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Violations of Health as a Human Right and Moral Distress: Considerations for Social Work Practice and Education

Healthcare professionals may experience moral distress when navigating difficult positions in which acting or providing for their patient’s best interest may not be possible due to barriers outside of their control. This phenomenon has primarily been investigated within nursing and other clinical disciplines; however, experiences of moral distress have also been noted in the social work profession. Healthcare professionals, including social workers, may experience moral distress when witnessing violations of their patients’ human rights. This article discusses research reporting on experiences of moral distress within the social work profession, a reality social work students may also face during their field placements. Understanding the causes and effects of moral distress within the social work profession is important when preparing social work students as they transition into the workforce. Future research investigating moral distress should include the perspectives of social work field students, as their experiences are understudied. This phenomenon is especially important to investigate, as the current COVID-19 pandemic is expected to exacerbate health challenges.


Introduction
One of the main goals of the social work profession is to uphold and promote the human rights of all persons. This article will highlight the challenges that social work professionals and field students may face when working toward ensuring health as a human right for the patients they serve. Specifically, this paper will discuss the consequences of moral distress, which social workers may experience when health as a human right is not upheld for patients. Moral distress, a term coined by Andrew Jameton (1984), describes a phenomenon in which a clinician understands the correct course of action for their patient, but they are unable to perform such action. Competing responsibilities to uphold professional ethics and meet organizational requirements may impede the ability of the worker to fulfill the action for the patient (Moffat 2014). Moral distress may pose significant challenges for social work professionals and field students; thus, better understanding of this concept is imperative for the social work profession.

Human Rights
Human rights are universally accepted standards that are secured by multiple international treaties. These rights cover a wide range of liberties including civil, cultural, economic, political, and social (World Health Organization & United Nations Office of the High Commissioner for Human Rights 2008). The Universal Declaration of Human Rights (United Nations General Assembly [UN-GA] 1948) is one of the most well-known human rights treaties created and adopted by several leading nations, including the USA (United Nations, n.d.). The mission and values of the social work profession are directly related to the protection of human rights, as "advocating and upholding human rights and social justice is the motivation and justification for social work" (International Federation of Social Workers [IFSW] 2014, para. 9). Specifically, the field of social work is characterized by six core values, "service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence" (National Association of Social Workers [NASW] 2017, para. 4), which inform ethical standards that social workers are expected to abide by. Social workers aim to preserve the human rights of their clients by exemplifying the aforementioned core values of the field. Further, these core values seek to uplift marginalized people, promote self-determination and empowerment, and bolster social relationships. For example, Article 1 of the Universal Declaration of Human Rights states: "All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood" (UN-GA 1948, p. 2). The core social work value of preserving the dignity and worth of all persons directly relates to Article 1. By operating from these core values, social workers aim to ensure the inalienable human rights outlined in the United Nations Declaration of Human Rights, including those rights focused on the health and wellbeing of individuals (UN-GA 1948).

Health as a Human Right
Health as a human right was briefly mentioned within the Universal Declaration of Human Rights in Article 25.1, stating: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care, and necessary social services and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control. (UN-GA 1948, p. 7).
Health as a human right was expanded upon within the International Covenant on Economic, Social and Cultural Rights (Gable 2011;United Nations General Assembly [UN-GA] 1966). Article 12 of this Covenant states that all persons have the right to obtain their highest level of health and provides steps for government entities to take to reach this objective (UN-GA 1966). In a later commentary, the United Nations Committee on Economic, Social, and Cultural Rights (UN-CESC 2000) clarifies that Article 12 of this Covenant operationalizes this right as the freedom of individuals to obtain the highest level of health within an equitable healthcare system. Further, the Committee discusses four dimensions of human rights that governing entities and associated institutions should seek to meet when providing health services. These dimensions, including availability, accessibility, acceptability, and quality of health, center on guaranteeing health services for all persons (UN-CESCR 2000).
According to the UN-CESCR (2000), availability is defined as the presence of an adequate supply of "health-care facilities, goods, and services" (p.4) that attend to the health needs and concerns of all citizens. These goods and services include essential infrastructure such as safe drinking water and clean air, as well as other determinants of health (UN-CESCR 2000). Accessibility includes the equitable opportunity to obtain safe and effective healthcare for all persons. This dimension contains four subcomponents: non-discrimination and physical, economic, and information accessibility (UN-CESCR 2000). Acceptability refers to humane treatment for all groups of people (UN-CESCR 2000). This includes respect for all persons by upholding ethical treatment and confidentiality (UN-CESCR 2000). Additionally, healthcare professionals and organizations are expected to respect the differences and personal preferences of individuals (UN-CESCR 2000). The final dimension, quality, signifies that all healthcare technology, products, and services should "be scientifically and medically appropriate and of good quality" (UN-CESCR 2000 p. 5).
These four dimensions are closely related with the social work field. The American Academy of Social Work and Social Welfare (AASWSW) officially presented what has been deemed the 12 Grand Challenges of the social work profession (Williams 2016). The Grand Challenges seek to create "a large-scale initiative to bring a focus and synergy between social work research, practice, and education to bear on a range of universal social, economic, political, environmental, and psychological problems" (Williams 2016, p. 67). Closing the health gap and promoting health equity are identified as key goals within the 12 Grand Challenges (Grand Challenges for Social Work n.d.b). This initiative is closely related with the right to obtain the highest attainable standard of health as described by Article 12 of the Covenant (United Nations General Assembly 1966). To positively impact this endeavor and support the right to attain the highest standard of health, availability, accessibility, acceptability, and quality of healthcare are important for the social work profession to address (Grand Challenges for Social Work n.d.a; UN-CESCR 2000).

