Fr. Michael Della Penna, ofm* and Francisca Burg-Feret*

This paper begins with a case study describing the perspective of a Catholic nurse who experienced moral distress while observing the tragic death of a newborn infant named Baby Mary. The purpose of this paper is to raise awareness and educate readers about the concept of moral distress and promote a greater understanding of the lived experience of Catholic health care providers who undergo this trauma. It also provides an analysis and some recommendations for practice that can help health care professionals make good ethical choices in difficult situations based on their faith.

Case Study Background

The following case study and journal entries reveal an attempt by one nurse to understand and describe the interior process of moral distress utilizing the concept of conscious reflexivity as defined by Wojtyla ( 1981) in which consciousness " ... enables us to have an internal view of our acts and their connection with the personal 'I' (p. 20).  "Reflexive thinking is an important element in the creation of all understanding .. .it is also an important element in the creation of knowledge about the self ... " (Wojtyla, 1981, p. 21).

The concept of conscious reflexivity or reflective thinking is demonstrated in the following journal entries written by a registered nurse working in a neonatal intensive care unit (NICU) in a tertiary hospital in Toronto, Canada. This nurse identifies herself as a Roman Catholic with a strong faith in God and supportive of the teachings of the Church on life issues. The names of those involved and location of the following case study are omitted for reasons of confidentiality. The case study and journal entries depict the nurse's experience with moral distress.

Medical History

A baby girl from immigrant parents was delivered in a peripheral hospital - the labour was difficult and the baby experienced hypoxia at delivery. The baby required resuscitation and ventilation to assist with poor respiratory effort. She was transferred to a NICU in a tertiary hospital where a head ultrasound and other tests revealed that there was some damage to the brain although the degree of damage could not be determined. The movement in her right arm was limited but movement in her other limbs was normal; she responded appropriately to stimulation. She was born on October 27th at almost 35 weeks gestation weighing 2760 grams -an appropriate size for her gestational age. A few days after birth the parents decided they wanted to withdraw care; at this point the health care team believed that when she was removed from the ventilator she would stop breathing, however after extubation, she started to breathe on her own and did not require any assistance or increased oxygen to maintain normal oxygen levels in her blood.

It is significant to note she did not have any seizures, no blood glucose issues, she was able to maintain her blood pressure and she did not have cerebral edema nor was she diagnosed with a disease or a syndrome. Her condition was considered stable. In this case the NICU protocol would be to slowly introduce feeds. If the baby did not have a strong suck reflex, which is common for an infant at 35 weeks gestation that has experienced a traumatic birth, then a nasogastric feeding tube is used until the baby is able to take full feeds on her own. When feeding is established and the baby is gaining weight, common practice would be to discharge the infant home to her parents with close monitoring in a neonatal follow-up clinic.

Instead, the parents instructed the doctors that they wanted to leave her to die; they did not want a handicapped child and did not want to bring her home.  Since she was stable and did not require level three care, the doctors transferred the baby to the level two nursery and the nurses placed her in the corner with a screen around her crib. The order was to "withdraw care". Her parents rarely came to visit her and they did not give her a first name. The baby was left for hours without being held or loved.

Journal Entries

Tuesday November 4

I woke up in the middle of the night last night and the question that came to me was "what are you going to do about it?" For hours I lay awake thinking about it and knew that I had to try to bring this baby home. My commitments to my work and my students made it difficult and I knew I would need help. In the morning I called my friend and told her the story - I said this baby has no name and my friend said her name is Mary of course.

Within the hour I had many compassionate and loving pro-life friends willing to come to my home to help care for Baby Mary. I then called the social worker assigned to this case thinking she was going to laugh at me but she said she had been thinking about the baby as well. I told her that I would be willing to foster this baby in my home and she informed me that she would offer this option to the parents - she never got back to me. When I called her again she spoke to me about respecting the parent's wishes. I believe there are a lot of factors here.

I truly believe that if Baby Mary's mother came and visited her often she would have asked to feed her. No mother could see her baby rooting for food and not want to feed her. I don't know all the reasons for her actions but I know this mother is grieving for her baby.

