When the Only Clinical Choices Are 'Lose-Lose'

Peter Yellowlees, MBBS, MD


October 08, 2020

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Among the many tolls inflicted on healthcare workers by COVID-19 is one that is not as easily measured as rates of death or disease, but is no less tangible: moral injury. This is the term by which we describe the psychological, social, and spiritual impact of high-stakes situations that lead to the betrayal or transgression of our own deeply held moral beliefs and values.

The current pandemic has provided innumerable such situations that can increase the risk for moral injury, whether we deal directly with patients infected by the coronavirus or not. Telling family members they cannot visit critically ill loved ones. Delaying code activities, even momentarily, to get fully protected with personal protective equipment. Seeing patients who have delayed their necessary or preventive care. Using video rather than touch to reassure people.

Knowing that we are following guidelines from the US Centers for Disease Control and Prevention (CDC) does not stop our feelings of guilt. The longer this pandemic goes on, the more likely it is that these situations will begin to take a toll on us.

For most of us, being exposed to moral injuries is new; they have historically been most associated with severe traumatic wartime experiences. Soldiers, philosophers, and writers have described the ethical dilemmas inherent in war for as long as recorded history. But the use of this term is a more recent development, which the Moral Injury Project at Syracuse University describes as probably originating in the Vietnam War era writings of veteran and peace activist Camillo "Mac" Bica and psychiatrist Jonathan Shay. Examples of wartime events that have been thought to lead to moral injury include:

  • Causing the harm or death of civilians, knowingly but without alternatives, or accidentally;

  • Failing to provide medical aid to an injured civilian or service member; and

  • Following orders that were illegal, immoral, and/or against the rules of engagement or the Geneva Conventions.

However, the occurrence of moral injuries in modern healthcare is increasingly being reported, primarily as an adverse effect of healthcare inefficiencies that can contribute to burnout. COVID-19 has now provided an array of additional stressors that can cause moral injuries among healthcare workers. A recent guidance document on moral injury published by the American Psychiatric Association noted that in the context of a public health disaster, such as COVID-19, it is sometimes necessary to transition from ordinary standards of care to those more appropriate in a crisis, as in wartime. This forces us all to confront challenging questions for which there may be no clear answers, and to make "lose-lose" choices in which no one involved — patients, family, or clinicians — ends up feeling satisfied or even comfortable.

Moral injuries affect most of us as physicians, as well as our colleagues and families, during this unusual, painful, traumatic, and potentially lethal time. Our lives have been altered significantly, and for many, completely turned upside down by enormous sacrifices and tragic losses. Globally, physicians account for over half of healthcare worker deaths. In the United States alone, over 900 healthcare workers have died of COVID-19.

Most of us have felt the symptoms of moral injury: frustration, anger, disgust, guilt. A recent report describes three levels of stressors in healthcare occurring during the pandemic, which are not dissimilar to those wartime events described previously:

  1. Severe moral stressors, such as the denial of treatment to a COVID-19 patient owing to lack of resources, the inability to provide optimal care to non–COVID-19 patients for many reasons, and concern about passing COVID to loved ones.

  2. Moderate moral stressors, such as preventing visitors, especially to dying patients, triaging patients for healthcare services with inadequate information, and trying to solve the tension between the need for self-preservation and the need to treat

  3. Lower-level but common moral challenges, especially in the community — for example, seeing others not protecting the community by hoarding food, gathering for large parties, and not social distancing or wearing masks. Such stressors lead to frustration and contempt, especially from healthcare workers making personal sacrifices and who may be at risk for infection caused by these behaviors.

Every one of us is affected by these stressors. I certainly am.

What are the outcomes? We know that moral injuries are a risk factor for the development of mental health problems and burnout, and not surprisingly we are seeing that mental health problems, suicidality, and substance use disorders have increased markedly during COVID-19, as recently detailed by the CDC.

Common emotions that occur in response to moral injuries are:

  • Feelings of guilt, shame, anger, sadness, anxiety, and disgust;

  • Intrapersonal outcomes, including lowered self-esteem, high self-criticism, and beliefs about being bad, damaged, unworthy, failing, or weak;

  • Interpersonal outcomes, including loss of faith in people, avoidance of intimacy, and lack of trust in authority figures; and

  • Existential and spiritual outcomes, including loss of faith in previous religious beliefs and no longer believing in a just world.

Moral injuries tend to originate primarily from systems-based problems, as we have seen with the lack of concerted national approaches to the pandemic. On the positive side, solutions typically also involve systems-based changes, which in this case may mean changes in leadership styles nationally and locally, as well as changes in the culture of medicine and the way healthcare is practiced and managed in the modern era. We are starting to see some of those changes with the increased use of telemedicine and health technologies, as well as more of a focus on the well-being of healthcare workers, now deemed "essential."

As individuals, we are not helpless. There are things we can do in our workplaces to create change. I suggest:

  1. Acknowledge that you, like me, are affected by these stressors. This is not a secret, and you should not be ashamed of your feelings.

  2. Talk with your colleagues, loved ones, and friends about how you, and they, are affected. You are not alone. Encourage others to share their thoughts, stories, and feelings.

  3. Put this topic on your meeting and departmental agendas and discuss these moral issues openly with your colleagues. Allow sufficient time to engage in open dialogue.

  4. Work out ways of assisting those who are in high-risk situations, especially for moderate to severe injuries. Be supportive towards those affected.

  5. Modify policies and change rosters and rotate staff between high- and low-stress roles. Protect and support at risk colleagues.

  6. Think about difficult ethical decisions in advance so they can be made by groups, not individuals, and certainly not "on the fly."

  7. Keep everyone in your workplace constantly informed, especially of impending staff or equipment shortages.

  8. Maintain your inherent self-care and resilience with rest, good nutrition, sleep, exercise, love, caring, socialization, and work-life balance.

  9. Be prepared to access the many professional support services available in our community if you are intensely distressed or if the above suggestions are not enough.

Remember, we are in this together and will find strength in each other. This too will pass.

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