Dilemmas in healthcare

Emily Mortimer, a Trainee Clinical Psychologist at the University of East London, on a moral judgements and a new study.

The NHS advocates for equal, fair and rational care for everyone. However, decision making within the NHS is becoming ever more complex, with a growing demand for services and competing pressures (NHS, 2019). At times, decisions can conflict with our beliefs, values and the responsibility to provide ethical care (Almutairi et al., 2019). 

Decisions made within the NHS, for example about people’s care, can challenge our moral values and beliefs. When decisions are ethically challenging or there are competing needs at play, staff might rely on their moral judgements to make sense of the situation and determine the best course of action (Hunter, 1996; Dickerson, 2010). 

Moral judgements can be understood as a process of reasoning, guided by our beliefs of what is right and what is wrong (Rest, 1994). These judgements can be influenced by social and cultural norms and values. Therefore, it is possible that both client and/ or clinician characteristics, such as age, gender, education and culture will affect moral judgements and decisions (Graham et al., 2016; Hill, 2010). If this is the case, can decision making within healthcare ever be completely fair and rational?

What does this look like? 

When decisions are morally challenging, such as when they challenge or conflict with our understandings of how to provide competent, responsible and ethical care, it can cause moral distress (Jameton, 1984). Some examples of when this might occur include when staff feel pressure to act unethically, believe they are colluding in wrongdoing and when decisions conflict with professional values (Hamric, 2014).  

Complex decision making and moral distress is by no means a new experience for healthcare workers. Yet numerous examples of healthcare decisions which might challenge our morals are found by looking into the impact of the coronavirus pandemic. In 2020, the pandemic resulted in the rapid re-organisation of mental health services. Decision making was largely guided by how to reduce the spread of infection and usual policies, pathways and methods of making decisions (e.g. MDT meetings, informal discussions, family/ carer involvement) were largely disrupted.  

For those whose work is often driven by building trusting relationships through communication or by facilitating engagement with the community, practicing in a way which fitted with one’s moral values and beliefs about wellbeing became increasingly difficult. Decisions about what support could be offered and how to do this was often uncertain. For example, was it safe to continue to offer clients face-to-face therapy if this was their preference? What about clients who could not access remote support? Is it fair to restrict a client’s leave from hospital in order to reduce the risk of infection? 

In addition, there were less opportunities for informal discussions about care. Staff often felt isolated when making decisions: “I don’t have as much information to make decisions so I’m questioning my decision-making more thoroughly. I’m frightened of making the wrong decision when I’m deciding whether somebody gets a service or doesn’t get a service. That’s quite problematic.” (Senior care coordinator, mental health service; Liberati et al., 2021).

When decision-making is a multifaceted, and often challenging process, with multiple competing interests, do our morals affect the decisions we make? Do our own beliefs, values and characteristics, or those of the client, affect these decisions?  

Why is this important? 

In situations where decisions are highly complex, and staff may be more likely to rely on their morals, are there certain client, clinician and environmental factors which are more likely to elicit or trigger negative moral judgements? If so, we might question whether characteristics which trigger negative judgements lead to different decisions being made and ultimately whether this contributes to the healthcare disparities that we know exist within mental healthcare. 

While there is some research exploring potential links between moral judgements, moral distress and client/ clinician characteristics, very little focuses on mental healthcare decisions specifically. The impact on known disparities within healthcare has not yet been explored.  

Additionally, as there are no biological tests for mental illnesses, clinicians rely on subjective accounts and clinical experience to make decisions (Aboraya et al., 2006). Arguably, this allows greater opportunity for factors such as emotion and bias to influence judgements. Understanding which factors might influence our judgements and whether morality plays a role might help to inform efforts to minimise these biases and provide mindful care. 

Research study 

I am carrying out some research exploring how a number of characteristics might affect our judgements and decisions. I am looking for anyone who works in mental healthcare in the UK and who is over the age of 18 to complete a short (approximately 20 minute) online survey and would be very grateful for any contributions. The study has been approved by the UEL School of Psychology Ethics Committee. The aim is to help understand factors which influence these judgements, in order to provide valued, accessible and mindful care to individuals accessing mental health support within these services.

Click here to find out more and take part.

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