4. CONSECUENCIAS DE LA CRISIS
4.3. DEVALUACIÓN SALARIAL Y REFORMA LABORAL
The concept of moral distress in an intensive care or critical care setting has been examined extensively (Gutierrez, 2005; Rushton, 2006; Schluter, Winch, Holzhauser
& Henderson, 2008). As transplant takes place in these critical care environments much of this literature may be highly relevant to transplant practices. End-of-life decision-making that accompanies transplant is often seen as a source of moral distress, as are the extreme mechanical measures sometimes required to maintain life (Corley, 1995). In many studies, transplant is mentioned in passing, though little discussion or critical appraisal is forthcoming (Beca & Astete, 2011; Ersoy &
Akpinar, 2005). Nierste (2013) notes that nurses may experience moral distress throughout the process of caring for transplant patients and their families.
However, Nierste (2013) writes from a Christian perspective and there may be an element of religious bias in the work.
In a policy recommendation article, Roels, Spaight, Smith and Cohen (2010) argue strongly that moral distress is highly relevant in transplant and has significant implications which extend beyond job satisfaction and staff retention into the realm of personal beliefs and transplant context. To this end, a small number of studies have considered moral distress and transplant in a more critical fashion.
Milliken and Wall (2014) present a case study where a patient is approaching brain death and a nursing sister requests the attending doctor to call a transplant
coordinator. The attending doctor is unwilling to comply with the nurse’s request because he or she wishes to have an end-of-life conversation with the family. In this case, the nursing sister experiences moral distress because she is unable to initiate a course of action which she believes is ethically correct – giving the family an opportunity to make a decision about organ donation (Milliken & Wall, 2014).
In commentary on the case, Milliken and Wall (2014) advise that health professionals in these situations should consider recommendations from the American Association of Critical Care Nurses (AACN, 2004, p.2) who advise four A’s for coping with moral distress – ask, affirm, assess and act. The four A’s are
depicted in Figure F3.1.
Figure F3.1 – The four A’s of moral distress (AACN, 2004, p.2)
Milliken and Wall (2014) conclude that the nursing sister is justified in any remedial action she feels necessary as she is vulnerable in this scenario, because of the health hierarchy.
Mandell et al. (2006) conducted focus groups with a large number of medical and allied transplant professionals. Moral distress was identified as a significant theme at the time when referral for donation and maintenance of the donor needed to take place. Moral distress appeared to be based on a lack of guidelines and protocols which caused confusion for participants. As the previous chapter showed, transplant in South Africa is poorly regulated, and such guidelines and protocols are also lacking in the Gauteng context. Wiegand and Funk (2012) show that nurses experienced moral distress when considering healthcare for future patients (potential transplant recipients). One nurse who participated in the study was hesitant about organ donation because of a concern that the potential donor was HIV positive. Pearson, Robertson-Malt, Walsh and Fitzgerald (2001) identified elements of moral distress amongst intensive care nurses managing brain-dead donors, though these are not explicitly acknowledged as such. They note that nurses felt uncomfortable maintaining brain-dead donors because there was an acknowledgement that the patient was dead but there was an obligation to treat that patient as though still alive.
3.3.1.1. Moral distress in tissue transplant patients
Begley and Piggott (2013) consider moral distress and how it may influence siblings in making decisions of whether or not to donate stem cells to another sibling – the pre-transplant process. Stem cells constitute human tissue, and tissue donation is less risky than organ donation because tissues regenerate. Begley and Piggott (2013) argue that an individual may feel moral distress if he or she is unable to fulfil the mandate of donating stem cells to a sibling. This mandate will either be
unfulfilled because the individual is not a good match, or because of another contraindication to donation. Begley and Piggott (2013) emphasise that moral distress can only be experienced in an agent who is constrained from acting in a way which he deems morally correct. Thus, a transplant coordinator in this type of
situation may experience moral stress in trying to facilitate dialogue and balance opinion between siblings who can and cannot donate stem cells. However, a coordinator does not experience moral distress because although the behaviour of the other siblings prevents facilitation of a transplant for the potential recipient, this is not a moral choice made by the coordinator, it is simply the result of situational circumstances (Begley & Piggott, 2013).
3.3.1.2. Gaps in organ donation and moral distress literature
As this section has clearly highlighted, moral distress is well recognised in the pre-transplant process (which will be discussed in more detail later in the literature review, Section 3.3) when referral of donors, brain-death and donor maintenance are considered. However, there appears to be very little literature considering moral distress at other points of the transplant process, such as when caring for potential recipients pre-transplant and in the surgical phase.