Abstracts
Abstract
Moral distress is an important topic, particularly given the impact of unacknowledged moral distress on professional practice, including social work. Interviews with Ontario Works (OW) case managers working in regional offices in southern Ontario form the backdrop of an analysis of moral distress in the context of a highly rule-bound environment combined with unmet needs. This study focuses particularly on the role of structural constraints, such as policy restrictions as contributors to moral distress. The concept of moral distress is complicated by noting that distress is not always in response to a desire to act in the best interest of the client. An argument is developed that situating moral distress in a discussion of professional and feminist ethics encourages a deeper analysis of the implications of moral distress for professionals working in restrictive policy environments.
Keywords:
- Moral distress,
- policy implementation,
- Ontario Works,
- feminist ethics
Résumé
La détresse morale est un sujet important, particulièrement en raison de l’impact de la détresse morale non reconnue sur la pratique professionnelle, y compris le travail social. Les entrevues avec les gestionnaires de cas d’Ontario au travail (OT) travaillant dans les bureaux régionaux du Sud de l’Ontario forment la toile de fond d’une analyse de la détresse morale dans le contexte d’un environnement fortement réglementé et de besoins non satisfaits. Cette étude se concentre particulièrement sur le rôle des contraintes structurelles, telles que les restrictions politiques, qui contribuent à la détresse morale. Le concept de détresse morale est compliqué par le fait que la détresse n’est pas toujours une réponse au souci d’agir dans l’intérêt supérieur du client. Un argument est présenté : situer la détresse morale dans un processus de discussion sur l’éthique professionnelle et féministe encourage une analyse plus approfondie des implications de la détresse morale pour les professionnels qui travaillent dans des environnements politiques restrictifs.
Mots-clés :
- Détresse morale,
- mise en oeuvre de politiques,
- Ontario au travail,
- éthique féministe
Article body
MUCH HAS BEEN WRITTEN about the impact of neo-liberal restructuring on social workers’ ability to practice according to the social justice commitments of the profession. Constraints on adhering to professional values result (Austin, 2012; Banks, 2014; Fine & Teram, 2013; Goethals, Gastmans & Casterlé, 2010; Jameton, 2013; Varcoe, Pauly, Webster & Storch, 2012; Weinberg, 2009, 2010), because new public management “operates with a different moral compass than public service” (Austin, 2012, p. 36). The concept of moral distress has been used in discussing the moral conflict between rationed services and client suffering. Developed in nursing (Jameton, 1984), the concept has parallels in other professions (Jameton, 2013) and has had some attention from social work (Lynch & Forde, 2016; Mänttäri-van der Kuip, 2016; Oliver, 2013; Weinberg, 2009, 2016). Moral distress is generally understood as the distress that arises from knowing an ethically appropriate action but being prevented from taking this course of action by institutional constraints (Corley, Elswick, Gorman, & Clor, 2001; Jameton, 1984, 2013; Mitton, Peacock, Storch, Smith, & Cornelissen, 2011; Oliver, 2013). It is particularly germane in bureaucratic settings where professional practice is highly rule-bound.
This article is based on interviews with 15 Ontario Works (OW) case managers working in southern Ontario. The initial focus of the interviews was on policy implementation and the use of discretion by case managers. Although not the original focus of the interviews, moral distress was a strong theme in case managers’ discussion of the systemic conflicts they navigated between a restrictive income support program and the complex needs of clients.
In this article, moral distress is explored by contextualizing it within a broader discussion of social work and feminist ethics. Particular attention is paid to the dilemmas of restrictive policy as a source of moral distress and the way feminist ethics allows for a deeper analysis of the experiences and implications of moral distress for OW case managers and others practicing in restrictive policy environments.
