What Is Moral Stress?

The term moral stress (also referred to as moral distress) was introduced in the human nursing profession to describe a circumstance “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton 1984). Moral distress has been defined as “The experience of psychological distress that results from engaging in, or failing to prevent, decisions or behaviors that transgress, …personally held moral or ethical beliefs” (Crane et al. 2013). Moral stress is therefore recognized as a consequence of experienced conflicts involving work-related obligations or expectations that do not coincide with one’s values (Rollin 2006; Fawcett and Mullan 2018).

Moral Stress in the Veterinary Profession

Rollin (1987) introduced the concept of moral stress among veterinary professionals associated with the killing of animals for reprehensible reasons:

The stress … of killing healthy animals (or being asked to kill them even if one refuses to do so) is, in my experience, the most demoralizing part of [veterinary] practice. In fact, this stress is so qualitatively different from what is normally called occupationally “stressful” … that I have called it moral stress, because it arises out of a fundamental conflict between one’s reasons for going into animal work and what one is in fact doing or being asked to do.

(2006)

Contributing factors to moral stress related to the killing or euthanasia of animals who could retain a good quality of life include a reverence for animals by those within the veterinary profession, the recognition that the affected animals are not benefiting from their death, the perception that one must suppress their moral outrage at those responsible for creating the ethical conflict, and a disinclination to discuss the problem with friends or family (Rollin 2011). In a study of small animal veterinarians, Morris discovered that interns experienced stress when they believed a high estimate of fees caused the client to elect for euthanasia, and nearly every veterinarian reported experiencing stress associated with frequent euthanasia procedures (Morris 2012). In accord with Rollin’s observations, Morris (2012) notes that: “Veterinary work often causes distress for practitioners because it requires people who care strongly for animals to kill them when they are not sick enough to easily justify their death.”

Prevalence of Stress

There has been an increasing research interest examining the occurrence of stress within the veterinary profession and among those who work with animals. A literature review discovered a high prevalence of occupational stress and euthanasia-related strain among people working in animal shelters, veterinary clinics, and biomedical research facilities (Scotney et al. 2015). Veterinary technicians have been found to be particularly susceptible to occupational stress and burnout (Kogan et al. 2020; Hayes et al. 2020). Numerous studies have also documented moral stress among veterinary students (Yang et al. 2019; Kipperman et al. 2020; Lokhee and Hogg 2021).

Several studies have evaluated the prevalence of occupational stress among veterinarians. A recent investigation noted that 50% of veterinarians had high burnout scores (Ouedraogo et al. 2021). A study of small animal veterinarians found that 49% reported a moderate to substantial level of burnout (Kipperman et al. 2017). Another report found that when North American veterinarians were asked “How often have you felt distressed or anxious about your work?”, 52% responded “often” or “always” (Moses et al. 2018). Veterinarians in the UK provided a mean score of over 4/5 when asked if veterinary work is stressful, and stress was thought to be one of the biggest difficulties in the profession (Institute for Employment Studies [IES] Report 2019). It’s apparent that work-related stress is a significant challenge for the veterinary profession.

Ethical Dilemmas and Moral Stress

A number of studies have investigated the association between specific types of ethical dilemmas and moral stress among veterinarians and veterinary students.

In one investigation, 52% of US small animal veterinarians reported that ethical dilemmas were the leading cause or were one of many equal causes of work-related stress (Kipperman et al. 2018). Veterinary students in the United States (Kipperman et al. 2020) classified almost all presented scenarios of potential ethical dilemmas with higher stress ratings than reported by small animal veterinarians (Kipperman et al. 2018). Veterinary surgeons in the UK assessed three ethical scenarios as “highly stressful”: convenience euthanasia of a healthy animal, a client demanding treatment despite poor patient welfare, and financial limitations of clients compromising treatment options (Batchelor and McKeegan 2012). Among small animal veterinarians, 61% reported moderate to very high stress when encountering economic limitations compromising patient care (Kipperman et al. 2018), and 77% of small animal veterinarians in another study reported that the economic limitations of clients (see Chapter 8 for a more detailed discussion) were either a moderate or primary contributor to their burnout (Kipperman et al. 2017).

