Now it is moral injury: The COVID-19 pandemic and moral distress

Not so long ago, a new term entered the medical literature in the debate about the nature of burnout in physicians. In somewhat unanticipated and unexpectedly prescient articles in this journal, the concept of moral injury was offered as a more accurate term for the contemporary stresses felt by physicians facing the new models of medical care. (1,2)

Coming from the observation and treatment of combat veterans, the term moral injury was originated by Shay (3) and has been characterized as a result of being forced to engage in actions contrary to one’s moral values. It has been further described as a morally injurious event related to perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations.(4) For physicians, moral injury was seen as a consequence of failing to practice to the level of one’s values and commitment ostensibly as the result of rules, regulations, insurance demands and the expectations of corporate medicine.

However, a later article in this journal by this author contended that application of the term moral injury from the battlefield to the practice of medicine was inappropriate.(5) The fundamental reason for this was the incongruence of the horrors of war and the practice of medicine (other than battlefield medicine). Physicians were described as being on the “front lines” and going to “battle” against insurance companies or for patient care.1 However, it was argued that this imagery was  in no way equivalent to the reality of the demands of war and, hence, without the same impacts.

A further difference discussed was that warriors operate in situations of grave danger to themselves, which is rarely true in the office, clinic or hospital. It was noted that physicians more readily have the option to leave a morally distressful situation by perhaps changing jobs or even a career, opportunities essentially not available to the military “grunt”. Further, it was pointed out, that, albeit mainly in the nursing literature, the concept termed moral distress   in medical care had been an issue since at least the 1980’s. (6,7) However, while difficult ethical challenges and dilemmas do occur for physicians, they are often sporadic.

Unfortunately, all this has now changed due the pandemic of COVID-19. The pandemic has muted or erased many of the distinctions between medical care and military conflict. The terms of war and battle are no longer inappropriate for confronting this crisis and it has truly thrust physicians (and nurses and all health care personnel) directly to the front lines. (8,9, 10)

Moral distress may now evolve into moral injury given the gravity, complexity and frequency of ethical challenges and moral dilemmas being presented. No longer is the distress over EMR “pajama time” or prescribing an antibiotic for a viral illness at the insistence of a difficult patient, as were offered as examples of moral injury heretofore. Critical and difficult life and death decisions such as triage and rationing of care are now required multiple times a day.

Decisions are being made and actions are being taken in ways that may contradict physician expectations of their practices and of a nature that may have only been discussed and debated abstractly, academically and theoretically in the past. The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care. In addition, the emblematic expectation of compassionate care is now too frequently partially or fully frustrated. As one emergency room physician reportedly observed: “This isn’t what we do. You stand. You wait. Time of death 7:19 P.M.” (10)

Another distinction between war and medical care that has vanished in the current pandemic is the danger to the physician. In the previously cited article, it was suggested that health care providers do belong to the HERO professions. HERO is an acronym (High Expectation and Risk Occupations) for professions where there are high expectations of performance and high risk to self and others. (5) While clearly true for police , firefighter and the military, for medicine that risk was mainly to others and not self. That is no longer true. The expectation that one might forfeit their life to save others is now very real for providers in this pandemic.

A final distinction that has been greatly muted is the luxury of a physician being able to exit situations found intolerable. While that option still exists in the setting of the pandemic, to do so would truly contravene professional, moral and ethical expectations. “Opting out” would no doubt leave significant psychological scars from the moral injury of abandoning colleagues and patients. The depth of this commitment and existential impact is evidenced not only by the heroic efforts of those who continue to fulfill their responsibilities, but in the thousands of providers who have heard the call and stepped up from the  comforts of retirement or safety of a spared location to volunteer to aid their colleagues.

The real potential for moral injury requires serious attention to it. As the predominant focus continues on eradicating the pandemic, there needs to be awareness and increasing efforts to mitigate the development of moral injury now and to monitor and address the effects of moral injury after the pandemic subsides.

Action to prevent or mitigate the development of moral injury begins with assuring resources are available, protocols are consistent, clear and communicated and environments are as safe as possible. There are individual actions that can help, as well.

It is important to focus on one’s efforts and not just outcome. Clearly, successful outcome is the gold standard for physicians. However, some factors are just uncontrollable, unknowable, or unpredictable. Desired outcomes require doing your best as circumstances allow. If there is a focus on what can be controlled, which is doing one’s best, the outcome takes care of itself.

One should maintain an awareness and appreciation for small successes. When there is a focus on failures, learned helplessness develops leading to struggles with a sense of futility and ultimately giving up. A standard of perfectionism tells us that nothing is ever good enough. The current pandemic calls for excellence, not perfection. A common tendency to discount small successes is not productive. It is important to avoid the “yes-but” syndrome such as “yes, I did my best today, but it doesn’t matter.” Insight from a colleague provided this counsel: Though losses may be inevitable; remember with your unique skills and determined care, more will survive. (11)

There should be consideration that self-care is not selfish. There is a duty to be well for oneself and one’s family. There is a duty to be well for your patients and colleagues.