Saturday November 8

Her chart entry says that she took a bottle and drank 40 mls quickly today - this is the last time she is to be fed. When I went to the L2 to hold her during my break the nurse wouldn't let me near her. She said she had "no religious hang-ups" and had no problem doing as the parents wished. The new doctor's order written in the chart says "no stimulation" i.e. no cuddling or holding and "phenobarb for comfort". I can't tell you how upset I was today.

I was working that day in an office by myself and there was-no one to talk to - no support. One of the nurses I was working on the project with came by - I thought I would feel her out about the no cuddle order and her response was: "it's too bad that we couldn't give something to hasten the death." I couldn't believe the words that I heard. I felt so alone, I felt fear, deep sadness, anger and helplessness. It is difficult to be a prolife nurse - the distress I have felt this past week is more than I thought it would be.

Wednesday November 12

Baby Mary is still alive - a bit dusky today - no food since Friday - she pees only tiny amounts and the nurse found blood in her diaper - she responds to sucrose and then settles back to sleep - she only lost 200 grams in 3 days and her face still looks full - not wizened and sunken like a starving person yet.

Sunday November 16

I called to see if she had passed yet and her nurse said to me on the phone "This is not right - I cried when I changed her at noon".

Wednesday November 19

Baby Mary cried out today when I was there - her eyes were wide open and she was rooting for food. One of the nurses who was caring for her today looked at me with tears in her eyes and said "this is not right - if they took her home and didn't feed her they would be charged - why is it okay for us to do this?"

Friday November 21

Baby Mary is still alive - I can't believe that it takes so long for a baby to starve to death - her parents gave her a name 2 days ago probably because they had to fill out the birth certificate and health insurance forms so the hospital and doctors can get paid - she now weighs 1950 grams and she looks like a starving infant - like the ones I saw in Africa. Unlike in Africa however - there is lots of good formula barely 10 feet away from her.

I was working in the level 3 today and it was very unusual for them to ask me if I would be willing to change assignments and move to level 2 because one of the nurses had to go on a transfer. Of course I said yes. When I asked her if she would mind if I picked up Baby Mary the nurse who was team leading responded: "I told them I didn't want to take care of this baby - I can't take it." As I held Baby Mary close, I prayed for her and her parents. She was very quiet and still and her breathing was shallow but I knew that it was a graced moment.  The next day she died - she lived for 27 days. God gave me consolation by providing the opportunity to give her my love.

Dilemmas

In the wake of Baby Mary's death, many complex questions arise which need to be answered, especially by the Catholic health care provider. Moral theologians and medical experts, for example, can debate important ethical questions like:

• Was Baby Mary's death murder?
• Was Baby Mary starved to death or was it the result of following a best practice?
• Was this a case of non-voluntary passive euthanasia or was it an informed and collective decision in accordance with standard procedure?

But there are other profound questions that go beyond the academic or medical inquiries and emerge in an alarming way within the hearts of the health care providers some of whom may be experiencing an awakening of their conscience. Agonizing questions like:

• Could I or should I have done more?
• Did I participate in an abortion?
• Am I complicit in murder?

And the question especially distressing to those affiliated with a Church; am I excommunicated?

Searching for answers to these questions in order to gain some understanding and meaning is particularly traumatic to a growing number of health care professionals who may or may not be prepared to grapple with the psychological and emotional anguish and/ or grave moral implications that these questions contain. In struggling with these and other moral dilemmas, more and more health care professionals are experiencing acute anxiety which has come to be identified as a condition known as moral distress.

What is Moral Distress?

While moral distress is pervasive, it is seldom recognized and is poorly understood (Cavaliere, Daly, Dowling and Montgomery, 2010). The study of understanding the exact nature of moral distress is at its beginning stages (Thibeault, 2001), (Corley, 2002) and is confirmed by the fact that early references to moral distress (Cavaliere et al. 2010) offer only incomplete definitions. In reviewing the literature it is apparent that the first definition of moral distress given by Jameton (1984) lacked reference to the spiritual and physical aspects; for him moral distress is the:

" ... painful feelings and/or the psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires, but cannot carry out that action because of institutional obstacles; lack of time, lack of supervisory support, exercise of medical power, institutional policy, or legal limits." (p. 6)

Pendry's more recent study (2007) expanded the definition to include the interior challenges, defining moral distress as "the physical or emotional suffering that is experienced when constraints (internal or external) prevent one from following the course of action that one believes is right." (p. 217). In Hanna's (2005) phenomenological study of nurses who assisted with legal, elective, and surgically induced abortions is noteworthy because it attempted to articulate a universal definition of the concept of moral distress. She seems to get at the underlying essence of moral distress when she defines it as "an act of interior aversion that occurs when some harm to an objective good is perceived." (p. 105).