Literature Review
Moral Distress
A number of dimensions of moral distress can be identified in discussions in the literature. First, moral distress refers to situations where there is an awareness of the right course of action and a sense of moral responsibility to take the right course (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005; Corley et al., 2001; see also Jameton, 1984, 2013). The concept is distinguished from a classic moral dilemma (choosing between two or more right courses of action), and from situations of moral ambiguity (Weinberg, 2009, 2016). Second, the concept includes references to barriers to enacting the ethical course of action. While some authors suggest internal barriers (e.g., Carse, 2013; Hamric, 2012; McCarthy & Deady, 2008) others emphasize institutional constraints (Jameton, 1984) or “factors outside of the self” (Weinberg, 2016, p. 17). These institutional constraints come in the form of the decisions of others in charge (Carse, 2013; Davis, Schrader, & Belcheir, 2012; Goethals et al., 2010; Jameton, 2013), and/or institutional structures that include lack of time for clients/patients, lack of resources, and conflicts between values and regulations (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004). The important role of policy as an institutional constraint is noted by some scholars (Lynch & Forde, 2016; Pauly, Varcoe & Storch, 2012) and Weinberg (2009) points to the struggle between rules and how one wants to act. Third, the term moral distress is distinguished from other kinds of distress. The term refers to a “serious moral compromise” (Varcoe et al., 2012) that impacts one’s moral integrity (Davis et al., 2012; Hamric, 2012; Peter & Liaschenko, 2013) through a failure to live up to one’s fundamental convictions and values (Carse, 2013; Goethals et al., 2010). Davis et al. (2012) suggest that long term exposure to moral distress can permanently alter one’s moral integrity leading one to trivialize or deny wrong-doing so that moral compromise is no longer seen as impacting a sense of right and wrong.
Conceptual Critiques of Moral Distress
Moral distress has been critiqued for a lack of definitional clarity and for diverse meanings and definitions in use (Hamric, 2012; Lützén, Ewalds, & Kvist, 2012; Repenshek, 2009). Weinberg (2009, 2010, 2016) argues that the term too easily assumes an appropriate way of behaving, when the field of social work is full of paradoxes and ethical dilemmas. In addition, while the concept assumes a known right course of action, moral distress may also arise from situations where there is no clear course of action in which all harm may be avoided (Weinberg, 2009, 2010, 2016).
In addition to a lack of clarity, some authors argue the term is in danger of being used to refer to psychological impacts rather than the stress of conscience that is at the root of moral distress (Lützén et al., 2012; McCarthy & Deady, 2008; Oliver, 2013). While psychological and emotional effects may accompany moral distress, it is not reducible to these effects (McCarthy & Deady, 2008). Sunderland, Harris, Johnstone, Del Fabbro, and Kendall (2014) echo this argument in noting the distinguishing feature of moral distress is not the type of feeling that occurs, but rather that the feeling occurs because one cannot act in accordance with one’s values.
Several authors caution that focusing on the negative effects of moral distress blinds us to the positive role of what Peter and Liaschenko (2013) call “moral agency” (p. 338); “ … moral distress alerts us that something of great significance is being threatened or constrained, namely our moral identities, responsibilities, and relationships” (p. 345). In addition, moral distress can function as an important reminder of moral obligation and a positive force in urging practitioners to follow their convictions (Lützén et al., 2012).
Lastly, Weinberg (2010, 2016) argues that moral distress is limited because it depicts the agency of workers as being constrained by, and separate from structures. Yet, “through one’s actions, individuals create the structures that exist” (Kondrat, 2002 cited in Weinberg, 2016, p. 17). This suggests the distress that workers experience can be understood as more active than not being able to do the right thing and may be rephrased as having to do the wrong thing.
Locating Moral Distress in Ethical Frames
Locating moral distress within the context of feminist ethics and social work ethics offers a deeper and richer analysis for understanding the implications, challenges, and possibilities associated with moral distress in practice. In contrast to the dominant theory of morality—a set of universal rules applied to all by an autonomous, distant and disinterested moral agent—feminist situated and relational ethics[1] depict a moral self that is embodied, emotional, connected, and situated within concrete relations (Banks, 2008, 2014a, 2014b; Gray, 2010; Pettersen, 2011; Tronto, 1993; Sevenhuijsen, 1998; Walker, 2007; Weinberg, 2014). Walker (2007) “locate[s] morality in practices of responsibility that …[track] who gets to do what to whom and who is supposed to do what for whom” (p. 16). Specific information about the characters, including their relationships to one another, the context, and history, is needed for ethical decision-making (Banks, 2008, 2014a, 2014b; Pettersen, 2011; Sevenhuijsen, 1998; Tronto, 1993; Walker, 2007; Weinberg, 2010, 2014). Lastly, an ethical relationship is characterized as “non-violative” towards the Other (Cornell, 1992, p. 62 cited in Weinberg, 2016, p. 18), doing no harm and encouraging flourishing (Pettersen, 2011).
