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Scientific Article
Moral Distress in Radiation Oncology: Insights
From Residents in Germany
Ricarda Peters, MD,
a,1
Annette Rogge, PhD,
b,1
J€
urgen Dunst, PhD,
a
Sandra Freitag-Wolf, PhD,
c
and Claudia Schmalz, PhD
a,
*
a
Klinik f€
ur Strahlentherapie, Universit€
atsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany;
b
Paracelsus
Nordseeklinik Helgoland, Helgoland, Germany; and
c
Institut f€
ur Medizinische Informatik und Statistik,
Universit€
atsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
Received 15 May 2023; accepted 12 September 2023
Purpose: Being challenged by circumstances that force one to act in discordance with one’s moral compass can lead to moral distress.
The phenomenon has been widely investigated among nurses. This study was designed to shed some light on the situation of resident
physicians in radiation oncology.
Methods and Materials: To gain insight into moral distress among residents in radiation oncology, a web-based questionnaire was
developed and distributed throughout Germany. Participants were asked to evaluate possible burdensome situations and different
options for relief. To outline the main issues of moral distress, an exploratory factor analysis was conducted. Relief options were
examined by frequencies.
Results: The factor analysis yielded lack of time, contradiction between patient request and indication, nonmedical interests, and
decisions between curative treatment and best supportive care as main issues for the 84 participants. Support from supervisors and
senior physicians, as well as exchanges with resident colleagues were indicated as forms of relief. Professional support, such as ethics
consultations, structured conversation groups (Balint), or psychological case supervisions, were rated as less helpful, although most
participants reported a lack of experience with these.
Conclusions: The results are in accordance with existing assumptions that moral distress among physicians is mainly due to
uncertainty. Regarding radiation oncology residents in particular, moral distress seems to be related to uncertainty in decisions and
conflicts about treatment options. Although senior physicians and supervisors present important role models in dealing with moral
distress, professional services such as ethics consultations offer an opportunity for relief that can still be expanded.
©2023 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Moral distress is a psychological concept originally
established by philosopher and psychologist Andrew
Jameton in 1984. Jameton described moral distress as
the mental and physical reaction when “one knows the
right thing to do, but institutional constraints make it
nearly impossible to pursue the right course of
action.”
1
Since then, there has been an ongoing debate
about moral distress and its precise definition, with
some authors criticizing the initial definition as too
narrow
2-5
while others defend the original concept.
6,7
In a broader context, Fourie described moral distress
as “a psychological response to morally challenging sit-
uations such as those of moral constraint or moral
conflict, or both”
8
emphasizing that moral distress
Sources of support: This work was supported by the Klinik f€ur Strah-
lentherapie, Universit€
atsklinikum Schleswig-Holstein, Campus Kiel.
Data generated and analyzed during this study are available upon
request from the corresponding author.
1
R.P. and A.R. contributed equally to this work.
*Corresponding author: Claudia Schmalz, PhD; E-mail: claudia.
schmalz@uksh.de
https://doi.org/10.1016/j.adro.2023.101378
2452-1094/©2023 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Advances in Radiation Oncology (2024) 9, 101378
according to Jameton’sdefinition is especially relevant
for nurses but probably does not cover the situation of
other health care professionals.
8
She later expanded
her definition to include situations of moral dilemma,
conflicting moral principles, or uncertainty about the
morally correct course of action, still without including
physicians as an affected group.
9
Other authors, too,
have stressed Jameton’sdefinition as unsuitable for
physicians,
10,11
because established measuring instru-
ments have found significantly higher moral distress
levels in nurses than in physicians.
10,12-14
For example,
in the intensive-care context, nurses seem to focus on
constraints imposed by the hierarchical health care
system, whereas physicians see moral dilemmas and
conflicts as the main issues for moral distress.
11
So far, research on moral distress specifically among
physicians has largely been conducted in intensive-care
settings,
12,13,15
assuming that professionals on these
wards are confronted with morally challenging situa-
tions more often than elsewhere. Nevertheless, Hlu-
bocky and colleagues listed unique characteristics and
difficulties in oncological settings. For example, they
named facing divergent values of patients, their rela-
tives, and/or members of the medical team, which may
lead to a demand for nonbeneficial treatment or a
refusal of treatment that is probably curative.
16
In a
subsequent work, they stated, “Oncologists are at high
risk for developing moral distress given their role in
delivery of serious news and end-of-life decision mak-
ing.”
