Moral injury is a feeling that one has participated, in some way, in actions that transgress one’s deeply held moral beliefs, or one feels betrayed by an authority figure, preventing them from doing what’s right. In healthcare, those deeply held beliefs are the oaths we swore to put patients first.
There was an epidemic of distress in healthcare for almost two decades before COVID-19. But many physicians didn’t feel like the concept of burnout, the most common way to encapsulate that sense of distress, was an accurate descriptor of their experience.
Moral injury—knowing what a patient needs but being unable to provide it because of constraints beyond one’s control—is acknowledged by most physicians as a more accurate descriptor of their experience.
The term moral injury arose when PTSD treatments for Vietnam combat veterans weren’t working. Physicians looked at the roots of their distress and realized it wasn’t a fear-based problem.
Patients with PTSD feared for their life or their safety in the situation that incited the condition. Those experiencing moral injury feared for their moral integrity. The two conditions may occur together, but they do not necessarily arise from the other.
Depression, similarly, may occur with moral injury, but it is not causative of, nor does it result from, moral injury. The caveat to that is that if moral injury is unrecognized and unattended, the learned helplessness that results can look much like depression.
That’s not to say it’s not important to do things to maintain a high level of resilience. But what is more important is to focus on ways to build community resilience—a workforce that supports each other, both suits and scrubs—and to change the system to make it easier, rather than harder, for physicians to do their already difficult jobs. Excellent patient care is the true north of any physician’s moral compass.
The analogy I like to use is that it’s important to keep a high-performance machine, like a Lamborghini, tuned but no amount of tuning up will help that car hum if it is out on backroads riddled with potholes.
Moral injury is a relatively new concept in healthcare, so its impacts are still being elucidated, but I believe the following:
*Check out this study, Spirituality and Moral Injury Among Military Personnel: A Mini-Review, for additional content on the spiritual impacts of moral injury in another population.
Leadership plays a crucial role in addressing moral injury, here’s how:
Yes. It is imperative that we recognize that healthcare workers during COVID-19 have run an ultramarathon without training for it. We would not expect someone who had run an ultramarathon to be jogging around the block the next day. We would let them rest and help them rehydrate and replenish. It is essential to do the same for those physicians who have been on the front lines for more than a year. They are exhausted and low on resources. Let’s help them recover.
Interested in learning ways to address moral injury at your healthcare organization? Contact us to learn more about our robust Physician Well Being Resources – built specifically to enhance all aspects of well being for physicians, providers and the organization as a whole. Peer Coaching is a phenomenal resource to help address and work through various aspects of moral injury, including stress and burnout.
Wendy Dean, MD is the President/CEO, and co-founder of The Moral Injury of Healthcare (fixmoralinjury.org), a nonprofit organization that provides training and consultation to organizations focused on alleviating distress in their workforce. A psychiatrist by training, Dr. Dean has been a practicing clinician, worked for the Department of Defense and as an executive for a large international non-profit supporting military medical research.