Recent literature associated with the practice of professional social work ethics highlights the limitations of rule-based ethics. First, the complexity and inherent paradox within social work practice makes the application of narrow codes of conduct and general rules to specific cases problematic (Weinberg, 2010, 2014, 2016). Likewise, professional social work ethics risks being used as a tool of new public management (Banks, 2008, 2014a; Weinberg, 2014). The challenge of professional rule-based ethics is particularly relevant for the OW case managers in this study who must navigate narrow codes and rules or risk discipline. The focus of this paper is to explore OW case managers’ experiences of moral distress within the context of broader feminist ethical considerations, namely as a situated practice of responsibility that encourages ethical relationships of doing no harm.
Methods
Ontario Works, the context for this study, is an income support program of last resort. It is an intensely bureaucratic workfare program with a myriad of rules regarding both financial eligibility and workfare compliance. OW case managers fill a number of administrative roles, which vary regionally and may include determining income eligibility, operating employment programs, working with special populations, and investigating fraud.
Interviews with 15 OW case managers in southern Ontario were conducted for a study which originally explored the role of bureaucratic discretion (Baker Collins, 2015, 2016), and which elicited conversations about moral distress. Case managers were recruited both formally and informally. Local social service agency personnel were asked to share information about the study with potentially interested OW case managers and an email recruitment letter was sent to case managers through a regional director of the program. Ethical approval for the research was obtained from the McMaster Research Ethics Board.
The case managers interviewed for this study are representative of a range of years of experience and case management roles. About one third of the case managers had been working in OW for less than five years, about one third between five and 10 years and about one third had worked for over 10 years with two case managers working very long term at 17 and 27 years. Case manager roles varied from income eligibility and employment counselling, to community outreach, training, and working with particular populations including the homeless, youth, and those with addictions and mental health issues. The case managers who took part in the study work in regional offices in southern Ontario. To preserve confidentiality, the location of specific offices where the case managers work is not being shared.
Case manager interviews were audio recorded, transcribed and analyzed using the MAXQDA qualitative data analysis program. Interviews with OW case managers were coded previously with several purposes in mind: to understand the views of case managers about the scope and means of their own discretion (Baker Collins, 2015) and to understand their approach to clients in the exercise of that discretion (Baker Collins, 2016). Already established codes from these two rounds of data analysis (contradiction/complexities, values, and comparisons among case managers) were analyzed further for references to moral distress.
Data were analyzed again both inductively and deductively. Deductively, aspects of the interviews, which related to the nature of the job, were coded and analyzed, including the rewarding and challenging aspects of the job, workload, and supervision. In addition, interviews were analyzed inductively for moral distress and the codes of moral distress and ‘not social working’ emerged. In summary, the data analysis for this discussion built on previous data analysis that was relevant to this topic and included new data analysis specific to the concept of moral distress.
Findings
The findings will be discussed under two broad themes: 1) systemic and contextual factors that contribute to case managers’ moral distress, and 2) resistance, including strategies used by OW case managers to cope with and respond to moral distress.
The systemic and contextual nature of moral distress — The impact of social service restructuring
Mänttäri-van der Kuip (2016) suggests that workload distress becomes moral distress when it impacts the quality of care given. The conversations below demonstrate the impact of rule-bound constraints on case managers’ ability to establish relationships with clients and offer holistic services, resulting in practices of responsibility that have the potential to do harm.
One barrier to enacting the ethical course of action manifests in a lack of time for clients. OW case managers describe heavy caseloads—“crazy overworked”—that limit the ability to get the job done, let alone having a relationship with clients that makes room for understanding the challenges in their lives. Large caseloads, combined with increased record keeping and pre-programmed OW technology, reorganizes institutional practices and crowds out conversations with clients. Case managers are severely constrained in their ability to engage in ethical —non-harmful—relationships and decision-making practices. Below, one case manager describes the limitations of prescriptive OW technology.
You ask the questions and there’s a screen shot so you go, income and expenses, assets, like bank accounts, accommodations…all these buttons on the side and you input the information, so at the end of the information you press this button to see if they’re eligible and how much they’re eligible for … When I was hired they said not to tell the person whether they’re eligible or not. Put all the information in, click this button, ok they’re eligible, or they’re not eligible.
OWCM 7
Another case manager uses sarcasm to acknowledge the changing nature of the case manager-client relationship and to mourn the past as a time when it was possible to develop relationships with clients and express interest in their lives. Instead of talking with clients, case managers focus on inputting the correct information into the computer.
