“I know I need help kicking heroin, so I will try to get to the Trust Clinic later this week,” said Mr. W. from his hospital bed. He looked down at his arm, where our team had drained a large abscess the night before.
“We can get you a shelter bed so you could stay away from the drugs at your encampment,” I replied. “I bet it would be easier to stay clean there. It frustrates me we can’t get you straight into a live-in drug treatment program.”
“No thanks, Doc, but I appreciate you caring.”
“Well, bless you, my friend, I will be praying for you,” I said. It usually feels good to offer a little love to my patients, but at times it feels embarrassingly insufficient. We have many more resources for those with mental health and substance abuse issues than in the past, but still a familiar sensation came upon me: a heaviness that comes from resignation and sadness.
There’s a specific name for that sensation: moral injury. Health care providers recognize that we can’t cure everyone. However, when we know solutions exist but the health care system doesn’t allow us to provide them, we can take an emotional hit. The same is true for educators, first responders, and everyone who routinely witnesses the suffering brought on by injustice and poverty.
Moral injury occurs when “we perpetuate, bear witness, or fail to prevent an act that transgresses our deeply held moral beliefs,” as Wendy Dean and her colleagues write in a 2019 paper. Psychiatrist Jonathan Shay coined the term in the 1990s to describe what he heard in the narratives of combat veterans, but the phenomenon must have existed since early in human history when our developing sense of morality came into conflict with transgressions brought on by battles for survival. The ancient Greeks commented on it, and it is an acknowledged part of the horrors of modern warfare.
Using the term to describe some of the suffering felt by health care providers only started in the last few years, and it caught the attention of people like me who serve organizations to promote the well-being of the health care workforce. Today, especially in response to COVID-19 conditions, more and more research is trying to understand the impact of moral injury on frontline providers. The reason for the interest is twofold: It provides a name to a phenomenon we all experience, and it offers a new framework to look at the critical issue of burnout.
Today, health care providers are desperate for help. As the pandemic winds down, there is a critical nursing shortage due to people leaving the profession—and about half of all doctors have some symptoms of burnout. Many hope that using the idea of moral injury to conceptualize the suffering of health care workers might shock the system out of some of its inertia to address some fundamental structural issues that lead to provider distress.
There’s a risk, however: The pent-up frustration providers feel—often a symptom of burnout—might lead to invoking moral injury indiscriminately to the detriment of provider and patient alike, for reasons I will explore. So, let’s look carefully at what moral injury is and isn’t—and when it can help and when it might not.
What do we know about moral injury?
Burnout and moral injury can go hand in hand, but there are key differences. Burnout is a form of exhaustion caused by experiencing prolonged emotional, physical, and mental stress; moral injury can happen when we must make choices that contradict our sense of right and wrong.
Workload, flexibility, efficiency, culture, and social support drive burnout, according to most researchers. As Wendy Dean and Simon Talbot note in their pioneering papers, breaches of our morals are behind many of those drivers—but, importantly, we must note, not all of them. That’s why it is best, in my view, to view moral injury as a subset among the causes of burnout.
Where does the research on moral injury stand? There is robust data on military combatants driven by validated measurement tools, and now treatment strategies are being evaluated. The science to date is weaker in other domains: For instance, in education, the most widely quoted study on moral injury was a survey for which the response rate was only 7%, making it unwise to draw any conclusions.
In health care, there are only a handful of studies and, so, the results should be seen as preliminary. One study looked at a population of medical providers in China early in the COVID-19 outbreak, when care had to be rationed. In that setting, rates of moral injury were near 50%, with nurses appearing to suffer more than doctors, the younger more than the older, and women more than men. It’s not hard to understand why: In hospitals around the world, providers were forced, by lack of normally available resources, to let people die.
Is this data generalizable, beyond emergency situations like the one faced in China? Most moral injuries in health care happen in a less dramatic and more insidious fashion. They have to do with seemingly needless paperwork to get patients tests or meds, long working hours, and (for some) the necessary, emotionally exhausting, largely uncompensated, and extremely long conversations that might prevent costly and needless suffering for those facing the end of life.
Is having to choose who gets the ventilator and who doesn’t in a COVID surge going to give you the same moral injury as repeatedly filling out authorization forms? Death by a thousand cuts is still a death, as I thought when I first heard the term. While I instinctively feel moral injury is an important idea, sometimes my instincts are not right and simply reflect wanting an easy way out. I do worry that using the notion of moral injury too broadly to describe all the emotional distress we experience as health care workers might be doing us all a disservice in several ways.
