How Healthcare Is Causing 'Moral Injury' to Doctors


March 13, 2019

In This Article

What Situations Create Moral Injury?

Situations that violate a physician's ethical belief in doing no harm and hamper the goal of making a patient well may lead to damaging emotional distress. Often for physicians, the challenges of trying to deliver the care they believe is best are counterbalanced by the relationships they have with patients, which is most important to doctors, says Bernstein. "That makes it worth the sacrifice," she says.

"However, physicians often get burned out because there's no way to balance those sacrifices. How this situation affects an individual doctor is highly variable and depends on what resources the person comes in with, what their home life is like," says Bernstein.

Ethical quandaries that arise on the job can also lead to moral injury — quandaries made all the more difficult by regulations, legalities, and the threat of consequences if a physician tries too hard to defend or promote his or her views.

Physicians Report Their Difficult Dilemmas

In Medscape's Ethics Report 2018: Life, Death, and Pain, more than 5200 physicians told us about their frustration over and reactions to ethical dilemmas in which they had participated. Some accepted these issues as part of the tough calling they had followed; others remained upset and disturbed.

"There's no question that ethical issues will always be present for physicians," says Becca Brendel, MD, JD, associate director of the Center for Bioethics at Harvard Medical School and vice-chair of the American Psychiatric Association's Ethics Committee. "As technology changes and there are a rapidly increasing number of options for treatments to keep people alive, physicians are often stymied from doing what's right."

In Medscape's Ethics Report, physicians described their toughest ethical dilemmas, which included the inability to relieve a patient's pain or suffering due to family control and goals that were not always noble (such as involving inheritance); inability to help suffering patients who were asking to die; quandary over keeping a less-than-competent physician from performing procedures for fear of retaliation; inability to save a child because the parents wanted to try "their own" treatment; and watching a patient die a preventable death because he or she refused to have a blood transfusion when needed.

"The worst experience I had was caring for a patient with ALS," said one physician. "Because of regulations involving medications, I could not do the best job of relieving her suffering. It was horrible to watch her gasp for air, miserable and unable to control her functions. I know she wouldn't have wanted to stay that way, but she couldn't speak for herself; and her family wanted us to do whatever we could to prolong her life, no matter the quality of that life. We met with them many times, but they would not budge. It was hard to put it out of my mind."

Said a critical care physician: "I saw a family who insisted on all treatment for a 95-year-old who was intubated, struggling and obviously in pain. The family wanted her alive, and it had something to do with money. The hospital ethics committee and legal team got involved, but the family threatened to sue. I'm supposed to 'do no harm,' but I couldn't stop this."

"I have performed abortions because I had to, even though it was against my beliefs," said one ob/gyn. "I basically liked my job, but I found another place to work where I didn't have to do that."

"Physicians have used terms like 'moral regret,' 'moral residue,'" Brendel says.


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