Computer system. Everything is electronic. I have to type everything into this thing. Why would I talk to anyone? … I always sit with my new hires to observe to see how they’re doing and they’re all like this, terrified to not feed the right information into the system and gone are the days where they actually look up and say ‘well how are you doing today? What is happening with your life today?’
OWCM 10
For Ontario Works case managers the stakes are high because their work determines whether or not basic needs are met for applicants. As one case manager expressed it, “You’re going home going ‘oh my God I didn’t do this’ and ‘oh my God I have to remember to do that’ … There’s a pressure in knowing that people’s incomes are tied to your ability to get those done.” (OWCM 2).
Thus, reflecting on workload constraints, prescriptive technology and complex rules, case managers worry about the quality of care they are able to provide, they lament the inability to establish relationships with clients, and the way technology limits their ability to respond to client needs. As Peter and Liaschenko (2013) note, moral distress signals that one’s moral relationships and responsibilities are being threatened or constrained.
Relationship between oppressive policy and client needs
Oppressive things we cannot change. An important theme in the distress described by case managers is the inability to meet very visible and pressing needs of clients due to restrictive legislation and inadequate welfare incomes. Several case managers acknowledge their role in perpetuating these practices, but also describe the difficult situation of “being stuck” and unable to act otherwise. As one case manager expressed it: “There are the things we cannot change. I can’t give you more. I am stuck with that.” (OWCM 7)
Another case manager discusses, with regret, the lack of options available to provide clients’ with the income needed to pay rent and make ends meet.
You’re very stuck at, uh you know, I’ve had a number of times people (say a single recipient gets $606) so they say ‘is that all you can give me? Is that, is there anything you can squeeze out?’ and I have to have this discussion about, it’s the ministry, it’s the province…There’s no way I can give you any more money, maybe a bus pass. […] But that’s the challenge definitely, where they say ‘how am I going to pay my rent?’ and I’m stuck {voice drops to a whisper}, I can’t, I can’t give them anymore right?
OWCM 7
In the discussions above, case managers are aware of the right course of action—the need for more adequate income—but they highlight the legislative barriers that prevent them from enacting that course of action.
While case managers are often experts at finding room in the legislation to meet needs (Baker Collins, 2015) there are many instances where even a creative use of discretion is not sufficient. The comments below reflect the distress and discomfort case managers feel when having to implement restrictive policy that negatively impact peoples’ lives:
It was never the people that I found the difficulty to deal with, not really, it’s the struggle between the oppressive policy and how you feel about it and how you know it affects people.
OWCM 12
Similarly, another case manager describes the difficulty of not being able to find or implement a loophole to benefit clients.
It’s frustrating that we’re kinda stopped by that—when there’s no grey area and you want to be able to help a client and you can’t. So that tends to be because of the policy and you have to try and find the loophole and sometimes you can’t and you get stopped by upper management so that tends to be, that tends to be hard.
OWCM 4
Case managers describe taking home the worst cases, where they were unable to bend the rules so as to meet pressing needs. The case manager below describes being unable to assist a client to find furniture for her apartment because she did not meet the stricter eligibility requirements of a revised housing benefit:
That really bothered me because I went home and I was actually thinking about it—I was actually thinking about ‘how can I do this? Is there any way that I can, you know, get around it?’ So I think what would have happened—with the new housing benefit you have to have, it’s very strict, you have to have documentation—she wouldn’t have been able to give me anything.
OWCM 7
As a result of the narrow and rigid work environment of OW, case managers express varying degrees of discomfort, distress, and remorse in having to implement limiting policies and practices along with empathy and a desire to do more.
Things I do not want to change: avoiding moral distress. Another important iteration of moral distress manifests in the avoidance of moral distress, through professional distancing and disinterest. The case managers in this study describe colleagues who feel little empathy and concern towards clients, or the desire for improved client-worker relationships often associated with moral distress and moral agency. For example, one case manager describes her own worry about heading down the path of cynicism and a more restrictive case management:
I can definitely admit that the longer I’m there the more uh bitter, it’s the wrong word but it’s definitely applicable, because you start to see the same situations over and over again, the same excuses, the same of everything and you get to a point where you know you can kinda see through it and you know ok you’re probably not putting forth the effort that you most could and you know you start to get a little bit tougher with everybody…
OWCM 11
Another case manager describes colleagues who enter the job with little personal attachment to helping others, who perform their job in a detached and bureaucratized manner:
My first year here I was shocked to discover that they [OW colleagues] had no particular personal calling to the job, it just happened to be the job they had. They could very well be bank tellers or working in the 7-Eleven or dry cleaners or something like that. That’s just where they were. So they didn’t bring any personal emotional attachment to the job. I find that people became uh, what I thought of as bureaucratized.