17
Considering that especially in radiation oncol-
ogy,thereisaneedtoprovidepalliativecarealongside
potentially life-saving treatments, it should be assumed
that radiation oncologists are prone to face moral dis-
tress, too.
The aim of this study was to gain initial insights in
occurrence, relevance, and handling of moral distress
among radiation oncologists in Germany. It was decided
to start with residents, because a lower position in the
hierarchical system or less decision-making authority
seems to be associated with increased levels of moral dis-
tress, as shown not only for nurses but also for medical
students.
18
Established instruments for measuring moral dis-
tress were usually created for nurses or intensive-
care staff, were not available in German at that
time, and commonly used a specificdefinition of
moral distress (which is still up for discussion, espe-
cially given the lively controversy about its suitability
for physicians). Thus, it seemed most reasonable to
develop a German questionnaire independent of a
fixed definition of moral distress. An exploratory fac-
tor analysis of the responses was conducted to iden-
tify the main issues for residents in order to
delineate the field of moral distress in radiation
oncology.
Methods and Materials
Instrument development
The questionnaire was developed in a multistage pro-
cess of expert interviews, using a variation of the Delphi
technique. Typically, the Delphi technique consists of
numerous iterations of anonymous interviews with the
same experts to reach a consensus on complex issues.
19
In
this study, initially, 5 residents from various radiation
oncology departments answered open questions about
job-associated moral conflicts or problems, types of dis-
tress, and their opinions concerning relief. Examples of
topics they mentioned were lack of space for conversa-
tions about therapy limitations or end-of-life care, deci-
sions between continuation of therapy and best
supportive care, conflict between the patient’s wishes and
the physician’s indication, time pressure due to high doc-
umentation effort, increasing influence of economic pres-
sure, or psychologically stressful individual fates (eg,
young patients with systemic progressive disease).
In the second phase, items were constructed from
issues mentioned by at least 3 participants and verbalized
as statements about the regular occurrence of a situation,
its moral relevance, and its perceived burden. Agreement
with these was rated on a 5-point Likert scale, from 1 (“I
don’t agree at all”)to5(“I totally agree”). Additional
items describing conditions or actions providing relief
were rated on the same scale, supplemented by an indica-
tion of the frequency of use (“I use this opportunity regu-
larly,”“I use this opportunity rarely,”“I have no
experience with this opportunity,”or “Idon’twantto
make specifications”). The third phase involved discussion
and revision of the items by an interdisciplinary focus
group (consisting of the first, second, and last authors),
anonymous evaluation by radiation oncology residents on
site, and finally, further revision. The final version of the
questionnaire contained 34 items, 9 of them about stress
relief, as well as 4 sociodemographic questions.
Survey design
The web-based questionnaire, using “SoSciSurvey,”
20
was distributed between May 20, 2020, and November 20,
2020, by requesting chief physicians of radiation oncology
departments throughout Germany via email to forward
the link to residents in their institutions. After partici-
pants were informed about their data protection rights
and assured of anonymity, informed consent was given by
ticking a box labeled “I agree.”The participating residents
were asked to indicate their opinion on situations with
moral distress and on different options for relief. This
way, given the ongoing discussion, it was possible not to
commit to one particular definition. Because the survey
2R. Peters et al Advances in Radiation Oncology: February 2024
period was in the middle of the COVID-19 pandemic and
influences of correspondingly changed working condi-
tions in the daily routine of physicians could not be
assessed, participants were asked to respond primarily by
recalling the time before the pandemic and were given the
opportunity to provide information on their current situ-
ation in 3 additional items.
The study was approved by the ethics committee of the
Christian-Albrechts-Universit€
at zu Kiel (application
number: D 428/20).
Statistical analysis
Statistical analyses were conducted with SPSS for Win-
dows, version 21 (IBM, 2012) in conjunction with R-Fac-
tor
21
and R.
22
The previously written R packages psych,
23
polycor,
24
ICS,
25
NFactor,
26
GPArotation,
27
and R.utils
28
were used for this purpose. To investigate different
aspects of moral distress, an exploratory factor analysis
(principal axes factoring) based on polychoric correlations
was performed on the 21 items concerning moral distress.
Initial communalities were estimated through multiple
correlations, using preset options in R-Factor.
