An intent Victorian physician leans toward the ailing child in Sir Luke Fildes’ 1891 painting The Doctor as forlorn parents look on helplessly from the shadows. Their darkened presence seems almost irrelevant because, as Fildes said, he meant to depict the epitome of a medical professional – a good, caring doctor, a “hero in the service of humanity.”
Physicians as heroes? That sounds familiar.
As the world crumbled last year, doctors saw an upgrade to their status. Suddenly, they were heroes in capes, likened to war heroes “at the front lines.” Already bound in an age-old contract with society, physicians rose to the occasion – perhaps at a cost to themselves. The hero status may be putting them at higher risk for moral injury.
Moral injury, defined as the psychological distress that comes from actions, or the lack thereof, that violate one’s moral or ethical code, was an issue for health-care workers long before COVID-19. The pandemic has exacerbated the problem and has potential long-term detrimental effects.
In a recently presented paper entitled Who are They Clapping For?: Tracing the Mytho-Politics of the COVID-Hero, the authors argue that hailing health-care workers as heroes is a “social analgesic” more than anything else.
“It is done as a way to reduce the collective anxieties of the public,” says co-author Indigo Wellar, a researcher and postgraduate student based at Harvard University.
But being a hero comes with high expectations.
The doctor-patient contract assumes that doctors’ expert knowledge will fulfill patient expectations, writes Jacalyn Duffin, a physician and medical historian, in her popular book History of Medicine: A Scandalously Short Introduction. When these expectations are met, patients give doctors respect and authority.
More than 3,000 years ago, being knowledgeable about disease and able to predict what would happen to a patient was the ultimate sign of success. These expectations changed – and increased – with the advent of anesthesia and antibiotics. Suddenly, cure, not care, became the stick by which physician credibility was measured.
This changed in the late 20th century. Society began to recognize that medical knowledge could be erroneous, medications have side effects, and that doctors can make mistakes. While this criticism was percolating, however, society’s expectations of doctors didn’t change: they still expected to be cured, an expectation that continues to underlie the doctor-patient relationship today.
As much as doctors would like to fit the image of the heroic Victorian doctor, they are sometimes unable to meet patients’ and their own expectations. This gives rise to moral injury, especially when faced with a virus that can be very hard to treat.
Moral injury first appeared in the literature in 1994, when psychiatrist Jonathan Shay described his observations working with Vietnam veterans – instead of post-traumatic stress disorder (PTSD), he found they carried an “internal wound.” When individuals learn that they cannot rely on themselves, or the system that they are a part of, to uphold expectations, they experience moral injury. Events causing moral injury can then lead to feelings of shame or guilt, which can lead to the development of mental health disorders such as depression, anxiety and PTSD.
Moral injury in health-care workers is perhaps best described by two physicians as “the challenge of simultaneously knowing what patients need but being unable to provide it due to constraints beyond our control.”
Says Katy Kamkar, a clinical psychologist and assistant professor in the Department of Psychiatry at the University of Toronto: “Any situation where we might be prevented from doing what we feel to be morally right can essentially set the stage for moral suffering, distress or injury.” She emphasizes that moral injury and burnout “are different constructs. One could increase the risk of the other but you should think about them as two distinct phenomena.”
While “burnout” seems to place the responsibility on “broken” individuals who lack resilience, some argue that moral injury emphasizes that the root of the problem is the broken system – not the individual. This has “re-energized the conversation,” says Harvard’s Wellar.
The recent suicide of a physician in Quebec from “pandemic-related stress” after the tragic death of another physician in New York City illustrates the gravity of the situation. Even before COVID-19, physician suicide was a growing problem, leading some to wonder whether unidentified moral injuries among health-care workers were potential contributors.
Research indicates COVID-19 has exacerbated the situation.
“Circumstances that the pandemic has created have certainly caused a disruption in our sense of standards, expectations, values and beliefs,” says Kamkar. “These can lead to inner conflict and increase the risk of moral suffering.”
A recent U.K. paper highlighted the likelihood of health-care workers experiencing greater moral distress and moral injury during the pandemic. In another study published earlier this month, functionally limiting symptoms of moral injury were found in a significant proportion of health-care workers and were associated with medical errors and clinician burnout.
This isn’t hard to imagine. Over the past year, physicians have suffered from cognitive and emotional burden from witnessing patients in distress without being able to help due to systemic pressures or medical uncertainty. Health-care workers have grappled with the unease of newly ascertained “standards of care” that have changed as quickly as they were formed. They have fought back their own discomfort in keeping patients’ families separated through feeble plexiglass and stern “No Visitors” signs. Trained to bear witness to human suffering, health-care workers have been asked to step away – limit, cut down, reduce “exposure” to people with failing lungs and desperate hearts.
Health-care workers have faced tremendous uncertainty and fear amidst ever-changing and sometimes contradictory guidance about required personal protective equipment (PPE). They have worked overtime, distancing themselves from loved ones. Others, showing signs of infection, have been forced to quarantine at a time when their colleagues are working even harder, further causing guilt. They have lost colleagues, family and friends to the same disease they have been trying to fight.
Perhaps other essential workers such as grocery store staff and delivery drivers are experiencing similar feelings. After all, a 2018 study found that exposure to moral injury is associated with multiple mental health disorders across a range of professions such as teachers and journalists.
Kamkar says that early recognition of and intervention for moral injury, along with ongoing research, is the key to prevention. “The first step is to have conversations about it,” she says. “The more we talk about this, the more we raise awareness and instill education about it. This is how we proactively prevent it.”
In the meantime, perhaps we should think more carefully about hailing health-care workers as heroes, heaping pressure on them. In fact, health-care workers in the U.K. criticized being labelled as heroes. “Clap for Our Carers” continued for 10 weeks during the first lockdown but was portrayed as a “clap-trap” when it was re-introduced as “Clap for Heroes” the second time around.
Wrote one nurse in response: “Heroes undergo their duties knowing there will be a risk to their life or their safety. When I became a nurse nine years ago, this is not something I had to consider. I’m no hero.”
About the cover art: “The Doctor,” Sir Luke Fildes, 1891; courtesy of The Tate; published under a Creative Commons license: CC-BY-NC-ND 3.0 (Unported).