No matter what, we live in a world of limited resources—and health care costs are crippling our society. Quite often these resources are not well spent. We will spend hundreds of thousands of dollars care on ICU care for people whose brains have ceased to function. The moral injury frame could help us advocate for more thoughtful spending, such as better funding for end-of-life discussions, but we need to be careful not to yell “moral injury!” every time we can’t bring all resources to all problems, if we want our voices to be respected by those allocating health care dollars.
More importantly, difficult emotions are inherent in life and, in particular, the work of those providing health care. We will all suffer pain, we will all suffer losses, and we will all die. As providers, we need to develop teachable skills to bring more compassion and love to the bedside of our patients. In doing so, grave illness or death can be transformed to connection, meaning, and wisdom for those involved. Reactively calling the bad emotions around these situations “moral injury” could rob us of an opportunity to transform suffering into the sacred—something that is intensely meaningful and worthy of awe and respect.
Counterintuitively, moral injury is often present in day-to-day work, when there is no crisis. The potential for this kind of injury is in the daily struggle to give each patient the time they deserve, deciding when to discharge and what services we can offer to the vulnerable people under our care. Every day, many doctors are forced to make decisions that challenge our oath to do all we can to serve our patients. What can we do, as individual providers and as organizations, to mitigate the possibility of moral injury in the midst of this quotidian struggle?
How are we addressing moral injury?
Recently, I had lunch with a radiologist who runs our community’s mammogram program. She had just seen an elderly, poorly resourced woman for her mammogram; it had taken the team many calls and help from another organization to get her to her appointment. Unfortunately, the image suggested a mass. Ideally, they would have done a biopsy on the spot—“but all the insurances want authorization for the biopsy!” she said. “So now my staff are working on making sure she has transport back here in a couple of weeks.” Clearly agitated, she added, “These are the things that keep me up at night!”
That’s a good example of why medicine can be stressful—and hints at why practicing medicine can lead to moral injury and burnout. Those afflicted with moral injury are subject to an array of negative cognitive states: guilt; shame; betrayal; loss of meaning, hope, and faith; along with more overt symptoms such as depression and anxiety. There are higher rates of health problems and suicide, too.
Research on moral injury treatments is all relatively new and almost all focused on the military population. Moral injury has a spiritual element—and, in fact, this research shows that religiosity can protect us against its effects. Appropriately, then, therapies to date often combine spiritual with more secular, psychological approaches, such as Religiously Integrated Cognitive Behavioral Therapy. There are forgiveness- and mindfulness-based treatments that have been studied, as well, on individuals or in groups. In the case of secondary trauma—which is the distress we can experience when exposed to another person’s traumatic event—cognitive “educational coping skills” can temper negative symptoms. In all of these approaches, the focus is on healing from, instead of trying to fix or eliminate, the sources of emotional suffering.
However, one implication of the concept of moral injury is that it squarely places the onus on the failures of the delivery system, from how providers are educated to how hospitals are run to the social systems that make tough choices necessary. This is typically almost absent in treatment strategies for health care burnout: For example, the Stanford Model for Professional Fulfillment that many organizations, including mine, use has a three-pronged approach aimed at practice, culture, and personal resilience.
At my own organization, I have been talking about this type of approach for more than five years, yet people still expect me to talk about yoga and meditation. This is true everywhere; our society tends to assign responsibility for individual burnout to the individual. Disengagement is a hallmark of burnout, and burned-out providers likely don’t know what they are feeling other than “bad.” There’s something in the idea of moral injury that leads us to think more carefully about our relationships to patients, each other, our values, and our health care systems.
By raising questions about right and wrong on the job, the term moral injury grabs people’s attention: They listen more intently, often something resonates with them, and they want different solutions, many of which are systemic. (At times, I worry it might resonate too much, as it is always easier if hard work is the responsibility of others—but that’s a danger to guard against, not a reason to drop the idea.)
So, while I am not abandoning the term burnout, I have started to invoke the notion of moral injury. It can help people like my radiologist colleague to better speak about her frustrations; it might help providers let themselves off the hook for not “fixing” their bad feelings. It can give them a language and energy to more effectively advocate for change. Not only do providers struggle to understand burnout, but their partners in health care do, as well—administrators, insurers, government funders. We can more forcefully advocate for and, I hope, partner on change with this evocative framing of the problem.
In world replete with suffering and injustice, moral injury can also lead us to acknowledge our own emotional vulnerability. Health care is sacred work, and being at the center of the beauty and the tragedy of the human condition can come at a price. Moral injury should also be a call for professional development to foster the many cognitive skills espoused by organizations like Greater Good that can temper the worst of the insults and guide us forward with more equanimity, compassion, and purpose.