Despite the fact that many people who suffer from moral distress are not familiar with the term, and despite how few studies have been conducted on what constitutes moral distress, it is cited in many medical codes of ethics. In Canada, for example, the Canadian Nurses Association (CNA, 2008) Code of Ethics defines moral distress (derived from Jameton, 1984) in the following way:

"Moral distress arises in situations where nurses know or believe they know the right thing to do, but for various reasons (including fear or circumstances beyond their control) do not or cannot take the right action or prevent a particular harm. When values and commitments are compromised in this way, nurses' identity and integrity as moral agents are affected and they feel moral distress."

Who experiences moral distress?

Today, health care teams commonly need to make decisions to sustain a life not considered viable twenty years ago and as a result, the number of those experiencing moral distress has increased. Although moral distress can affect all health care professionals, the intimacy of the relationship between a nurse and a patient can make nurses more vulnerable.

It is not surprising that studies indicate that nurses, whose work is essentially a "moral endeavour," experience moral distress more frequently than physicians. (Janvier, Nadeau, Deschenes, Couture and Barrington, 2007; Rittenmeyer and Huffman, 2009).

Nurses working in a NICU setting, for example, are at an increased risk of experiencing moral distress due to the frequency with which their patient population encounters life issues. While there are a limited number of studies in the NICU setting, neonatal nurses, who care for patients who are extremely vulnerable, work in an "emotionally and ethically sensitive area" every day (Cavaliere et al, 2010, p. 146) and confront many difficult decisions. In these cases, which involve questions of life and death, the long-term outcomes of premature infants must be considered and weighed against the considerable pain and suffering these tiny patients must endure. Furthermore, nurses may be required to perform many painful procedures on these infants while having limited influence on major treatment decisions (Thibeault, 2001). When discussing whom the legitimate decision maker is when making ethical decisions about a baby - the nurse often feels powerless to influence the doctor or the family who sometimes make uninformed choices or elect treatments that the nurses disagree with or may feel are non-beneficial.

In one study in a NICU, almost all the nurses experiencing moral distress told stories of a baby who died (Thibeault, 2001). The stress of having to watch an infant suffer extreme pain while knowing the infant cannot speak or make a choice is extremely difficult for anyone to endure. For nurses, however, it is even more so as this feels contrary to what is at the core of the caring profession - that of advocacy and seeking the good of the patient as priority. Janvier et al. (2007) found in a study conducted in Quebec that 35% of all nurses and 19% of the residents experienced frequent ethical confrontations that were stressful- the rates for NICU nurses in tertiary hospitals were higher at 56%. A systematic review of 39 qualitative studies on moral distress found nurses in critical care settings experienced high levels of moral distress which not only affected them psychologically and physically, but even spiritually; thus negatively impacting their self-image and job satisfaction (Rittemeyer and Huffman, 2009).

Situations that contribute to moral distress

There is a dichotomy between what nurses are trained to do and how they actually perform in the clinical setting; in practice, ideals are contradicted by realities. The Canadian Nurses' Association (2008) Code of Ethics for Registered Nurses clearly articulates the ideal in the following way: "Nurses intervene, and report when necessary when others fail to respect the dignity of a person receiving care, recognizing that to be silent and passive is to condone the behaviour." (Code, 04). In addition the nursing baccalaureate programs teach nursing students ethical principles - that of autonomy, beneficence, non-maleficence, justice and fidelity. They are taught to respect all persons and promote their independence, self-determination and selfreliance.  Nursing educators specifically teach students not to blindly follow medical orders but to carefully assess patient needs and then to develop a plan of care to meet these needs. Nurses are committed to caring and not intentionally inflicting harm or injury - they are responsible for ensuring safe and competent care.

