Moral distress is now being recognized as a frequent experience for many health care providers, and there's good evidence that it has a negative impact on the health care work environment. However, contemporary discussions of moral distress have several problems. First, they tend to rely on inadequate characterizations of moral distress. As a result, subsequent investigations regarding the frequency and consequences of moral distress often proceed without a clear understanding of the phenomenon being discussed, and thereby risk substantially misrepresenting the nature, frequency, and possible consequences of moral distress. These discussions also minimize the intrinsically harmful aspects of moral distress. This is a serious omission. Moral distress doesn't just have a negative impact on the health care work environment; it also directly harms the one who experiences it. In this paper, I claim that these problems can be addressed by first clarifying our understanding of moral distress, and then identifying what makes moral distress intrinsically harmful. I begin by identifying three common mistakes that characterizations of moral distress tend to make, and explaining why these mistakes are problematic. Next, I offer an account of moral distress that avoids these mistakes. Then, I defend the claim that moral distress is intrinsically harmful to the subject who experiences it. I conclude by explaining how acknowledging this aspect of moral distress should reshape our discussions about how best to deal with this phenomenon.

Harrowing stories reported in the media describe Covid‐19 ravaging through families. This essay reports professional experiences of this phenomenon, family clustering, as encountered during the pandemic's spread across Southern California. We identify three ethical challenges following from it: Family clustering impedes shared decision‐making by reducing available surrogate decision‐makers for incapacitated patients, increases the emotional burdens of surrogate decision‐makers, and exacerbates health disparities for and the suffering of people of color at increased likelihood of experiencing family clustering. We propose that, in response to these challenges, efforts in advance care planning be expanded, emotional support offered to surrogates and family members be increased, more robust state guidance be issued on ethical decision‐making for unrepresented patients, ethics consultation be increased in the setting of conflict following from family clustering dynamics, and health care professionals pay more attention to systemic and personal racial biases and inequities that affect patient care and the surrogate experience.

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points raised with respect to the need to address medication delivery systems for clinical decision-making. Our Clinical Practice Guideline relied on the available literature to date to perform a rigorous, PICO (Population, Intervention, Comparator, and Outcomes)-driven distillation of scientific evidence to provide recommendations pertaining to key questions regarding the pharmacologic treatment of chronic obstructive pulmonary disease. However, the available evidence did not allow us to address the merits of specific medication delivery devices. As per the committee discussions, we raised the issues of feasibility and acceptability as playing a role in the decision to prescribe various types of inhalers. Though we noted issues such as cost and burden of use of inhalers, we did not specifically identify cognitive ability, dexterity, coordination, and inspiratory flow as additional issues to be addressed. We thank the authors for raising these important considerations in this forum and look forward to future randomized trials that address matching medication delivery devices to specific patient characteristics. nAuthor disclosures are available with the text of this letter at www.atsjournals.org.