How Gratitude Can Help Resolve Ethical Dilemmas

All eyes at this year’s NBA draft in June were on Zion Williamson, the 18-year-old superstar basketball athlete from Duke. There was little doubt that he would be the #1 pick at the draft, but few commentators would have predicted his outpouring of emotion soon after he crossed the stage to begin his professional basketball career.¹ Williamson initially held back tears, and remarked how amazed he was that he never thought he would get to this place.  As he began to talk about the influence of his mom on his career and thank her for her support, he became emotionally overwhelmed, tears streaming down his face, and was unable to go on.  For viewers, this moment was a genuine and moving display of intense emotion from an extraordinary athlete, but it also was a reminder of the power of gratitude and its potential role in well-being, and success. 

Much has been written recently about the use of “gratitude interventions” and professional coaching in helping health care professionals manage dissatisfaction and burnout. Professional coaching helps physicians increase their internal locus of control by enhancing self-awareness, questioning self-defeating thoughts and beliefs, and reframing and reconsidering maladaptive patterns in their professional practice.² The conscious reflection of noticing and appreciating the positive in life, that is, expressing gratitude, is part of an orientation to help physicians cope with the challenges of professional life, improve satisfaction with patients, and manage the daily stresses of the job. Researchers hypothesize that gratitude helps to counterbalance strong and sometimes overwhelming negative emotions like shame, frustration, inadequacy, and anger that can powerfully influence one’s perspective and satisfaction with work.³ As symptoms of professional dissatisfaction and burnout can compromise the effective management of clinical ethical dilemmas, gratitude may have a useful role in helping to manage these issues when they arise.

Although ethical dilemmas commonly arise in clinical practice, clinicians are often able to manage them in the regular course of their work. When clinicians have less reserve to manage the regular challenges and when they are burned out and feeling less resilient, dilemmas which may normally have been manageable, may become overwhelming. But doing the right thing is not always easy, and even when one knows the right thing to do, feeling overwhelmed may short circuit good judgment and reasoning.  A busy clinical practice may interfere with a physician’s ability to reflect on a problem. Gratitude may be a valuable tool that helps clinicians to develop “moral clarity” by improving the quality of their thought processes.    

There is an emerging evidence base on the relationship between gratitude and positive outcomes like health and satisfaction.  First, to be effective, gratitude should be expressed regularly and consistently. Like a muscle, it needs to be exercised to function well. Some studies have found that individuals have improved feelings of well-being when they write down 3 things that went well that day before going to bed. However, training oneself to do this regularly during the course of the day may be more effective. This active process may help the brain develop patterns of scanning the environment for opportunities to feel gratitude and prime oneself for positive rather than negative experiences. Other studies suggest asking oneself a daily series of questions to raise self-awareness and build resilience:  What did I learn today?  What 3 things am I grateful for today?  What inspired me?  How did I talk to myself today?  Did I take myself too seriously?⁴  Professional coaches also reinforce the concept of reframing previously negative patterns of thinking into more positive ones. For example, identifying a challenge as an opportunity rather than another example of bad luck may help to reverse engrained patterns that reinforced a fixed negative mindset.⁵ 

How does this apply to a specific ethical dilemma? Consider the case of a difficult-to-help patient who monopolizes your time by blaming you for their medical problems and refuses to follow any of your reasonable clinical recommendations. It would not be uncommon to fall prey to a common set of responses when caring for these complicated patients: feelings of frustration and “heart sink” for having to provide what feels like futile care; anger at the consistent delay it creates in your busy day; and ultimate withdrawal from the patient. These emotions together are unproductive, and both the clinician and patient are left unsatisfied and unhappy. Gratitude may play a role in better understanding, experiencing, and responding to these clinical challenges. The clinician can express gratitude in diverse ways, beginning with gratitude for the ability to help a suffering patient, for the skills one possesses, for the opportunity to learn new skills in managing patients, and for one’s overall good fortune in spite of these encounters.

Some are likely to be skeptical of this approach. Stalin reportedly said, “Gratitude is an illness suffered by dogs,” suggesting with neither subtlety nor empathy that there may be problematic forms of gratitude. Although pathologic expressions of gratitude are likely to be rare in the professional settings I have described (they primarily exist in abusive, intimate relationships), clinicians should evaluate for themselves whether the benefit/burden ratio favors making some of the changes suggested. They may also wish to await further research that better characterizes how, when, and for whom gratitude is most helpful and promotes well-being.⁶

For now, there probably is not much risk or opportunity cost to expressing more gratitude or expressing it more frequently in our professional lives. On balance there may be a lot to gain with making these changes in your practice. If gratitude has the potential to improve our helping behaviors, which are central to the practice of medicine, then it deserves at least some consideration in the work of medical professionals.

David J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.

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References

1. Zion Williamson Emotional After Being Selected #1 OVERALL 2019 NBA Draft. https://www.youtube.com/watch?v=zBfjHyDrYYQ
2. Gazelle G, Liebschutz JM, Riess H. Physician burnout: coaching a way out. J Gen Intern Med. 2015;30:508-513.
3. Wood AM, Froh JJ, Geraghty AW. Gratitude and well-being: A review and theoretical integration. Clin Psychol Rev. 2010;30:890-905.
4. Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Pract Manag. 2013;20:25-30.
5. Popova M. Fixed vs. growth: The two basic mindsets that shape our lives.  Brain Pickings.  Accessed at:  https://www.brainpickings.org/2014/01/29/carol-dweck-mindset/
6. Wood AM, Emmons RA, Algoe SB, et al. A dark side of gratitude? Distinguishing between beneficial gratitude and its harmful impostors for the positive clinical psychology of gratitude and well-being.” In: The Wiley Handbook of Positive Clinical Psychology. 2016:137-151. Accessed at: https://www.researchgate.net/publication/315798626

This article originally appeared on Renal and Urology News