In practice however, ethical or moral decision-making is not only influenced by the ideals of personal values and the values of the profession but by concrete factors in the particular system they work in. The question is often not what is morally right or wrong but how can nurses act in a moral way in a particular environment when some factors may prevent this. The inability to follow their conscience is a major problem among nurses who work in critical care areas of a hospital - especially with the critically ill and dying and those with life prolonging treatments. Distress is heightened for nurses who work in environments that are resource constrained, have excessive workload assignments or experience problems around resource allocation. Other unique challenges include: the fear of facing adversity through whistle blowing, weak policies and the moral distress experienced when nurses advocate for their patients but feel their voices are not heard (Rittenmeyer and Huffman, 2009).  Rittenmeyer and Huffman's (2009) study on the experience of moral distress, reported by nurses themselves using a variety of methodologies, uncovered four syntheses that highlight the difficulty of moral orthopraxis. The four syntheses include:

a) the inability to advocate for the patient and institutional constraints,

b) the patient's pain and suffering and the inability to influence decisions about their care,

c) power hierarchies and lack of recognition for nurse's expertise,

d) perceived employment risk if they were to voice their concerns.

What are the signs and symptoms of moral distress?

Nurses' reactions to moral distress contain a wide range of physical, psychological, spiritual and stress responses.  Thibeault' s (2001) descriptive exploratory study of moral distress experienced by NICU nurses attributed the complexity to several factors: an increase in technology and the number of interventions as well as the fragile condition of premature infants. Most literature describes similar themes where moral distress was the result of needless pain and suffering inflicted on babies. One prevailing theme was the feeling of powerlessness. Most organizations have an unequal hierarchy in which doctors have the power to decide, despite rhetoric about teamwork, inter-professional collaboration and shared decision-making. Nurses often fear raising concerns because of possible repercussions - they fear the doctors as well as the administrators. Nurses experienced "profound disillusionment" when they were repeatedly unable to practice their core values, especially when doctors and nurses differed in opinion over the right treatment of a patient (Rittenmeyer and Huffman, 2009, p. 1242). When coping strategies are inadequate, nurses may get burned out and/or leave the unit, the institution or even the profession. Some nurses either distance themselves becoming callous and indifferent or alternatively, they choose to act as advocates for patients and are sometimes successful (Cavaliere et al., 2010).

Rittemeyer and Huffman (2009), found responses to moral distress include feelings of: anger, loneliness, depression, guilt, anxiety, powerlessness and emotional withdrawal as well biopsychosocial responses. These symptoms include sleeplessness, headaches, nausea, dreaming and fatigue.  Lasting effects of moral distress include:

a) A profound sense of sadness - the feelings of sadness were not correlated with either successful or unsuccessful coping - they were just pervasive.

b) An increased sense of patient advocacy - many NICU nurses felt the baby's voice needed to be heard and that "we forget that babies are persons" (Thibeault, 2001, p. 53).

Moral distress is a subjective experience yet can be objectively observed and measured to some extent. In an effort to describe the spiritual aspect in a scientific way, Hanna (2005) used the Roy Adaptation Model of nursing (a theory most RNs are familiar with) as the conceptual basis for her study as well as the philosophy of Wojtyla. His work is significant to qualitative inquiry because it focuses on the phenomenological analysis of the moral/ethical nature of the human person. Phenomenology is a scientific way to discover universal truths. Sr. Callista Roy's philosophical assumption is derived from the view "that truth exists and its fullness is found in the creator." (p. 98).

Not all health care professionals react in the same way when experiencing an ethical dilemma; therefore, by studying their lived experience, we are able to gain understanding in order to find ways of supporting others. After Hanna analyzed her phenomenological data through four different perspectives: the lived body, the lived space, the lived relationship and the lived time, she added a fifth perspective derived from Wojtyla's work- the concept of conscious reflexivity or lived consciousness. By looking through this lens, Hanna (2005) sought to analyze the data related to moral/ethical/spiritual self. The findings in Hanna's qualitative study found that the nurses who utilized conscious reflexivity were able to describe their values and were able to journey interiorly in order to grow through their experience.

Hanna describes moral distress as an act of interior aversion that usually begins with a pre-cognitive "physical" type of perception that is experienced through the senses. Hanna later goes on to describe a second level of perception that happens at the cognitive level. By consciously reflecting on significant events in clinical practice we are able to interiorize our internal view of our acts.

