Psychiatrist Dr. Jonathan Shay first used the term “moral injury” in 1998 to describe the heavy conscience weighing on war veterans following their involvement in combat.1He discovered that many of his military and veteran patients accounts revolved around the perceived injustices they endured at the hands of the leadership figures who required them to participate or witness situations that breached their own moral and ethical standards.1,2
Fast-forward 20 years to the year 2018. “Moral injury” is now being applied to individuals in the medical field for the first time in a publication titled, “Physicians aren’t ‘burning out.’ They’re suffering from moral injury.”3In the article the authors condemn the term “burnout” to describe the emotional hardships physicians and nurses are facing. These authors propose that the connotation associated with burnout places the majority of blame on the victim for their lack of resilience or ability to effectively cope with their experiences. In this post we will explore what moral injury encompasses, as well as how it is impacting the medical profession.
Moral Injury Defined
According to Dr. Shay’s original definition of moral injury, three components are required in order for moral injury to occur: (i) betrayal of what is right (ii) by someone who holds legitimate authority in a (iii) high stakes situation.2Physicians consistently meet the second two components on behalf of the inherent duties and responsibilities accompanying the profession.
Medical doctors have historically received the respect of society being considered as the leaders of health care authority and expertise. They are also often faced with tough situations requiring decisions of life or death, as well as dilemmas regarding pain and suffering or quality of life. When these decisions present difficult ethical quandaries a perceived betrayal of one’s morals can develop.
Psychiatrists who have spent time studying moral injury have communicated moral injury is a normal human response to an upsetting event.1,2It is therefore not unusual for a doctor to respond to such an event questioning their identity and moral standards. However, despite moral injury being a natural response and fairly common occurrence among physicians, no specific solutions to this problem have been offered. Without any legitimate solutions currently available most of the victims to struggle through the effects of moral injury on their own.2
The Long-Term Implications of Moral Injury
The culmination of moral injuries happening over time can deeply impact physicians’ outlook on their abilities as a health professional and working environment. The manifestations of moral injury include poor self-care, substance abuse, recklessness, self-defeating behaviors, hopelessness, decreased empathy, and a preoccupation with internal distress.4Although each individual reacts/responds to moral injury differently, the narratives of numerous individuals who have dealt with this issue convey the feeling of overwhelming shame.1,4
A Flawed System to Blame?
The medical environment has never been without its fair share of hardships, but the environment physicians are currently navigating on a daily basis may be one of the most challenging to date. The biggest challenges physicians perceived going into 2018 were: remaining dedicated to medicine, electronic health record data entry, too much time spent on financially uncompensated tasks, and third party interference.5Physicians are now more than ever struggling to remain devoted to medicine, and they themselves are voicing their concerns over it.
Profits Versus The Patients
So why is this epidemic happening? Doctors who initially entered into the medical field to help and serve others are increasingly faced with choosing between their professional obligations and providing the highest quality care to their patients.1Profit and business are becoming the driving forces of the industry, which is ultimately taking emphasis away from what is best for the patients.3This ongoing dilemma is causing substantial moral injuries to our doctors. If this continues it will not only negatively impact our physicians’ well being, but the overall health of the public could be at risk as well.
- Kane L. How healthcare is causing ‘moral injury’ to doctors. Medscape.com. https://www.medscape.com/viewarticle/910309. Published March 13, 2019. Accessed July 16, 2019.
- Wible P. “Not burnout,” not moral injury—human rights violations. Idealmedicalcare.og. https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/. Published March 18, 2019. Accessed July 16, 2019.
- Talbot SG, Dean W. Physician’s aren’t ‘burning out.’ They’re suffering from moral injury. Statnews.com. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Published July 26, 2018. Accessed July 16, 2019.
- Nuckols CC. Treating moral injury. Naadac.org. https://www.naadac.org/assets/2416/cardwell_nuckols_treatingmoral.pdf. Accessed July 16, 2019.
- Bendix J, Krivich RS, Martin KL, Mazzolini C, Shyrock T. Top 10 challenges facing physicians in 2018. Medicaleconomics.com. https://www.medicaleconomics.com/medical-economics-blog/top-10-challenges-facing-physicians-2018/page/0/3. Published December 25, 2017. Accessed July 16, 2019.