An Iliad of Injury in the Age of Covid

The terms ‘moral injury’ and ‘moral distress’ in a medical context date from the 1980s when the ethics philosopher Andrew Jameton wrote of the psychological impact on nurses in situations where they were constrained from acting in accordance with their moral beliefs—that is, in doing what they believed was right. Jameton felt that nurses, not doctors or medical administrators, occupied the moral centre of the healthcare profession; this was because of the extended time they spent with the patient, their concern with non-medical factors in the patient's health and their interactions with the patient's family. Situations in which Jameton observed moral distress were characterised by the ethical dilemmas faced by nurses compelled to perform painful but futile procedures on dying patients or provide intensive care to premature babies who were not expected to survive. 1

The terminology was adopted in the 1990s by the psychiatrist Jonathan Shay in an entirely different context— that is, in the treatment of Vietnam War veterans suffering post-traumatic stress disorder (PTSD). Drawing on the depiction of Achilles in Homer's Iliad, Shay perceived an undescribed psychological condition at the heart of the veterans' PTSD, that of a moral injury resulting not from a single traumatic event but rather from feelings of betrayal of what is right by their commanders and the onset of a berserk state in which the soldier experiences profound grief, rage and disconnection from humanity. Shay saw in these veterans not just a psychiatric illness but what he described as an erosion of ‘good character’. 2

In more recent times, moral injury has been applied widely and indiscriminately in medical contexts as a descriptor for the psychological distress, dissatisfaction and burnout felt by clinicians working under extreme stress due to any number of factors, including long hours and lack of efficacy, autonomy or resources. According to Google's Ngram Viewer, use of the term ‘moral injury’ in English texts grew almost five-fold between 2010 and 2019, partially a reflection of its rising usage in military-related literature, but also as a result of heightened recognition of the condition among healthcare workers. 3 In this context, observers speak of potentially morally injurious events (PMIEs) that may affect the mental and physical health of workers, symptomatically as ‘exhaustion, frustration, helplessness, guilt, shame and worry’, and ultimately leading to burnout or moral injury. 4

It's worth noting that some researchers describe moral injury as a sustained form of moral distress, 5 while others formally distinguish the causes, describing moral distress as the condition that may arise from the health worker being required to violate an external set of ethical rules such as a code of conduct, in contrast to moral injury which may arise from a violation of the health worker's internally-held personal beliefs about behaving morally. 6 What is generally agreed is that, following Shay, moral injury is marked by an erosion of trust in self and others.

Expanded use of the term in medical contexts has tended to blur or weaken the individual's ethical or moral standpoint in the described condition in preference for a generalised notion of ‘what is right’. For example, in 2018, the American plastic surgeon Simon Talbot and psychiatrist Wendy Dean argued in an influential opinion piece that moral injury arises from a ‘broken healthcare system’ which fails to ‘consistently meet patients' needs’, and from ‘conflicts of interest’—such as financial considerations, business metrics and the threat of litigation—which combine to influence a doctor's decision-making in a way that may in some instances actively harm a patient. Here, they claim, the moral content of the injury experienced by the physician is the fact of ‘being unable to provide high-quality care and healing.’

The result is not burnout, although the symptoms are similar, but rather the physicians are cast as ‘the canaries in the healthcare coalmine’ with their injuries alerting the health authorities to a systemic crisis. 7

However, Talbot and Dean fail to address the relativism inherent in this conception of moral injury. The quality of healthcare systems varies enormously across jurisdictions, health sectors and disciplines, yet participation in one system is not rendered a PMIE for simply being inferior or limited in its quality of care, compared to that of another system with more resources or better health outcomes.

Being unable to provide high-quality care depends on what the health worker understands to be of a high quality and the particular reasons for the available care falling short of this benchmark. Hence, systemic conceptions of moral injury tend to raise more questions than they answer.

In general, it is theorised that at least some forms of moral injury in health care arise when the individual's personal (and often rigid) morality comes into conflict with the (often more morally flexible) utilitarian judgements of the organisation in which the individual is employed. 8

Unsurprisingly, as with any novel stress on a healthcare system, the COVID-19 pandemic has brought added attention to the impact of changed clinical practices, policies and work-related stress on health workers. Examples in the literature dealing with moral injury have typically focused on shortages of life-saving equipment such as ventilators, escalation-of-care decisions in triage and restrictive visitation policies for families of COVID patients.

In countries with healthcare systems acutely affected by the pandemic, a few health workers have been forced to make fateful decisions over whether to provide a particular patient with a bed— and, in doing so, condemn another to likely death.

Locally and more commonly, the impact has been of a chronic nature made worse by the pandemic. In this context, Yee Leung, head of department at the Western Australian Gynaecologic Cancer Service at King Edward Memorial Hospital in Perth, lists administrative burdens, overcomplicated rules and budget cuts among the chronic factors

that undermine goodwill and manifest in disengagement, conflict with colleagues and anger towards managers. Adopting a broad interpretation of moral injury, he says the ‘incessant pressure to cut services’ in a system seemingly at odds with providing the best health care ‘creates a workplace that potentially promotes moral injury in these workers’. 9

Prof Leung's article in an online newsletter attracted some startling comments, including one from a GP who claimed that pre-pandemic Australian doctors enjoyed ‘a vastly superior working life’ compared to their counterparts in the UK's National Health Service. Another comment described medical administration (presumably in Australia) as ‘corrupt, inept and ignorant’; a third blamed the adoption in the 1980s of American models of nursing and hospital administration and ‘the burden of paperwork’ which keeps nurses and doctors from their patients.

