Moral decision-making
Governance can be recognised as a moral undertaking, especially when characterised as ‘doing the right things in the right way’.
Ethical (or moral) decision-making involves use of a ‘moral compass’, guided by agreed values, to make decisions which are both legally and ethically sound. The quadrant chart below summarises the combinations facing non-profit directors when they are balancing conformance and performance considerations.
Moral (ethical) culture
‘Organisational culture’ is also recognised as a governance responsibility, and this extends the moral dimension of the board’s work beyond decision-making to promoting and monitoring the desired moral climate for those working on behalf of the organisation.
One moral compass model offered to assist directors and management to create more sustainable enterprises, is summarised in the header image above (based on one devised by Marco Grasso and J. David Tàbara, Towards a Moral Compass to Guide Sustainability Transformations in a High-End Climate Change World, Sustainability 2019, 11, 2971; doi:10.3390/su11102971). Unlike some compasses, which distinguish between right (true North) and wrong options, this one outlines three sets of considerations relating to values, standards, and principles, all of which are recommended as decision-making aids or factors.
Moral distress has been defined as occurring “When one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton 1984). This condition is different from a moral dilemma where two or more equally valid actions are known but a choice must be made between them. It also differs from moral ambiguity or confusion, where the right course of action is not known. Part 2 in this series of posts will offer further perspectives on these distinctions.
Doing the right things the wrong way
Focussing on ‘adding value’ and ‘productivity’ as boards are required to do, can sometimes mean that employees and volunteers are placed under moral pressure. Where this occurs, it could be thought of as ‘doing the right things the wrong way’, and so directors and managers need to be alert to this risk, and use appropriate preventive controls.
There can be a mismatch between what staff or volunteers believe is right and what they are being asked to do – or not do. This may lead to moral distress and/or injury, as outlined in the continuum chart below (adapted from a chart in a presentation by Gerri Lamb PhD, Taking Care of the Compassionate Care Team: Conversations about Moral Distress and Moral Injury, delivered courtesy of the Providers Clinical Support System and the National Association of Community Health Centres, March 2020).
Moral (ethical) governance requires attention to the elements of the organisational climate and culture which support and enhance the meaningful engagement of staff and volunteers.
Moral Climate and Culture
When the moral climate in an organisation is the cause of moral distress, it could seem like ‘victim blaming’ to suggest that a ‘resilience bundle’ should be provided to employees or volunteers to help them to cope. As with any risk analysis, unless you identify and address the root cause of a problem, it will recur.
Non-profit directors and managers share responsibility for creating and maintaining a moral (ethical) climate and culture, which supports staff and volunteers in a manner that boosts morale rather than eroding it.
Apart from compliance with work health and safety obligations, non-profit boards should also consider their ’employer of choice’ status, and the organisation’s cultural profile – sometimes called ‘reputation’. Having the right policies, expectations, behaviour standards, and resource levels helps, but engaging people in a manner which respects their need to express their moral values (i.e. their moral agency) is also necessary.
Moral distress risk analysis
As with any risk analysis, it is important to understand contributing factors, causes and triggers for a moral distress ‘event’.
Carina Fourie PhD (Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of Moral Distress, AMA Journal of Ethics, June 2017, Vol 19, No.6, 578-584) has argued that moral distress may be experienced due to a range of factors. She suggests that it is helpful to distinguish between these causes, which may exist separately or in combination, depending on the circumstances in each case.
‘Constraint distress’ could arise due to such internal or external factors as under-staffing, insufficient budget, unmet demand levels, lack of equipment, or policy restrictions which prevent delivery of the ‘right’ care or service.
‘Uncertainty distress’ could eventuate where inadequate directions, supervision or training are provided.
‘Conflict distress’ can happen when two morally valid options are available, but only one can be employed. It might also arise where a more senior person gives a directive which the employee or volunteer sees as conflicting with their values and moral code.
Moral Distress Levels, Factors, and Agency
Peter and Liaschenko (2004) define moral agency and its relationship with moral distress as follows:
“Moral agency is defined as the capacity to recognise, deliberate/reflect on, and act on moral responsibilities. In order to experience moral distress an agent is required to possess at least some autonomy in recognising and reflecting upon moral concerns. Yet on the other hand, an agent’s autonomy must be at least somewhat constrained in acting upon the very moral responsibilities s/he understands him/herself to have. This apparently irresolvable contradiction is moral distress.”
Moral distress is also cumulative, and some authors have described this as a crescendo effect, in which the stress response grows as each instance or trigger event occurs, so that more serious and longer-term psychological damage is experienced. One event might produce extreme discomfort, but a series of events, and the anticipation that more will follow, can lead to PTSD, nervous breakdown, and other trauma, up to and including self-harm.
Moral Distress Prevention and Response
Certainly, for many suffering this level of moral distress, leaving their role seems to be the only option. When people leave, the organisation potentially suffers as well as the employee. The cost of selecting and inducting a replacement, and the lower productivity they are likely to offer while onboarding, are secondary harms resulting from the moral distress experienced by the staff member or volunteer.
For those who stay, disengagement from their work (presenteeism), absenteeism, depression, low productivity, compassion fatigue, or worse, deliberate sabotage of processes or systems, are just some of the possible consequences. See Part 1 of this series of posts for a chart illustrating the continuum of moral distress and injury.
The header image above illustrates some of the elements of the organisation’s moral climate likely to be considered by directors attending to their ‘duty of care’. Based on Victor and Cullen’s (1988) conception of ‘The organisational bases of ethical work climates’, this schematic uses three ethical criteria (benevolence, principle, and egoism, or self-interest) as lenses through which to consider three levels of focus (individual, organisational, and societal).
The governance mechanisms involved in preventing moral distress and promoting a positive ethical climate include your:
- Strategy – especially the section on values, but also collectively how reasonable to scale and scope of your goals might be given your resource capacity
- Code of conduct
- Governance standards regarding conflict of interest, gifts and hospitality, information privacy, information security, third party relationships, etc.
- Policies on matters such as human rights, modern slavery, equal opportunity, discrimination, bullying and harassment, performance management, complaints and grievances, sustainability, etc.
- Risk management framework and plan – especially control measures designed to prevent moral distress
- Stakeholder relations and service delivery standards
To the extent that governance and management systems and processes effectively promote a positive moral climate, directors and managers will themselves avoid experiencing moral distress.
Moral (Ethical) Concepts
Parts 1 and 2 of this series of posts on moral governance referred to various ethical concepts and defined certain terms with a focus on distinguishing between causes and symptoms of different degrees of moral distress.
With a view to offering a more extensive list of key ethical concepts and terms used in moral governance, this part is focused on two versions of the same chart – a summary version in the header and a more detailed list of definitions in the one below.
Links to further information appear below most of the terms listed, and to obtain a pdf with active links, you may wish to click here.
Background to the Moral Governance series
My interest in exploring governance aspects of moral distress was triggered by a mentoring session I held with a mentee in a large public hospital. She had been tasked with adjusting demand management measures for her department in the light of the hospital having reached capacity. Part of our session dealt with discussions brokered between her team and hospital ethicists about any moral distress that might have arisen from proposed changes.
It struck me that moral distress is a condition that is experienced in most organisations (even the Federal Parliament) at some stage or other, and that non-profits of all types are faced with the same issues of internal and external constraints, uncertainty, and conflicts as larger institutions. Very few, if any however, would be likely to have ready access to ethicists to facilitate decision-making that could prevent moral distress and other ethical concerns. The responsibility for governing and managing in an ethical manner is held personally by non-profit directors and managers, and it is up to them to ensure that their policies, systems and processes support ethical decisions and behaviour.
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