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Moral Injury in Medicine

Sept. 19, 2018

The following blog is authored by Carrie Barron, M.D., director of the Creativity for Resilience Program, and David Ring, M.D., Ph.D., professor of psychiatry, surgery and perioperatve care, and associate dean for Comprehensive Care.

The concept of moral injury arose in war. In addition to the physical injury of combat, there may be emotional shame (moral injury) that arises from killing when one believes killing is immoral. Or not being able to justify combat but being compelled to continue the fight. Moral injury may create anxiety, depression, guilt, shame, anger, emotional numbing and a loss of a sense of meaning. This may take the form of “shell shock” or post-traumatic stress disorder.

Journalist Diane Silver describes moral injury as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” It involves going against the self to comply with an order, set of rules, or a flawed system. If the edict feels unethical or senseless, it can take an insidious psychological toll. A sense of helplessness and feeling possessed by an irresolvable conflict can take hold and cause debilitating symptoms and questions. “What is happening? Why am I doing this? How did I get here? Something is wrong. I can’t go on.”

In a compelling blog, Simon Talbot and Wendy Dean applied the concept of moral injury to “burnout,” or what we and others prefer to refer to as loss of joy in practice. Going against one’s expertise, values, morals or sense of calling in medicine can create moral injury. Feeling that one is not spending enough time with individual patients, concern that bureaucratic morass makes things difficult for people seeking care, emphasis on electronic health record, pressure to perform procedures when it conflicts with professional values and a checklist culture as opposed to open-ended inquiry and connection can cause moral injury.

For example, when a physician succumbs to pressure to provide antibiotics for a viral illness, orders a low-yield potentially harmful test, or performs an injection or surgery when he or she feels strongly that these are not appropriate interventions he or she may experience moral injury. Ethical conflict arises when the patient craves an unwarranted procedure or administrators are dominated by financial goals. Saying no on the basis of quality or safety may confront these other agendas. The physician may feel that the truth — “surgery is unwarranted” or “pills are risky” or “the injection will give only temporary relief, if that,” is the most compassionate and ethical expert opinion. Yet it may not be what someone wants to hear. And it may not make money for the practice or hospital. Pressure to deliver what the institution or the individual demands or desires when it goes against one’s better judgement, can cause inner conflict. Repetition of the conflict can cause anxiety, depression, numbing and soul wrangling — symptoms of moral injury.

People are called to medicine because they are hard workers, risers to responsibility, self-starters and driven to help those in need. Doctors choose a stressful, but meaningful life. Philosopher Friedrich Nietzsche said, “He who has a why, to live can bear almost any how.” We doctors don’t mind the sacrifices of the profession when we know we are doing something that matters. But when practice becomes much about compliance with outer demands that are in conflict with inner morals and record keeping compromises much of the day, our “why” is deeply compromised. Energy depletes. We can become exhausted, detached and pervaded by a sense of ineffectiveness (the burnout trio). Turning doctors into drudges, drones, data entry experts and diminished substitutes of themselves is a misuse of their talents and leads to moral injury. Our loss of joy in practice, our 50% rate of symptoms of “burnout,” may be due to moral injury in medicine.

Physicians may be “the canary in the coal mine” signaling problems with the commodity-based concepts of health that have taken hold. There is a growing emphasis on restoring joy and meaning to medical practice. When we feel that what we do matters — that we are acting in accordance with our professional values, moral position, expertise and genuine concern for the patient — our days are both challenging and rewarding. This is what we signed up for. Humanism — “devotion to human welfare” is the warp, weft, wonder and joy of medicine.