As medical professionals try to stay compliant with increasing regulations and avoid legal violations, many are left at risk of “moral injury.” Although it is often mischaracterized as burnout, moral injury is a deeper concern than just exhaustion and lower productivity.
What is moral injury?
Moral injury originally applied to veterans who struggled to come to terms with some of their actions during war. According to a 2009 study published in Clinical Psychology Review, moral injury comes from “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” This can be “emotionally, psychologically, behaviorally, spiritually, and socially” harmful to a person in the long-term.
However, veterans are not the only group who experience moral injury. Healthcare professionals often face a difficult decision: doing what is best for their patients, or following the dictates of regulation, financial interests, or litigation.
Technology such as EHRs, while valuable, can also be overwhelming and distract providers from face-to-face patient interactions. Financial considerations may interfere with treatment decisions. Providers afraid of litigation may order excessive tests and overreact to a client’s condition, which could be detrimental. Clinicians may avoid giving helpful but disagreeable advice, for fear of negative customer survey responses. Business or payer requirements may limit clinician referrals to their own system, even when that may send patients to less effective care.
All these factors can cause ethical conflicts that lead to serious emotional and moral pain. When repeated frequently over time, it can lead to moral injury. Clinicians may feel discouraged and disengaged, especially those who chose their careers with a sense of purpose and passion.
“Every time medical professionals have to choose anything other than their patient, it can be indicative of moral injury, or it predisposes them to moral injury,” says Dr. Wendy Dean, author of If I Betray These Words, a forthcoming book on moral injury in medicine.
What can be done about moral injury?
Dr. Dean and Dr. Simon Talbot have co-founded Moral Injury of Healthcare, LLC, a 501(c)3 nonprofit that aims to improve medicine and address moral injury through awareness and education. They also offer related consulting services for clinicians and healthcare leaders.
In a 2018 article, Dean and Talbot point out that the complex problem of moral injury calls for significant, industry-wide solutions. Wellness programs, flexible schedules, and changing to team-based care are not enough.
Recommendations they offer include:
- Healthcare leadership that respects and values the knowledge and skills of senior doctors, rather than seeking to replace them as soon as possible
- Encouraging patients to demand appropriate, optimal care from their insurers, hospitals, or health care systems, without being overridden by other entities
- A free market for insurance and health providers that encourages self-regulation and patient-driven care, rather than pushing financial obligations onto providers.
“We need leadership that has the courage to confront and minimize those competing demands,” Dean and Talbot write. “Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.”
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