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Ethical Dilemmas in Healthcare: The Bystander Effect

Nurses are typically known for being compassionate, caring, and kind. Most nurses enter the profession knowing that they will be exposed to some death and suffering. Many hope to make the world a better place by easing the suffering of their patients and helping people improve their health. Unfortunately, ethical dilemmas in healthcare are common, and there is rarely a clear solution. Dilemmas like these can lead to moral distress for nurses and the dangerous bystander effect.   

Moral distress among nurses  

Moral distress happens when a person feels unable to perform an ethically correct action. People experience moral distress when they must act in a way that conflicts with their core values. Among nurses, this is most common in critical care areas such as the intensive care unit or emergency department. 

Recommended podcast: Moral Distress: How, Can, and Should We Respond to It? 

Some nurses may feel moral distress when continuing life-saving measures that cause the patient pain or injury, prolonging life for someone diagnosed with brain death, or withdrawing care on patients before the nurse feels the time is right. Other reasons for moral distress include disrespecting patient autonomy, therapeutic obstinacy, poor competence of the work team, and nurses’ denial of patient advocacy.  

Moral distress may cause both emotional and physical symptoms such as headaches, fatigue, emotional instability, and insomnia. Some nurses misunderstand moral distress and believe they are dealing with burnout rather than moral distress.  

This may lead nurses to mistakenly believe that simply taking time off or lessening their workload will help them feel better. In addition to taking time off, nurses dealing with moral distress should seek social support, discuss ethical dilemmas in healthcare with their managers, and work to build resilience.  

What is the bystander effect? 

The bystander effect is a surprising phenomenon that occurs in public and within healthcare teams. The term “bystander effect” describes how a group of people are less likely to aid a person in distress. Several studies have shown that an individual is more likely to help a distressed person when asked. On the other hand, a group of people asked to provide aid will usually not step in to help that same distressed person. This phenomenon can be observed in critical situations like car accidents, on the internet, with non-critical problems, and even in children.  

In healthcare, a providers’ lack of confidence and hope that another provider will step in to make decisions or provide care may explain this effect. Many nurses and other healthcare providers also fear making a mistake in a crisis or being judged by their peers for making the wrong decision or taking inappropriate action. Additionally, people often feel that if others are not already jumping in, the situation may not be critical.  

Moral distress may cause bystander effects in some situations. Moral distress may also exacerbate the bystander effect. For example, when a patient’s autonomy is threatened by caregiver interventions, or when a treatment conflicts with group core values, nurses and other providers may be more hesitant to act. In a difficult pattern, inaction or taking an action that is ethically complex may cause caregivers to experience more moral distress, and the cycle continues.  

Recommended course: Ethics and Moral Distress for Healthcare Professionals 

Developing resilience through ethical dilemmas in healthcare 

Because healthcare will always be a place where difficult decisions must be made, there are few ways to eliminate ethical dilemmas and moral distress. However, resiliency training is one of the best ways to combat moral distress and bystander effect. Teaching caregivers to remain resilient in the face of difficulties not only reduces symptoms like insomnia and depression, but it also improves patient care and teamwork.  

Resilience defines the ability to adapt to challenges and maintain flexibility in the face of both internal and external demands. A resilient caregiver is one who can witness patient suffering or experience loss, then move on to provide excellent care to their next patient with compassion.  

This does not mean that nurses do not grieve or feel upset by ethically upsetting situations. Instead, they can sit with those feelings, process them in a healthy way, and move forward. Nurses who complete resilience training have lower rates of depression, anxiety, and burnout than those who do not.  

Supporting nurses through ethical dilemmas in healthcare 

Social support is vital for healthcare workers, especially those working in areas where they experience frequent moral distress. Sharing feelings with a trusted friend or co-worker can help a person process and understand their own thoughts and emotions.  

Nursing leaders working in critical care or other difficult units can be proactive by offering debriefing and opportunities for discussion after difficult patient cases or interactions. Many employers also offer Employee Assistance Programs with free counseling services for their nurses.  

Acceptance, bias, and compassion in nursing 

Moral distress commonly occurs when nurses care for patients who have different belief systems than they do. For example, a nurse may struggle to care for a patient who has chosen to get an abortion or have difficulty accepting the death of a patient who refused all blood products.  

Nurses have a responsibility to allow patients to make their own healthcare decisions, but it is not always as easy as it sounds. Abortions, organ donation, blood product use, treatment choices, and end of life choices can all cause strong feelings for both the patient and the nurse.  

Nurses should be aware of any biases they have about people and their healthcare choices, and work hard to be accepting of others’ belief systems. Caregivers who feel strongly about a patient’s care choices may need to ask for assistance or speak to their charge nurse about changing patient assignments.