Is the NICU a morally stressful place to work? If so, is that necessarily a bad thing? According to a study by Janvier et al., the answer to these questions depends less upon the medical conditions of the babies in the NICU and more on the sociocultural milieu of the unit. In units where everybody agrees about the proper approach, there is less moral stress. When people disagree, the workplace is more stressful. Unfortunately, agreement does not necessarily reflect correctness of knowledge or attitudes.

Janvier and co-workers studied pediatrics residents, obstetrics residents and nurses who work in various perinatal settings in four university-based tertiary care centers in Quebec. Although the characteristics of the babies admitted to these NICUs are not reported in the study, we assume that the NICUs served a relatively similar population of patients (with the exception of the nurses working in an ‘outborn NICU’).

The main outcome measure of the study was self-reported rates of ‘ethical confrontation.’ The reported rates of ‘ethical confrontation’ differed among the different NICUs. Overall, 35% of nurses and 19% of residents reported that they frequently experienced ethical confrontations in their workplace. The most significant predictor of the likelihood of experiencing ethical confrontations was the place of work. Some NICUs are, apparently, more full of confrontation than others. In one center, none of the residents reported frequent ethical confrontation. In another center, 36% of residents experienced such confrontation.

Such a study begs the question of whether ethical confrontation or ethical controversy is a good thing or a bad thing. Some of the study's findings suggest that it may not be all bad. For example, respondents who reported fewer ethical confrontations at their place of work were also less knowledgeable about outcomes for tiny babies. They were more likely to incorrectly underestimate the likelihood of a good outcome for premature babies. Often, these incorrect assessments led them to not offer resuscitation to babies who would likely have had a good outcome. In doing so, they were acting in harmony with the prevailing practices at their centres. They seemed to feel good about it. There was no ethical confrontation.

This finding suggests that a prevailing consensus about appropriate practice can minimize ethical controversy without necessarily being associated with up to date and accurate knowledge or the best practices. The authors tactfully note that a lack of ethical confrontation ‘does not necessarily mean that the practices are more ethically appropriate.’ Conversely, the presence of ethical controversy does not necessarily mean that the practices are less ethically appropriate.

The phenomenon of a morally problematic consensus is a familiar problem in philosophy and politics. The fact that there is a widespread consensus about some activity or practice does not necessarily mean that it is morally correct. Famous examples include slavery in the American South, the euthanasia of mentally retarded people in Germany in the early and mid-twentieth century, or laws prohibiting interracial marriage in many States in the United States. The existence of a widespread consensus is no guarantee of moral rectitude.

Mark Twain satirically offers a famous example of misguided moral distress in his novel The Adventures of Huckleberry Finn. Huck is traveling down the Mississippi River on a raft with the runaway slave Jim. Huck knows, from his upbringing in the south, that it is ‘wrong’ to help a slave escape to freedom. The ‘right’ thing to do is to turn the slave in. However, Huck has become friends with Jim and learned of Jim's burning desire to escape to freedom. Huck struggles between his desire to do what he has been taught is right – that is, turn Jim in – and his own emotional impulse to help his friend escape, even though he's been raised to think it wrong. Twain writes (in Huck's voice),

‘I’d got to decide, forever, betwixt two things, and I knowed it. I studied a minute, sort of holding my breath, and then says to myself: ‘All right, then, I’ll go to hell.’ It was awful thoughts, and awful words, but they was said. And I let them stay said; and never thought no more about reforming. …I would go to work and steal Jim out of slavery again.’ (Twain M. The adventures of Huckleberry Finn. Accessible at http://www.geocities.com/swaisman/huckfinn.htm).

This passage, in which Huck assumes that he will go do hell for doing what we readers all recognize as the right thing, famously suggests how moral distress or ethical confrontation occurs when a society is in a time of moral transition. At such times, moral distress and moral confrontation arise precisely because there is a lack of consensus. People are unsure which moral position is correct and need to argue it out – with themselves or with others. They must decide whether to go with the prevailing but crumbling consensus or with the controversial but appealing challenge to that consensus.

It may be that we are witnessing such a shift in societal attitudes toward extremely premature newborns from one which classified infants using rather blunt prognostic determinants such as birthweight or gestational age to one in which treatments are offered or withheld based upon individualized assessments of prognosis. Such a shift would lead to treatment decisions that mirrored those made for other patients of other ages in other clinical settings. That shift, however, is likely to lead to unsettled ethical feelings, moral distress and confrontations. Those might be a sign of progress, rather than a sign of problems.