Moral Injury Continues to Increase as Pandemic Enters Third Year

John Whyte, MD; Rita Nakashima Brock, PhD; Mona Masood, DO

Disclosures

January 27, 2022

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JOHN WHYTE: Welcome, everyone. You're watching Coronavirus in Context. I'm John Whyte, the chief medical officer for WebMD.

As we enter the third year of the pandemic -- the third year -- people are burned out, especially health care workers, first responders. They're frustrated. They're angry about people coming in seeking care, they're unvaccinated. They're mad about schools being closed down. There's this concept of moral injury that we talked about a few months ago.

And just to remind you, I want to tell you what moral injury is. "It's the suffering, the distress, and trauma that people experience when they're forced to act in ways that violate their moral conscience." To help us dig a little deeper into this, I'm joined by Dr. Rita Brock. Dr. Brock is one of the nation's foremost experts on moral injury. And she's the senior vice president and director of the Shay Moral Injury Center at Volunteers of America in Alexandria, Virginia.

And I'm also joined by Dr. Mona Masood. She's a psychiatrist and founder and chief organizer of the Physician Support Line, a line that she created at the start of the pandemic. Doctors, thanks for joining me today.

RITA NAKASHIMA BROCK: Pleasure to be with you.

MONA MASOOD: Thank you for having me.

JOHN WHYTE: Dr. Masood, I want to start with you. You created this support line. Over 3,000 health care professionals have called in seeking help. What are they talking about?

MONA MASOOD: The topics of discussion have definitely evolved over the course of this pandemic. As you mentioned, it's been coming on, we're going to enter our third year of this pandemic. And the stress and the moral injury that physicians have been facing has evolved alongside that. And originally when I had started this, the things that we were supporting, the subject we were supporting physicians on, were about lack of PPE, or, “Do we even know how to help patients?” “What do we know about this virus?”

It truly was new to physicians as well. And so we were trying to get as many answers as possible. But we were also finding out that we ourselves, as human beings, have limited information to help others, and that those two, that conflict was incredible, that we were expected to be the leaders and heroes of a pandemic. And at the same time, we ourselves felt very much lost and scared.

JOHN WHYTE: Where's the moral injury here? We were talking to Dr. Art Caplan, a leading ethicist, the other day about these Twitter feeds that talk about physicians saying, “Hey, maybe we shouldn't triage those that are unvaccinated.” Or, “Hey, we need to stop gloating on people that are unvaccinated and had bad outcomes.” Where is the moral injury here in the setting of COVID?

MONA MASOOD: When it comes to moral injury and having to really navigate our moral compass and our calling, where it manifests for physicians is that we have the training and we have the knowledge to be able to treat so many physical illnesses. And now with COVID, we have vaccines. And we have monoclonal antibodies, and we have different types of antivirals. And though those tools theoretically are in the palm of our hands, they are limited in terms of their availability and resources. And we are limited in terms of our ability to be there for everyone.

If there are limited amounts of physicians and health care workers in comparison to the demand of the people flooding our hospitals with this illness, then we are going to have to make decisions on who gets prioritized. And that is an incredibly -- incredible moral injury of having to decide who lives, who dies, who gets treatment, who doesn't. It is incredibly overwhelming and a burden to bear.

JOHN WHYTE: But does it violate their moral conscience? Or is it just difficult decision-making?

MONA MASOOD: Oh it definitely violates a moral conscience. Because who gets to really decide who gets treatment or not? That becomes this affinity to playing God, which is something that physicians are not wanting to be. We want to be human beings. And we are human beings. And being asked to decide, “Does a person who's vaccinated versus unvaccinated get treatment?” That is something that we never signed up for.

JOHN WHYTE: Dr. Brock, it's nice to see you again. Welcome back.

RITA NAKASHIMA BROCK: Thank you.

JOHN WHYTE: You've been involved in this concept of moral injury for a long time, mostly from the perspective of the military. And that makes sense in veterans, in terms of what their mission is, in terms of what they do. Are you surprised to see this amount of moral injury that we've been talking about in health care workers?

RITA NAKASHIMA BROCK: Not at all. I think the risk or moral injury is endemic in any kind of serving profession where there are high-stakes situations. And the pandemic has just escalated beyond belief the level of the high stakes in medicine right now and in all health care, including senior care, and other places.

So any time you're in life-or-death conditions like that, and pressure's on, and you have to act quickly, and you have to work relentlessly through fatigue, through total exhaustion, things go wrong. And whether or not you intend for them to go wrong, the fact that you are responsible for them going wrong is a moral judgment about yourself. And there's a serious problem when people that should be looking out for the common good, because they swore to do that in the work they do, are recommending people not be vaccinated. This includes public officials, includes religious leaders -- people that should be wanting to protect people's lives are choosing to advocate for not being vaccinated.

And I think it's heartbreaking for health care workers who early on had no solution for COVID and had to watch people die. And it was such a gift to finally have working vaccines. And then to have people refuse to take them as something that health care workers knew would work, it's just devastating. It's such a sense of betrayal and heartbreak that you have --

And of course their job is to take care of everyone. So you're going to take care of the unvaccinated. And they're now the sickest people. But it's an inner conflict. And that kind of moral distress can accumulate after you encounter it over, and over, and over again to the point that people actually break. And they may leave their work and walk away, start doing -- even take their own lives.

