Managing clinical uncertainty

In the day-to-day routine of critical care physicians, end-of-life care and medical ethics are frequently incorporated into comprehensive care plans. What happens when the laws impede the ability to honor family wishes?

Imagine this: You are a critical care physician whose partner is five months pregnant. One of the patients in the critical care unit this week is a young woman who tragically became brain-dead late in her second trimester after a large intracranial hemorrhage. The hospital’s ethics and legal services are both involved, and you have just been advised that because of recent changes to state law, you will be required to maintain the patient’s body indefinitely against the wishes of her family. You cannot help but imagine yourself and your partner in this situation. How can you keep your personal and professional selves separate while caring for this patient?

Recent ethical debates surrounding the care of brain-dead or severely neurologically injured pregnant patients highlight growing tension between clinical ethics and public policy. These cases are medically complex and emotionally devastating for families.

But cases involving pregnancy and severe neurological injury also are especially difficult for the medical team. Clinicians already must navigate competing obligations: the patient’s wishes, the fetus’ potential outcomes, the family’s grief, institutional policies and increasingly restrictive laws. When legislation such as fetal personhood statutes limits how clinicians are allowed to care for their patients, it creates a fundamental conflict between ethical training and legal compliance. For example, in Texas, physicians face a fine of $100,000, felony charges and imprisonment for violation of this fetal personhood statute.

A key concern for healthcare teams in this issue is moral distress, which is described in our recent commentary in the American Journal of Bioethics. Moral distress occurs when clinicians are unable to act in ways they feel are most ethical. When the distress accumulates, it can develop into moral injury, a deeper psychological and professional harm that affects clinicians’ sense of integrity and purpose and can degrade mental health as well as professional satisfaction.

The consequences are not abstract. Research links moral injury in healthcare workers to burnout, depression and even suicidality. Importantly, these outcomes are not primarily driven by individual resilience or a lack of “wellness.” Instead, they often stem from systemic conditions: legal ambiguity, institutional risk-management and policies that remove clinical judgment from the bedside.

Healthcare professionals are accustomed to managing clinical uncertainty. What erodes trust and morale is not uncertainty itself, but rather external forces requiring clinicians to work against the ethical foundations of the profession. Transparent communication with surrogate decision makers, empathy and acknowledging systemic limitations are key to maintaining trust under these restrictive laws.

Protecting patients and protecting the moral integrity of clinicians are not competing goals. In the long run, they are the very same mission.

By Dr. Avni M. Kapadia, assistant professor of neurology – division of neurocritical care and vascular neurology, and obstetrics and gynecology, Baylor College of Medicine, and Dr. Hannah L. Kirsch, clinical associate professor in the Neurocritical Care Division of the Department of Neurology & Neurological Sciences, Stanford University School of Medicine