“Front-line”, “battle”, “the trenches”. These terms are all too familiar when talking about modern medicine. Why are we referencing war when we should be talking about healing? In this article, I will argue that medicine today is more reflective of a war zone and, like in battle, the consequences will be more than burnout: sustained conflict will result in physician moral injury.
Military terms are fitting metaphors for healthcare today. Insufficient resources, excess demand, blood, death, shouting (and in the US at least, countless firearms) are all there. Doctors and other healthcare workers, like those in the armed forces, often face a profound and unrecognized threat to their well-being.
Moral injury is frequently mischaracterized. In soldiers, it is diagnosed as post-traumatic stress disorder (PTSD); physicians moral injury is labeled as burnout. Some researchers have voiced a concern “that burnout does not become the catchall term for emotional distress experienced by physicians.” I have previously written on this in relation to “resilience” programs which I call both a sticking-plaster solution and potential red herring.
But without a clear distinction between PTSD, burnout, and moral injury, the underlying causes cannot be addressed, and the healers cannot be healed. And while the caregivers suffer, patients suffer, too.
Moral distress is defined as the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action. Even without an understanding of the morally correct action, moral distress can arise from the sense of a moral transgression. More simply, it is the feeling of unease stemming from situations where institutionally required behavior does not align with the clinician’s moral principles.
This can be caused by a lack of empowerment, or structural limitations, such as insufficient staff, resources, training or time. The individual suffering from moral distress need not be the one who has acted or failed to act; moral distress can be caused by witnessing moral transgressions by others.
The pandemic headlines of doctors having to choose which patients were admitted to Intensive Care, leaving those they did not have the resources to take to almost certain death, sums this up. In thousands of different ways, physician moral injury plays out daily in our healthcare system.
Moral injury then can arise where sustained moral distress leads to impaired function or longer-term psychological harm. Moral injury can produce profound guilt and shame, betrayal, anger, and “painful feelings and/or psychological disequilibrium”. Moral distress has subsequently been shown to be associated with burnout, which includes poor coping mechanisms such as moral disengagement, blunting, denial, and interpersonal conflict. It has also, unsurprisingly, been linked to severe mental health issues.
Moral injury seems to occur in both high and low resource settings, at all ages and levels of medical training and career, and in all levels of resources. Undoubtedly, the COVID-19 pandemic has heightened at least awareness of, and probably the prevalence of, moral distress and moral injury.
Estimates of moral distress or injury 50 – 90% in different settings and healthcare professions, but because we lack a clear cut-off for moral distress, studies are difficult to compare with confidence. Over the Pond, a British Medical Association 2021 survey revealed that nearly 80% of UK physicians experienced moral distress, and over 50% moral injury.
“Moral distress” was originally conceived by Jameton (1984) and concerned the experiences of our nursing colleagues. Short answer: we are all suffering in the medical trenches. The medical literature has only started recognizing moral distress in younger physicians, despite evidence that medical students and residents are particularly susceptible to moral distress. This vulnerability in our junior colleagues is thought to reflect the strongly hierarchical nature of medical training, and the worsening state of the healthcare system.
Consequently, the term “moral injury” pertains to sustained moral distress causing harm or impaired functioning. It was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it in relation to combat veterans as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”
How can the experience of soldiers relate to those of doctors and nurses in peacetime? The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.
Most physicians enter with a desire to help people. Many approach it with vocational conviction, incurring many costs along the way: loss of sleep, years of carefree young adulthood, the costs of medical school, family strain, financial insecurity, and often neglecting our self-care for our studies and patients.
The reality of modern medical working life is very different from simply giving the best care to the patient before us. Daily, clinicians are forced to choose between many factors working against their patients’ best interests. These include an increasingly profit-driven health care environment, the constant Sword of Litigation hanging over us which may lead us to over-investigate, over-react, and sometimes even cause unintentional harm, all to avoid medico-legal issues. Electronic health records distract us from patient contact and fragment care but must be completed to satisfy the administration’s need for ‘metrics’. Financial conflicts are common: between hospitals, health care systems, insurers, patients, and sometimes of the physician themselves.
Resultantly, physician moral injury as a concept adds depth to the distress that we are under as a profession and as human beings. We are routinely being forced to make choices that do not fit with our values, because of the decisions made by our commanders. This is not just a recipe for physician burnout: it is the perfect storm to cause physician moral injury.
Moral injury occurs when good people are forced to make bad decisions because of circumstances outside their control. This causes moral distress, and if repeated enough, moral injury. Moral injury is linked to burnout, mental illness, and worse patient outcomes.
Yet, too many of us do not recognize it, or if we do, we are afraid to seek help.
In the next article, we look into the impact of moral injury and explore potential solutions.
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