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Moral Injury in Health Care and COVID-19
By Scott Janssen, MA, MSW, LCSW

Though it’s a relatively new concept, moral injury has been around since antiquity, according to Jonathan Shay, MD, PhD, in Achilles in Vietnam: Combat Trauma and the Undoing of Character. In modern times, it was first identified in soldiers returning from war. According to the Moral Injury Project at Syracuse University, moral injury involves “damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.”

Common symptoms can include depression, shame, guilt, and remorse, as well as a sense of being psychologically and/or spiritually damaged and an inability to forgive one’s self for perceived violations of one’s moral code. Though often associated with PTSD, with which it can co-occur, moral injury is distinct in the way it alters a person’s sense of self.

Much of the literature on the causes of moral injury focuses on acts that are witnessed, enabled, or perpetrated against someone else. For example, Litz et al., in Clinical Psychology Review, define moral injury as the “psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Shay, in Achilles in Vietnam and Odysseus in America: Combat Trauma and the Trials of Homecoming, offers a different but complementary theory about causation that emphasizes the negative impact of betrayal. In his formulation, moral injury can arise from being betrayed by another person or system with legitimate authority in a high-stakes situation in ways that violate the moral/ethical values of the one who is betrayed. Or, as Shay puts it, a violation of one’s sense of “what’s right.”

Such high-stakes betrayals can undermine trust in one’s self, others, and the world. They can shatter a person’s sense of moral identity and undermine their belief in the goodness of others or one’s self.

In the military context, such betrayals may involve being placed in harm’s way under false premises, insufficient training or personnel to carry out a dangerous mission, receiving unethical orders, covering up war crimes, equipment failures in a life-threatening situation, and/or inadequate support at a time of crisis.

It’s easy to understand how the violence of war can leave individuals suffering with moral pain and confusion, but moral injury is more widespread. It has even been identified in health care workers, according to the Emergency Medicine Journal.

In STAT, Talbot and Dean contend that moral injury is a significant factor behind high rates of burnout and suicide among physicians. Citing “business-oriented and profit-driven” priorities that can undermine the provision of good care, they argue that the “moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.”

Health Care and the COVID-19 Crisis
When institutional and local pressures lead to poor patient outcomes, medical staff may perceive themselves as complicit in acts that let patients down and violate their moral codes. They may even feel betrayed, lied to, or coerced by systems, institutions, and/or leadership that set priorities that fail to align resources and behaviors with a medical professional’s judgment about what is needed.

This intersection of moral injury due to not being able to properly care for patients along with a sense of being betrayed by the larger systems in which health care is delivered is now playing out in full view as the COVID-19 pandemic spreads.

Consider frontline staff currently putting themselves at risk of COVID-19 infection or of transmitting it to other patients, coworkers, or loved ones because they do not have adequate personal protective equipment (PPE), or because they do not have adequate testing to diagnose the virus in a timely manner. Not only does this compromise patient care, but it also places workers at an elevated risk of harm, even death, because of improper planning, bad policy decisions, perceived foot-dragging, or failures to remove barriers to the procurement of supplies and testing kits on a local and/or federal level.

From the Frontlines
In an article on moral injury and COVID-19 in Times of Israel, journalist Ethan Eisen makes the point that medical professionals are “making tremendous sacrifices—leaving their families for the foreseeable future so that they do not spread the virus to their families and communities, and working with insufficient protection and supplies. When they have moments to think in the midst of the chaos, they may also feel betrayed by the medical systems or responsible government agencies whose decisions have left them, their families, and their patients more vulnerable.”

Given the lack of treatment options and rapid spread of the illness, it is conceivable—some would say likely—that there will not be enough ventilators to keep patients alive in some locations. Medical staff may find themselves in the painful position of having to make choices about who lives and who dies. And they may be forced to be the bearers of these decisions to frightened and grieving family members.

In an article in the British Medical Journal, Greenberg et al. paint a troubling scenario: “The COVID-19 pandemic is likely to put health care professionals across the world in an unprecedented situation, having to make impossible decisions and work under extreme pressures. These decisions may include how to allocate scant resources to equally needy patients, how to balance their own physical and mental health care needs with those of patients, how to align their desire and duty to patients with those to family and friends, and how to provide care for all severely unwell patients with constrained or inadequate resources. This may cause some to experience moral injury or mental health problems.”

In Just Security, Holly Tabor, PhD, and Alyssa Burgart, MD, MA, warn that for professionals grappling with these kinds of moral dilemmas in the midst of a crisis there may be a tendency to “second guess these decisions, and perhaps be haunted by them forever.”

Flaws in the local and federal response to COVID-19 have combined with medical systems that are being overwhelmed and have insufficient staff and a frustrating lack of space and resources, creating conditions for moral distress and injury. Here’s an illustrative sample of first-person reports by medical staff, some submitted anonymously due to fear of reprisal.

A physician in the United Kingdom, via The Guardian:

“I am terrified. I’m seriously considering whether I can keep working as a doctor. I may be OK—I’m young and healthy—but I can’t bear the thought of infecting other patients with a disease that could kill them. And that is the risk, without proper PPE. It’s terrifying; it’s indescribable. This is not seasonal flu. This is a new virus with greater mortality and we know much less about it.

