9 March 2026

What happens after the shift

Aged care's ethical frameworks govern workers’ behaviour, but not their conscience

The trolley problem asks what you would do. It never asks what it costs you to decide. (Visual by Lisa Larson-Walker)

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Article summary (by AI)

• Aged care's ethical frameworks govern behaviour but do not address the psychological cost to workers who act within them
• Real ethical decisions involve ambiguity that formal frameworks cannot resolve, such as sedation when distress is severe but the legal threshold for harm is unclear
  
• Personal care workers routinely make ethically loaded decisions alone, without clinical supervision or ethical support for the moral weight involved
  
• Research on moral distress in aged care is thin: a 2022 global review found only fourteen studies, no causal evidence, and no interventions
  
• In Australian aged care, ethics has been absorbed into compliance, which measures whether the right thing was done but not what it cost the person who did it
  
• Failing to name the accumulation of moral residue in aged care workers guarantees they will continue to carry it alone
  

The trolley problem is philosophy's most famous ethical scenario. A runaway trolley hurtles toward five people on a track. You can pull a lever to divert it onto a side track, where it will kill one person instead. What do you do?

The philosopher Roger Scruton called these thought experiments useful only in the sense that they eliminate "just about every morally relevant relationship and reducing the problem to one of arithmetic alone." He had a point. The trolley problem gives you two options, perfect information, and no consequences beyond the immediate choice. However, real ethical decisions have none of these features. They arrive without warning, involve competing obligations that can't be ranked, unfold in conditions of uncertainty, and leave psychological and moral residue that the person who made the call has to carry afterward.

In ethics classrooms and even in corporate training modules, this stripping-away of context is done on purpose. It isolates a single ethical variable or scenario, so it can be examined cleanly. However, in real life aged care, context is the problem.

What the frameworks say

Australian aged care has an ethical architecture. The Aged Care Code of Conduct, introduced under the Aged Care Act 2024, outlines eight required behaviours for providers, responsible persons, and workers. The Aged Care Quality Standards reinforce these expectations at the organisational level. Other frameworks, such as restraint minimisation policies, dignity of risk, and person-centred care principles fill out the picture.

All these are of uttermost importance. These frameworks exist because older Australians were being harmed, and the Royal Commission made that harm undeniable. This ethical architecture is necessary.

But it is also incomplete in a specific way that is not discussed often. These frameworks govern behaviour, not the workers’ conscience. They tell workers what they should do, but not how they should live with what they had to do.

The ethical architecture is necessary. But it tells workers what they should do, not how to live with what they had to do.

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The context in real life decisions

Scenario 1: A resident with advanced dementia is agitated, distressed, calling out, pulling at her clothing. She has been like this for over an hour and a half. The registered nurse on shift has tried redirection, has tried comfort measures, has sat with her. Nothing has worked. The resident's behaviour support plan includes a PRN sedative for situations where the resident is at risk of harm to herself or others. But here, right now, there is no clear and immediate risk of harm. There is distress – visible, sustained, and resistant to intervention available. The nurse makes a judgement call: the agitation is escalating, harm is plausible, and continued distress at this level is itself a form of suffering. She administers the PRN. The resident grows quiet within twenty minutes. She slumps in her chair and sleeps through lunch.

Was this lawful? Under the current Australian framework, chemical restraint is permitted only as a last resort to prevent harm, with prescribing, consent, and behaviour support plan requirements in place. Distress alone does not meet the threshold. The nurse knows this. She also knows what an hour and a half of escalating agitation looks like, and what it can lead to. She documented the decision as a last resort. It is probably defensible, but not clearly justified based on the current frameworks. And that gap between "probably defensible" and "clearly justified" is exactly where moral residue accumulates. The nurse does not go home thinking she broke the rules. She goes home thinking the rules did not quite cover what actually happened.

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Scenario 2: A personal care worker is helping a resident shower. The resident has moderate cognitive impairment and does not always understand what is happening. Today, he resists. He pushes the carer's hands away. He says no, and he says it clearly. The care worker has two choices: respect the refusal and leave him unwashed, which will lead to skin breakdown and a clinical incident report, or persist gently, working through the resistance to complete the task. She persists. She talks softly, moves slowly, finishes the shower. The resident does not appear distressed afterward.

