DISCUSSION COMMENTARY

 

Health science researchers at risk of experiencing unprecedented moral distress

 

 

Jacqueline Hoare

Department of Psychiatry and Mental Health, University of Cape Town, South Africa

Correspondence

 

 

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ABSTRACT

SIGNIFICANCE:
Cuts in funding from organisations like USAID, PEPFAR and the NIH can lead to a cascade of challenges for researchers, including causing moral distress which could impact their mental health, job security, and the overall landscape of scientific research. By understanding these complexities, we can work towards creating more supportive environments that prioritise both the well-being of researchers and the importance of their contributions to society.

Keywords: moral distress, health science, mental health

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A decision to terminate South African related grants from the US National Institutes of Health (NIH) would have a devastating impact on public health efforts in the country - efforts which have already been severely compromised by cuts to the US Agency for International Development (USAID) and the US President's Emergency Plan for AIDS Relief (PEPFAR).¹ As many NIH grants to South Africa focus on tuberculosis (TB) and HIV/AIDS, researchers are very much aware that this abrupt termination of funding will leave the most vulnerable of South Africa's population at risk and are experiencing widespread confusion, anxiety and fear as a result.² The implications of reduced research funding extend beyond the academic sphere and into the realm of public health. These constraints will create and exacerbate existing ethical challenges in health care.³ South Africa has one of the highest HIV prevalence rates in the world, as well as significant burdens from TB and non-communicable diseases. Research funded by these grants often informs public health policies and interventions. A decline in research output could slow progress in combating these diseases, resulting in higher morbidity and mortality rates. Scientists' and researchers' feelings of moral distress are already palpable across academic institutions in South Africa. The term 'moral distress' originated in the field of health care and was conceptualised as a psychological and emotional response experienced by healthcare professionals when they believe they know the morally correct course of action but are unable to act accordingly due to various constraints such as institutional policies, hierarchical structures, legal and ethical dilemmas, resource constraints or conflicting values within a healthcare setting.⁴ While moral distress is often discussed in healthcare settings, it is also relevant for researchers, especially in clinical research, and has been reported in studies. Based on research conducted prior to the current NIH budget cut crisis, contributors to moral distress have included the commodification of research; concern for research participants; compromised science; structures of hierarchy; and the experience of racism.⁵ Now we face unprecedented "sweeping" cuts to NIH funding which are causing significant distress across the research community. These cuts are impacting research institutions and universities, potentially jeopardising vital research projects and harming the careers of researchers. The extent of the moral distress facing the clinical research community is currently only speculative; however, we have cause to be concerned, and we should name and raise the concern. We need the right words to define our experience, and we need the right words to have the conversations that matter and to access help that will be meaningful.⁶ Naming moral distress is the start of best supporting health science researchers going forward. Healthcare research frequently involves caring for sick and otherwise vulnerable patients - patients whose level of suffering, whose dignity, and often whose lives are improved by being a research participant.⁷ It is no small thing for researchers to fail to meet what they feel their moral responsibilities are.

Austerity, by its very nature, imposes constraints.³ Researchers in South Africa frequently work on projects that directly impact the lives of participants and their communities. The sudden loss of funding can halt these projects, leading to ethical dilemmas in which researchers are unable to fulfil their commitment to improving their participants' health outcomes. The inability to complete research can lead to feelings of frustration, especially if the work was aimed at addressing critical health issues or advancing scientific knowledge. This can create a profound sense of helplessness for researchers, as they come to terms with a new reality of health care and healthcare research in South Africa. Each will have to reconcile their internal drive to serve the public with the reality of now being severely constrained to do so. Many researchers have a deep-seated commitment to their local communities, with the aim of addressing pressing health issues through their work. Funding cuts to critical interventions and innovations may be delayed or abandoned, leading to a sense of betrayal towards the communities they serve.² This moral distress is compounded by witnessing preventable health issues persist or worsen without the means to intervene effectively.² In a context of a society characterised by poverty, deep inequality and violence, the environment in which research is performed is deeply distressing in itself.⁸

One of the most troubling aspects of the termination of US health funding to South Africa is how quickly everything is happening. Researchers may be faced with morally distressing situations such as abruptly terminating TB treatment in participants enrolled in a clinical trial for tuberculosis. This would require an enormous amount of planning as participants require ongoing treatment against a backdrop of an underfunded and resource-constrained healthcare system.⁹ Researchers are also very aware that participants who are vulnerable, such as women and children enrolled in longitudinal cohort studies, will no longer have access to the supportive structure of the research team that has become a safe place to turn to in times of trouble. Researchers facilitate referrals to social workers, alcohol and drug counselling centres or NGOs that support those who have experienced intimate partner violence when needed.