21
The data set contained substantial correlations with a Kai-
ser-Meyer-Olkin criterion (KMO = .616) that can be classified
as “mediocre,”
29
and the measure of sample adequacy also
met standards almost thoroughly (17 of 21 items met the
requirement of measure of sample adequacy ≥.50; only 1 item
failed to meet the absolute minimum requirement of ≥.40
according to Basto and Pereira
30
). Combined with the Bartlett,
Jennrich, and Steiger tests, all indicating a significant (P ≤
.001) difference between the correlation matrix and the iden-
tity matrix, the items appeared suitable for an exploratory fac-
tor analysis.
After an initial varimax rotation, an oblique promax
rotation with (with k= 4) was performed to allow for inter-
related factors. Only important items, which met a signifi-
cance criterion of CV ¼5152
ffiffiffiffiffiffiffiffiffiffi
ðN2Þ
pby Norman and Streiner,
29
were used when naming the factors. To estimate reliability,
the internal consistency, namely the ordinal coefficient a
(a version of Cronbach’safor ordinal data),
30
was calculated
for each factor. According to recommendations from litera-
ture, avalues of ≥.70 for each factor should be achieved for
an acceptable factor solution.
31
For insights into the extent of moral distress and bene-
fit of relief options, absolute and relative frequencies of
participants’agreement and medians, modes, and inter-
quartile ranges were calculated.
Results
Informed consent was given by 113 participants in
total. Of these, 29 records were excluded from the analysis
because the questionnaire had not been completed suffi-
ciently (11 participants dropped out immediately after
giving informed consent). With the remaining sample of
84, a subject-to-variable ratio of 4 was achieved.
Most respondents were between 25 and 35 years old
(63 [75%]) and mainly worked about 40 to 50 hours per
week (61 [72.6%]). The majority worked at university
hospitals (58 [69%]). The distribution of years of training
in radiation oncology along with further detailed informa-
tion can be found in Table 1.
Aspects of moral distress—Exploratory
factor analysis
Principal axis factoring revealed 4 factors according to par-
allel analysis, comparison data, and optimal coordinate (devi-
ating proposals according to Velicer’s minimum average
partial [retain 2 factors], acceleration factor [retain 1 factor],
and the Kaiser criterion [retain 6 factors] were disregarded).
The4factorsexplained84.68%ofthevariance(Table 2 shows
variance explained by individual factors). Because the first fac-
tor comprised 2 significant items (according to the significance
criterion by Norman and Streiner
29
)onlackoftimeinpatient
care, it was labeled “lack of time”(a= .773). The second factor
was built of 4 significant items describing situations with
patients who reject curative treatment despite medical indica-
tion, with patients who demand curative treatment although
there is no medical indication, and with the treatment of ter-
minally ill patients. Therefore, the factor was given the name
“contradiction between patient request and indication”
(a= .811). The third factor was termed “nonmedical interests”
because its 4 significant items addressed decisive motives other
than the patient’s best interests or economic interests of the
hospital (a= .812). The 2 significant items of the fourth factor
dealt with continuation of curative treatment and delayed
decision for best supportive care and with the decision
between continuation and limitation of treatment, so it was
called “decision between curative treatment and best support-
ive care”(a= .732). Detailed information on factor loadings,
eigenvalues, variance explained, and ordinal coefficient a,as
well as the median of the responses, can be found in Table 2.
Dealing with moral distress—Relief options
The ratings of the relief options and the indicated fre-
quencies of use are shown in Fig. 1. The participants
stated they had the greatest relief by knowing their super-
visors were on their side.This was followed by profes-
sional support from senior physicians, as well as their
support in decision-making situations and case discus-
sions with resident colleagues. These 4 options were indi-
cated to be used regularly by most respondents (41
[48.8%], 53 [63.1%], 52 [61.9%], and 48 [57.1%], respec-
tively). Whereas reducing burdens with the help of
Advances in Radiation Oncology: February 2024 Moral distress in radiation oncology 3
medical and interdisciplinary colleagues was rated as the
next most helpful, there was no clear trend in frequency
of use (36 participants [42.9%] stated, “I use this opportu-
nity regularly,”and 34 [40.5%] stated, “I use this opportu-
nity rarely”). Moreover, participants declared that experts
(eg, psychologists, people from an ethics committee, or
palliative care physicians) as well as ethics consultation
would be helpful in morally challenging situations but
simultaneously clarified that most of them had no experi-
ence with these services (40 [47.6%] and 57 [67.9%],
respectively). Finally, Balint groups and psychological
case supervisions were rated as not very helpful for stress
relief, although even more respondents answered that
they did not have any experience with these (69 [82.1%]
and 78 [92.9%], respectively).
