restricted access When Moral Uncertainty Becomes Moral Distress
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When Moral Uncertainty Becomes Moral Distress

This narrative is really for me about a process of discovery, it begins with a discrete event of moral distress, but it certainly does not stop there. It really represents for me a transformative moment, radically altering my career path, and changing how I define medical wisdom and judgment. The day it occurred I arrived at work to find my list had been altered rather significantly; the first case in my room was to be an organ donor, which in and of itself was not too unusual. What made this case very different though, quite beyond the experience of the team, was that we were dealing with a maternal case of brain death with a still viable, but extremely premature fetus. Questions arose in my mind. This fetus was too young to be delivered now, but had the possibility of trying to maintain the pregnancy been reasonably explored? Would that have been an option this mom would have chosen? Had the father been offered the opportunity to consider this? All would seem to be important questions for the team to consider. What really struck me that morning was despite the unusual circumstances of the case, the complexity of the case, the lack of expertise with regards to the uncertain clinical and ethical dimensions of the case, there had been no “ . . . heads up, just thought you should know that . . .” phone call the day before. The head of the intensive care unit had not been informed either, so I was certainly not alone in being out of the information loop. I should make it clear that the nature of organ donation is such that these cases takes hours to organize, to find recipients, to mobilize the necessary teams for harvesting, so organ donation is not an emergent case. Given this lag time there was certainly time to not only inform the team, but given the unusual circumstances, time to initiate a more comprehensive consultation process, a consultation process that could have ensured that the ethical and clinical dimensions of the case had been reasonably explored. Of course by the time I had arrived that morning the teams were on their way, there now was an urgency to get the donor to the operating room. [End Page 106]

I felt unease about the case, and questioned the nature of the consent provided by the family. Were they made aware that choices had to be made? Did they understand that there was a paucity of evidence regarding these choices and that in these circumstances they need to make a decision that best reflects the wishes and values of the patient? My questions regarding the consent went unanswered so I asked for an ethics consult (I was surprised that this had not been done already, given the complexity of the case). This request was unfortunately denied, the explanation being that the family had already signed a consent. Maybe I failed to be clear in my request, that it was the circumstances and informed nature of the consent that I was questioning. Here, I admit I was beyond my experience, I had never had reason to question a signed consent form before, and maybe it was this lack of experience that impacted the request and hence led to the denial. Maybe the ethics team was satisfied with the consent, but they did not communicate why they were satisfied and so I felt that I was still left with reason to doubt the moral support for that document.

I am prepared to deal with moral uncertainty in the tertiary and often quaternary care nature of my practice. We often are called upon to make clinical decisions without all the relevant information in terms of risk and benefit. What makes moral uncertainty something that we can come to terms with is the knowledge that the patients can at some level understand this uncertainty and trust in the decision–making and advice of the team (and team, in the face of uncertainty and complexity ought to be broadly construed). There needs to be an acknowledgement of the necessary time and space for adequate reflection for often these decisions are irreversible and...