What Is a Moral Dilemma and What WouldYou Do if You Were Faced with One?

J. Anne O’Neil, PhD, RN

IN THE AWARD-WINNING PLAY Wit, amiddle-age professor’s experiences with

ovarian cancer are vividly depicted. If you havenot read the play, seen it on stage, or viewed thevideo I urge you to do so. It is a true work ofmoral relevance. Take heed of the insensitiveresearcher, the unthinking oncology fellow, andthe uncaring technicians’ actions highlightedwith the human element left to the nurse, SusieMonahan, RN, BSN. It is Susie who brings updo not resuscitate orders with Vivian Bearing,her patient, and who fights successfully to stopcardiopulmonary resuscitation when Vivian’sheart stops. But it is also this nurse who, withagony, acquiesces when Vivian, in severe pain,is started on a morphine drip with no discussionof alternatives such as the patient-controlledanalgesia pump Susie believes would be a betterchoice. What was going through her mind atthat point? Did she realize Vivian was not al-lowed to make an informed choice and that herautonomy as a human was not being respected?Jameton (1984) classifies three aspects of

moral concern we as nurses might have. First,he speaks of moral uncertainty when we are un-sure what the moral problem is or what valuesor principles we feel have been violated. Weknow something just does not feel right aboutthis situation, but it is hard to pin down exactlywhat the problem is and why we feel so uneasy.For instance, when I first graduated from nurs-ing school, children were routinely tied in theirbeds. Somehow, this seemed inhumane to me,but as a very young nurse I was not sure if I justdid not understand the demands of pediatricpractice or if there might not be another waychildren could be kept safe without constant

restraint. Second, Jameton describes a moral di-lemma as when we know there is a moral prob-lem, but are forced to choose between two ormore options, each of which supports moralprinciples, but call for inconsistent courses ofaction. For example, as busy professionals howdo we balance the moral obligations of both ourpersonal and professional lives? When we areasked to work overtime how do we decide theobvious moral dilemma between not abandon-ing the children in our care at the hospital andthe needs of our children at home? And third,Jameton describes moral distress as when weknow what is the right thing to do, but sometype of restraint makes it difficult or impossiblefor us to do what we believe is the morallycorrect action. More and more nurses are find-ing themselves in situations where good nursingpractice is hindered by institutional, insurance,and other constraints. How often do we dis-charge children home from the hospital beforethey are truly medically ready to leave? Whatconcerns us when we are floated to an unfamil-iar unit?In Wit, the script reveals that Susie believes

there is a clinical problem with using a mor-phine drip for a patient in this terminal state andthat the risks and benefits of all pain medicationchoices should be presented to Vivian, lettingher make the decision between the drip and thepump. Where Susie seems to run into a problemis with not doing more to assure that Vivian hasa choice. The “power” of the world-renownedresearch physician appears to leave Susie feelingthat she is unable to counter him and effectivelyadvocate for her patient’s rights. What do youthink Susie could have said or done to guaranteethat Vivian was given those choices? Could shehave looked for support from others? Wouldher nurse manager have backed her up if shehad stood her ground? Or, would she have beentold not to question the physician because “youknow Dr. Kelekian brings in all that money.”We will never know why Susie did not believe

Consultant for Ethics Research and Education, Baltimore, MDAddress reprint requests to J. Anne O’Neil, PhD, RN, 636

West Conway Street, Baltimore, MD, 21230. E-mail:joneil@umaryland.edu

© 2002 by Association of Pediatric Oncology Nurses1043-4542/02/1904-0006$35.00/0doi:10.1053/jpon.2002.126058

