Lifestyle

Identifying, measuring and minimizing moral distress

By Paul Basilio

At a time when the number of equine veterinarians leaving practice due to long hours, compassion fatigue and other factors is increasing, recognizing the causes of moral distress and understanding the tools to minimize its impact are critical to the future of the field.

Moral distress is defined generally as a mental state that occurs when a person faces an ethical dilemma, judges the best course of action and is forced to act in a way they believe is morally wrong. The term was introduced in human medicine in the 1980s to describe nurses facing institutional constraints, but its effects are not limited to human medicine.

In 1 study, more than 75% of veterinarians reported experiencing moderate to severe stress due to ethical dilemmas, and 70% of those veterinarians had little to no training in resolving them.

For Barb Crabbe, DVM, MA Bioethics, moral distress presented itself early in her career when an older horse’s owners elected euthanasia because the horse had lice. Dr. Crabbe tried to explain that the condition was easily treatable, but the owners refused and insisted that the patient be euthanized.

“I did it, and I felt deep down at the time that I probably wasn’t doing the best thing for my patient,” she said. “That horse’s story has haunted me for my entire career.”

Dr. Crabbe and Cara Wright, DVM, MS, a senior professional services veterinarian at Merck Animal Health, brought attention to moral distress in equine practice through 2 presentations at the 71st Annual AAEP Convention in Denver.

The ideal vs the real
To illustrate one of the multiple ways in which moral distress can pop up in equine practice, Dr. Crabbe first described an ideal, morally unambiguous scenario in which a practitioner is called to examine an 8-year-old horse with colic that requires surgery. After the veterinarian recommends referral to a surgical hospital, the owner says, ‘The trailer’s hooked up, we’re ready to go, and I’ll call the insurance company on the way.’

“But that’s not always what happens,” said Dr. Crabbe, a member of the AAEP’s Professional Conduct and Ethics Committee and the AVMA’s Council on Veterinary Services.

Instead, several other scenarios are more likely. Perhaps the owner loves the horse, but can’t afford to pay the bill, so they request that the horse be euthanized.

“We don’t love that response, but you understand it, and you euthanize the horse,” she said. “We accept that as part of our job, but for many of us, it can cause a small level of moral distress every time it happens, even if we don’t realize it.”

In another scenario, a misinformed owner may not only refuse the colic surgery, but they may also refuse the euthanasia and insist that the horse be managed with pain medications or fluids because they don’t understand the situation fully, and a neighbor said their horse with colic did just fine without surgery.

“In this situation, we might be tempted to refuse to provide treatment, but we may feel compelled to continue because we don’t want to abandon our patient,” Dr. Crabbe said.

Sometimes, an owner may request immediate euthanasia for the horse with colic because they don’t want to spend any more money on the problem. “They may acknowledge that it’s a pretty nice horse, but they’ve done the math, and they can just replace the horse for the cost of surgery,” she explained.

This situation is one of the most striking examples of moral distress because the veterinarian places a higher value on the patient’s life than the owner does. Euthanizing the horse feels wrong, but abandoning the horse and refusing to euthanize it also feels morally wrong.

“You’re forced to euthanize the patient, and you’re likely to experience moral distress,” Dr. Crabbe said. For younger veterinarians who may feel they lack the agency to push back or voice their concerns, such situations can be an enormous source of moral distress, increasing their risk of leaving the profession.

Measuring distress
Unrecognized and unaddressed moral distress builds up over time. For every moral dilemma that causes distress, lingering feelings or moral residue can accrue even after the problematic situation has passed. Each time that happens, a new baseline of moral distress is created.

In human medicine, several measurement tools have been published to identify or measure moral distress, but it wasn’t until recently that Australian researchers published a pilot moral distress scale specifically for veterinarians. The Measure of Moral Distress for Veterinary Clinicians (MMD-VC) scale is based on the Measure of Moral Distress for Healthcare Professionals (MMD-HP) scale used in human medicine.

The authors divided the moral challenges faced by veterinarians into 3 primary areas:

1. Team conflicts: “I disagree with my colleague. How do I handle that?”
2. Client conflicts: “My client wants to euthanize a perfectly healthy horse for convenience.”
3. Personal threats: “If I don’t do this, I’m going to lose my job.”

The scale was published in 2025, and it is a promising step toward drawing more attention to moral distress and minimizing its potential effect on veterinarians, which the profession cannot afford to lose, according to Dr. Crabbe.

Minimizing distress
In the second presentation, Dr. Wright identified actions that can reduce the psychological burden of moral distress at the individual level.

On a personal level, the first step toward lessening moral distress is to take stock of your values and find a practice that aligns with them.

“Super easy,” Dr. Wright joked, adding, “if you don’t know what is most important to you and what you hold dear, then it is going to be really hard to make a decision when you are faced with a morally dubious case.”

If everyone is on the same page, you will experience less moral conflict on a day-to-day basis, she said. If a practice makes you feel uncomfortable, then it’s probably not going to be a good place for you to work in the long term.

Another way to minimize moral distress is through mentorship. Dr. Wright explained that mentorship should encompass the science and technology of practice, as well as the inevitable moral and ethical dilemmas. If you’re not comfortable speaking to someone at your practice about mentorship, there are other options, such as Decade One and Mentor Vet. The AAEP also offers Outrider, which facilitates professional relationships between newer and more experienced AAEP members.

“My other challenge for veterinarians is that if you [encounter someone on a case] that makes you uncomfortable, get more uncomfortable and ask that person about it,” Dr. Wright said. “Maybe there’s information that you don’t have that could complete the picture, or maybe you are just on separate planets about how you would deal with the case.”

Both Drs. Crabbe and Wright stressed that moral distress is everywhere and underacknowledged.

“With individual actions, practice actions and professional actions, we can hopefully lessen the burden on ourselves, decrease the rate of burnout, and keep people doing better in equine practice.” MeV

FOR MORE INFORMATION
Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250-6. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2001.01658.x

Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330-342.
https://doi.org/10.1086/JCE200920406

Moses L, Malowney MJ, Wesley Boyd J. Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians. J Vet Intern Med. 2018;32(6):2115-2122.
https://academic.oup.com/jvim/article/32/6/2115/8471032