Hanna (2005) was able to classify three types of moral distress: shocked, muted and suppressed. Nurses with shocked moral distress begin with a clear perception of harm to an objective good that is matched with an immediate interior rejection of that harm, and a "fight or flight reaction". These nurses seek others they trust to listen to their stories in order to receive support. It is possible that the nurse in this case study experienced shocked moral distress. She was certain that Baby Mary's lack of care was wrong and was facing grave harm. Her visceral reaction as a result of her conscious awareness of her position on euthanasia created an internal conflict. Her attempt to bring Baby Mary home was her effort to "fight" what was happening - however her inability to speak out was dominated by the fear of losing her job. The communication of peers who openly shared their abhorrence was reassuring and the support of her spiritual director and pro-life community helped her to journey through this difficult time.

Nurses with muted moral distress avoid discussion with others while interiorly dialoguing and through conscious reflexivity and they can be lead to increased self-knowledge and healing. Nurses with suppressed moral distress avoid selfconversations and rarely discuss their experience with others; for these nurses the issues remain unresolved. The study suggests that the nurses' health and sense of wholeness can be affected if they resist the process of conscious reflexivity (Hanna, 2005).

Guidance from the Catholic Church

Human life is sacred from the very first moment it begins because it involves a creative act of God and always remains in a special relationship with the Creator, for whom all life is directed as its sole end. Donum Vitae (1987) thus concludes: "No one can, in any circumstance, claim for himself the right to destroy directly an innocent human being" (p. 76-77). Catholic health care professionals can be guided and consoled by this truth and by John Paul II's reminder in Evangelium Vitae (1995) that emphasizes the "incomparable worth" and "inestimable value" of the human person in regard to these or any issue that threatens or opposes life: Even in the midst of difficulties and uncertainties, every person sincerely open to truth and goodness can, by the light of reason and the hidden action of grace, come to recognize in the natural law written in the heart (cf. Rom 2: 14-15) the sacred value of human life from its very beginning until its end, and can affirm the right of every human being to have this primary good respected to the highest degree. (EV 2) Nurses therefore need only trust and listen within themselves to the voice of God that speaks to them in the interior of their heart. Gaudium et Spes, as quoted in the Catechism (1994), affirms this same universal and divine truth which echoes deep within the conscience of every person, a voice "ever calling him to love and to do what is good and to avoid evil" and that remarkably "sounds in his heart at the right moment." (CCC 1776).

Pope Francis (2013), however, alluded to a "widespread mentality" which makes it difficult to hear this voice because it enslaves the hearts and minds of so many, producing a "throw away culture" which seeks to eliminate human beings, especially the physically and socially weak. The Pope even stated that this "cultural disorientation has affected a sphere that seemed unassailable", the medical profession. He continues by saying, "Although being by their nature at the service of life, the health professions are induced sometimes not to respect life itself." The medical environment, conditioned by certain factors, can ironically become a place in which "life is not always protected as a primary value and a primordial right of every man," a place which not only prohibits the exercise of our conscience but clouds it (Francis, 2013). The consequence of this is summed up by John Paul II who concludes:

The end result of this is tragic: not only is the fact of the destruction of so many human lives still to be born or in their final stage extremely grave and disturbing, but no less grave and disturbing is the fact that conscience itself, darkened as it were by such widespread conditioning, is finding it increasingly difficult to distinguish between good and evil in what concerns the basic value of human life. (EV 4)

Benedict warns us of the danger in Caritas in Veritate (2009), which affirms that openness to life is crucial to the development of society. He explains that a society that moves towards the denial or suppression of life ends up no longer finding the necessary motivation and energy to strive for man's true good, resulting in the "withering away" of other forms of acceptance that are valuable for society. On the other hand, he confirms how the acceptance of life strengthens our moral fiber, promotes virtuous action and engenders the capacity of people to mutually help one another (CV 67). In cases like Baby Mary's, the Church clearly guides moral decisions regarding the extubation and withdrawal of extensive lifesaving interventions when the prognosis is poor as seen in the Vatican's Declaration on Euthanasia (1980):

"It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources." (4).