OWCM 8
In another example, a case manager describes the strategy of detachment used by some case managers when required to implement a negative decision: “…and it kind of makes caseworkers kinda detach themselves from the human side of it because you’re like ‘well you know I feel bad for you. This is just the policy.’” (OWCM 4)
The case managers in this study describe colleagues who sidestep moral distress by entering into the job without a commitment to “making a difference in people’s lives” and others who had lost that commitment, or seen it diminish over time, through fatigue and the ongoing struggle between inadequate policies and client suffering.
Embracing the “fairness” of punitive rules. In the literature, moral distress is characterized as the failure to take the right course of action, often due to institutional constraints. The application of the concept in the literature and in the examples previously given—policy constraints that prevent acting in the client’s best interest—imply the right course of action is to resist neoliberal, bureaucratic, and technological constraints. In other words, the implication is that moral distress is progressive by nature. In conversations with OW case managers, however, it is clear that the inability to act in the client’s best interest is not always the cause of their moral distress.
One case manager—who adhered to the workfare principle that recipients must earn their social assistance—complained about a situation in which a client failed to meet the (too vague) conditions of the participation agreement and did not lose their benefits. For this case manager the right course of action was to sanction the client and cut them off assistance:
You know, what they were, they said they would go to school and they haven’t gone to school for six months. We gave them opportunity after opportunity but the agreement just said, “must go to school full time,” no explanation about what the consequences would be…so someone who is truly not earning the assistance that they are receiving, gets off on a technicality. And you look at that and I go, ‘I see the technicality, do I make the decision, because it’s truly the right thing to do’.
OWCM 11
Likewise, several case managers disparage “fraudulent letters” from landlords—letters meant to document the client’s address and rental costs. While case managers are encouraged to take these letters at face value, they chafe under this approach when they suspect misrepresentation.
I’m sure we would all agree when we can see a big fraud happening, but because of legislation and our policy around confidentiality we can’t call it.…But really what we’re told from above it’s none of our business. If they hand in a landlord letter that’s their declaration, you’re not fraud, take it, that’s, don’t really dig into it … we’re supposed to be trusting people at their word which would be lovely to be able to do but …
OWCM 5
In the example below, another case manager mirrors the frustration and distress, noted above, of having to accept documentation at face value:
Talk about landlord letters—I think it’s ridiculous. Anyone can fill out a landlord letter. Anyone can fill out a little letter saying: “George is residing with me.” Okay? And we are to accept it as is.
OWCM 15
As the discussions above suggest, OW case managers not only experience moral distress when they are unable to expand entitlements for clients, but also when they are unable to implement professional rules and codes—what is considered fair practice—and when they suspect clients are dishonest and have broken trust.
Resistance
Resistance is characterized here as a range of strategies used by case managers to respond to the systemic and contextual constraints that lead to moral distress, ranging from small, and often hidden, acts of refusal to more creative and open forms of micro-resistance.
Complicating the directive that a “good” case manager is “not a social worker”
The demands of bureaucratic accountability coupled with complex rules require case managers to spend a great deal of time determining eligibility (Pennisi & Baker Collins, 2017). The narrow focus on determining eligibility requires case managers to compartmentalize and reduce the complexity of clients’ lives. In the midst of their encounters with clients’ complicated lives case managers are reminded by their supervisors that they are not social workers, they are case managers.
In the excerpts below case managers not only discuss the limitations and tension associated with being a “good” case manager but also reflect on the importance of being empathetic, caring, and responsive to client needs. By acknowledging, or bearing witness to client suffering, these case managers are engaging in a subtle form of resistance that manifests in a refusal; namely, a refusal to ignore human suffering and need, by adhering to the rigid requirements of the job. In the first example, the case manager displays empathy for the client’s ‘horrible’ situation, while reflecting on inadequacy and narrow parameters of the job.
