Moral distress in the context of family ethics, hierarchical power, and structural constraints: a qualitative study of oncologists in China

Moral distress arises when healthcare professionals recognize the ethically appropriate action but are constrained from acting upon it. It is associated with burnout and reduced quality of care. However, limited research has examined moral distress among oncologists, particularly within oncology settings in China. This study aimed to explore how oncologists in the present study describe morally distressing situations in clinical practice and how these experiences are shaped by sociocultural and institutional contexts. A qualitative descriptive design was adopted. Sixteen oncologists were recruited through purposive and snowball sampling. Semi-structured interviews were conducted to explore their accounts of morally distressing and ethically challenging situations. Data were analyzed using thematic analysis. Four themes were identified: (1) Family-Mediated Ethical Tensions, (2) Institutional and Hierarchical Constraints, (3) Emotional Consequences of Moral Distress, and (4) Strategies for Managing Moral Distress. Moral distress arose when physicians perceived an ethically or professionally appropriate course of action but were constrained from acting accordingly by family expectations, hierarchical decision-making structures, financial barriers, or other systemic pressures. These intersecting forces constrained physicians’ moral agency and prompted adaptive responses, including strategic communication, professional self-protection, relational negotiation, and personal emotional coping. Moral distress among the participating oncologists was not solely an individual ethical conflict but was embedded within a broader moral environment shaped by relational expectations and structural power relations. Efforts to address moral distress should therefore extend beyond individual coping strategies to include institutional and organizational reforms that strengthen the ethical climate, support moral agency, and acknowledge contextually situated decision-making practices.