Residency, and internship in particular, are characterized by intense experiences and challenges. The challenges seem essential to the learning; physiology becomes remarkably tangible when there is a wheezing, frightened child in front of you. The benefit of residency training is that it balances that difficulty with the guidance needed for learning and protection. The moral challenges of residency, although equally intense, are often left unanswered by the guidance and support so crucial for education and growth. As part of a new curriculum in clinical medical ethics for pediatric residents, we asked interns to write a brief reflection on a personal “ethics” experience. We did not define ethics or give direction as to the content of the written reflection, listening instead for the interns' own interpretations. More than half of the interns wrote about an experience in the neonatal intensive care unit (NICU). That was not surprising; most pediatricians will remember the NICU as one of the most medically and emotionally powerful experiences of residency. I was, however, unprepared for the beauty and power of the reflections we received and surprised by the moral distress they detailed, a distress that the interns felt unable to voice in their daily practice.
In a recent article, John Lantos wonders whether the moral distress trainees experience in settings like the NICU is evidence of a problem or a sign of intellectual vigor and willingness to question prevailing practice.
Moral distress and ethical confrontation: problem or progress.
The two reflections that follow give ample evidence of the latter. In clear and accomplished voices, Drs Platt and Tschudy describe their efforts to understand care provided at the very edge of life, with all of its expense, agony, and uncertainty. The moral pain and questioning are palpable, and their desire to understand and make the right choices is heroic. If there is a problem in the experience of moral distress in residency training, it is that we have not yet become adept at addressing questions that arise, at balancing the challenge with support and guidance. We all can remember the difficulty of learning to care for critically ill children, facing overwhelming questions of resource allocation and quality of life, trying to understand the impact of “heroic” measures on infants and families, and trying to balance hope with realism. I read these reflections with two minds, one full of admiration for the strength and honesty of the ideas and the other certain that we can do more to transform distress into education.
Moral distress and ethical confrontation: problem or progress.J Perinatol. 2007; 27: 201-202
Margaret Moon is an Assistant Professor of Pediatrics in the Division of General Pediatrics and Adolescent Medicine at the Johns Hopkins School of Medicine and also works in the Johns Hopkins Berman Institute of Bioethics.
© 2008 Ambulatory Pediatric Association. Published by Elsevier Inc. All rights reserved.