Cite as: Garros D. Moral injury: losing ourselves in the pandemic aftermath. ASRA News 2021;46. https://doi.org/10.52211/asra080121.055.   

After another pandemic wave, we may be exhausted. We may be overwhelmed. We may be stressed out. Or perhaps we may be injured. Mentally injured. Morally injured. Some of us already are.

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Among physicians, moral injury is frequently confused with burnout. But without understanding the critical difference between burnout and moral injury, wounds will never heal and physicians and patients alike will continue to suffer the consequences.

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Moral injury is a term that was first used to describe soldiers’ responses to their actions in war.¹ In health care, a moral injury occurs as a result of moral distress and refers to being unable to provide high-quality care and proper healing, such as when limited resources make it necessary to determine who will get care and who won’t (ie, who will live and who will die). It encompasses guilt and shame and can lead people to feeling betrayed and angry and as if they’ve lost their moral integrity.²

Brett Litz and colleagues described moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”  As a result, “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society” may be experienced.¹

Among physicians, moral injury is frequently confused with burnout. But without understanding the critical difference between burnout and moral injury, wounds will never heal and physicians and patients alike will continue to suffer the consequences.^2,3,4 Burnout is a group of symptoms that includes exhaustion, cynicism, and decreased productivity. There is plenty of literature about that, and it is not the focus of this manuscript.²

During this pandemic, most profoundly during post-pandemic surges, some of us physicians have been left with a “sick stomach” kind of feeling, not to mention a crushed soul.

When we change the language from burnout to “moral injury,” it is important to identify the problem as not related to physician weakness but as a deleterious attack on the moral values of the medical profession.⁴ What kind of values we have seen eroded during the pandemic?

As physicians Cunningham, Diaz, and Slawek wrote in June 2020, “We have lost the intimate connection with our patients at their most vulnerable points; felt powerless in the face of the very real fear felt by patients, trainees, and our colleagues alike; and, worst of all, have been left unprotected.”⁵

Patient- and Family-Centered Care

One of the main values we have practiced over the last few decades is patient- and family-centered care. We were told that those values did not count during the pandemic, instead taking a utilitarian approach. Most unfortunately, restrictive hospital visitation policies implemented by public health officials deprived our patients of the comfort and support of their family members—for reasons that may not have been based on evidence. Patients were left to die alone. “The conditions of the pandemic constrain us; we cannot do what we know is best. Therein lies our distress,” Feltmand and colleagues recently wrote.⁶

Resources

We indeed provided the best medical care, intubating patients in challenging conditions and looking after their daily medical needs despite the lack of proper personal protective equipment and scrambling to maintain standards of care. Sometimes we even had to work without proper medications to alleviate anxiety and pain. Worse of all, our nurses and RTs had to hold an iPad in front of an intubated patient for their spouse or family member to say goodbye. Some colleagues reported experiencing the worst day of their careers many times over.⁵

Trainees

Balancing the need to guide and protect our trainees while experiencing a profound shift in the way we provide care and interact with patients has been extraordinarily challenging. Unfortunately, teaching and mentoring became secondary tasks.⁵

Resolution

How can we overcome such difficult and unprecedented times and continue to be effective physicians, remain true to our calling, and preserve our integrity? Fortunately, most of us will overcome this and do well. For some, however, it has become very difficult.

Choice

We need to choose how to respond to the ethical challenges, the suffering, and the inequities that we have witnessed. We have to find ways to preserve our integrity, minimize our own suffering, and allow ourselves to continue to serve with the highest purpose.⁷ The choice we have to make is to see this as an opportunity to grow, striving to be the best professionals we can be, and learning from what we have witnessed.

Refocus

We must recognize suffering and reframe in our minds that we are doing our best despite circumstances that are beyond our control. We need to create our own narrative that is meaningful.⁸

Solidarity

Our challenge is to find moments of humanity and kindness in the face of immeasurable suffering and trauma. We find strength in our “community of practice” and in one another. Our colleagues can be the ears we need; they can provide the shoulders we lean on and the hands we can hold onto. We have to learn to listen to one another without trying to fix the situation, which can be challenging. It takes suspending judgment, generous listening, acknowledging, validating, normalizing, and reframing.

It is possible to do self-care together, for example, using social media. We can post humor or uplifting messages to each other, as well as self-care suggestions and “hacks.” Each person can ask how the other is doing. We can be honest about our own experiences and difficulties and give others permission to voice theirs. Simple questions can become powerful tools: “You seem anxious, are you okay?” “How can I support you right now?”⁸

Advocate for Change

We also need to dedicate time and effort to advocate for structural changes to the health care system that will prevent future instances of the devastation, heartbreak, and loss of humanity we have experienced during this pandemic. This needs to be done with courage and respect.

Gratitude

According to R. Emmons, gratitude means an affirmation of goodness.⁸ We affirm that there are good and worthy things in the world, and that we are on the receiving end of them. As we know, life is imperfect; gratitude does not ignore complaints, burdens, and hassles. When we look at life as a whole, gratitude inspires us to identify some amount of goodness in our life, even in the midst of chaos. Recognize first that sources of goodness are outside of ourselves. Express this recognition. And be ready to receive goodness.⁹

In conclusion, moral injury can indeed be a result of this unprecedented pandemic and its impact on the way we practice medicine. But we can overcome it, with resolution, refocusing our minds, and counting on the support of our colleagues. We will get through this!

Daniel Garros, MD, is a clinical professor of pediatrics in the Critical Care Division at the University of Alberta and a pediatric intensive care unit attending physician at Stollery Children’s Hospital in Edmonton, Canada.

References

1. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clin Psychol Rev 2009;29:695-706.  http://doi.org/10.1016/j.cpr.2009.07.003.
2. Dean W, Talbot SG, Caplan A. Clarifying the language of clinician distress. JAMA 2020;323(10):923-4. https://doi.org/10.1001/jama.2019.21576.
3. Shay J. Moral injury. Psychoanal Psychol 2014;31(2):182-91. https://doi.org/10.1037/a0036090
4. Talbot S, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT 2018, July 28. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed April 02, 2021.
5. Cunningham CO, Diaz C, Slawek DE. COVID-19: The worst days of our careers. Ann Intern Med 2020;172(11):764-5. https://doi.org/10.7326/M20-1715.
6. Feltman DM, Moore GP, Beck AF, Siffermann E, Bellieni C, Lantos J. Seeking normalcy as the curve flattens: ethical considerations for pediatricians managing collateral damage of coronavirus disease-2019. J Pediatr 2020;225:233-8. https://doi.org/10.1016/j.jpeds.2020.06.067.
7. Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. AACN Adv Crit Care 2016; 27:111–9. https://doi.org/10.4037/aacnacc2016275.
8. Bell J. The positive impact of gratitude on mental and physical health. Big Think 2020, April 21. https://bigthink.com/mind-brain/benefits-of-gratitude-robert-emmons?rebelltitem=1#rebelltitem1. Accessed April 19, 2021.
9. Garros D, Austin W, Dodek P. How can I survive this? coping during coronavirus disease 2019 pandemic. Chest 2021;159:1484-92. https://doi.org/10.1016/j.chest.2020.11.012.