For more than a decade, burnout has been identified as an occupational hazard plaguing professionals in many fields, but for health care workers, it can be particularly harmful. The meaningful connections that these professionals develop with people are often intense, emotional and although gratifying can also be stressful. In the 2016 Survey of America’s Physicians, more than 60% of Texas physicians reported their morale as “somewhat or very negative.” Texas had the lowest morale when compared with all other states, making Texas physicians more susceptible to burnout.
These challenges — along with other external demands such as changing electronic medical records, financial pressures and emphasis on efficiency, productivity and loss of autonomy — can contribute to burnout . Burnout goes beyond feelings of stress and frustration. It can cause serious psychological harm, including lack of empathy, PTSD and suicide.
Recently, health care professionals started using the term moral injury to describe the effects of working on the “front line of battle” in the current health care system. Moral injury is typically used to describe painful experiences and is defined as the ontological pain from committing or failing to respond when witnessing a transgressive act or experiencing betrayal that violates one’s moral well-being. Although physicians acknowledge that moral injury in health care is not the same as moral injury experienced by combat veterans, e.g., killing someone in combat, they do believe it can be as harmful. Moral injury can cause guilt, shame and existential conflict. These core symptoms can lead to secondary symptoms such as anxiety, depression, social problems and self-harm including suicide.
During this COVID-19 crisis, some health care professionals have to make morally objectionable decisions about the lives of the people they vowed to save. Owing to shortages of resources and to the overwhelming numbers of patients, health care providers have to decide how best to allocate intensive care beds and ventilators needed for the most acute cases, and whether to use do-not-resuscitate (DNR) policies for patients with lower chances of survival out of a concern for the high risk of infection that health care personnel face when administering lifesaving efforts. These practices are incongruent with the Hippocratic Oath and with health care professionals’ code of ethics, all of which could be boiled down to the phrase “First, do no harm.”
The symptoms of moral injury are commonly mistaken for burnout. But burnout implies that the problem rests with the individual, and to solve it, the individual must de-stress and find healthier ways to cope, such as through practicing mindfulness or yoga, improving nutrition, getting more sleep or exercising regularly. Those practices can be helpful for anyone, but mindfulness will not heal the deep wounds that health care professionals may suffer from withholding care from patients. Good nutrition and sleep will not soothe the aching spirit of health care workers who have had to choose between protecting their patients’ lives, their own lives, and the lives of colleagues.
What we all need to know is everybody is susceptible to moral injury, including law enforcement officers, journalists, chaplains, social workers and teachers. Anytime one’s actions transgress deeply held moral beliefs, it can cause dissonance and raise deep existential questions. We need funding for research on causes, treatment and prevention of this debilitating type of injury, because without answers and solutions, people will continue to suffer. And we need to fix our broken health care system, where business profits and financial stability are put ahead of patient needs.
We should express gratitude to health care professionals while also understanding that the label of “hero” although well intentioned, can be embarrassing when health care professionals feel morally or psychologically broken from saving most but losing so many. We must recognize they are both survivors and heroes of this crisis. They are risking their lives to save ours. They need our empathy and unconditional acceptance now and for the unforeseeable future.
We all must do our part. Otherwise, we are complicit in what causes these moral injuries.
Lataya Hawkins is a doctoral student in the Steve Hicks School of Social Work at The University of Texas at Austin.