Moral Distress
Social work field students may experience moral distress as an internal response to human rights violations in healthcare settings. For example, a social work field student may receive a request from a physician to obtain specialized medical equipment for a patient but may be unable to secure the requested item due to insurance restrictions. Even if the field student tries their best to address the needs of the patient, in alignment with their professional core values, their efforts may be unsuccessful due to external barriers, possibly leading to feelings of moral distress.
The concept of moral distress was first noted by Jameton (2017) in the nursing profession, specifically in situations where ethical dilemmas were prevalent. Jameton (2017) noted these situations were common among his nursing students caring for terminally ill patients, stating some nurses described instances where they were required to perform a procedure they knew would be ineffective, and sometimes painful, for their patients and endured personal moral distress as a result. Prior literature exploring these effects has noted feelings of depression, fatigue, and occupational burnout among nurses experiencing moral distress (Jaskela et al. 2018). Despite its origins in the nursing field, moral distress has been observed in several other disciplines, including social work (Jameton 2017).
Moral distress helps to define "the psychological and emotional pain that arises when professionals feel blocked, due to institutional constraints, from doing what they perceive is right" (Weinberg 2009, p. 140). Moral distress is distinct from other common experiences of helping professionals (Weinberg 2009). Specifically, a moral component accompanies moral distress and delineates it from other occupational stress that may occur, such as burnout or ethical dilemmas (Mänttäri-van der Kuip 2016; Weinberg 2009). Mänttäri-van der Kuip (2016) describes a pertinent example of the differences between moral distress and work-related stress, noting that social workers with high caseloads may experience work-related stress; however, this work-related stress may develop into moral distress if they perceive the quality of the care they are providing to patients has been compromised.