145Journal of Pediatric Oncology Nursing, Vol 19, No 4 (July-August), 2002: pp 145-147

she could speak up, but we can look at our ownnursing practice and the manner in which wedeal with morally problematic concerns.The question we need to ask ourselves is how

do we handle similar situations in our ownpractice? How do we know when we are trulyfaced with an ethical dilemma that requiresaction? As nurses in a demanding specialty area,we are continually faced with questions arisingfrom attempts to distinguish what is in our pa-tient’s best interests, their rights, and their rela-tionships within families. Think of a time whenyou had conflicting information from a patientand his or her parents. The child wanting to stopineffective treatment and go home and parentswho are hungry for each day a blood transfusionmight allow. You ponder what the child’s rightsare and do they take precedence over the par-ents’ rights and legal responsibility for makingcare decisions. You may ask yourself what youcan possibly do about this situation.When we review Jameton’s categories of

moral concerns we may find ourselves in a busytreatment room listening to many statementsfrom children that reflect their wishes, disap-pointments, anxieties, and fears. Our moral an-tenna needs to be attuned to the statements fromchildren that need to be listened to seriously. Toclarify our own moral uncertainty, a child’s state-ments of discontent need to be explored fully toknow if there is indeed a moral dilemma. Is thechild wishing to stop all treatments or simplytoday’s treatments? Does the child understandwhat will happen if treatment is stopped? Havethe child’s fears been truly heard by his parents?If not, why? What are the parents’ views onstopping treatment? Are the other members ofthe treatment team aware of the possible differ-ences between the child and parents’ goals? Hasthere been a case conference to discuss anddecide on treatment goals and the balance be-tween benefit of another transfusion and thechild’s potential for suffering? Answers to theseand other questions can help in deciding if thereis truly a moral dilemma.Ideally, we all work in supportive environ-

ments where the above questions are asked,open communication between all people exists,and trust among health care practitioners, par-ents, and children is exemplary. Questions ofthis nature are then addressed in a caring man-

ner sensitive to the moral values of all involved,whether they be the physician concerned withcure, the parents wishing for a few more days oftouching and holding their child, the childbrought to the hospital for one more essentiallyfutile visit, and the nurse caring for and aboutthe child and family.However, if the environment we work in does

not support the asking of the types of questionsaddressed here, nurses may find themselves inmoral distress. What then might the pediatriconcology nurse do after he or she has exploredthe dilemma and believes he or she must act toprotect the young patient, family, and thenurse’s professional integrity? The term moraldistress reflects the gravity of this type of situa-tion. Distress accompanying decision-making isseldom a happy state unless it might be whentrying to choose between two wonderful alter-natives, such as winning a new car or a trip tothe Bahamas. When we add the adjective moralto the mix we are then speaking of deeply heldvalues of right and wrong and decisions be-tween courses of action that are at least trou-bling if not distressful to our sense of well-beingand how we think about ourselves. Nursingsometimes requires true moral courage. How dowe know when moral courage is indicated? Letus think about some questions that may help usto decide:

● First, are we sure of all our information? Dowe have facts or assumptions? How mightwe gather more information?

● Are we able to clearly articulate what themoral/ethical dilemma is? What moralprinciples are of concern in this situation?

● What is the range of possible moral actionsopen to us? Are we able to describe thebenefits and burdens of each action?

● Do we have a clear understanding of theconsequences of our potential actions—toboth our patients and ourselves? Will theseactions require moral courage of us? Arewe ready to accept these consequences?

● Whom might we talk with and join with forsupport and substantiation of our dilemmaand the actions we decide on? Is there anethics committee to turn to for advice andassistance?

146 O’Neil

Think back on a situation you personallyfaced, a true moral dilemma that was creatinga sense of moral distress within you. Workthrough the questions above. Think about howthis analysis might have assisted you to workwith your distress and resolve your ethical con-flict in a more satisfactory manner. What mightyou have done differently? Would you havechecked out your information a bit more thor-oughly? Would you find out if others you workwith were feeling a similar distress and wouldbe willing to support your efforts for change?Would you think a little more deeply about yourwillingness to accept the consequences of your

plan of action? Are there other questions youneeded to ask yourself and answer before pro-ceeding?If you would like to continue this discussion

please do contact me at joneil@umaryland.edu.We cannot help the nurse in Wit, but we canmove to help each other and ourselves when wefind ourselves with a heavy load of moral dis-tress.

ReferencesEdson, M. (1993). Wit. New York: Faber & Faber.Jameton, A. (1984). Nursing practice: The ethical issues.

Englewood Cliffs, NJ: Prentice-Hall.

147Moral Dilemma