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Abstract
For healthcare professionals and organizations, there is an emphasis on addressing moral distress and compassion fatigue among clinicians. While addressing these issues is vital, this paper suggests that the philosophical concept of agent-regret is a relevant but overlooked issue in healthcare. To experience agent-regret is to regret your harmful but not wrongful actions. This person’s action results in someone being killed or significantly injured, but it was ethically faultless. Despite being faultless, agent-regret is an emotional response concerning one’s agency in a situation that results in death or significant harm. In healthcare, many clinicians are likely to experience regret for faultless actions that significantly harm or cause the death of a patient. The recognition of agent-regret in healthcare is significant because it differs, conceptually and practically, from moral distress and compassion fatigue. Building on the work of Wojtowicz (Citation2022), we should strive to understand clinicians’ agent-regret by recognizing their agency in the situation, not lessening or removing it.
ACKNOWLEDGMENTS
I would like to express deepest appreciation to my colleague, Dr. Gavin Enck, for his invaluable partnership and unwavering commitment to this paper. His collaboration and dedication ensured that the clinical knowledge embedded in this work was front and center enriching its content and impact. I am also deeply indebted and would like to extend my heartfelt gratitude to my husband, Tanner, and children, Jack and Lucy, for their constant support and encouragement throughout my journey into academia and research. Their understanding, patience, and unwavering belief in my endeavors have been a continuous source of inspiration, pushing me to strive for excellence. To my colleagues in the University of Oklahoma Fran and Earl Ziegler College of Nursing who have directly or indirectly impacted me or contributed to my success, your support and guidance have been instrumental in making my ability to be published a reality. GGE: My sincere appreciation goes to Beth Condley. Amongst healers, I know none better than her. This manuscript first grew out of interacting with Jake Wojtowicz’s exceptional work on agent-regret. The theoretical and practical significant of the issues were made clear from weekly rounds in Riverside Methodist Hospital’s Medical (RMH) Intensive Care and Cardiovascular Intense Care units, as well as multi-disciple meetings with the Palliative Care team and Neurological Critical Care Units. These units, teams, and clinicians fearlessly care for patients, often at great personal cost. Healthcare in the United States needs to do better in caring for these that care for patients. Dwight Davidson provided insightful and critical comments to the manuscript. Shannon Storey and Jake Wojtowicz’s input was crucial. RMH's Medical Library assistance was crucial and their ability to find any article or book is amazing. David Reidy’s mentorship on my philosophical thought is evident. Finally, despite being the only metaphysician (i.e., real doctor) in the class, the support from the Brazilian Jiu-jitsu morning class at Super System BJJ was pivotal.
DISCLOSURE STATEMENT
No potential conflict of interest was reported by the author(s).
Notes
1 Does luck undermine knowledge claims or moral responsibility? In moral philosophy and epistemology, the role of luck is a crucial question. In epistemology, the question is whether knowledge can result from lucky beliefs, whereas in moral philosophy, the question is whether luck undermines conditions of control (Engel Citation1992; Hartman Citation2017; Levy Citation2011). Explaining the full range of issues and concerns involving luck in detail in these domains is beyond the scope of this paper. Nonetheless, this paper’s type of luck or chance would be categorized as “resultant moral luck,” cases in which the outcome of a person's action is beyond their control, affecting their praiseworthiness or blameworthiness (Hartman Citation2017).
2 Taken from the work of Alice Gregory’s (Citation2017) New Yorker article on accidental killers
3 Regarding moral responsibility, the lorry driver and Patricia are not blameworthy or subject to approbation for their conduct. Safe driving was ethically permissible (and even commendable) in their situations.
4 In this paper, the agency is acting for a reason or intentionally (Nguyen Citation2020). Similar to Nguyen, noting hinges on using a broad notion in our work. Like Nguyen, we acknowledge this is a broad stipulative definition of agency. However, unlike Nguyen, this project's scope and length constraints limit us from further argumentation.
5 This emotional response is agent-regret and not guilt. As Wojtowicz (Citation2022) argues, guilt is an appropriate emotional response to a wrong action, an action that is ethically impermissible, forbidden, or prohibited. If the lorry driver and Patricia were not practicing safe driving, they would (or should) experience guilt. However, the lorry driver and Patricia were practicing safe driving and were not a fault, so guilt is an inappropriate emotional response.
6 There may be concerns that while it may be appropriate for the lorry Driver and Patricia to have agent-regret, it is possible to extend the notion of agent-regret beyond a reasonable measure. In other words, when is one not reasonably culpable for the outcome of an action? This concern centers on the difficulty of tracking and disentangling the metaphysics of causation. Wojtowicz (Citation2022) draws on tort law as a reasonable basis for defining and limiting the scope of responsibility for causation. Nevertheless, as noted by Wojtowicz in personal communication, agent-regret does not require or depend on a specific account of causation. One could, for example, rely on Woollard's notion that an agent counts as doing harm if and only if some fact about the agent's behavior (action) is part of the sequence leading to that harm (Woollard, Citation2015). This behavior (action) only counts as part of the sequence leading to harm through a complete chain of substantial facts. In the examples in this paper, all the actions count as part of a sequence of substantial facts. The Lorry Driver and Patricia's actions were substantial facts in a chain of events that led to the death of the child and motorcyclist. If they were non-substantial facts, they would be mere conditions. However, Lorry Driver and Patricia's actions were not mere conditions; they were direct causes of the child and motorcyclist's death. A range of causation accounts could help define and limit the causal scope of responsibility for persons in agent-regret situations.
7 We use the term chance or happenstance, not luck, to avoid issues and concerns of moral luck. While moral luck is relevant, discussing it will take us too far. The justification for avoiding moral luck here is that there is no dispute regarding the moral responsibility of these agents. There is agreement that the Lorry driver, Patricia, and Cr. C is not morally blameworthy but was ethically permissible.
8 Medically inappropriate is narrowly understood as Non-Beneficial Treatment (NBT). Medical interventions or treatments are NBT when they meet three conditions: They are physiologically ineffective or have a low probability of success; causing harm, burdens, and risks to patients without any benefit; and; they will not prevent the imminent death of the patient or achieve their goals of care. In a situation in which CPR is NBT, there is no obligation for clinicians to offer or implement it (Bosslet et al. Citation2015; Kon Citation2016)
9 For situations like Billy, relevant tools only provide statistically aggregated outcomes. They do not offer guidance on individual cases. However, I use the percentage here to emphasize that the success or failure of CPR is not conclusively knowable in newborns like Billy (https://www.nichd.nih.gov/research/supported/EPBO)
10 Even if these percentages were accurate, it does not follow that they provide conclusive guidance in terms of death, disability, or care plans for specific individual cases (Wilkinson Citation2013).
11 While a mislabeling and manufacturing error like this is rare, the look-alike, a sound-alike name error is disturbingly common, with morphine and hydromorphone being one of the most common (Bryan et al. Citation2021; Lowe et al. Citation2017).
13 NARCAN is an opioid antagonist used to reverse the effect of opioids in an overdose (NIDA 2022, January 11. Naloxone DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/naloxone on 2022, December 19).
14 One may object to the claim that chest compressions that break a patient's ribs are an ethically justified intervention. However, this objection fails to understand the efficacy of CPR in the clinical setting. Under normal conditions, the effectiveness of CPR depends on several interventions to restart (and preserve) cardiopulmonary functioning, e.g., mechanical ventilation and chest compressions. To provide only one CPR intervention is to implement ineffective CPR. For example, providing mechanical ventilation but no chest compressions is ineffective CPR. While limiting resuscitation interventions may be justified, this justification must be for clinical reasons, such as a patient's physiology or condition making use of all interventions clinically inappropriate. In many situations, providing limited CPR without clinical reasons is unethical.
15 Framing as an accident does not mean the hospital, pharmacy, or company loading the machine is faultless. We are making the modest and narrow claim that Nurse M is faultless.
16 In other words, had resuscitation efforts worked, it would not have been shocking to the healthcare clinician or outside the prediction offered by the statistical averages for patients like Billy.
17 A reviewer mentioned that the term “agent-regret” in this situation is misleading. From Dr. C being sad, the contention was that it does not follow that Dr. C is experiencing agent-regret. The authors of this paper have worked to clarify the case to make sure it is explicit and clear that Dr. C is experiencing agent-regret. We thank the reviewer for helping us ensure the case is clear. First, sadness, as an emotional state and term, is broad. It is consistent for a person to be sad while experiencing differing emotions, such as anger, guilt, shame, or regret. It is conceptually or practically consistent to hold that Dr. C is sad and experiencing agent-regret. Second, we directly state that Dr. C is experiencing agent-regret to avoid confusion.
18 Four key features of moral distress have been identified:
Epistemic: one believes they know the morally right action in the situation
Constraints: There are internal or external factors that constrain this person’s action
Violation: this act violates the person’s moral integrity or core values.
Reaction: this act results in the clinician experiencing initial distress that develops into a distress response (Sanderson et al. Citation2019).
19 A revised version of Campbell, Ulrich, and Grady’s (2016) definition.
20 While including these critical features, proposals often aim to broaden or narrow the definition of moral distress. Broad accounts aim to expand the notion of moral distress by focusing on the clinician’s affective reaction. Narrow accounts aim to restrict the definition of moral distress. Some accounts aim to narrow moral distress by focusing on the constraint feature, such as requiring organizational and structural constraints preventing clinicians from acting. Other accounts of moral distress are narrow because they distinguish or clarify moral distress from other reactions to moral stressors, such as moral frustration or moral discomfort.
21 For healthcare systems that follow this practice, out of fear of ligation, please know you are evil.
22 JW pressed the authors on this point directly. Telling someone it was an accident conveys that the community views them as faultless. It also makes sense not only why a person would tell someone this but also why it could relieve agent-regret.
23 However, evidence of self-justification of action is often for facilitating a bad action or distorting one's blame for a bad action (Shalvi et al. Citation2015)
24 Consider, for example, certain games of chance, such as roulette, in which the outcome is entirely based on chance. It would be odd to hold that the bettor lacked agency, despite factors outside their control or as the result of chance. In healthcare, patient outcomes often result from factors outside healthcare clinicians' control or the result of chance. Yet, it would be odd to regard healthcare clinicians as lacking agency.
25 Although not directly referenced, Nguyen's concerns about gamification and value clarification influenced the authors' views on including, rather than reducing, complexity (Nguyen Citation2020).