‘Cause some of our folks are in a horrible situation and have nowhere else to go and the only person they really have to talk to is their worker. Now unfortunately everybody calls us social workers, we’re not social workers, we’re case managers—very different … Case managers are responsible in determining eligibility and financial assistance. A social worker would be dealing with all the other components of living—health and wealth and family connections and all of that—so unfortunately some of our clients think that we are able to do that stuff and they’ll pour on all this stuff and the worker doesn’t know what to do with it (emphasis added).
OWCM 10
Reflecting on the limitations of the job, another case manager acknowledges the complexity of clients’ lives and the toll it takes when hardship and suffering go unacknowledged.
There are so many more complex issues going on with people that we’re not equipped to deal with yet, just like no one recognizes that this is the kind of stuff that people are coming in with and we don’t have, you know, we’re there to issue benefits but people are coming in with serious addiction, mental health, and when I mean mental health, for some it’s just isolated depression but some of it is long term and stuff that we can’t diagnose and then just complex issues with family, you know, it’s, it’s really tough.
OWCM 1
Another case manager describes—with empathy and disbelief—the job as “heartbreaking” when, “ … the pain and the frustration and the tragedy that you can be bombarded with in one given day is awesome, it really is … it’s just mind blowing.” (OWCM 6)
Below, another case manager discusses the constraints of the job and the need to go beyond the limits of the position by providing support and counselling to clients.
We truly all do the best we can with what we’re given and you know some people have different skill sets than others and some of us stronger counseling background and are able to apply that a little better than others and which may be more effective with working with clients but at the same time we’ve also been told we’re not to counsel in our job—we’re actually not paid to counsel so if we say that we counsel we’re actually told according to this we’re not paid to do even though we actually do it.
OWCM 11
Case managers face at least two systemic sources of moral distress. They encounter clients with complicated and distressing lives, but the moral position required by the system is to ignore human suffering and to reduce this complexity to a set of computerized screen options and focus narrowly on eligibility. Similarly, in the face of troubled lives, they are reminded they are not social workers or counsellors. Case managers resist this moral stance by refusing to operate within the narrow constraints of the job. They do this by acknowledging the severity and complexity of clients’ suffering and needs, displaying empathy, and by providing counselling and support to clients.
The use of small concessions. Being caught between policy directives and human need goes beyond being unable to meet the needs presented and includes making decisions that will add to the hardship of clients. In this section, case managers’ discuss the challenge of being required by legislation to enact decisions that will make clients’ lives worse and describe the small concessions they use to help alleviate the sting. Below, one case manager times the delivery of bad news in order to lessen the damage.
I always think to myself ‘what’s the best day of the week to deliver bad news’ cause I’ll have something that’s not approved and I know this client’s gonna be bawling and heartbroken, and it’s like well do I do it on a Friday? Should I do it on the Monday? Like what, you know.
OWCM 4
The most severe decision that can be made by a case manager is to remove a client from the caseload, thereby cutting off their income support. Failure to meet the conditions of a workfare participation agreement, for example, can result in the client being removed from the caseload. In the excerpt below, the case manager strategically plans the timing of the suspension notice to minimize the impact and buy time for clients to sort out the issue. The case manager also ensures that clients do the necessary follow-up.
I don’t suspend anybody at the end of the month. If I have to suspend someone I’m always doing it at the first of the month so that’s good. Everyone still gets their cheque, they still get the 30 days to sort out, make sure they follow through with that piece.
OWCM 9
Another case manager uses hope as a strategy to minimize bad news and to help clients.
I see my job as trying to help each one of these individuals, I have to help them get through the moment and I have to try to somehow locate something that’s hopeful that I can give them. I have to deliver bad news sometimes. I have to make things worse sometimes.
OWCM 6
Thus, despite the requirement to implement policies that make people’s lives worse, case managers use strategies of timing and hope to minimize the impact on clients. In doing so, case managers demonstrate an awareness of the right course of action and a desire to engage in less harmful and more ethical relationships.
Moral agency and creative resistance. One of the critiques of moral distress, noted earlier, is that the focus on negative impacts tends to blind one to the positive dimensions of moral agency (Peter & Liaschenko, 2013) and moral obligation (Lützén et al., 2012), particularly for professions with social justice commitments. Although case managers in the study work within a highly constrained environment, some engage in small-scale forms of creative resistance. In the discussion below the case manager actively seeks out connection and engagement with clients as a way to overcome the default mode of professional distancing. This particular case manager works several days a week in a community setting, which makes her more accessible to clients, and she also participates in neighbourhood events with her family:
I can put a face to my clients where most of the workers can’t … They know who I am and they can put me in the context, so I am a good worker because I don’t separate them out from anything other than the fact that they’re people in need at this point in time other than that, so that to me is the difference. You have the good workers who don’t use professionalism as the way out of connecting with their clients … There’s a lot of workers who don’t want that connection.
