The Burden of Caring: Moral Injury during COVID-19

By: Yeeun Lee

Moral injury can be defined as “the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.” The term is thought to have originated during the Vietnam War, when veteran and peace activist Camillo “Mac” Bica described post-war trauma in his writings. While moral injury is often discussed in the context of war, it is now being used to describe the experiences of the healthcare workers fighting COVID-19. In war, examples of moral injury include giving orders that lead to the death of a fellow service member or failing to give aid to an injured person.

For frontline healthcare workers, moral injury may arise when having to make difficult decisions, such as which patient will receive a ventilator or whether to go to work despite the lack of protective equipment. BBC interviewed a young doctor who explained how “the most anxiety [she] has is around ventilator allocation. Seeing people die is not the issue. We’re trained to deal with death. Nor is it the volume of people dying. The issue is giving up on people we wouldn’t normally give up on.”

In both situations, individuals are placed in a position that leads them to act in a way that goes against their moral code, which in return causes serious distress, depression, and even suicidality — all which gravely affect a person’s mental health and moral identity. Beyond the consequences it has on the individual, moral injury can also change a person’s ability to trust others, which can then lead to them distrust a community or system. Hence, moral injury has immense social, psychological, behavioral, and spiritual consequences.

An important term to consider when evaluating moral injury is moral responsibility. Doctors are being asked to take responsibility for how to best ration their hospital and country’s resources. They are being asked to make decisions taking into consideration that some people will inevitably have to die. We are asking doctors to take on an immense responsibility, which comes with stress. This huge weight plus the changing pace of work, an overwhelmed system, and fatigue, consequently creates room for moral mistakes. The costs and uncertainties will weigh heavily on all doctors, causing them even more distress now and in the future. Recently, a top ER doctor in New York died by suicide. Dr. Lorna Breen had contracted COVID-19, recovered, and still continued to treat patients. Her father states that she, like many other doctors, was working 18 hours a day, which eventually led her to be hospitalized for exhaustion.

As stated by Charlottesville Police Chief RaShall Brackney, “frontline healthcare professionals and first responders are not immune to the mental or physical effects of the current pandemic.”

Dr. Jessi Gold explains that deciding who gets a ventilator goes against a physician’s moral code because doctors do not go into medicine to decide and control the supply of life-sustaining and life-giving devices. And now, physicians have to make these decisions every single day, multiple times a day. Not having enough protective equipment goes against a physician’s moral code because it puts the physician at risk of getting infected and thus infecting their patients and even their loved ones. Moreover, the lack of trust and support doctors are experiencing from organizations and governments can also add to that moral injury.

In an interview between Lorie Brown, a registered nurse, and Dr. Mady Stovall , a doctor who studies moral injury, Dr. Stovall explains how the core symptoms of moral injury include guilt, shame, and loss of trust in oneself and in others. The secondary symptoms include depression, anxiety, social problems, and suicidal ideation. The secondary symptoms of moral injury are similar to symptoms of post-traumatic stress disorder (PTSD). However, while PTSD is a mental health condition, moral injury is not. Thus, a way to distinguish moral injury from PTSD is the feeling of guilt.

Moral injury causes a violation of our own world views, which causes guilt and shame. Moral injury makes the person feel as if they betrayed themselves by going against their beliefs, and it can lead people to feelings as though the system betrayed them or that they betrayed their patients. In return, this can lead to negative thoughts and feelings, which can contribute to developing a mental health condition such as depression or PTSD. And while people who suffer from PTSD can also suffer from guilt, it is a core symptom of  moral injury. In addition, while PTSD requires a diagnosis, moral injury is considered to be a “dimensional problem”, meaning, according to the VA,  it has “no definable threshold for its presence.”

In that same interview, Dr. Stovall noted that healthcare workers often receive no support after experiencing a traumatic event, whether it be treating a terrorist or treating patients who were present during a mass shooting. Nurses and physicians are expected to simply move on after going through a traumatic event — to ignore their feelings. However, a paper in The British Medical Journal (BMJ) stated that how much support a person receives before, during, and after a challenging experience can determine if they develop a moral injury.[1]

Another term that could be mistaken with moral injury is burnout. Both terms describe clinician distress. Physician burnout is a result of excessive demands on a person, which can lead to fatigue, frustration, and inefficacy. Certainly, excessive demands are being placed on physicians right now and thus some physicians must be experiencing burnout. Nevertheless, what most physicians and healthcare workers are currently experiencing goes beyond that. They are being faced with a challenging situation in which they know what care patients need but cannot provide them with those services due to factors beyond their cannot control. They are experiencing moral injury. Differentiating the two terms is important because while burnout suggests that the problem is individual, moral injury hints at something larger — a problem within the healthcare system.[2]

Deciding who gets a bed or ventilator is an extremely difficult decision to make. In Italy,  doctors have been asked to take a utilitarian approach. That is, allocating the available resources to the patients with the highest chance of survival. By doing so, doctors are being asked to change their patient-centered approach to practicing medicine, which not only affects a physician’s moral values but their moral identity as well. Thus, while a utilitarian approach seems to “facilitate” the decision-making process for doctors, it also asks them to change their beliefs, which comes with lasting consequences.

All in all, moral injury is extremely complex. There are myriad factors that contribute to it and it is an issue that is experienced by individuals from all kinds of professions. We are living through a chaotic, uncertain, and highly stressful situation. When this over and our healthcare systems change and adapt, it is imperative to also address the emotional wellbeing of healthcare workers. After all, COVID-19 is a battle and will indefinitely leave scars on healthcare workers.

References

[1] Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, 368, M1211.

[2] Dean, W., Talbot, S., & Dean, A. (2019). Reframing Clinician Distress: Moral Injury Not Burnout. Federal practitioner : for the health care professionals of the VA, DoD, and PHS, 36(9), 400—402.