Moral Distress and the Intrapsychic Hazards of Medical Practice

In this chapter, I will consider Miller’s reading of Augustine on the emotions that should arise in a person who, in pursuing justifiable ends, causes morally undesirable eventualities. Drawing on Miller’s article “Augustine, Moral Luck, and the Ethics of Regret and Shame,” I focus on the concept of what he calls “intrapsychic luck” and argue that it offers a new, further humanizing insight into discourses on moral distress in modern medicine. Moral distress, which was first coined in the nursing literature in 1984, has since gained traction in the wider medical literature, with some now hypothesizing it as a root cause of clinician burnout. I will briefly review this development and re-describe moral distress as a feeling of agent-regret that aptly arises in circumstances of what Miller calls “extrapsychic luck.” On this picture, intrapsychic luck clarifies an added source of moral distress that attends to the self’s anarchic desires. I illustrate this point in terms of the pervasive threats of self-interested careerism and commercialism in modern health care and the clinician’s struggle against self-alienation. I show that this struggle further elucidates moral distress as a deeper problem of professional identity and conclude by considering some practical implications of that insight.