Medicine is inherently a moral practice, yet physicians often face challenges that prevent ethically appropriate care, which leads to moral distress. Persistent distress may progress to moral injury, marked by guilt, shame, and impaired functioning. Factors such as policy changes, ethical dilemmas, and systemic pressures contribute to distress. While distinct due to burnout characterized by depersonalization (DP) and emotional exhaustion (EE) scores, which can contribute to and intensify burnout over time. Both affect workforce retention and care quality. Understanding their differences and overlaps is essential to developing targeted interventions as well as improving physician well-being and healthcare delivery systems.
A recent study published in JAMA Network Open aimed to examine the relationship between burnout and moral distress among physicians, including how often they occur together or independently, and to assess their association with doctors’ intent to reduce work hours (ITR) or intent to leave (ITL) clinical practice.
In this cross-sectional national survey study, data were collected from the American Medical Association physician professional data and surveying US physicians (n = 5741, median age = 53 years [44-62], female = 40.1%, male = 58%) across specialties from October 19, 2023 to March 5, 2024 through mailed questionnaires and online, with oversampling of non-primary care fields. A general non-physician US working population sample (n = 3501, age range = 29-65 years) was also surveyed. Measures included demographics, burnout (Maslach burnout inventory [MBI]), professional fulfillment, moral distress (Moral distress thermometer [MDT], range from 0 to 10), ITR and ITL (definitely, moderate, none, slight, and likely), as well as work characteristics. All statistical analyses were carried out using R version 4.5.0.
The mean MDT for the physician group was found to be 3.29±2.81, with 39.1% (n = 2243) reporting a higher moral distress (≥4). Multivariable analysis revealed that female doctors had higher odds of moral distress compared to males, with an odds ratio (OR) of 1.29 (95% confidence interval [CI]: 1.12-1.48). Similarly, higher moral distress was observed in married physicians compared to unmarried physicians with an OR of 0.69 (95% CI: 0.56-0.84).
There was a high levels of distress was observed in general internal medicine doctors (OR = 1.92, 95% CI: 1.42-2.59) and emergency medicine doctors (OR = 3.16, 95% CI: 2.27-4.4) when compared to internal medicine specialists whereas pathologists had lower odds of high levels of moral distress (OR = 0.43, 95% CI: 0.25-0.73). The mean DP score, EE score, and the proportion of doctors with burnout were higher with every one point of increase in moral distress score. The overall association between the moral distress score and the DP score was found to be R = 0.50 and p <0.001.
Furthermore, 30.7% of physicians (1068/3477) with a moral distress score of <4 experienced burnout compared to 75.1 (1675/2231) with a score of ≥4 (p <0.001). Among the 2739 physicians with ≥1 symptom of burnout, approximately 61% (n = 1671) had a moral distress score of ≥4.
Moreover, ITR and ITL were enhanced along with a point rise on the MDT scale. Particularly, 18.2% (619/3404) with low moral distress reported ITL within one year when compared to 34.5% (748/2171) those with high moral distress, with p <0.001. Physicians had higher odds of high moral distress compared to non-physician US workers with an OR of 4.40 (95% CI: 3.84-5.06).
This study’s limitations include low patient response rates, potential response bias, as well as social desirability bias, and a cross-sectional design of the hospital, limiting causality. The single measure may not capture moral distress complexity, though, because findings support sample representativeness.
In conclusion, about 40% of physicians reported high moral distress, which exceeds general workforce levels. It is linked to burnout, ITL, and ITR, and often coexists with the burnout workforce, which requires systemic interventions.
Reference: Tutty MA, West CP, Dyrbye LN, et al. Moral Distress and Occupational Burnout in US Physicians. JAMA Netw Open. 2026;9(3):e263161. doi:10.1001/jamanetworkopen.2026.3161