OWCM 5
Case managers also report distress over the nature of “suspend letters”, which suspend cheques for missing information or failure to abide by some aspect of the workfare participation agreement:
And we wish we could say, ‘I wish the letters did not look the way they did’ because yes, it gives people a heart attack because of the way they’re written. Yes I wish we had a little bit more leniency that we didn’t have to request this, that and the other thing, but it’s out of our hands.
OWCM 11
Both the content and style of the suspend letter, which is difficult to understand and conveys certainty about suspension, is mandated by the Ministry of Community and Social Services and cannot be altered by the case manager. However, some case managers actively resist by including a hand written note on the letter outlining the steps the client can take to avoid suspension.
Despite a highly constrained work environment, case managers use their moral agency to engage in creative forms of micro-resistance aimed at prescriptive practices. Case managers find ways to build relationships and connections with clients and actively help clients navigate the system and rules. These small-scale acts of resistance reflect case managers’ efforts to take the right course of action.
Discussion
In examining moral distress from the perspective of OW case managers, the role of restrictive policies and regulations is particularly evident. Systemic constraints significantly impact the work of case managers resulting in a range of complex responses. The following discussion focuses on the insights, opportunities, and questions that emerge from exploring moral distress within the context of broader feminist relational and situated ethics.
Understanding the Complexity of Moral Distress
Literature on resistance within human service organizations is often characterized as complex and contradictory work (Aronson & Sammon, 2000; Aronson & Smith, 2010; Smith, 2007; Weinberg, 2009, 2016). Similarly, in this study, conversations with case managers reveal a broad range of strategies used to navigate and negotiate feelings of moral distress. These strategies range from critiques of existing policies, organizational practices, and job requirements; subtle forms of refusal and more active resistance; and professional distancing. At the same time, the findings suggest the contradictory nature of that moral distress. For some case managers, moral distress—or the inability to take the right course of action—is positioned as social justice-oriented. Yet, for other case managers the inability to take the right course of action is understood within a rule-based frame, as not being able to implement or follow prescribed rules or policies.
The contradictory nature of moral distress points to the limitations of the concept. On its own, moral distress is unable to clarify or provide the means for understanding how taking the right course of action is determined. Thus, moral distress lacks the conceptual and theoretical tools to critique current moral practice and the underlying assumptions that perpetuate moral decision-making. The rule-based iteration of moral distress, for example, underscores case managers’ ongoing attachment to liberal conceptions of fairness and rule-based morality. Without these conceptual tools, and an alternate framework for understanding moral and ethical decision-making, it may be difficult to use moral distress to build and sustain a comprehensive social justice critique.
Despite the limitations, moral distress is a useful concept because it names and locates distress within a moral register and signals the inadequacy of the current moral framework. Situated within a framework of feminist relational and situated ethics, the insights of moral distress have greater significance. By historicizing and contextualizing liberal notions of ‘fairness’—which assume everyone begins from the same starting point—(Sevenhuijsen, 1998; Walker, 2007; Weinberg 2014) social work can begin to disrupt and chip away at the liberal myths that form the basis of current universalistic, rule-based approaches to morality.
In a sense, feminist situated and relational ethics picks up where moral distress leaves off. Feminist ethics highlights the importance of relationship, interdependence, context, and emotions for moral decision-making. From this broader perspective, taking the right course of action involves being non-violative (Cornell, 1992, p. 62 cited in Weinberg, 2016, p. 18) or non-harming (Pettersen, 2011) towards Others. Situating moral distress within a broader framework of feminist ethics generates the insights needed to resolve the challenge of competing and contradictory understandings of taking the right course of action.
