Equal is not equitable: moral distress in health care

Population health data is often grim during a pandemic, but occasionally it tells us a good-news story.

One such tale in Ontario has been the clear data on how prioritizing the first rounds of vaccinations for the chronically ill, elderly and staff and residents of high-risk congregate care settings helped quell the fires that ravaged long-term care (LTC) in the first waves of the pandemic. An efficient and targeted vaccine rollout dramatically reduced death and morbidity in those spaces.

Ontario also has clear data on the fires burning in essential workplaces and neighbourhoods that are considered “ethnically diverse” in public health terms. We are seeing communities already impacted by racism and discrimination being disproportionately hit by high COVID-19 rates and deaths. And yet, vaccines are still not getting to these work settings and communities at anywhere near the purposeful pace that we saw with LTC.

Over the last few weeks, trying to get vaccinated as someone under the age of 55 – age groups highly represented within the workforce – has been likened to getting concert tickets or participating in The Hunger Games. Not only have essential workers not been prioritized, but booking a spot has required a certain level of digital literacy, free time, mobility, social resources and good old-fashioned luck; these are all known barriers to health-care access among communities made vulnerable by social determinants of health. This approach might provide equal access to everyone based on age, but it certainly does not provide equitable access based on the evidence of who needs protection first.

In research, we call the disconnection between evidence and practice an implementation gap.

It seems Ontario’s vaccine rollout is showing us the tipping point at which an implementation gap translates to social injustice.

As a result, we are also witnessing public expressions of moral distress: That horrible feeling people have when the responsibility they are tasked with does not align with their ethical sense of what ought to be done. We have seen clinicians and scientists on the brink of tears with frustration over the deaths they see as preventable based on data and clinical experience. We have seen workers on social media expressing their fear of getting sick without adequate protection or paid sick days. Bereaved family members have shared their heartbreaking stories of loss and what-ifs. We have seen non-essential workers thrilled to be getting vaccinated but question why them instead of those who do not have the privilege of working from home.

Moral distress is not new in health care. There is plenty of literature on how clinicians struggle to make choices within conditions that constrain their preferred course of action. It has garnered attention in medical education and professional training as one of the causes of prevalent burnout, chronic stress and job dissatisfaction seriously impacting health-care providers and their work in the field.

There are at least two ways that what we are currently seeing unfold in the pandemic is unique: One, the unprecedented scale at which health-care systems and providers are being asked to make hard decisions; two, the scale and scope at which public health and health care have been intertwined in our daily practices, sense of being and political discourse. This pandemic has created a pervasive public culture focused on health, illness and end-of-life within which this moral distress can be given meaning in our everyday lives.

As health-care and adjacent care systems eventually rebuild after COVID-19 has loosened its grip, it will be crucial to understand the social and psychological impacts of moral distress among our front-line workers and in our culture more widely. It will be equally important to explore and heal the collective traumas of health inequity that may impact vulnerable communities long after the pandemic ends. This work cannot be done for communities, but hand-in-hand with them in a move towards empowered systemic change.

COVID-19 has brought the relationship between care-provider burnout and health inequity into public dialogue. Now is a critical time to build momentum towards solutions. It is imperative not only to rebuild but to re-imagine more equitable and sustainable systems of care.