JOHN WHYTE: You recently wrote an editorial in The Hill where you say, “Can we heal the moral injury of our nation?” I want to read a quote from it. You said, "we're reeling from loss, outrage, utter exhaustion, fear of violence, shame, and feelings of failure, and from the betrayal of the vision of our democracy as a place where there is liberty and justice for all." Where are hope and healing to be found?

RITA NAKASHIMA BROCK: I think it is partly to be found in creating spaces for conversations for people to actually talk about their experiences in ways that they can begin to process them. Because I think most of us are just trying to grit our teeth and survive all of this and get our jobs done. So there's a lot of stored-up anguish in a lot of people, myself included. We just are trying to get through this and help other people and get our jobs done.

But at some point, if we can't discharge that moral distress, if we can't find a way to look at it, and think about it, and begin to integrate it, then we won't heal. And I mean Volunteers of America has an online hourlong program that runs 3 days a week that people can -- it's peer-facilitated. It's not a mental health program. But it's peer-facilitated by people who just want to give that space to people. And so people can just show up because they need to talk to somebody about their moral distress or their moral injury and receive nonjudgmental hearing where you're just listened to so that your experience can be validated as real and as painful.

So that's one way. And I think Dr. Masood saw that early on, 2 years ago, that this was going to be necessary.

JOHN WHYTE: I want to ask her about that because she also spoke at a conference recently. So here you start it, the support line, in March 2020. It's almost March 2022. What have we learned?

MONA MASOOD: We have learned that it's not just one solution of how to navigate it. Having individual narratives is important in first validating that this even exists. And in medicine, that is an incredibly difficult ask. Physicians don't want to talk about what is going on with their mental health. They see it as a weakness. They have been validated, if anything, over the years amongst their own that it is a weakness to admit that you are not doing well.

We also have this inherent belief that the work that we do is a one-way street, that wellness is only for our patients, it's only for the people that we serve. And so for physicians to look for wellness for themselves, it feels like it's selfish. It doesn't sound like self-care. And so these are concepts that it's very hard for them to even grasp.

JOHN WHYTE: How do know if you're suffering from moral injury? So a viewer is listening to you and thinks, “That could be me.” What's your advice for them in terms of recognizing the symptoms?

RITA NAKASHIMA BROCK: The people who are experiencing moral distress will often pull away from important relationships, that they won't be as emotionally available and present. And so you may feel somewhat distant or unable to talk to people that you would normally be warm and friendly with. You just don't have the energy for it. That's a sign that something's going on emotionally as a conflict inside. You may be outraged, just furious about all kinds of things. The administration in your hospital or the patients that are unvaccinated, or people around you that normally don't annoy you, you're suddenly now sort of have a short trigger for anger.

That's another sign that you're not OK, that something is bothering you deeply. And maybe even rightfully so. It's not like moral injury is a disorder. It may be a moral response to terrible things happening, that this is what people with consciences do. They react to bad things through their conscience and make judgments about them. And if they're involved in those things, they can feel pretty awful. So emotional withdrawal, I think, is a major sign. You stop trusting people so much. You're disillusioned. You may become starting to get cynical or callous.

So you start to lose your capacity emotionally, empathetically, to connect to people. You may be drinking more, or turning to drugs, or having a really terrible time sleeping. These are all signs that something is stirred up inside that your brain is not able to calm down and restore you to an equilibrium. And I don't know anyone actually in my life who hasn't had some kind of moral distress going on in this pandemic. It's why we wrote our op-ed.

Kelly Brown Douglas and I wrote that op-ed in The Hill that it's the whole country is experiencing moral injury. And we need nonjudgmental caring and listening spaces for people to discharge that stuff.

JOHN WHYTE: Well I want to thank you both for raising awareness of what people are experiencing. Let's talk about resources. Dr. Masood, tell us about how people can get in touch with your support line.

MONA MASOOD: To reach us, you can just call our toll-free number, this is nationwide, at 1-888-409-0141. Again, that's 1-888-409-0141. We are available from the hours of 8 a.m. to 1 a.m. Eastern Standard Time, 7 days a week. Please give yourself permission to speak what's on your mind.

JOHN WHYTE: And Dr. Brock, what resources would you recommend?

RITA NAKASHIMA BROCK: At Volunteers of America, we have a program that you can find at voa.org/rest. This is voa.org R-E-S-T. And it when you go to that site, you will see a schedule of sessions that are available for people to join and to be able to share their stories with each other, and give each other support, and to be believed, and to begin that process of externalizing and talking about what we're all trying to stuff down to keep functioning. And the stuffing-down is part of why we're not functioning.

So it's a way to discharge moral distress with others who are also there to do the same thing. So your story becomes something valuable to others who can support you and learn from you and learn from each other.

JOHN WHYTE: Well again, I want to thank you both for raising awareness of this.

If you have questions about moral injury, you can always drop us a line at drjohn@webmd.net. Thanks for watching.

This interview originally appeared on WebMD on January 26, 2022

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