Causes of Moral Distress in Healthcare Settings
Studies examining moral distress specifically among social work students are limited. However, literature examining the causes and implications of moral distress among working professionals may illuminate situations students encounter while interning at their field placement. Prior literature has highlighted various challenges social workers face in relation to the availability of healthcare services. According to Jaskela and colleagues (2018), some Canadian social workers have reported difficulty providing services to all patients largely due to insufficient staffing and subsequent time constraints. Similarly, Mänttäri-van der Kuip (2016) states budget limitations, deficient internal resources, and high caseloads have contributed to moral distress among social workers. While facilities may be physically available, limitations of the internal infrastructure within the healthcare organization may restrict the availability of social workers to provide needed services for their patients. Social workers may experience moral distress when resources are insufficient to meet patient needs (Jaskela et al. 2018).
Regardless of service availability, not all populations have equitable access to health services. Several studies have demonstrated that social workers have experienced moral distress when unable to assist patients with accessing healthcare services (Armin 2019;Fronek et al. 2017;Jaskela et al. 2018). Within the literature reviewed for this article, most challenges centered around discrimination and economic accessibility. Some social workers have reported an inability to refer patients to needed services because the patients' prior history disqualified them from admission (Jaskela et al. 2018). Previous substance abuse, mental health history, and occupational status (i.e., sex work) were cited as causes of discrimination (Jaskela et al. 2018). In the USA, for example, certain eligibility categories, including citizenship and/or immigration status, can also prevent one from accessing needed services (Armin 2019). One study highlights the challenges of providing healthcare services to undocumented immigrants due to a lack of eligibility for health insurance, including public health insurance (i.e. Medicaid) and limited economic resources (Armin 2019). Inability to ensure access to healthcare for patients has been described by some social workers as a cause of moral distress (Jaskela et al. 2018). In addition to eligibility barriers, social workers in South Korea stated that operating within a corrupt system caused significant accessibility issues and subsequent distress for social workers (Fronek et al. 2017). For example, participants described instances where they were asked to prioritize economically advantaged patients with high social status to the detriment of patients in need (Fronek et al. 2017). This unjust and inequitable access to vital health resources was a primary cause of distress for Korean social workers within this sample, as they were unable to advocate for their vulnerable patients (Fronek et al. 2017).
Parallel to accessibility, acceptability emphasizes nondiscrimination in service provision. Some social workers have described instances where they observed biased treatment of patients by other healthcare professionals, resulting in subpar medical care (Jaskela et al. 2018). Further, social workers have cited disrespect for patient autonomy and decision-making as a catalyst for experiences of moral distress (Jaskela et al. 2018), as respect for self-determination is a central component of the core values of the social work profession (NASW 2017). An imbalance of power between members of the healthcare team (i.e. physician vs. social worker) can pose barriers for social workers to effectively promote change and compound this distress (Jaskela et al. 2018). Though the social worker is responsible for advocating on behalf of their patients, these efforts may not always yield the expected outcomes and may result in feelings of moral distress.
Examples discussed within the preceding paragraphs demonstrated the overlap between the dimensions outlined by the UN-CESCR (2000). Specifically, a deficiency in one or more of the dimensions may result in suboptimal quality of care received by a patient. Exposure to these situations may induce moral distress among social workers and diminish the quality of care provided (Fantus et al. 2017; Mänttärivan der Kuip 2016). Weinberg (2009) mentions that, while the field of social work has recognized the ramifications of burnout, moral distress is under-examined. Further, Weinberg (2009) comments that while the social work profession emphasizes the holistic treatment of clients based upon the person-in-environment perspective, it is unusual that the field has not fully recognized the implications of moral distress on social workers in the same manner. To effectively alleviate moral distress, it is crucial to first identify moral distress when it is occurring and understand that its causes may stem from larger organizational and societal policies and, as such, may require equally substantial solutions.

Effects of Moral Distress in Healthcare Settings
Moral distress has been less explored within the social work field (Fantus et al. 2017;Jaskela et al. 2018). However, prior research notes social workers employed in health settings are often privy to problematic situations for which a resolution is difficult and sometimes unattainable (Jaskela et al. 2018). For example, a social worker may experience moral distress when advocating for their patient's right to self-determination about their medical care when the patient's wishes are not in alignment with the medical team (Fantus et al. 2017). In this example, medical personnel may look to the social worker, alongside the interdisciplinary team, to help explain to the patient why treatment is necessary and recommended. However, the social worker's main priority must be to ensure the patient's autonomy and wishes are honored. The professional core values of the social worker may be in conflict with the values of the interdisciplinary team and the organization (Moffat, 2014).
These situations may subsequently lead the social worker to experience the effects of moral distress. Similar to the effects described by the nursing profession, the symptoms of moral distress in social workers have been described as fatigue, sleep disruption, anger, withdrawal from personal relationships, and self-doubt in their role as a social worker (Jaskela et al. 2018). Further, moral distress may lead to job dissatisfaction, which may contribute to high turnover among the social work profession (Jaskela et al. 2018;Mänttäri-van der Kuip 2016). The symptoms described here are not unique to moral distress alone and may be experienced with burnout and job dissatisfaction. However, as previously mentioned, to experience moral distress, a moral dilemma must be present (Mänttäri-van der Kuip 2016).
Understanding the concept of moral distress as distinguished from general work-related stress may help inform solutions for social workers encountering unresolved moral dilemmas in the workplace. Such interventions may require attention at the mezzo or macro levels in order to be effective and sustainable, as many situations that produce moral distress involve institutional or policy barriers (Weinberg 2009).
Negative implications of moral distress have also been noted among social work students in their field placements. Weinberg (2009) states that social work field students have observed "discrepancies between what they would like to do and what seems feasible in their agencies" (p. 140). Further, students have communicated concerns about challenging the status quo in their field placements when observing these discrepancies between classroom and practice, in fear that doing so may jeopardize their job prospects after graduation (Lynch and Forde 2016). For example, a social work student may encounter a situation in which a hospital patient needs a specific medication but is unable to obtain the medication in the community. Understanding the core values of social work, the student knows they should advocate to their field agency on behalf of the patient for a sustainable, long-term plan to ensure the patient's access to the needed medication in order to improve their quality of life. However, the student may find themselves in a situation in which only a short-term solution is attainable, despite advocacy efforts. The student may perceive their status as an intern to have insufficient power to effectively address the situation and provide for the patient's needs. Further, the student could perceive pushing the issue as being in conflict with organizational goals and potentially interfere with their success in completing their internship and/or harm their future employment opportunities.