Discussion
This questionnaire-based study aimed to gain insights
in moral distress among residents in radiation oncology
in Germany. The exploratory factor analysis carried out
for this purpose resulted in 4 factors:
1. Lack of time (eg, too high a workload, which means
that conversations with seriously ill patients cannot be
held in sufficient detail and necessary information is
not obtained).
2. Contradiction between patient request and indication
(eg, a patient with a metastatic colon carcinoma has
unrealistic goals and refuses systemic therapy but asks
for radiation therapy, although the tumor has spread
widely and itself is not radiosensitive).
3. Nonmedical interests (eg, a patient is treated with che-
motherapy without medical indication to justify hos-
pitalization).
4. Decision between curative treatment and best sup-
portive care (eg, a patient experiences immense
adverse effects from radiation therapy, and some
team members would recommend to stop it and pro-
vide best supportive care whereas others still see a rel-
evant chance of recovery).
Table 1 Sample characteristics
Variable
No. (%)
(N = 84)
Age, y
20-25 -
26-30 20 (23.8)
31-35 43 (51.2)*
36-40 15 (17.9)
41-45 2 (2.4)
46-50 2 (2.4)
>50 2 (2.4)
Year of training in radiation oncology
First 9 (10.7)
Second 13 (15.5)
Third 16 (19)
Fourth 13 (15.5)*
Fifth 13 (15.5)
More than five 19 (22.6)
“I don’t want to make specifications”1 (1.2)
Time worked per week, h
<20 -
»20 2 (2.4)
»25 1 (1.2)
»30 5 (6)
»35 3 (3.6)
»37.5 2 (2.4)
»40 33 (39.3)*
»50 28 (33.3)
»60 6 (7.1)
>60 3 (3.6)
“I don’t want to make specifications”1 (1.2)
Hospital provider
University hospital 58 (69)*
Public hospital 8 (9.5)
Private hospital 4 (4.8)
Outpatient medical center or doctor’soffice 12 (14.3)
None of these options 1 (1.2)
“I don’t want to make specifications”1 (1.2)
Respondent worked in a different specialization
Yes 32 (38.1)
No 52 (61.9)
If respondent had worked in a
different specialization, were the
(continued on next page)
Table 1 (Continued)
Variable
No. (%)
(N = 84)
situations of the questionnaire
experienced similarly?
Yes 7 (8.3)
No—less distressing 8 (9.5)
No—more distressing 15 (17.9)
Respondent was never in comparable situations 2 (2.4)
* Median value for the variable.
4R. Peters et al Advances in Radiation Oncology: February 2024
Table 2 Exploratory factor analysis
Median (IQR) Item Factor loading
F1 F2 F3 F4
Factor 1: Lack of time
2 (2) Time pressure in my work as an assistant physician often
prevents me from acting medically according to my own
moral standards.
.949*
,y
−.032 −.065 −.188
3 (2) In my daily routine in patient care, I experience consider-
able time pressure.
.712*
,y
.167 −.256 −.004
3 (1) Economic interests of my hospital play a major role in my
medical decisions.
.567*−.303 .328 −.195
4*(2) When time pressure in my work prevents me from acting
medically according to my own moral requirements, I feel
very burdened.
.451*.087 −.075 .223
3 (2) I find situations where patients disagree with their relatives
about their chosen treatment option morally difficult.
.377*.179 .071 .024
2 (2) I feel burdened for moral reasons by situations where
patients disagree with their relatives about their chosen
treatment option.
.315*.200 .303 .138
Factor 2: Contradiction between patient request and indication
2 (2) A patient’s wish to forego a possibly curative therapy and
decide for best supportive care poses a moral problem for
me in everyday life.
−.080 .896*
,y
−.122 −.184
2 (1) To me, it is very stressful when I find myself in a moral con-
flict because my patient wants to forego therapy but I con-
sider a potentially curative treatment to be indicated.
−.009 .846*
,y
−.225 .075
4*(2) To me, it is very burdensome when patients demand cura-
tive treatment despite lacking a medical indication.
.166 .644*
,y
.001 .047
2 (2) I find it hard to bear when no more curative treatment is
possible for a patient and palliative treatment is started.
−.038 .618*
,y
.164 −.286
4*(3) I see myself in a moral conflict when patients demand cura-
tive treatment but I see no medical indication for it.
