The concern has intensified since January 2025, when executive orders aimed at reducing or prohibiting DEI programs and preferences began affecting public and private institutions. In April 2025, another order targeted the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, arguing that medical training standards should focus on quality of care rather than what it described as unlawful discrimination. According to the perspective, the LCME and ACGME subsequently removed accreditation requirements related to diversity. These changes have affected programs intended to address documented disparities in health and education, including the underrepresentation of Black, Latinx, and Indigenous physicians, barriers faced by women in advancing toward leadership, and gaps in care for patients from historically marginalized groups. The authors argue that dismantling such programs can affect both the future workforce and the ability of health systems to understand and respond to the communities they serve.

Moral distress is not a new phenomenon in medicine. The term was introduced in 1984 by Andrew Jameton and Eileen Jackson and was initially connected to nurses’ experiences of being unable to provide what they believed was appropriate care. It later became a broader concept applied during the COVID-19 pandemic and in conflicts over abortion care and gender-affirming care. The authors note that the condition can affect people who experience a conflict between their professional obligations and external constraints, even when the individual has not personally made a morally wrong decision. In health care, this distinction is important because distress may arise not from a personal failure but from the gap between what clinicians know is needed and what institutional structures allow them to do. A physician may be forced to withdraw support for gender-affirming care, discontinue training programs that prepare doctors to serve demographically similar patients, or comply with policies that reduce attention to inequity.

Research cited in the perspective links moral distress with emotional exhaustion, a central component of burnout, and with clinicians’ intention to leave their jobs. A 2025 systematic review and meta-analysis found a statistically significant, moderate relationship between moral distress and emotional exhaustion among healthcare professionals. Another study, using a validated moral-distress assessment tool, found that institutional leaders—including clinical supervisors, managers, educators, directors, and administrators—reported the greatest distress compared with other healthcare workers. That pattern is consequential because leaders shape workplace culture, staffing decisions, educational programs, and the response to policy changes. In the same study, nurses accounted for 42.2% of respondents considering leaving their positions because of moral distress, while workers on mixed-acuity medical-surgical floors represented 22.8% of that group. The authors caution that the findings do not mean every physician experiences the same level of distress, but say that conversations within national professional organizations have revealed a persistent undercurrent of concern among clinicians.

The perspective recommends both individual and organizational responses, while warning that self-reflection alone cannot solve a problem created partly by institutional conditions. At the individual level, the authors describe the American Association of Critical-C Nurses’ “4 A’s” model: ask what emotion is being experienced, affirm one’s professional responsibility, assess the risks and benefits of pursuing the right course, and act. The model asks clinicians to identify moral distress, consider how their professional values apply, analyze patient safety and organizational realities with input from trusted colleagues, and choose an action that can provide some emotional resolution. Suggested professional virtues include integrity, compassion, self-effacement, self-sacrifice, and humility. Another approach is to focus on factors that can be influenced, shifting attention from outcomes outside a clinician’s control to the part of the problem that can be changed. Although these techniques may help people navigate difficult cases, the authors worry that they place a heavy burden on professionals who are already exhausted.

Evidence from physicians in abortion-restricted states suggests that support and peer connection can make a meaningful difference. Qualitative work with obstetrics and gynecology residents after the 2022 Dobbs v. Jackson decision identified several coping strategies: maximizing clinical care within legal constraints, supplementing education, engaging in advocacy, and obtaining support from personal and professional relationships. Residents valued faculty members who modeled going beyond routine expectations for patient care, institutions that were transparent about local limitations, and leaders who created space for discussion. Advocacy had variable effects. Some residents felt empowered, whereas others became burned out when advocacy produced no change. The findings suggest that support networks can help clinicians share concerns, align efforts, and identify resources, but they cannot substitute for institutional action or eliminate the legal and policy barriers that generate distress in the first place.

At the organizational level, the authors call for education about moral distress, stronger connections among workers, and better measurement of the relationship between moral distress and healthcare outcomes. Yet they note that the evidence base remains limited. A systematic review of interventions found 16 studies that met its quality criteria, using approaches such as ethics consultations, multidisciplinary rounds, facilitated discussions, mindfulness, reflective writing, and narrative writing. Most programs focused on nurses, many were conducted at a single site without a clear comparator, and only some produced statistically significant differences between pre- and post-intervention surveys. This absence of strong comparative evidence does not mean the interventions are ineffective, but it highlights the need for multi-site studies with standardized outcome measures. The authors argue that institutions should identify where moral distress is occurring, learn which interventions improve working conditions, and protect the clinical values that are difficult to measure through conventional performance metrics.

Despite restrictions, the perspective urges physicians to continue advocating for patients and learners, although the form that advocacy takes may have to change. One priority is to remain grounded in the evidence that a diverse and inclusive healthcare workforce contributes to better patient outcomes. Another is mentorship: students and trainees watch how senior physicians respond when policies conflict with professional values, and they may rely on mentors to interpret difficult situations. Physicians are also encouraged to align with professional organizations that resist overcompliance and to make their own views known when institutional silence or superficial renaming obscures the loss of substantive programs. The authors suggest that advocacy can include speaking with elected representatives, participating in advocacy days, and writing opinion pieces, with clear disclosure when personal views do not represent an institution. Seeking leadership positions may also prepare the profession to rebuild programs when the regulatory climate permits.