Tachi Zhong Hu, a radiation oncologist at Liverpool Hospital in Sydney, says the pandemic has severely tested the resilience of healthcare workers and increased the likelihood of moral injury in the medical workforce. ‘We had to rotate to work in the COVID ward to relieve our colleagues who have been working tirelessly since the beginning of the pandemic, often working 12-hour shifts without breaks to ensure patients are attended closely and reviewed,’ with limited availability of BiPAP ventilators, and while enduring headaches, sweating and skin irritations from full-body PPE and N95 masks.

Dr Zhong said the tight visitor rules and the need to use phone or video for oncological conversations made communication with patients' families very difficult, especially when the oncologist had bad news to deliver. ‘It definitely added to the family's or patient's frustration over the delivery of care and it impacted on the rapport between patient and healthcare workers.’ He is aware that some doctors, nurses and paramedics suffered burnout symptoms and were forced to reduce hours or take a break to recover from the stress they felt over the last two years.

On a personal level, Dr Zhong struggled as a College trainee during the early months of the pandemic. ‘I had to sit for my phase 1 exam in 2020 and it was difficult juggling work, dealing with COVID, studying, adapting to work rule and policy changes and mentally facing the uncertainties in general. Although I passed my exam, I felt very burnt out and depleted through the journey.’ Other trainees were in a ‘similar or worse position than me,’ he said.

For Dana Tipene-Hook, a consultant radiologist at Taranaki Radiology in Auckland, an individual's propensity for moral distress or injury is influenced by their world view and cultural background—in her case, living and working as a Māori doctor ‘in a system that is already geared against Indigenous peoples.’

Noting the arrival of a ‘veritable tsunami of moral injury’, Dr Tipene-Hook views the condition and the psychological impact of the pandemic through the prism of racism.

Disadvantaged, susceptible populations (Māori, Pacifica, Aboriginal and Torres Strait Islanders) disproportionally bear the brunt of disease.

Consequently, the shortcomings in the healthcare system when health services are being rationed, delayed or denied due to a pandemic, fall most heavily on the Indigenous cohorts.

She has experienced this at a personal level, in the ‘overt, casual or unconscious racism from patients and colleagues’, as well as in observing the impacts on whānau (extended family) members, associates and friends. ‘Being witness to and a player within the racist system is morally injurious . . . and the risk for moral injury that existed pre-pandemic is now obviously more intensified and prevalent,’ she said.

In general, measures to identify, assess and treat cases of moral injury are hampered by a lack of precision in definition, its causes and its overlap with burnout and latent psychiatric illness— all three often share similar symptoms, including fatigue, depression, depersonalisation and suicidality. 10 Resilience training is not considered an effective treatment or preventative for moral injury—indeed resiliency training programs, although popular in health organisations and elsewhere, appear to lack any reliable level of efficacy for the improvement of mental health. 11

Suggestions for the prevention of moral injury include shorter working hours for residents and ethical guidelines promulgated by professional associations to support clinicians to refuse to comply with a direction that might entail moral injury. 12 Referring to the approach outlined in the Australian Commission on Safety and Quality in Health Care (ACSQHC) comprehensive care standard, Prof Leung has called for a collaboration by clinical heads and health administrators to achieve a ‘balance between fiscal accountability and maintaining safety and quality’ in health care.

Dr Tipene-Hook advocates more Indigenous representation in the College and the clinical workforce. And, mindful of pandemics beyond COVID-19, Dr Zhong hopes the College will continue to modernise its examination methods and policies to minimise the impacts of future public health crises.

Notwithstanding these suggestions, the responsibility for maintaining mental health returns eventually to the clinicians themselves, although not for each clinician alone in a private purgatory. To this end, psychologists have put forward a raft of first-aid measures for mending moral wounds incurred in the pandemic. 13 Unsurprisingly, they depend heavily on collegiality, showing respect for each other's work, staying connected even in disagreement, and remaining united in common professional purpose. It is too easy for a sense of common purpose to falter and fall under the wheel of careworn criticism of decisions or policies that rankle or frustrate. The recommended measures include the acknowledgement of stress and pressure at all levels in the workplace, ‘leaning’ on colleagues and talking about your ethical concerns. Williams et al. highlight the value of building ‘routines that emphasize mutual understanding of each other's struggles and contributions’. And, finally, they advise health workers to find ways to connect emphatically with patients—to remind yourselves, even in the midst of a crisis, why you are doing this job, and in helping others, to kindle some self kindness.

Brett Wright BA (Hons.) PhD is an independent historian with research interests in science, technology and medicine. He is currently writing a history of Bendigo Hospital.