It is helpful to remember that these are extraordinary times.  Such circumstances call for flexibility and adjustments in expectations. The problem with perfectionism was already mentioned. Crisis expectations are different from “normal” practice.  Such a reality is found in the words of General Walter Kerwin, the father of the modern volunteer army, who said: "The values necessary to defend the society are often at odds with the values of the society itself." (12)

Mitigating moral injury may require a temporary “philosophical reconciliation” where alternate goals are defined and accepted as legitimate and valuable. It should not be forgotten that end of life care and facilitating peaceful transitions are worthy actions of all physicians, not just those in palliative medicine. The wisdom of a 15th century folk saying remains relevant: To cure sometimes, To relieve often, To comfort always.

What is typically called burnout does not recede during a sustained crisis. It is important to maintain those interventions as may already be in place. Strengthening coping abilities should be comprehensive, addressing physical, emotional and spiritual needs. Time to “reset and recover” is essential, but often ignored. There should be planning and follow-through on periods to reset and recover during each shift, as well as after. Mindfulness is well known to be restorative, but also effective is engaging in periods of alternate mindLESSness and other distracting activity.

The psychological performance enhancement technique called Mental Rehearsal can be valuable for preparing to engage in difficult situations. It can help maximize physical skills, as well, manage emotional responses.

This is a time to make use of psychological support services.  It is a time to be honest with oneself. It is a time to frequently monitor one’s stress and coping and to listen to others who may be voicing concerns in caring about you. Most health systems have scaled their professional assistance programs to meet the psychological demands of this pandemic and provide valuable short term and more extended support for providers and their families.

Inter-collegial support should be maintained and, better yet, enhanced. This advice is oft-repeated, because it is essential.

Mitigation of moral injury is critical, but moral injury is not the only untoward reaction from a crisis such as this pandemic. Post-traumatic stress is a very likely consequence. Other responses that can be expected are depression, anxiety, grief, hypervigilance, survivor guilt, scapegoating and sleep disturbance. While not all health care providers will develop problematic issues and some will even experience what has been called post-traumatic growth, many will have lingering negative effects.

Therefore, as important as recognizing this is that, much like the currently ubiquitous forecast that the economy will not recover immediately like throwing a light switch, neither will the psychological impact of these experiences vanish with the ebbing of this pandemic. Monitoring of staff and colleagues’ adjustment will be an essential component of post-pandemic planning and return to more normal daily professional care and life.

This is perhaps, most easily understood and instituted in residency programs where that monitoring and support can be provided by program directors, faculty and/or mentors. However, a plan for all personnel should be in place to provide support as they process their experience with the unique aspects and challenges the pandemic has presented to them.

COVID-19 has tested physicians and all health care providers with challenges and dilemmas heretofore never experienced in recent times. The question of whether burnout is really moral injury has not been resolved, but is currently irrelevant. Moral distress is clear, and now, the potential for moral injury itself is real and valid. It will be essential for providers and Systems to be aware of and take action to mitigate this impact while the pandemic rages and in its aftermath. (13)

Michael J. Asken, Ph.D. is the Director of Provider Well-Being at UPMC Pinnacle in Harrisburg, PA. Correspondence may addressed to him at askenmj@upmc.edu. Special appreciation is expressed to Laurie Schwing, MLS and John Goldman, MD for their comments in the preparation of this paper.

References:

(1) Talbott, S. & Dean, W. (2018). Physicians aren’t “burning out:” They’re suffering from moral injury. https://www.medicaleconomics.com/med-ec-blog/beyond-burnout-real-problem-facing-doctors-moral-injury

(2) Talbott, S. & Dean, W. (2019). Beyond burnout: The real problem facing doctors is moral injury.
Medical Economics. https://www.medicaleconomics.com/med-ec-blog/beyond-burnout-real-problem-facing-doctors-moral-injury

(3) Shay, J. (2014). Moral Injury. Psychoanalytic Psychology, 31 (2), 182-191.

(4) Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W, Silva, C., Maguen, S. (2009). Moral injury and moral repair in veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29 (8), 695-706.

(5) Asken, M. (2019). Its not moral injury: It’s burnout or something else. Medical economics: June 7,
https://www.medicaleconomics.com/burnout/its-not-moral-injury-its-burnout-or-something-else.

(6) Jameton, A. (1984). Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall.

(7) Fourie, C. (2017). Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to broad definition of moral distress. AMA Journal of ethics. 19, (6), 578-584

(8) George, J. (2020). Covid-19 update: 9000 health workers affected. MedPage Today, 4-15-20. www.medpagetoday.com.

(9) Ripp, J., Peccoralo, L., & Charney, D. (2020). Attending to the Emotional Well-Being of the Health Care Workforce in a New York City Health System During the COVID-19 Pandemic DOI:10.1097/ACM.0000000000003414

(10) Gold, J. (2020).  Moral injury on the front lines. MedPage Today,4-17-2020. www.medpagetoday.com

(11) Mark Bigger, Ph.D. personal communication, 4-15-2020

(12) – Kerwin. Time Magazine, 08-04-08, p.26

(13) Darnall, B. (2020) Staying sane and current on COVID-19 -Advice and resources by specialty, for those caring for patients. MedPage Today, 3-27-2020. www.medpagetoday.com.