Tentative Hope/Uncertain Optimism
Case managers’ displays of empathy, and their mourning of a past that allowed for relational ways of being among workers and clients, can be seen as a sign of limited hope. The desire for relationship, connection, and context, which prescriptive technology denies, along with the refusal to operate within the confines of the job and ignore human suffering, mirror claims from feminist-situated and relational ethics that ethical decision-making must be addressed through a holistic and relational approach that takes into account the person’s complex life (Banks, 2008, 2014a, 2014b; Franklin, 1999; Pettersen, 2011; Sevenhuijsen, 1998; Tronto, 1993; Walker, 2007; Weinberg, 2010, 2014). Unlike rule-based morality that calls for a rational and detached approach to moral decision-making, feminist ethics argues that emotions, such as empathy, are essential to ethical decision-making (Banks, 2014a, 2014b; Pettersen, 2011; Warren, 2000; Weinberg, 2014, 2016).
It is tempting to assume that case managers’ feelings of moral distress in response to oppressive policy and practice represent an inclination towards feminist ethics in practice. Yet, the certainty of this optimism cannot be guaranteed. Moral distress may also signal the mourning of the ideals of progressive liberalism. Attachment to these ideals enables social workers and case managers to practice under a veil of kindness and position themselves as helpers (Smith, 2007), while at the same time reproduces oppression and functioning “as agents of the state” (Weinberg, 2016, p. 1).
Thus, moral distress may, or may not, signal a desire to engage in an ethical relationship of doing no harm. What it does signal, however, is the need to explore and deconstruct hidden assumptions and taken for granted positions of power and privilege associated with helping and mourning the past, and how these impact moral and ethical decision-making. Situating moral distress within a feminist relational ethics framework invites further exploration of the location or source of moral and ethical values and assumptions, as well as how relationships, identity, and moral values are intertwined and reproduced within social processes and practices (Tronto, 1993; Sevenhuijsen, 1998; Walker, 2007; Weinberg, 2016).
Positioning social work education within feminist ethics can help in “reclaiming the ethical” by problematizing social work ethics as merely professional rule-based ethics (Banks, 2014a, p. 22). Feminist ethics provides the conceptual tools to interrogate dominant conceptions of morality and ethics, which privilege sameness over difference and seeks to eliminate context (Sevenhuijsen, 1998; Walker, 2007; Weinberg, 2014). Relationality and interdependence, key features of feminist ethics, implicate human service workers in social processes that reproduce oppression and domination. Thus, feminist ethics has an important place in social work education and practice. Moral distress is a useful departure point for engaging in a deeper and broader conversation about the location and nature of social work ethics.
Using the Present as Possibility for the Future
Over the past decades, neoliberal restructuring has had a devastating impact on the welfare state and on those providing services and seeking support. In a curious way, neoliberal restructuring, with its exaggerated focus on economic efficiency and hyper-individualism, has opened up a space from which to question and problematize current moral decision-making and what taking the right course of action means. Constrained work environments and compartmentalized and decontextualized relationships help to expose relations of power and privilege as well as the contradictions inherent within the helping relationship (Gray, 2010; Weinberg, 2010, 2016) that were less visible under more benevolent iterations of the welfare state. Discussions with case managers suggest that it is difficult to engage in the contradictory practice of being both a helper and an agent of the state (Weinberg, 2016; Maynard-Moody & Musheno, 2003) without experiencing some form of moral discomfort or distress. In this sense, neoliberalism represents an urgent opportunity to use moral distress as a starting place for exploring the complexity and assumptions associated with the helping relationship and moral decision-making. Situated within a framework of feminist ethics, moral distress can relocate the conversation to a deeper, philosophical level rather than focusing solely on expanding rights and entitlements. Such a conversation would shed light on how “the ethical is framed” (Banks, 2014a, p. 22), how need arises and is maintained in the first place, and how power and privilege is perpetuated within frameworks of morality. Thus, neoliberalism creates the opportunity to bring to the forefront that which was previously hidden and to use moral distress and discomfort as an invitation, or entry point, for engaging in more critical forms of inquiry. From a position of discomfort, feminist ethics has the ability expose the limitations of existing moral practices while providing an alternate framework for ethical and moral decision-making, a framework with radical and transformative potential (Banks, 2014a).
Appendices
Biographical note
Stephanie Baker Collins is associate professor at the School of Social Work, McMaster University. Sheila Cranmer-Byng is a PhD candidate at the School of Social Work, McMaster University.
Note
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[1]
We use the term feminist situated and relational ethics as a broad category, which includes range of distinct approaches, rather than focusing on the merits of each approach. In the paper the term feminist situated and relational ethics is used synonymously with feminist ethics.
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