118. Moral Injury | The crossroads of conscience

Moral injury, a term initially used in the military context during the Vietnam War to describe the psychological trauma soldiers experienced, has become increasingly relevant in medicine. In this episode, we discuss how moral injury manifests as psychological distress when healthcare professionals’ actions, or inactions, contradict their moral or ethical codes, leading to feelings of guilt, inadequacy, and a sense of betrayal.

Our conversation will navigate through the history of this term, its definition, relationship with burnout, PTSD, and moral distress. We’ll examine real-life scenarios where healthcare workers face moral dilemmas, feeling trapped in a system that often works contrary to their values. 

Moreover, we’ll explore individual and systemic actions that may help mitigate the impact of moral injury.

Guest Bio: Kim Bambach, MD  is an Assistant Professor of Emergency Medicine at The Ohio State University and Assistant Director of the Kiehl Resident Wellness Endowment 

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We Discuss

Origin of the term ‘moral injury’

• Moral injury came into common usage during the Vietnam war. First used to describe the emotional wound that soldiers experience when, in the course of war, they transgressed their values or witnessed acts that transgressed their values. 

A definition 

• Moral injury is the psychological distress caused by action, or inaction, that results in a violation of your moral or ethical code. 
• Brett Litz, Professor, Department of Psychiatry and Psychology, Boston University: “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”
  • “Feeling like a moral failure”, “Doing what feels wrong”, “not living up to my profession, my calling” “We did the best we could, but not the best for the patient ”
  • Identity is deeply intertwined with our role- moral injury ruptures self-identity 
  • Feelings of guilt, betrayal, inadequacy, disappointment, shame, anger
  • A specific case or situation: a morally injurious event 

Facing out, facing in

• Physicians are taught to face outwards- treating, stabilizing, and addressing the needs of others. What I hope that listeners will take from this discussion is the ability to acknowledge when they are suffering and treat themselves with compassion. 
• What it’s not
  • Relationship to moral distress (which is unavoidable)
  • Relationship to Burnout 
  • Relationship to PTSD
    • Lots of overlap/comorbid
• What about spiritual/existential questions
  • Loss of faith, questioning morality, nihilism
• A result of the intrinsic difficulty of making complex medical decisions, complex social situations, but also competing demands beyond patient care
  •  Pressure from insurers, pressure from administrators (RVUs, patients per hour, Press Ganey) focused on the bottom line 

Examples:

• A bad patient outcome
  • Ex. a patient has a bad outcome because of a missed diagnosis or an error in judgment. You violated your moral code of nonmaleficence. You wanted to do no harm. 
• Triage decisions
  • The waiting room: In emergency medicine you often have to make rapid decisions on who goes back to the next bed
• Resource allocation
  • Who needs that ICU bed the most? 
  • To admit or discharge a patient with complex social needs? 
• End-of-life care
  • Have you ever had a patient receiving medical care that you find objectionable? Maybe someone who didn’t leave clear advanced directives and whose family elects to continue care despite a poor quality of life/inability to interact meaningfully 
• Health and well-being of our families (and ourselves)
  • This may be the least intuitive one, but how many clinicians and their families made deep personal sacrifices due to their medical training
    • Ex. Choosing to separate from family during COVID-19 to prevent loved ones from becoming sick 

What to do about it 

• You might feel the urge to withdraw- guilt and shame cause you to curl into a ball 
• There is no perfect evidence-based cure-all 

Individual

• Stimulus episode 46 goes in-depth on individual tools for integration of trauma, de-stressing the nervous system
• Acknowledge the injury, even on shift 
• This is a form of mindfulness, and vulnerability can be a tremendous strength
  • Also signals to others that this is a psychologically safe space 
  • Others may have also experienced similar feelings from the injurious event 
• Collaborate with administration
• Seek more formal sources of support
  • Burnout, PTSD, depression, and anxiety are comorbid 
• An interesting suggestion per the SAEM Wellness committee: participating in politics
• Compassion over empathy
• Agency, what is in your control? Opinions, judgments, values, initiation of action. Everything else is outside of your complete control. Act only on what you can control.
• Right speech, gratitude, not demeaning of the system
• Moral injury journal – situations, what went well, what could go better
• Being present, making patients feel that everything that can be done with them is being done for them

Systems

• Organizational support
  • If you’re in a position of power, if you’re an administrator, if you aren’t but are willing to be a squeaky wheel and engage the powers that be
    • Build more resilient systems, not just resilient individuals
      • Arming clinicians with appropriate resources 
      • Prioritizing well-being – Make clinician satisfaction a financial priority
      • Transparent decision-making. Bring together the 2 sides of the health care house: administrators and clinicians
      • Autonomy, appropriate use of metrics 
      • Make sure every physician leader has and uses the cell phone number of his or her legislators
      • Reestablish a sense of community among clinicians

A parting recommendation: Dr. Wendy Dean

• Book: If I Betray These Words 
• Podcast: Moral Matters 

References

1. Moral Injury in Health Care Workers – PTSD: National Center for PTSD. www.ptsd.va.gov. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury_hcw.asp
2. Giwa A, Crutchfield D, Fletcher D, et al. Addressing Moral Injury in Emergency Medicine. The Journal of Emergency Medicine. 2021;61(6):782-788. doi:https://doi.org/10.1016/j.jemermed.2021.07.066
3. Norman S, Maguen S. Moral Injury in the Context of War – PTSD: National Center for PTSD. Va.gov. Published 2014. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp
4. Barnes HA, Hurley RA, Taber KH. Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different. The Journal of Neuropsychiatry and Clinical Neurosciences. 2019;31(2):A4-103. doi:https://doi.org/10.1176/appi.neuropsych.19020036
5. Doctors have their own diagnosis: “Moral distress” from an inhumane health system. NPR. Published August 2, 2023. https://www.npr.org/sections/health-shots/2023/08/02/1191446579/doctors-have-their-own-diagnosis-moral-distress-from-an-inhumane-health-system
6. Press E. The Moral Crisis of America’s Doctors. The New York Times. https://www.nytimes.com/2023/06/15/magazine/doctors-moral-crises.html. Published June 15, 2023.
7. Vanyo L, Sorge R, Chen A, Lakoff D. Posttraumatic Stress Disorder in Emergency Medicine Residents. Annals of Emergency Medicine. 2017;70(6):898-903. doi:https://doi.org/10.1016/j.annemergmed.2017.07.010
8. Moral Injury: What It Is, What It’s Not, and What We Can Do About It. SAEM Wellness Committee. www.youtube.com. Accessed January 17, 2024. https://www.youtube.com/watch?v=GRrAcxsCaJM&t=3s&ab_channel=SAEM
9. Balint S, Karalius V, Ritchie A, Bitter C Kontrick A, Alvarez A, Deutsch A. “Moral Injury: What It Is and What We Can Do About It” SAEM Pulse Newsletter. March- April 2023.https://issuu.com/saemonline/docs/saem_pulse_mar-apr_2023/s/20454731
10. Amsalem D, Lazarov A, Markowitz JC, et al. Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era. BMC Psychiatry. 2021;21:546.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8571005/
11. Dean W, Jacobs B, Manfredi RA. Moral Injury: The Invisible Epidemic in COVID Health Care Workers. Annals of Emergency Medicine. Published online June 23, 2020. doi:https://doi.org/10.1016/j.annemergmed.2020.05.023
12. Dean, Wendy, Simon Talbot, and Austin Dean. “Reframing clinician distress: moral injury not burnout.” Federal Practitioner 36.9 (2019): 400 Full Text