Moral Injury in Healthcare

I’m beginning to note that more and more articles are addressing moral injury outside of combat veterans. Recently, the medical professions are using the discourse of moral injury to describe what in the DSM and elsewhere is referred to as secondary trauma. This latest article begins by noting:

In our view, “burnout” suggests a lack of resilience on the part of clinicians, implying that better self-care will resolve our distress, whereas “moral injury” more accurately locates the source of distress in a conflict ridden healthcare system.

We believe that distress is a clinician’s response to multiple competing allegiances—when they are forced to make a choice that transgresses a long standing, deeply held commitment to healing. Doctors today are caught in a double bind between making patients’ needs the top priority (thereby upholding our Hippocratic Oath) and giving precedence to the business and financial frameworks of the healthcare system (insurance, hospital, and health system mandates). 

Interestingly, Freud made a similar argument in his “defense” of Warner-Juaregg:

military psychiatrists-not the soldiers-had “acted like machine guns behind the front” and were the “immediate cause of all war neurosis.” Freud was called on by the legal community when Julius Wagner-Jauregg, a future Nobel Prize winner (and also future Nazi Party adherent), head of the municipal Clinic for Psychiatry and Nervous Diseases, was accused of the lethal use of electrotherapy on shell-shocked soldiers

A side note, Warner-Juaregg, despite his ‘trial’ for the way he seemingly dismissed and denigrated the combat soldiers sent to him for evaluation, went on to win the Nobel Prize in medicine/physiology in 1927. Freud noted that the minute a psychiatrist/doctor/psychoanalyst agrees to work for the state (the Austrian state in this case), he necessarily subordinates his duty to patients to the state. Whether the state or an institution, this seems to apply to the current literature addressing this, particularly in the NHS of the United Kingdom and others, whereby the state has taken over, thereby making patients secondary to the institutions goals. I think this is the main reason we are seeing moral injury being written about in the medical community. In fact, these authors state that explicitly:

We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction.

It is, as I predicted in the future directions section of my dissertation that moral injury is not confined to the domain of combat veterans.