Not 'Burnout,' Not Moral Injury--Human Rights Violations

Pamela L. Wible, MD


March 20, 2019

In This Article

The Issue Heats Up

Last week the anti-burnout buzz accelerated when ZDogg quoted my 2015 blog—Burnout is BS—in his viral video, It's Not Burnout, It's Moral Injury, echoing my advice that we stop saying the victim-blaming term.

Now we're getting somewhere. But is it really moral injury?

Moral injury is a term applied to combat veterans in 1998 by psychiatrist Dr. Jonathan Shay. Moral injury is damage to one's conscience when perpetuating, witnessing, or failing to prevent acts that transgress one's own moral beliefs, values, or ethical codes of conduct (often resulting in profound shame). Moral injury is a normal human response to an abnormal traumatic event—a deep soul wound shattering one's identity and morality.

Dr. Shay's original definition was based upon his patients' war narratives and Homer's Iliad (762 B.C.) and required three components: (1) betrayal of what's right by (2) someone who holds legitimate authority in a (3) high-stakes situation. Individuals with moral injury may see themselves and the world as immoral and irreparable.

Moral injury now extends beyond combat veterans to include physicians in 2018 when Dean and Talbot announced their opposition and alternative to the label physician "burnout." They believe (as I do) that physician cynicism, exhaustion, and decreased productivity are symptoms of a broken system. Economic forces, technological demands, and widespread intergenerational physician mental health wounds have culminated in a highly dysfunctional and toxic health care system in which we find ourselves in daily forced betrayal of our deepest values.

Manifestations of moral injury in victims include self-harm, poor self-care, substance abuse, recklessness, self-defeating behaviors, hopelessness, self-loathing, and decreased empathy. I've witnessed all far too frequently among physicians.

Yet moral injury is not an official diagnosis. No specific solutions are offered at medical institutions to combat physician moral injury, though moral injury treatment among military may include listening circles (where veterans share battlefield stories), forgiveness rituals, and individual therapy. The fact is, most victims of moral injury struggle on their own.

With no evidence-based treatments for physician moral injury and zero progress after 40 years of burnout prevention, what next? Enter the real diagnosis—human rights violations—with clear evidence-based solutions.

Human rights is a term coined by Eleanor Roosevelt in 1947 when she suggested "rights of man" be changed to "human rights," leading up to the 1948 Universal Declaration of Human Rights adopted by the UN General Assembly as a standard for all people in the world.

Physicians are strong human rights advocates—even activists in disaster zones—yet we have failed to protect the human rights of our own trainees and doctors. In 2014, I began reporting human rights violations in medicine after uncovering widespread abuse in medical training and practice via my physician suicide helpline. Since 2012, I've spoken to thousands of suicidal doctors—even published a book of physician suicide letters. Doctors have the highest suicide rate of any profession. Why?

Not burnout. Not moral injury—human rights violations. And those who survive the abuse often suffer lifelong sequelae from the trauma.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: