Bokek-Cohen, Y. ; Marey-Sarwan, I. & Tarabeih, M. (2024). Deontological Guilt and Moral Distress as Diametrically Opposite Phenomena: A Case Study of Three Clinicians. Journal of Bioethical Inquiry 21 (3):449-459.
Introduction
There are a great variety of definitions of the concept of guilt in the professional psychological literature (Tilghman-Osborne, Cole, and Felton 2010), and it can be argued that feelings of guilt are human emotions that may arise if a person committed an action that contradicts basic moral mores or failed to commit an action that is considered moral according to their ethical standards and values.
The scholarship in the last decade has identified two distinct types of guilt: Altruistic guilt (AG) and deontological guilt (DG). AG emerges when the individual feels that through their action or omission, an innocent victim has been caused harm, while DG results from the individual’s sense of having violated some internalized norm (Basile and Mancini 2011; Basile, et al. 2011; Mancini and Gangemi 2015, 2021; Mancini, Rogier, and Gangemi 2021). It has been demonstrated that the two types of guilt are distinct from each other (Basile and Mancini 2011; Mancini and Gangemi 2015, 2021). In AG, no moral principles have been transgressed, yet there is a victim, and the subject feels a sense of not having acted altruisti cally. In contrast, in DG, the sense of guilt arises from having violated one’s own principles, even if there is no victim. In such a case, the person suffers guilt feelings despite having acted with intent to benefit the victim, or in healthcare, to benefit the patient because of violating a moral rule or norm.
Besides analysing guilt from a psychological per spective, guilt can be interpreted as a philosophical concept. Moral behaviour is prosocial behaviour, i.e., behaviour that promotes and fosters cooperative interactions between members of a group, so that a failure to behave in that way may lead to feelings of guilt (Teroni and Bruun 2011). A long-standing tradition in philosophy holds that guilt has a posi tive role in social regulation as aversive reactions to socially transgressive behaviour (Morris 1976). In many cases, the solution to feelings of guilt is forgiv ing; it can serve to release the guilty, opening up both parties to a more harmonious future (Derrida 2000; Ricoeur 2004). Nelkin (2019) distinguished between Bad-Guilt and Good-Guilt, stating that Good-Guilt entails caring about the right things, as manifested by guilt under the right circumstances. Another philosophical theorization by Martin Heidegger refers to guilt as “existential guilt,” i.e., guilt is an ever-present and unavoidable part of human existence. In other words, human beings are always and necessarily guilty, and they exist in such a way that implies that they are constantly accountable to themselves (Hei degger 1996).
Interpretation Within the Context of the Wider Literature
Most theoreticians who analysed guilt agree that this emotion has moral implications where one is trou bled by committing ethical transgressions that violate one’s own sense of “right” and “wrong.”
DG arises from moral introspection and the acknowledgement of having transgressed societal norms and moral principles. Moreover, DG drives individuals to mod ify their conduct to fit the rules of their society and culture (Carni, et al. 2013). Most definitions of DG include moral rather than social transgression as the basis for guilt feelings (Tilghman-Osborne, Cole, and Felton 2010), as is the case with the three gynaecolo gists we interviewed.
In contrast to consequentialist morality, where the act is judged solely by its conse quences, DG is a direct result of deontological moral ity, which derives from the physicians’ assumption of having violated their own moral standards and norms, even though no harm results from this transgression. Feeling DG involves the acknowledgement that one has violated an internalized moral principle and is responsible for an action or failure to act although free of material and moral limitations (Basile and Mancini 2011; Basile, et al. 2011; Mancini and Gangemi 2015, 2021). DG guilt is usually characterized by a sense of responsibility, leading to punishment seeking and sin expiation, which indeed appeared in the narratives of the three interviewees. This may lead physicians to experience guilt feelings after the violation of their inner ethical standards and principles, even in the absence of any direct damage or victim. While physi cians are prone to experience AG following a medi cal mistake or negligence, committing what Mancini and colleagues (Basile and Mancini 2011; Basile, et al. 2011; Mancini and Gangemi 2015, 2021; Man cini, Rogier, and Gangemi 2021) call “deontological wrong” may lead to a difficult moral predicament and pain due to having provided medical care to benefit one’s patients despite moral prohibitions, in this case, stringent Islamic religious prohibitions.
It seems that guilt feelings represent the phenom enon which is diametrically opposite to moral distress (MD). In situations where it is clear to healthcare pro viders what action is morally required of them, but they are unable to perform it, they may suffer MD. This phenomenon, too, has not received sufficient empirical examination, although an intensive litera ture search revealed a small number articles discuss ing the subject, based on the findings of empirical studies. MD is described as the experience of stress symptoms that arise when the medical practitioner feels unable to maintain their ethical integrity. Indeed, a major source of stress and burnout among health care providers is decreased job satisfaction and MD that comes from being required to work in a way that conflicts with one’s ethical principles. MD is a moral emotion based on moral conflict or angst (Dudzin ski 2016). Medical practitioners may feel threatened, impotent, blameworthy, or confused (Tarabeih and Bokek-Cohen 2020a, 2020b).
The most salient characteristic of MD is the sense of suffering that results from the perceived violation of the individual’s professional duties and integrity. MD as experienced by a medical practitioner refers to feel ing responsible for the moral implications of how the patient was treated, and thus suggests the positive moral traits of the practitioner (Førde and Aasland 2008; Lamiani, Borghi, and Argentero 2017). Moreover, MD is triggered by a concern for the well-being of patients rather than for oneself (Dudzinski 2016). Typically, the causes are recurring unresolved moral dilemmas and conflicts, experienced as emotional pain or anguish. When the practitioner identifies a moral dilemma, real izes their own responsibility to act but feels powerless to take the ethically right course of action, due to real or perceived barriers, the outcome is moral distress (Rath ert, May, and Chung 2016). Figure 1 graphically illus trates the difference between DG and MD