The authors reject the idea that improving conditions for one group necessarily requires worsening conditions for another. What they call a scarcity mindset can intensify conflict, undermine long-term goals, and deepen moral distress. In their view, a healthy healthcare system and workforce cannot be sustained without efforts to make the workplace more equitable and allow more people to thrive. They are optimistic that anti-DEI rhetoric may be temporary, but they acknowledge that work in this area is already being delayed or reversed. A recent analysis linked the post-Dobbs reduction in residency applications in abortion-restricted states with a potentially shrinking future workforce in those regions; the authors note that approximately 56% of trainees remain where they complete residency, so recruitment effects can have long-term consequences. The central message is that moral distress should not be treated as a private emotional failure. It is a warning sign of conflict between professional ethics and institutional policy, and responding to it requires both individual resilience and organized efforts to preserve equitable, accessible care.

Subject of Research: Physician moral distress caused by anti-DEI healthcare policies and proposed coping strategies

Article Title: First Do No Harm: Moral Distress and the Attack on DEI Initiatives

Article References: Chisty, A., McNamara, M., Farkas, A. H., Cioletti, A., Bhayani, R., & Koch, J. (2026). First Do No Harm: Moral Distress and the Attack on DEI Initiatives. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10938-x

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10938-x

Keywords: moral distress, physicians, DEI, healthcare equity, medical education, burnout, patient care, organizational ethics, health policy, advocacy, First, Harm

For centuries, moral philosophy has wrestled with the definition of harm. The idea that one person’s actions can damage another’s well-being underpins applied ethics, moral theory, and most systems of law, yet the fine details remain hotly disputed. Kandlbinder’s starting point is the observation that three well-established accounts dominate the debate. The counterfactual comparative account, championed by Derek Parfit and Joel Feinberg, holds that an event harms someone if they end up worse off than they would have been had the event not occurred. The temporal comparative account defines harm as being worse off after an event than before it. The non-comparative, or causal, account—defended by philosophers such as Elizabeth Harman and Seana Shiffrin—says an event is harmful simply if it causes a person to be in an objectively bad state. None of these is canonically accepted, and each has attracted serious criticism, but all continue to shape moral reasoning in bioethics, law, and policy.

To see how these accounts work, Kandlbinder offers a simple illustration. A man hit on the head with a beer bottle in a bar fight is straightforwardly harmed. On the counterfactual account, he is worse off than he would have been had he stayed home that evening. On the temporal account, he is worse off after the fight than he was at work beforehand. On the non-comparative account, concussion and a painful laceration are objectively bad states, and the bottle caused them. The example seems airtight—but epigenetics, she argues, reveals cracks that run far deeper than this apparently clean case of cause and effect.

The trouble begins with identity. Person-affecting views of harm assume that for an event to count as a harm, it must be harmful to a specific someone with a distinct numerical identity. For much of the twentieth century, that identity was assumed to be fixed by genetics: the unique set of nuclear DNA in each cell, established at conception, defined the biological individual. This genetic essentialism still lingers in legislation and regulation of reproductive technologies. Yet developmental biology has rendered it untenable. Epigenetic mechanisms—chemical modifications that regulate which genes are switched on or off—respond to environmental circumstances, shape phenotypical traits such as appearance, behavior, stress response, and disease susceptibility, and begin operating as early as the embryonic stage. As scholars such as Daniela Cutas and Andrea Smajdor have noted, the new science blurs the boundary between genetics and environment, dissolving the old dichotomies of nature versus nurture and biological versus social.

This shift has consequences for the notorious non-identity problem, introduced by Parfit in 1984. The problem holds that existence-constituting events cannot make a person worse off, because without those events the person would not have existed at all to be harmed. Traditionally confined to reproductive and population ethics, the problem now leaks into the lives of existing people. If even modest environmental shifts alter gene expression, and if such changes are taken to alter identity, then arguably ‘new’ people are being produced all the time—which would make it impossible to classify everyday events as person-affecting harms or benefits on either comparative account. Smajdor has warned that numerical genetic identity can no longer sustain the weight the non-identity problem expects it to bear.

The non-comparative account escapes this identity trap, since it measures harm absolutely—being caused to be in a bad state—rather than by comparison. But it stumbles over two other requirements: a fixed categorization of ‘good’ and ‘bad’ states, and a strict criterion of causation. Both falter under epigenetic scrutiny. Critics including Elisabeth Carlson, Johan Johansson, and Olle Risberg have questioned whether intrinsic harms exist at all, and disability scholarship has shown that lived experience of biological traits is far more ambiguous than generalized intuitions suggest—a caution against embedding anti-disability bias into philosophical definitions of the ‘bad’ state. Epigenetics compounds the ambiguity: as Carlo Dupras and Vardit Ravitsky have observed, an epigenetic change may be adaptive in one context yet harmful in another. Metabolic shifts toward insulin sensitivity triggered by prenatal malnutrition, for instance, can help a fetus survive early life while raising the risk of type 2 diabetes decades later. Moreover, Erla Moormann has argued that epigenetic changes rarely trace back to a single causal event, undermining causation-based accounts that presume the neat linearity of a beer bottle to the skull.