Decisions regarding euthanasia are common causes of moral stress for veterinary professionals (Rollin 2006; Morris 2012). Moses et al. discovered that 63% of veterinarians experienced moderate to severe distress as a consequence of inappropriate requests for euthanasia (2018). Another study found that the highest levels of stress were associated with euthanasia compared with other ethical conflicts, as 73% of small animal veterinarians reported moderate to very high stress associated with euthanasia requests believed to be due to lack of financial means, and 80% indicated moderate to very high stress associated with circumstances where euthanasia was requested because the practitioner believed that the client was unwilling to pay for treatment (Kipperman et al. 2018). The lower ratings of reported stress when confronting economic constraints not associated with euthanasia may reflect an acquiescence that such circumstances are considered to be normal within small animal practice, or moral stress may be perceived as more significant when economic limitations are directly associated with a patient’s death.

A report of veterinary students yielded similar conclusions, as 62% reported high to very high stress when encountering euthanasia requests believed to be due to lack of financial means, 84% reported high to very high stress when euthanasia is requested because the respondent believes that the client is unwilling to pay for treatment, and 92% reported high to very high stress when contemplating euthanasia requests based on client convenience (Kipperman et al. 2020).

In light of the association between euthanasia requests that the practitioner may consider unethical and moral stress, it seems logical that veterinary professionals would develop emotionally protective strategies to alleviate this burden. Bartram and Baldwin (2010) have suggested that veterinarians encounter unpleasant contradictions between their desire to sustain life and the inability to successfully treat patients, which could be allayed by changing their beliefs to view euthanasia as a beneficial conclusion. Veterinarians may develop an acceptance of euthanasia as an adaptive mechanism to the constraints of the profession on their capacity to help animals. Morris discovered that one of these strategies was to rationalize: “Participants eased their ethical discomfort with some euthanasia procedures by viewing them as a better alternative for the animal than abandonment” (2012). A study corroborates these observations, concluding that veterinarians and veterinary students in the later stages of training were more tolerant of convenience euthanasia compared with preclinical veterinary students (Ogden et al. 2012).

A study examining utilization of euthanasia in practice found that more small animal veterinarians agreed (45%) than disagreed (37%) that veterinarians use euthanasia as an aid or method to resolve difficult cases when this may not be in the best interest of the patient, and 42% of practitioners reported that they had done this at least once (Kipperman et al. 2018). This suggests that veterinarians may find euthanasia acceptable when this is not justified based on animal welfare considerations. The availability of euthanasia in the veterinary profession as a viable alternative for ending the suffering of animals, as well as a societal expectation for resolving ethical conflicts, can be both a blessing and a curse, respectively, for animals and veterinary professionals.

There is compelling evidence that ethical conflicts (Case Study 22.1) contribute to moral stress among veterinary professionals, and there is an increasing understanding of some of the specific work-related expectations they are subjected to, as causes.

Consequences of Moral Stress

Studies in veterinary medicine have suggested or documented that moral distress is inversely associated with well-being and correlates with career dissatisfaction and attrition (Morris 2012; Chun et al. 2019). Rollin refers to emotional distancing as an adaptive mechanism for veterinary professionals to cope with moral stress:

It is not surprising that some people in these fields protect themselves … by abandoning the moral concern that is the chief source of the moral conflict that generates their stress, by thinking of themselves only as “scientists” …, by taking the view that animals don’t suffer or that their suffering doesn’t matter.

(2011)

The effects of work-related stress on mental health are well documented and include emotional exhaustion, anxiety, and depression (Ganster and Rosen 2013; Oh and Gastman 2015). A study has identified a correlation between stress and depression among veterinary students (Killinger et al. 2017). Moral stress has been associated with mental health problems in veterinarians including burnout (Kipperman et al. 2017) and compassion fatigue (Moses et al. 2018).

Numerous studies have documented high rates of suicidal ideation and suicide in the veterinary profession compared with those in the general population and other healthcare professionals (Nett et al. 2015; Volk et al. 2018; Tomasi et al. 2019; Witte et al. 2019). Some studies contend or conclude that moral stress may be a contributing factor to the high prevalence of suicide in the veterinary profession (Bartram and Baldwin 2010; Fink-Miller and Nestler 2018).

Let’s now consider factors that may enhance one’s susceptibility to experiencing moral stress.

