How COVID-19 has placed health care providers at grave risk of moral injury

Obviously the coronavirus pandemic is squeezing the capabilities of our health care systems. It also is impacting the psychological health and well-being of health care providers on the front lines of treating COVID-19 patients, especially as they strive to provide life-saving treatment without adequate resources.

The ultimate nightmare scenarios include choices that may have to be made when the number of severely ill patients exceeds the number of intensive care unit (ICU) beds and ventilators. For example, here in Massachusetts, a task force of doctors and medical ethicists has developed a controversial protocol for determining who gets ventilators and other treatments and who does not, when demand exceeds availability. As reported by Adam Gaffin for Universal Hub, a local online news site (link here):

The “crisis standards of care” guidelines are designed for a hospital system in the process of collapse – too many sick people and not enough medicine equipment and healthcare providers to care for them all – possibly because they themselves might be knocked out by the virus.

When that happens, and patients are coming in faster than hospitals can provide intensive care for them, doctors will have to switch from trying to care for each individual patient to trying to maximize total “life years saved” for the community as a whole, the task force concluded.

To do that, a designated a triage doctor will assign patients scores based on such factors that include not just the severity of their Covid-19 infection but their age and preexisting conditions, with points added for each. Doctors, nurses and other healthcare workers, as well as patients who otherwise would be involved in “maintaining societal order,” however, would have points subtracted….In the event of a tie score between two patients, the younger one would “win,” because of the priority of maximizing total “life-years” saved.

…Patients with the lowest scores would then have their medical records color coded – so that ICU staffers know at a glance who’s next for a ventilator – possibly even if that means removing somebody with a higher score from one. Red-tagged patients would be first in line, orange next and then all the older, sicker patients would be marked as yellow.

The guidelines promulgated in Massachusetts are similar to those developed in other states and nations. Basically, if the swell of COVID-19 infections is overwhelming the availability of hospital resources, doctors and other health care providers are directed to institute a triage system that determines who gets potentially life-saving treatment and who does not. 

The specter of moral injury

The excruciating challenge of treating patients with inadequate supplies is placing health care providers at grave risk of moral injury. “Moral injury,” as defined by Syracuse University’s Moral Injury Project (link here), “is the 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.”

As Dr. Wendy Dean, psychiatrist and co-founder of Fix Moral Injury, a non-profit organization, explains in Time magazine (link here):

If healthcare workers can’t provide the care they typically believe is medically necessary for their patients, they may experience a phenomenon known as “moral injury,” says Dr. Wendy Dean, a psychiatrist and the co-founder of the nonprofit Fix Moral Injury. Dean says that American healthcare providers are used to doing anything and everything to help their patients, but inadequate protective gear and triage procedures will force them to make “exquisitely painful” decisions, such as choosing whether or not to risk infecting themselves, their family and other patients in order to help everyone in their care.

The consequences of moral injury can be significant. According to the Syracuse Moral Injury Project:

Moral injury can lead to serious distress, depression, and suicidality. Moral injury can take the life of those suffering from it, both metaphorically and literally. Moral injury debilitates people, preventing them from living full and healthy lives.

The effects of moral injury go beyond the individual and can destroy one’s capacity to trust others, impinging on the family system and the larger community. Moral injury must be brought forward into the community for a shared process of healing.

The specter of moral injury is among the reasons why our health care providers will require ongoing help in dealing with the psychological burdens and health risks of working to save lives during this pandemic. This experience will leave its formative mark on current generations of health care workers for decades to come. We owe them our support for the short and long runs alike.

2 responses

  1. Nurses have all but given up on vindication and justice but Covid awoke a sleeping giant. Help is on the way.

  2. David, having co-edited a book on Combating Physician Burnout, I ended up feeling that the use of “moral injury” is actually injurious to physicians! It is potentially another blame the victim strategy, like organizational wellness programs. The causation is mainly the systems, so at best the term should be moral injurers or moral homicide.

    – Steve Moffic, M.D.

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