The paper’s most provocative claim goes further still. Drawing on feminist phenomenology—from Iris Marion Young’s account of embodied spatiality to Judith Butler’s argument that identity is co-constituted through relationality—Kandlbinder contends that lived experience, embodiment, and gene expression form a circular system that collectively constitutes identity itself. Environment shapes gene expression; gene expression shapes phenotype; phenotype shapes how a person is perceived and how they move through the world; those experiences in turn reshape biology and identity. On this view, there is no ‘original’ identity that exists prior to and apart from the events that befall a person, which means any account of harm that separates who someone is from what happens to them is conceptually doomed to chase its own tail.

To make the stakes vivid, Kandlbinder constructs a hypothetical figure named Mona, a woman in her thirties who carries epigenetic changes triggered by her mother’s malnutrition during pregnancy. Living in a higher-weight body, she faces chronic weight-based discrimination rooted in social norms; the resulting stress elevates her risk of anxiety, hypertension, and cardiovascular disease; those conditions limit her employment options, deepening financial precarity, which further raises stress levels—all well-studied ‘social determinants of health’ largely outside her control. Where, Kandlbinder asks, in this cascade of entwined circumstances stretching from the prenatal period onward, could one pinpoint a discrete harmful event that made Mona worse off, on any of the three accounts? Her harms are, at the same time, inseparable from who she is.

The proposed way out is methodological rather than destructive. Kandlbinder endorses multi-dimensional accounts of harm, such as Moormann’s, which incorporate lived experience and relationality, and urges that they be merged with relational conceptions of identity like Françoise Baylis’s, in which the self is co-constructed through iterative cycles of private and public interaction—now understood to operate at the molecular as well as the social level. Such a framework would treat benefit and harm as more than additions or subtractions to a person’s well-being, recognizing instead that events constantly reshape identity without thereby dissolving the person altogether. Even the humble bar fight looks different through this lens: rather than a unilateral cause acting on a pre-existing victim, it becomes one strand in a web of sociocultural and embodied conditions. As debates over germline genome editing and epigenetic editing intensify—framed by bodies such as the World Health Organization around imperatives to maximize benefits and minimize harms—philosophy may need to abandon the comfortable fiction of a fixed biological self. What epigenetics ultimately teaches, Kandlbinder concludes, is that harming and benefiting someone cannot be understood apart from understanding who they are becoming.

The timing of Kandlbinder’s analysis is notable. Bioethical attention since the advent of CRISPR/Cas9 gene editing has concentrated overwhelmingly on alterations to the nuclear DNA sequence itself, even though germline alterations can also arise through changes to molecular structures other than DNA. Epigenetic editing, which modifies gene expression rather than genes, can influence phenotypic outcomes without touching the underlying sequence, and the article argues that debates about the ‘potential benefits of human genome editing research’ must therefore expand to cover these non-sequence-based mechanisms of biological change.

The epigenetic paradigm also carries implications beyond philosophy seminars. Epigenetic mechanisms influence phenotypic markers including appearance, behavior, stress response, and disease susceptibility, and these processes begin acting as early as the embryonic stage. Because some epigenetic states can be shaped by nutrition, stress, and other environmental conditions, the boundaries between individual responsibility, parental influence, and societal obligation become harder to draw. A trait that diminishes well-being in one sociocultural setting may be neutral or adaptive in another, which complicates any regulatory framework that assumes harms can be identified and attributed in a straightforward manner.

Kandlbinder’s intervention also situates epigenetics within a longer philosophical tradition. The margins of life—its beginning and its end—have long been recognized as especially troublesome for theories of benefit and harm, and questions about whether a person can be harmed before existing or after dying remain unresolved. What the epigenetic paradigm adds is the recognition that such puzzles are no longer confined to the edges of a lifespan. If embodied experience, epigenetic change, and identity are co-constitutive throughout life, then the conceptual work of defining harm must become multi-dimensional and relational, integrating biological, embodied, and sociocultural dimensions rather than treating them as separate spheres.

Subject of Research: The philosophical implications of epigenetic mechanisms for conceptualizing benefit and harm to individuals.

Article Title: Philosophical complications of epigenetic benefit and harm

Article References: Kandlbinder, A. E. (2026). Philosophical complications of epigenetic benefit and harm. Epigenetics Communications, 6(1), Article 8. https://doi.org/10.1186/s43682-026-00049-3

Image Credits: AI Generated

DOI: 10.1186/s43682-026-00049-3

Keywords: epigenetics, harm, benefit, identity, non-identity problem, bioethics, gene expression, well-being, feminist philosophy, genetic essentialism, social determinants of health, philosophy of biology