In focusing on these concrete circumstances, probabilities, statistical analysis and research however, the key is not losing sight of the totality of the human person. Francis points out, "The credibility of a health care system is not measured only by efficiency but above all by the care and love of persons, whose life is always sacred and inviolable." (2013). One must not become distracted by the medical complexities and so emphasize the case over the gift and dignity oflife and be led into neglecting or omitting to do what is necessary. When the ultimate end of medical action ceases to be the defense and promotion of life, sin enters into the arena. This is in fact a grave sin of omission, as proposed by Harrington and Keenan (2002) who define sin as "our failure to bother to love" (p. 100). The health care environment must become a place in which we always strive to love and thereby transform the occupation into a mission (Benedict, 2012).

Our hope, then, lies in striving "to interpret the data of experience and the signs of the times assisted by the virtue of prudence, by the advice of competent people, and by the help of the Holy Spirit and his gifts." (CCC, 1788). We as Catholics are mandated to be witnesses for the "culture of life". We have a great responsibility to ourselves to live a committed Christian vocation. We also have a responsibility toward our culture, to recognize God's work in every human person; this sometimes requires "going against the current" (Francis, 2013). The nurse in Baby Mary's story faced this challenge; that of acting on her conscience and speaking up knowing it could have jeopardized her professional career. Although the CNA ensures that nurses who declare a conflict of conscience receive fair treatment and not experience discrimination, few nurses are aware of this provision and fewer exercise it. Taking note of the "tide of popular culture and peer pressure that is indifferent, if not hostile, to Christian morality", John Paul II (1987), in his address while visiting the United States said:

In a secularized world, to speak and act in the name of Jesus can bring opposition and even ridicule. It often means being out of step with majority opinion. Yet if we look at the New Testament, we find encouragement everywhere for perseverance in this testing of our faith. (3)

In the New Testament after Jesus, we find Mary the Mother of God is the paragon who embodies all the virtues. In the face of confusion Mary gives us a powerful example of how to ponder in our heart, to think about something carefully and weigh it in our mind - it implies a serious process of mental activity - a careful consideration of all the pertinent factors involved. "Ponder" in the Greek implies not just considering but an attempt to put things together. To ponder in our heart and mind is a kind of holistic contemplative response or a type of reflexive thinking. She helps the Church to discern the battle lines of the war and helps to understand exactly what is at risk; that every human life is always at the centre of a great struggle between good and evil, between light and darkness (EV, 104). John Paul II (1995) points to the child in Revelations 12:4, who is held by his mother, (a symbol of Mary, the Mother of God), as "a figure of every person, every child, especially every helpless baby whose life is threatened because as the Council reminds us "by his Incarnation the Son of God has united himself in some fashion with every person". (EV, 104)

Some Implications for Practice

Despite clear guidance from the Church supporting the rights of Baby Mary to life, we find decisions that support a culture of death quietly being made in our North American hospitals every day. The question remains how else can nurses and other health care professionals feel supported in order to continue to care for the sick and dying in a system dominated by moral relativism? Implications for practice include providing education on the effects of moral distress, by giving nurses a voice in order to express their views and concerns and providing an environment where nurses can practice without either being coerced or violating their values. There is a need to raise awareness of the moral nature of nursing work as well as the lived experience of moral distress in Catholic nurses and other helping professions, particularly those who are responsible for counseling persons experiencing ethical dilemmas. Research is important in order to assess the effectiveness of possible strategies to implement that can decrease the effects of moral distress. (Rittenmeyer and Huffman, 2009). Also, Catholic nurses need to advocate for policies that support those who stand firm in their own core beliefs about good nursing care and patient advocacy.

Thibeault's study (2001) identified several key strategies to help nurses who experience moral distress. The most effective strategy was the importance of peer support, this is especially important to pro-life nurses as many institutions are not supportive of nurses with Catholic and prolife views. In her study, Zuzelo (2007) found that while nurses identified various support groups, most named nurse managers, ethics committee consultation and chaplains as most helpful. Discussing ethical practice concerns in a safe place will decrease the chances that she will experience the consequences of using negative coping strategies (CNA, 2003). Nurses must be encouraged to engage in self-reflective practices as mandated by their College, as they are often active participants in care they feel is wrong (CNO, 2002). If they do not participate in a reflective process to facilitate moral growth they may be left with unresolved healing.