From a compliance perspective, this barely registers as an event. But the care worker has just overridden a person's clearly expressed refusal. She has decided, on his behalf, that hygiene outweighs autonomy in this instance, and she is probably right. But she made that decision alone, in a bathroom, with no clinical supervision, no ethical consultation, and no training that prepared her for the specific weight of that moment. She is paid in the low $30s per hour. She will make a similar decision tomorrow, and the day after, and the day after that.

What the research consistently describes is a workforce absorbing ethical strain without the structural supports that exist for other healthcare professionals.

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Where the weight falls

The concept of moral distress was introduced into nursing literature in the 1980s by the philosopher Andrew Jameton, who defined it as the distress that arises when a person knows the right thing to do but is prevented from doing it by institutional constraints. The concept has since expanded. Moral injury, a term originally developed to describe the psychological harm experienced by combat soldiers, is now applied to healthcare workers who are exposed to sustained situations that violate their deeply held values. In 2025, the American Psychiatric Association formally recognised moral injury as a diagnosable condition.

Research on moral distress in aged care exists, but it is quite thin. A 2022 scoping review of moral distress among eldercare workers found only fourteen relevant studies in the global literature, most of them qualitative and small. The review found no reliable evidence on causal effects and no interventions designed to address the problem. A separate Australian study found that aged care workers do experience moral distress, with insufficient staff competency, poor communication, and delays in palliative care among the primary causes. When the distress occurred, it was felt with moderate to high intensity.

What the research consistently describes is a workforce absorbing ethical strain without any of the structural supports that exist for other healthcare professionals. Hospital doctors have ethics committees, clinical ethics consultation services, professional colleges that engage with moral complexity, and a broader cultural recognition that their work is inherently moral in character, that their decisions carry ethical weight and deserve to be respected.

Aged care personal care workers – the people who make intimate, ethically loaded decisions, more frequently than almost anyone else in healthcare – have a code of conduct, a set of compliance frameworks, and usually an employee assistance program offering short-term counselling.

Their moral distress is less visible, less studied, less named, and less supported — not because it is less real, but because the setting in which it occurs does not command the same attention.

Compliance asks whether the right thing was done, but does not address what it cost the worker who did it.

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What compliance measures and what is misses

The deeper issue is structural. In Australian aged care, ethics has been almost entirely absorbed into compliance. The Code of Conduct is enforceable and workers can be reported for breaching it, the ACQS are auditable, restraint use is reportable, etc. These are accountability mechanisms, and they absolutely serve a purpose.

But compliance is concerned with whether the right thing was done. It is not concerned with what it cost the person who did it. Compliance asks: was the restraint a last resort? Was it documented? Was consent obtained? It does not ask: how did the nurse feel when the resident went quiet? What did the care worker carry home? How does someone process the fourty-sixth time they've overridden another person's expressed wishes, even when it was clinically justified?

And the truth is that this is not a gap that better policy can close. More training, clearer guidelines, and stronger accountability frameworks are all well and good, but they address the ethical architecture. They do not address what happens inside the person who works within that architecture every day, making decisions that are technically correct and emotionally corrosive.

What remains

Our sector has become sophisticated at naming structural problems: workforce shortages, funding constraints, regulatory burden, the gap between person-centred rhetoric and institutional reality. But we have not yet named this very internal problem – the accumulation of moral residue in the people who do the work.

There is no framework that resolves this, or audit that captures it. It sits with the nurse who administered the PRN, and the care worker who finished the shower.

And of course, naming it alone will not fix it. But failing to name it guarantees that the people who carry it will continue to do so alone.

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References

Scruton, R. (2017). On Human Nature. Princeton University Press. 

Pirhonen, J., Vähäkangas, P., & Laitinen, A. (2022). Understanding Moral Distress among Eldercare Workers: A Scoping Review. International Journal of Environmental Research and Public Health, 19(15), 9303. https://www.mdpi.com/1660-4601/19/15/9303

Burston, A. S., & Tuckett, A. G. (2013). Validation of an instrument to measure moral distress within the Australian residential and community care environments. Nursing Ethics. https://pubmed.ncbi.nlm.nih.gov/28008747/

Harvard T.H. Chan School of Public Health. (2025). Moral injury officially recognised as mental health condition. https://hsph.harvard.edu/news/moral-injury-officially-recognized-as-mental-health-condition/

Image Source: Lisa Larson-Walker for Slate: https://slate.com/technology/2018/06/psychologys-trolley-problem-might-have-a-problem.html