Moral injury in health care: What have we learned?


STAT_LogoWhen we began exploring the concept of moral injury to explain the deep distress that U.S. health care professionals feel today, it was something of a thought experiment aimed at erasing the preconceived notions of what was driving the disillusionment of so many of our colleagues in a field they had worked so hard to join.

As physicians, we suspected that the “burnout” of individual clinicians, though real and epidemic, was actually a symptom of some deeper structural dysfunction in the health care system. The concept of “moral injury” seemed to encapsulate the organizing principle behind myriad drivers of distress: the growing number of reasons we couldn’t keep the oath we had made to always put our patients first.

Moral injury describes the mental, emotional, and spiritual distress people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” It was originally described by VA clinicians to account for the way that the suffering of some military veterans did not respond to standard treatment for post-traumatic stress disorder. This way of conceptualizing soldiers’ suffering felt deeply familiar to us, and we thought it might provide a compelling account of the cause of the burnout we have witnessed in our colleagues and ourselves.

Posing a new question in the conversation around physician burnout, we published a First Opinion on moral injury on this date last year. We were stunned by the response. That article started an international conversation among health care professionals and others about the moral foundations of medicine and has begun to change the language around clinician distress.

Since our article appeared in STAT, we have discussed, debated, and reconsidered our thoughts about moral injury with audiences across the breadth of health care — in person, on podcasts, by phone and email, on social media, and from podia across the country. In the process, we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.

The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.

But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.

Day after day, health care professionals find themselves with no viable choice but to act in ways that transgress their deeply held beliefs in the primacy of care. As a result, many experience the well-understood symptoms of burnout — and they keep burning out, in defiance of the many and well-meaning interventions designed to combat it. The burnout epidemic continues unabated because the moral injury at the root of the problem remains unaddressed. Burnout may be the symptom, but in many cases moral injury is the cause.

From our conversations over the past year, we have learned that moral injury resonates because it suggests a broadly shared cause for the seemingly solitary experience of burnout. In other words, moral injury lets us understand that we are burned out as individuals because each of us is trying, in vain, to compensate for the dysfunctional way health care is structured for everyone.

Collective action for structural challenges

Those who suffer from moral injury in health care are desperate for healing. How do we do that? Each of us has been trying to fix the system on our own, in our own individual ways. Now it is time to work together to that end. Clinicians get burned out because health care is rife with double binds and no-win situations for clinicians and the patients we care for. Changing that system to make it less harmful will demand collective action from everyone called by conscience to do better.

When an individual falls ill, her or his clinician looks for the cause of the problem and its corresponding medical solution. We need to approach moral injury in the same way, knowing full well that the solutions aren’t medical but are social, economic, and political.

The conversation around moral injury, then, summons clinicians to look outside their own expertise to heal the system that is harming themselves, their colleagues, and their patients. The solutions to heal moral injury don’t look much like the medical interventions we are used to. They are more likely to come from the tool kits of epidemiology and public health, public policy and law, and grassroots organizing.

In order to make real change, we will need to engage “activists” from all aspects of the health care system — clinicians, health care administrators, policymakers, and, above all, patients and their families — to pitch in to address the structural causes of moral injury in health care.

Here are a few ways that have emerged to nudge the U.S. toward moral health care:

Value health care professionals. When clinic or hospital policies and insurance constraints force health care professionals to deliver suboptimal care to their patients, providers feel powerless. Administrators must recognize their clinicians’ expertise, earned by years of grueling training, and seek their input before implementing policies that could affect patient care. Forming focus groups of health care professionals to advise on the consequences of policy changes is an important first step toward ensuring that their voices are heard. Holding administrators responsible for the work environment in health care is a strong second step.

Privilege the patient-clinician relationship. Clinicians are stationed on the front lines of health care and are solely responsible for tailoring treatment plans to meet the needs of each patient. Insurers and health systems must allow clinicians the latitude to treat patients according to their specific needs without constraining the tests they can order, the drugs they can prescribe, or the referrals they can make without incurring undue burdens. Health care professionals abide by an oath to do no harm while doing everything in their power to heal the sick and injured — they must be trusted to uphold this oath as they are trained to do.

Reestablish a sense of community. The hypercompetitive, perfectionistic, resource-scarce health care environment has eroded a sense of community among health care professionals. Each of us instinctively guards our own territory, fearing the encroachment of others as a threat to our already scarce resources and to our professional survival. Nurses are pitted against physicians, advanced practice providers are pitted against both, and we are all pitted against patients (satisfaction surveys, anyone?). No one wins in that scenario, and patients lose the most.

Advocating effectively for the sweeping changes desperately needed in health care requires health care professionals to look in other places for inspiration and to work together toward a common goal. Industry constraints affect every health care professional in some way, and we must be united — with each other and with patients — to drive the changes we believe are necessary.

When we boil the ocean of health care down to its single organizing principle, all health care professionals — nurses, doctors, first responders, physical therapists, respiratory therapists, phlebotomists, technologists, and more — are in this together with a single goal: to provide the best care for patients. When we get back to this, we all win.

Simon G. Talbot is a reconstructive plastic surgeon. Wendy Dean is a psychiatrist and senior medical officer, Henry M. Jackson Foundation for the Advancement of Military Medicine.  This article originally appeared in STAT News.

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