In addition, as seen in the journal entries of the nurse who cared for Baby Mary, telling and retelling our stories can make a contribution to the understanding of this lived experience and also begin the process of healing. For Catholic health care professionals, prayer, hospital chaplains, good spiritual direction and conversation in confession can be sources of great comfort and support, which foster the reflective process. One of the most important aspects is the development and education of the conscience. The Catechism of the Catholic Church emphasizes that the education of the conscience is a lifelong task that can prevent fear, guilt and feelings of complacency. The education of the conscience guarantees freedom and engenders peace of heart(1784, 5).

• Note: On 18 March, 2014, the Project Administrator sent this information to the Toronto Police Service homicide section using the email form provided on the Toronto Police Service website.  Not having received a response, on 25 March, 2014, the Administrator faxed a letter and the information to Toronto Chief of Police William Blair.  Toronto Police acknowledged receipt of the information in a letter dated 27 March, 2014, stating that someone would contact the Administrator.  A member of the Homicide Squad contacted the Project Administrator on 15 August, 2014, requesting any further available information.  The Administrator replied the same day. On 14 April, 2015, in response to an enquiry from the Administrator, the member of the Homicide Squad advised that the journal article above disclosed "no criminal offence" and that "the circumstances surrounding this death would fall under acceptable medical protocols that are followed by medical practitioners in neonatal care facilities."  That being the case, the Toronto Police did not begin a homicide investigation.  

---

References

Benedict XVI, (2009). Caritas in Veritate.

Canadian Nurses Association (CNA), (2008). Code of Ethics for Registered Nurses, Ottawa ON.

Canadian Nurses Association (CNA), (2003). Ethical distress in health care environments. Ethics in Practice for Registered Nurses.

Catechism of the Catholic Church. (1992).

Cavaliere, T., Daly, B., Dowling, D. & Montgomery, K. (2010). Moral distress in neonatal Intensive care unit RNs. Advances in Neonatal Care, 10 (3), p. 145 - 156.

College of Nurses of Ontario (CNO), (2002). Professional Standards. p. 1-13.

Congregation for the Doctrine of the Faith. (1987). Donum Vitae.

Corley, M. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics. 9(6), p. 636 - 650.

Hanna, D. (2005). The lived experience of moral distress: nurses who assisted with elective abortions. Research and Theory for Nursing Practice: An lnternational Journal, 19 (1), p. 95 - 124.

Harrington, D. & Keenan, J. (2002). Jesus and virtue ethics: Building bridges between new testament studies and moral theology. Lanham, Maryland Chicago Illinois.

Jameton, A. (1984). Nursing practice: The ethical issues . Englewood Cliffs, NJ: Prentice-Hall.

Janvier, A., Nadeau, S. , Deschenes, M., Couture, E., & Barrington, K. (2007). Moral distress in the neonatal intensive care unit: caregiver's experience. Journal of Perinatology. 2 7, 203-208.

John Paul II, (September 15, 1987). Address of His Holiness John Paul II Apostolic Journey to the United States and Canada, Visit to the Cathedral of Saint Vibiana.

John Paul II, (1995). Evangelium Vitae.

Pendry, P. (2007). Moral distress: Recognizing it to retain nurses.  Nursing Economics. 25(4), p. 217 - 221.

Pope Francis. (September 20, 2013). Address at a meeting of the International Federation of Catholic Medical Associations.

Pope Benedict XVI, (May 3, 2012). Address to the Catholic University of the Sacred Heart of Rome.

Rirtenmeyer, L., Huffman, D. (2009). How professional nurses working in hospital environments experience moral distress: a systematic review. Journal of Advanced Nursing. 7 (28), p. 1233 - 1290.

Thibeault, M. (2001). The experience of moral distress in neonatal nurses. Unpublished master's thesis, Dalhousie University, Halifax, Nova Scotia, Canada.

Wojtyla, K. (1981). Toward a philosophy of praxis: An anthology. A. Bloch & G.T. Czuczka (Eds.). New York: Crossroad.

Zuzelo, P. (2007). Exploring the moral distress of registered nurses.  Nursing ethics. 14 (3), p. 344 - 359.