Implications
There are several implications of this research to consider, from education, practice, and research perspectives. The following subsections delineate implications from these perspectives and the impact on social work field students.

Implications for Social Work Education and Practice
The concept of moral distress is not formally included within social work education (Lynch and Forde 2016). Prior literature has noted the discord between what is taught in the classroom and what is experienced in practice (Lynch and Forde 2016). This discord between social work ethics and the reality of the field can produce feelings of moral distress in both professionals and social work students in their field placements.
Recognizing the occurrence of moral distress and its consequences is important for social work practice. Specifically, moral distress can impact social workers' confidence in their ability to effectively perform their professional duties and may lead to job dissatisfaction and turnover within the profession (Jaskela et al. 2018;Mänttäri-van der Kuip 2016). Moral distress is also relevant to field educators and social work students, as situations of moral distress are likely to arise during field placements. Adding the concept of moral distress to social work curriculum could act as a preventative measure, preparing students further for real-world, moral situations for which solutions are difficult to identify and carry out. Understanding the concept of moral distress and addressing its importance within field education and curriculum could help educators and students develop effective ways to mitigate and reduce the negative consequences of moral distress (Lynch and Forde 2016).

Recommendations for Future Research
Further research within the social work field is needed with a focus on moral distress and its relevance to social work education. Research on moral distress within the social work profession is especially important in preparing social work students for work in advocating for the human rights of their patients, as directed by the NASW (2017). Future studies could focus on answering the following research questions: (1) What are the experiences of social work students with moral distress in their field placements? (2) How might experiences of moral distress vary between social work field placements? For example, is moral distress experienced within the child welfare system in the same manner as the healthcare system? (3) What strategies and solutions do social work students propose that could help address the moral distress they may experience within their field placement and/or future careers?
Additional research on moral distress within social work is imperative when considering the current global pandemic, COVID-19. Human rights violations as a result of resource insufficiencies and service-related issues, as described above, are likely to be exacerbated because of the effects of COVID-19. This pandemic has resulted in resource scarcity within healthcare organizations, including personal protective equipment and hospital beds. Further, the pandemic has increased financial constraints due to increasing unemployment, which may lead to negative health outcomes and decreased quality of life for patients. These limited resources may restrict patient access to necessary healthcare services. Social workers may be at risk of experiencing moral distress when working within these situations, bearing witness to health inequity exacerbated by a global pandemic in which they may be unable, in many circumstances, to fully provide needed services despite their efforts. Further, the risk of transmission has caused many face-to-face services to be quickly transitioned online. Lack of appropriate technology may impede the ability of some patients to access virtual sessions with social workers, such as therapy and/or case management. Not only could patient services be disrupted, but social workers may be inhibited from providing needed care because of recommended public safety protocols (i.e., social distancing). Inability to provide services as usual could produce moral distress among social workers during these unprecedented times, as social workers recognize the human right to health (as described by the UN-CESCR 2000) may be unmet for some clients they serve, despite efforts to ensure otherwise.

Conclusion
This article has explored moral distress that occurs when social workers face challenges in ensuring health as a human right for the patients they serve. The examples discussed in this paper highlight the discrepancies between various national social work values and ethics and the organizational systems in which social workers operate, contributing to the moral distress of social workers and students in the field (Fronek et al. 2017;Lynch and Forde 2016). For example, the USA has yet to ratify the International Covenant on Economic, Social and Cultural Rights, including Article 12, that expands upon health as a human right (Gable 2011;UN-CESCR 2000; United Nations Office of the High Commissioner Human Rights n.d.). Despite this, the social work profession operates from the notion that health is a human right.
The ramifications of moral distress may not only result in negative implications for social workers but also inadequate care for their patients (Fantus et al. 2017;Jaskela et al. 2018). As Fronek and colleagues (2017) state, moral distress among social workers "was not simply a result of the allocation of resources rather it was strongly connected to values, breaches of human rights and discriminatory policies" (p. 12). Further, moral distress not only impacts social work professionals in the field but can also negatively affect social work students in their field placements. The causes of moral distress for social workers are multifaceted and largely stem from witnessing human rights violations for which solutions are unattainable, despite social worker advocacy within the organization. Thus, it is vital that interventions be considered at multiple levels (micro, mezzo, and macro) in order to mitigate the effects of moral distress and support social workers and field students in their roles as human rights advocates. Advocacy for increased resources, patient access to equitable healthcare, and inclusion of moral distress within Council on Social Work Education accreditation, especially within field education courses, are examples of interventions that could address experiences of moral distress among social work professionals and field students.

Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.