On April 27, 2020, we learned that Dr. Lorna Breen, head of the ER at a New York City hospital, committed suicide after fighting on the front lines in the coronavirus battle. Just two days earlier, John Mondello, a Bronx EMT, also took his own life after witnessing the human tragedies that seem ubiquitous on the front lines of this war.
We cannot know, of course, what was going through Dr. Breen’s or Mr. Mondello’s minds, but these tragic deaths harkened us back to a blog post from just two months ago that we wrote about moral injury.
The health care workers who are heroically fighting the virus in hospitals, assisted living facilities, and elsewhere face all sorts of trauma. They may contract the disease themselves. As of mid-April, more than 9,000 health care workers around the country had contracted COVID-19. They may die from the disease. Nearly thirty had passed away by mid-April. They must worry about infecting their family members. Many health care workers have isolated themselves from their families to avoid spreading the disease, causing emotional distress to everyone involved.
These health care professionals thus face all manner of injury from the virus, and that includes moral injury. Moral injury occurs when someone learns of, sees, fails to prevent, or takes part in actions that are inconsistent with their moral beliefs. The classic example occurs in wartime when soldiers who believe that they are fighting on the side of right find their comrades, and perhaps themselves, taking the lives of innocent civilians. For instance, commanders may have to choose between bombing a village, knowing that many innocent civilians will die, or endangering their own soldiers.
Medical professionals are used to making hard choices. They are familiar with illness and death. But in the hardest-hit areas, including New York City, the ruthless onslaught of COVID-19 and the conditions under which this battle is being fought, have combined to make moral injury a particular peril. Health care workers have often had to make extraordinarily difficult choices.
- Which workers will be provided face masks and other personal protective equipment, and which ones will not?
- Who among those standing in an endless line out in the cold will be tested for the virus, and who will go untested?
- Who will be admitted to the hospital, and who will be sent home?
- Given the shortage of ventilators, which patients will be put on one, and which patients will have to go without?
- Which patients will have to die without any loved ones around them?
- Which patients with significant non-coronavirus medical issues should be sent to the end of the queue until the pandemic’s pressures lessen?
Although these seem to be choices that should seldom confront workers in a modern health care system in the wealthiest nation on earth, nonetheless these are the sorts of choices that today are relentlessly confronting health care workers who are often exhausted by long hours and overwhelming COVID-19 caseloads.
In our earlier blog post, we noted: “It has been suggested (Talbot & Dean) that physicians who suffer from ‘burn out’ are actually manifesting a form of moral injury that arises from continually being unable to provide high-quality care and healing in a broken health care system.”
Our UT colleague, psychology professor Art Markman, was recently quoted as observing: «Few people in healthcare have had real-life experience with triage in which a significant number of life-and-death decisions had to be made because of equipment shortages. That increases the chances that they may experience moral injury as a result of their jobs.»
Psychiatry professor Jessica Gold made a similar point:
Some health care workers are using words like betrayal and coercion and moral injury to describe this experience. They feel betrayed by their employers, the health care system, and the government, all of which were woefully unprepared for a pandemic and then chose to ignore their warnings. Some are concerned they will be called upon to do work they have not done in years due to staffing needs. Even still, others are grieving the traumas they will see and the decisions they will be forced to make. Some have said even they will simply not come to work and would rather quit medicine altogether.
The point of our earlier blog post was that the true cost of business corruption includes not only the monetary damage to fraud victims and the stock price crash that follows the disclosure of the fraud, but also the moral injury to employees who find themselves in a corporate culture where they make decisions and take actions that are inconsistent with their values and that may well haunt them for the rest of their lives. Similarly, the true cost of the COVID-19 pandemic cannot be fully tallied without taking into account the moral injury inflicted on health care workers.
Melissa Bailey, “Beyond Burnout: Docs Decry ‘Moral Injury” from Financial Pressures of Health Care,” KHN.org, Feb. 4, 2020, at https://khn.org/news/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care/.
Wendy Dean, “COVID-19 Is Making Moral Injury to Physicians Much Worse,” Medscape.com, April 1, 2020, at https://www.medscape.com/viewarticle/927859.
Jessica Gold, “The COVID-19 Crisis Too Few Are Talking About: Health Care Workers’ Mental Health,” STAT, April 3, 2020, at https://www.statnews.com/2020/04/03/the-covid-19-crisis-too-few-are-talking-about-health-care-workers-mental-health/.
Zahra Hirji, “Thousands of US Health Workers Have Been Infected by the Coronavirus. Here’s How Each State Stacks Up,” Buzzfeed, April 10, 2020, at https://www.buzzfeednews.com/article/zahrahirji/us-health-care-workers-coronavirus.
- Patricia Hynes, “The Iraq War and Moral Injury,” Truthout, March 20, 2013, at https://truthout.org/articles/the-iraq-war-and-moral-injury/.
James Jeffrey, “Coronavirus: Why Health Care Workers Are at Risk of Moral Injury,” BBC, April 6, 2020, at https://www.bbc.com/news/world-us-canada-52144859.
Giulia Lamiani et al., “When Healthcare Professionals Cannot Do the Right Thing: A Systematic Review of Moral Distress and Its Correlates,” Journal of Health Psychology 22:51-67 (2017).
Michael Matthews, “Moral Injury: Toxic Leadership, Maleficent Organizations, and Psychological Distress,” Psychology Today, March 10, 2018, at https://www.psychologytoday.com/us/blog/head-strong/201803/moral-injury.
Elizabeth Rosner & Kate Sheehy, “Top Manhattan ER Doc Commits Suicide, Shaken by Coronavirus Onslaught,” New York Post, April 27, 2020, at https://nypost.com/2020/04/27/manhattan-er-doc-lorna-breen-commits-suicide-shaken-by-coronavirus/
Jonathan Shay, “Moral Injury,” Psychoanalytic Psychology, 21(2): 182-191.
Simon Talbot & Wendy Dean, “Physicians Aren’t ‘Burning Out.’ They’re Suffering from Moral Injury,” Boston Globe, July 26, 2018, at https://www.bostonglobe.com/ideas/2018/08/04/physicians-aren-burning-out-they-suffering-moral-injury/xGsJTQBHBzHdM2CvrWLa0M/story.html.
Syracuse University, “The Moral Injury Project,” at http://moralinjuryproject.syr.edu/.
Victoria Williamson et al., “Occupational Moral Injury and Mental Health: Systemic Review and Meta-Analysis,” The British Journal of Psychiatry, 212(6): 339-426 (2018).