the aim of avoiding compromise to maintain one's integrity, individuals could instead come together with compromise as their aim.
Excluding integrity from the definition of MD is a pragmatic and coherent conclusion in line with the method of RBL. It is justified because integrity did not emerge as a finding in the empirical data, it is coherent because the inclusion of integrity provides no further conceptual clarification, and it is pragmatic because it paves the way for recognizing that compromise between HCPs, families and patients is both inevitable and potentially positive.

| CON CLUS ION
We have presented three possible objections to our broader definition of MD and pragmatic, justifiable and coherent responses regarding why this broader definition should be adopted. Importantly, our definition of MD is grounded in participants' reports of MD experiences. These empirical data support theoretical arguments, also made by others, that the definition of MD should be broadened. 69 In empirical bioethics, the aim of the researcher is not to simply accept participants accounts but to maintain a 'critical stance', thus enabling the formation of normative conclusions. 70 Due to our feminist commitment to uncover and address oppressive practices, we grounded our normative arguments with these values and argued that denying these participants experiences are MD would be an act of testimonial and hermeneutic injustice. We have tried to pre-empt the main objections to our account by using deviant cases from our data and others' arguments in the literature. Importantly, we have argued that broadening the definition may also have practical benefits as it may help to break down barriers between healthcare professionals and help moral communities grow. For those that may argue MD (as described by Jameton) is a 'term of art' and broadening the concept makes it analytically and diagnostically meaningless, we suggest sub-categorizing MD according to its cause, as suggested by Fourie.
Sub-categorizing MD into different types provides a compromise between those who think the broader conception captures their ethical experiences and those who suggest that central to MD is constraint. By striking this middle ground, we suggest that MD will not become so broad that it is meaningless, but instead we can be even more specific about the cause of distress which will ultimately enable us to develop more targeted and effective interventions to mitigate its negative effects. We suggest that a promising direction for future research would be an exploration of which types of MD seem to be most commonly experienced amongst different groups of healthcare professionals in various settings, and identifying whether targeted interventions do in fact mitigate these different types of MD.

ACK N OWLED G EM ENTS
This work was made possible by a Society and Ethics Fellowship for Healthcare Professionals from the Wellcome Trust (Grant ref.: 108640/Z/15/Z).

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.