“I’m losing faith in the leadership, medical as well as political. It doesn’t look like there’s a plan. We had weeks to prepare and we are still running out of PPE. And clearly, doctors are expendable. Why sacrifice us when there aren’t enough of us as it is? How many of us will still be able to work when the ‘right time’ finally arrives? They are throwing us into the slaughterhouse. This is what they are doing.”

A young ICU nurse in New York State, per the American Journal of Nursing Off the Charts blog:

“Coworkers and I are feeling a vast array of emotions and one of the worst ones we feel is deserted—we hear very little from hospital administrators.

“Our earliest confirmed COVID case was not isolated or swabbed for COVID until the day he died (at which point countless staff had been exposed). Several of us nurses requested that the patient be tested earlier in his admission, but mostly due to lack of preparedness and testing protocols on the hospital’s part, the patient was not tested until the fifth day of his admission.

“Meanwhile, hospital administrators had sent us text messages telling us we were not allowed to use any masks in patients’ rooms, unless the patient was officially ordered for isolation precautions, in anticipation of PPE shortages. So despite our suspicions that the patient had COVID, we were not allowed to protect ourselves.

“It is a nightmare. I personally never heard back from occupational health about my earlier exposure, but it seems irrelevant at this point since I most certainly am exposed every time I go to work now.”

An emergency physician, per the American Medical Association:

“It is frustrating and anxiety-producing,” Dr. Ranney said. “I was a Peace Corps volunteer. I’ve worked in resource-poor settings. I never imaged my daily practice in the U.S. would be similar to how medical workers sometimes must work in low- and middle-income countries. This pandemic may be unprecedented, but it was certainly predictable. We did not have to be in this situation.”

A staff person at a walk-in clinic, via the Los Angeles Times:

“I’ve come to the realization that I’m going to catch this thing,” said an employee at one Los Angeles walk-in clinic, where N95 respirators are completely gone. He said the clinic’s administrators are adamant that paper surgical masks, still in stock, will be enough to protect the staff from COVID-19. “The denial is really frustrating.”

Such reports, and there are many more, are palpable expressions of emotional, psychological, and moral pain. As one angry and exhausted nurse practitioner working in a VA hospital said to me, “It’s a setup from the damn President on down. And it’s the patients and me and my coworkers who are going to wind up dead.”

Amidst this crisis, frontline social workers are in key positions to help. Whether it’s providing a listening ear or crisis counseling to colleagues, or reaching out by phone to support a patient’s morally anguished loved ones who have been turned away due to a hospital’s restrictions on visitors, we serve as essential supports for those in danger of walking away with moral injury.

The Social Work Response
Social workers sensitive to the potential for moral injury will be better able to mitigate the risks that colleagues will wind up struggling with its long-term effects. By listening for personal narratives, beliefs, and statements that suggest someone is struggling with a sense of moral failure and guilt at not being able to provide optimal care, social workers may be able to help colleagues stay grounded and focused on what they can control rather than what they cannot.

Social workers can attune to and affirm the difficulty of the position in which so many health care professionals are finding themselves. And we can help individuals and teams frame a meaning to events that reduces powerlessness, underscores a sense of purpose and efficacy, and leverages internal strengths, team cohesion, positive coping skills, and external supports.

Social workers can be a safe presence for the fear, anger, and grief, bearing witness to the courage and sacrifice with which health care workers are serving others under adverse conditions. If we hear indications of distress and anger at being betrayed by leadership, we may be able to help colleagues recenter into the core values which are driving their behavior without having to take responsibility for things that are not within their direct control. We can help them not lose sight of the value of what they are doing rather than getting lost in what they aren’t able to do.

Social workers can validate a coworker’s subjective experience while bringing some empathy and perspective, where appropriate, for those in leadership who are making good-faith efforts. What looks like betrayal when one is in the thick of a crisis and feeling threatened may actually stem from larger barriers leaders are facing as they try to hire more staff and obtain critical resources.

Social workers are also advocates on an organizational level. We have a responsibility to push those in power to synchronize their actions with the needs of patients and ground-level staff. We can push for more transparent, responsive communication, as well as realistic strategies for ethical decision making. And we can offer our efforts in helping those in positions of leadership overcome barriers they are encountering.

This may mean changing or adapting policies and protocols to better respond to the challenges at hand. It may mean establishing formal opportunities for psychological support from peers or professional counselors. It may mean developing rituals or support groups that communalize the experience of being on the frontlines of a pandemic. It may involve tracking down resources or serving on task forces charged with implementing staff supports, streamlining procurement, accessing community resources, identifying suppliers, and developing community partnerships.

Of course, social workers on the frontlines of this pandemic (whether in hospitals, urgent care, public health, home care, or geriatric residential settings) are also susceptible to moral injury. Not to mention a range of associated consequences from secondary traumatic stress and PTSD to burnout and complicated bereavement. We need to care compassionately for ourselves as well. We need to care for each other.

— Scott Janssen, MA, MSW, LCSW, is a hospice social worker with UNC Health Care Hospice, and a member of the National Hospice and Palliative Care Organization’s trauma-informed care work group.