.240 .445*.095 .110
Factor 3: Nonmedical interests
2 (1) In my impression, motives other than the patient’s best
interests are decisive in decisions between palliative and
curative treatment.
−.135 −.172 .982*
,y
.025
2 (1.75) I feel burdened by the fact that decisions between palliative
and curative treatment are often made for reasons other
than the patient’s best interests.
−.005 .016 .868*
,y
.037
2 (2) The economic interests of my hospital often prevent me
from acting medically according to my own moral stand-
ards.
.505 −.276 .726*
,y
-.036
2 (1) I feel burdened by the fact that the economic interests of my
hospital prevent me from doing medical work that corre-
sponds to my own moral standards.
.020 .101 .615*
,y
.120
2 (1) My patients often disagree with their relatives about the
most suitable treatment option for themselves.
−.171 .185 .435*.064
2 (1) As a resident, I regularly see patients who reject any treat-
ment, even though a promising curative approach could
be taken in their case.
−.233 .239 .311*−.147
(continued on next page)
Advances in Radiation Oncology: February 2024 Moral distress in radiation oncology 5
The factors “lack of time”and “nonmedical interests”
have already been described as relevant among nurses.
32-34
As for lack of time, this consensus is in line with the
widespread phenomenon of lack of time in health care. It
can be assumed that this problem affects physicians and
nurses alike. However, nonmedical interests seem some-
what different. In the aforementioned studies, nurses
indicated that they experience moral distress due to
instructions or decisions they themselves do not support
but still have to carry out. In contrast, physicians often
have to make quick decisions and balance conflicting inter-
ests. These may be, for example, medical versus economic
interests. However, the rather low level of agreement with
the corresponding statements in this questionnaire
Table 2 (Continued)
Median (IQR) Item Factor loading
F1 F2 F3 F4
Factor 4: Decision between curative treatment and best supportive care
3.5 *(2) Adherence to the curative treatment by senior colleagues
and the belated decision, from my point of view, for best
supportive care leads to a moral conflict for me.
−.140 −.171 .080 .908*
,y
4*(1.75) I often face decisions between continuing vs limiting a treat-
ment in favor of palliative care.
−.207 .024 −.146 .742*
,y
3 (2) Part of my daily routine in radiation oncology is that
patients wish to continue their treatment although this is
not indicated from my medical point of view.
.100 .024 −.146 .483*
3 (2) For moral reasons, I feel burdened by adherence to curative
treatment with the renunciation of best supportive care.
.220 .083 .262 .396*
Eigenvalue 4.823 4.147 4.885 3.927
Variance explained (after rotation), % 22.97 19.75 23.26 18.7
Cumulative variance explained, % 22.97 42.72 65.98 84.68
Ordinal coefficient a.773 .811 .812 .732
* Factor loadings belonging to each factor and median values >3 (indicating agreement with the statement).
ySignificant factor loadings (P= .001), according to CV.
23
Figure 1 Assessment and use of relief options. Participants’agreement to statements about relieving situations or actions
on a 5-point Likert scale are shown as colored columns, together with the frequency of use indicated in each case as a pat-
terned area (n = 84).
6R. Peters et al Advances in Radiation Oncology: February 2024
indicates economic considerations were no major source of
moral distress in the studied group, presumably because
economic issues usually do not have to be considered first
by residents in Germany. The other 2 factors, “contradic-
tion between patient request and indication”and “decisions
between curative treatment and best supportive care,”
encompass common decision-making situations for radia-
tion oncologists that occur right from the start of their
career. Unlike situations leading to moral distress in nurses,
these situations are not characterized by clear barriers or
constraints that prevent taking the right path. Rather,
uncertainty about the right course of action is prevalent.
This insecurity relates to both the medical and moral
assessment, reflecting the difficulty of many medical deci-
sions, namely the numerous dimensions that need to be
considered. Consistent with these results, other studies on
moral distress among oncologists also identified decision-
making under uncertainty as a main cause of moral distress
for physicians.
35,36
The findings here also support the sug-
gestion by Prentice and colleagues that “nurses express a
‘voicelessness’and ‘powerlessness’within the constraints of
the medical hierarchy [whereas physicians’][...]moraldis-
tress is described in terms of dilemmas or ethical
confrontations.”
11
The second objective of this study was to explore the
residents’handling of moral distress. In nursing, it has
been an accepted objective to examine the extent, sources,
and (primarily negative) consequences of moral distress
to discover ways to alleviate and thereby improve and
eventually optimize working conditions, personal well-
being, and most notably, patient care. In contrast, this
approach seems unlikely to change the detected causes of
moral distress for physicians.