The interruption of funding has triggered distress as research scientists will face significant financial instability in their research centres or units. Many researchers rely on grants not only for their salaries but also for the salaries of research teams and doctoral and postdoctoral students, and they are feeling the devastating burden of having to retrench staff when funding is cut. When funding is reduced, job losses become a reality. The uncertainty of NIH funding is creating a high-stress environment in which researchers constantly worry about their future and the future of those they have supported financially through their research units, leading to anxiety and feelings of inadequacy. The cumulative stress from job insecurity and project disruption in research staff can lead to significant mental health challenges. Researchers may experience feelings of depression, anxiety and burnout. The pressure to constantly seek new funding sources can create a relentless cycle of stress, which impacts researchers' overall well-being. Additionally, many researchers may feel isolated in their struggles, as the academic culture often prioritises success and productivity, leaving little room for vulnerability or discussions about mental health challenges.

Opportunities for developing the careers of the next generation of South African health scientists through publishing, attending conferences and engaging in collaborative projects will diminish. The combination of these factors can lead to significant emotional and psychological distress. Researchers may experience feelings of frustration and anxiety, as they grapple with the implications of halted projects on their students' careers. As funding opportunities diminish, there is a growing risk of a brain drain, with talented researchers seeking opportunities abroad in countries where funding is more stable and abundant. This migration can deplete the local research landscape of its expertise, making it increasingly difficult for South Africa to develop its own solutions to health crises. The loss of skilled professionals can have long-term detrimental effects on the country's research capacity and public health infrastructure.

A decrease in funding can create a risk-averse culture within research environments. Researchers may be compelled to focus on safer, more conventional projects that are more likely to secure limited funding, rather than pursuing research that could lead to the improvement of pressing public health issues in South Africa. This shift can be disheartening for researchers who are passionate about their work, as they may feel constrained by the necessity to prioritise funding over the potential societal impact of their research.

Addressing the mental health challenges associated with funding cuts will require a robust institutional response. There is stigmatisation in medical culture of uncertainty, a perception of vulnerability as failure, and shame for needing support. Reflecting on how to navigate these unhelpful beliefs will be critical as universities and research organisations must play a critical role in providing mental health resources.¹⁰ Universities will need to foster a supportive environment, and encourage open discussions about the pressures that researchers face. There is little doubt that we are facing tough times in healthcare research in South Africa. Leaders in research will frequently be in a position of having to deliver news to colleagues that causes distress to themselves and their colleagues.² Many principal investigators will be left feeling powerless, hopeless and stuck. By having regular updates and face-to-face meetings, actively listening to others, considering their perspectives, and acknowledging their distressing emotions and experiences, university leaders can have honest dialogue and more constructive resolution of difficult circumstances.¹¹ Tough feedback is more effective when leaders see the colleagues that they are giving feedback to as people who are distressed because their ability to heal and care is being constrained.²

In the context of austerity and cuts to resources, responses to moral distress that only target an individual's distress are insufficient.³ Approaches that focus on reactively providing support to individual researchers who become distressed may also unwittingly 'blame' the individual for not managing themselves and their stress, pathologising them rather than acknowledging that the loss is real and affects an already traumatised health care system.¹⁰ Avoidable challenges created because of systemic and political austerity policies require a different kind of resilience.³ Where moral distress results from austerity, it is not only healthcare institutions but also the political system that should be held responsible.³ Advocacy for sustained and increased funding in critical research areas is essential. Engaging with policymakers, stakeholders, and the public to highlight the importance of ongoing support for research initiatives can help mitigate the long-term effects of funding cuts.

In summary, the cuts in funding from organisations such as USAID, PEPFAR and NIH can lead to a cascade of challenges for researchers, including causing moral distress which could impact their mental health, job security, and the overall landscape of scientific research. By understanding these complexities, we can work towards creating more supportive environments that prioritise both the well-being of researchers and the importance of their contributions to society.

 

Declarations

I have no competing interests to declare. I have no AI or LLM use to declare.

 

References

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Correspondence:
Jacqueline Hoare
Email: Jackie.hoare@uct.ac.za

Published: 29 May 2025