Demographic Risk Factors for Moral Stress

Numerous studies have concluded that younger, less experienced veterinarians have a higher prevalence of serious psychological distress or find ethical dilemmas more stressful compared with veterinarians as a whole (Nett et al. 2015; Kipperman et al. 2018; Volk et al. 2018). One might presume that with experience a practitioner would develop improved moral reasoning skills, which could moderate distress. However, a study documented no improvement in moral reasoning of veterinarians with experience, which disputes this assumption (Batchelor et al. 2015). The changes seen across age groups may instead represent enhanced coping strategies, which is supported by evidence that mental health of the public improves with age (Thomas et al. 2016). Alternatively, experienced practitioners over time may become desensitized to circumstances that novice colleagues may find ethically problematic and a source of moral stress.

Studies of veterinarians (Nett et al. 2015; Kipperman et al. 2018) and veterinary students (Killinger et al. 2017; Yang et al. 2019; Kipperman et al. 2020) have concluded that females experienced substantially greater levels of psychological distress and moral stress compared with males. Reports have also documented that female students in animal science and veterinary programs have greater empathy for animals than males (Hazel et al. 2011; Calderón-Amor et al. 2017) and that female veterinary students show more concern for animal welfare than their male counterparts (Cornish et al. 2016; Mariti et al. 2018). It seems reasonable to suggest that these characteristics would predispose an individual to experience moral stress.

Environmental Risk Factors for Moral Stress

Autonomy “refers to decision latitude or skill discretion that reflects control over one’s own work” (Wallace 2017) and is generally accepted as being associated with well-being (Kogan et al. 2020). Female practitioners and nonveterinary employees describe less autonomy and are less likely to be in a position of authority compared with male veterinarians (Wallace and Buchanan 2019). Reports have documented that lack of autonomy is a risk factor for burnout in female animal health technologists (Wallace and Buchanan 2019), and veterinary technicians (Kogan et al. 2020; Liss et al. 2020).

Perceived support in one’s workplace has been shown to be an important factor influencing moral distress (Rushton 2016; Carse and Rushton 2017). The ability to speak up without fear of negative consequences reduces risk of moral distress. Therefore, organizational structures that encourage discussion of ethical dilemmas can decrease moral distress in healthcare settings (Vaclavik et al. 2018; Krautscheid et al. 2020).

Ambiguity has been defined as “vagueness and uncertainty” (Hancock et al. 2015). An increased likelihood of stress and burnout has been identified in general practitioner physicians in training with low tolerance of ambiguity (Cooke et al. 2013).

Personality Risk Factors for Moral Stress

Perfectionism is a personality attribute in which there is a propensity for very high expectations of oneself and/or others (Holden 2020). Perfectionism has been established as a common attribute among veterinary students (Holden 2020). The competitive nature of being accepted into veterinary school likely selects for perfectionism as a necessary trait for a prospective veterinarian to be successful. Studies of veterinarians have concluded that perfectionism increases susceptibility to moral stress and psychological distress (Crane et al. 2015; O’Connor 2019). Perfectionism is therefore a double-edged sword, improving one’s capacity to become a veterinarian, but also increasing one’s vulnerability to moral stress as a consequence of the “imperfections” inherent in veterinary practice.

This dichotomy of adaptive and maladaptive perfectionism was first described as “normal and neurotic perfectionism” (Hamachek 1978). Neuroticism is the personality trait that describes “individual differences in negative emotional response to threat, frustration or loss” (Lahey 2009). Individuals with high levels of neuroticism have a tendency toward maladaptive emotional responses to stressful situations (Smith et al. 2014). Numerous authors have noted the relationship between neuroticism and perfectionism (Smith et al. 2014; Holden 2020). In a study of veterinary students, perfectionism significantly correlated with neuroticism, and neuroticism was found to have a negative correlation with resilience (Holden 2020). While both traits likely impact the experience of stress, neuroticism may play the greater role. A study of medical students showed that perfectionism alone was not a reliable predictor of stress, and some forms of perfectionism enhanced resiliency, whereas neuroticism was a robust predictor of stress (Enns et al. 2005).

The interplay of these personality types is relevant to veterinary professionals, as veterinarians have been found to have an increased incidence of perfectionism and neuroticism (Zenner et al. 2005; Strand 2019). Furthermore, these traits correlate with higher levels of occupational stress, burnout, and negative well-being (Crane et al. 2015; O’Connor 2019). Dr. Elizabeth Strand, Director of Veterinary Social Work at the University of Tennessee, suggests there are strategies available to mitigate the negative aspects of some personality types (Fender 2019). Let us now examine what can be done to alleviate both the occurrence and the pernicious effects of moral stress.

Mitigation of Moral Stress