It has even been suggested that moral distress, espe-
cially due to being confronted with difficult medical deci-
sions, may well be an appropriate response.
5,11,37
It was
stated that moral questions, and thereby moral distress,
are to some extent unavoidable when facing decisions
about ceasing life-sustaining therapies.
5
Moreover, as
some authors have mentioned, considering the complex-
ity of clinical situations together with the uncertainty of
outcomes in patient care, moral distress could simply be
seen as an expression of the ambiguity in medical deci-
sions.
11
Still others regard some constraints, such as eco-
nomic or distributional considerations, as inherent to
health care and hence consider moral distress as an asso-
ciated part of medical work.
37
Furthermore, moral distress
resulting from difficult moral conflicts or dilemmas is
seen as inappropriate but unlikely to be eliminated by
changing the external conditions.
37
In this study, participants stated they perceived super-
visors and colleagues as particularly relieving. This high
estimation of supervisors and senior physicians highlights
their importance as role models. In addition to their med-
ical expertise, they could set an example of handling diffi-
cult decisions or moral dilemmas, exemplify good moral
distress management, and reduce the burden for residents
in challenging situations. Unlike other options rated as
helpful, participants reported they would use these
options regularly, also indicating them as easily accessible.
Contrarily, most participants stated they did not have any
experience with professional services such as ethics con-
sultation, psychological case supervisions, or structured
conversation groups (“Balint groups”).
38
Maybe there is
no easy access to these; Balint groups, for example, are
not short-term solutions, because one needs to be placed
into a group and attend several meetings before being
able to report on one’s own difficulties or problematic
cases. Moreover, meetings usually do not take place often
enough to facilitate quick relief. It therefore remains ques-
tionable whether professional services could serve as an
additional tool to reduce or prevent moral distress even if
used more often. Another conceivable option could be
regular rounds with psycho-oncologists on the wards,
which could enable better accessibility of interventions in
case of moral distress among residents.
Clinical implications
As the reported results show, residents in radiation
oncology are repeatedly confronted with morally chal-
lenging situations, such as contradictions between appro-
priate therapeutic procedures and patient wishes, and
they feel burdened by them. To ensure good clinical prac-
tice, responsible handling of such situations should be an
essential part of medical knowledge, in addition to profes-
sional competence. This includes not only dealing with
one’s own moral distress but also having open communi-
cation with patients at eye level—for example, with the
help of shared-decision-making.
Study limitations
Major shortcomings of this study are the indeterminate
validity of the questionnaire, the minimal estimation of reli-
ability, and the clearly limited generalizability of the sample.
Because only first insights into the situation of residents in
radiation oncology were intended, no further reliability esti-
mates or validation steps were undertaken. Therefore, the
questionnaire cannot be considered a measuring instrument
for moral distress. The results refer exclusively to the stud-
ied group of radiation oncology residents in Germany, and
no extrapolations can be made to other specialties, training
levels, or countries. Further research is necessary to reveal
whether leading physicians experience comparable moral
distress. Moreover, it remains to be seen whether another
definition of moral distress more fittingforphysiciansis
necessary as a result of different measuring instruments.
Forexample,aneedforvariousquestionnaire items for dif-
ferent disciplines and hierarchical levels should be created.
Advances in Radiation Oncology: February 2024 Moral distress in radiation oncology 7
Conclusion
The results confirm existing assumptions that moral
distress among physicians is mainly due to uncertainty.
For radiation oncology residents in particular, moral dis-
tress seems to be related to uncertainty in decisions and
conflicts about treatment options. Senior physicians and
supervisors present important role models for dealing
with moral distress, whereas professional services such as
ethics consultations offer an opportunity for relief that
can still be expanded. Overall, according to our results, it
seems desirable to put more emphasis on teaching com-
municative skills, medical ethical viewpoints, and dis-
charge options to medical students
39
as well as during
training of young physicians in radiation oncology.
Disclosures
The authors hereby declare, that none of them has any
competing financial or nonfinancial interests or personal
relationships that could have influenced the work.
Acknowledgments
We sincerely thank all participants of the Delphi process
for the development of the questionnaire at the annual
meeting of the German radiotherapy Society, DEGRO,
2019, for their kind collaboration. We also thank all partici-
pants of the questionnaire. Special thanks to Petra Fischer
for proofreading and editing.
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