Physicians were strained prior to the COVID-19 pandemic: long hours, clicking through electronic health records, endless emails with administrative issues, changes in reimbursement, and decreased time with family and friends. The pandemic has changed these stressors and the healthcare environment.
The impact of the spread of COVID-19 cannot be overstated. There are daily reports of large numbers of infections and deaths. There are shortages of supplies and blood. At the time of writing this, elective surgery has ceased throughout the country, and independent practices are financially threatened. Orthopaedic surgeons have been asked to work outside their field. Many of the stressors that caused orthopaedic surgeons to feel burned out before the pandemic are now compounded, with increased risk of moral distress and injury leading to increased burnout within the orthopaedic community.
In the face of a pandemic, we are likely to face stressful situations that challenge our ability to care for our patients and increase the likelihood for moral distress. In 1984, Andrew Jameton, PhD, defined this concept as a situation in which a healthcare provider or nurse is cognizant of the morally correct action but is constrained in some way from taking that action. In many instances, institutional factors or resource disparities create moral distress. A classic example of a morally distressing situation is a family member requiring a healthcare team to continue care they deem futile. In the current pandemic, the risk for moral distress is more likely to occur in the opposite scenario—we may be limited in the resources available for any one patient.
There have been reported shortages of equipment, protective gear, ventilators, blood, and other critical resources, and these constraints can make it difficult to pursue the preferred course. Fourie et al., argued that differentiating between categories of distress due to constraint and uncertainty is morally relevant and should factor into the analysis. Constraint can also occur when one feels compelled to perform an activity as directed by another. The activity may not feel or be morally correct. Uncertainty relates to simply distress from the unknown and how to proceed in a gray zone, or one where there is no clear answer. Both factors may be relevant during the current pandemic.
The uncertainty of the pandemic’s progression can cause further distress for those who are asked to work in areas outside their primary training and expertise. The stress of this situation is compounded by uncertainty about the disease, resources, and decision-making. We may be asked to act contrary to our training—at the edge of our expertise rather than within our skill set. This situation is likely to create moral distress, as practicing at the boundaries of our comfort level is likely to conflict with our view of the morally correct action—that is, practicing as a specialized expert. If the development of moral stress is not abated, it can progress to moral injury.
In times of stress in combat, military personnel can develop combat fatigue or post-traumatic stress disorder. Loneliness, depersonalization, and maladaptive behaviors can develop. This is related to the daily physical and psychological stresses placed on individual combatants. Similar phenomena are observed in healthcare personnel. Unabated moral distress leads to moral injury, defined as an injury occurring to an individual’s values or conscience from act(s) of moral uncertainty or perceived moral transgression. Various emotions can surface as a result. Shame, guilt, anger, feelings of betrayal, and a significant “moral disorientation” can occur. Although war is a common setting, first responders and emergency providers are at risk in the face of frequent trauma in a resource-limited environment.
It is important to note that moral distress does not inevitably lead to moral injury, although the presence of prolonged exposure to morally distressing situations increases the risk. Shay et al., define the concept of moral injury as having three parts: There is a betrayal of what is right by an individual in authority which occurs in a high-stakes or impacting situation.
Moral injury can affect physicians’ ability to care for patients and themselves. There can be emotional lability, a loss of interest, poor decision-making, and poor patient care. Affected physicians may lose personal self-esteem and sense of self-worth. Family life can be harmed, and injured physicians may not care for themselves; they may develop insomnia, loss of appetite, and depression.
We need personal and systematic solutions to face the moral dilemmas of the pandemic. At the personal level, there are steps physicians can take to build their resilience in the face of challenge. According to the work of Derek Roger, PhD, and Nick Petrie, a key cause of stress is rumination—the mental process of thinking over and over about something that happened in the past or could happen in the future and attaching negative emotion to it. Practicing mindfulness and focusing on the present can help stop rumination. Rather than ruminating on a difficult event, physicians should try to learn from the past, avoid reliving negative experiences, be present in the current moment, and develop a plan of action for moving forward.
Petrie et al., provided four steps for shifting from rumination to positive presence:
We can also manage stress and build resilience by strengthening our awareness of emotions. When an emotion arises, naming that emotion can be a powerful way to begin managing and even lessening its impact. This acknowledgment of emotions also promotes greater self-awareness. Other helpful techniques include mindfulness meditation, social connections, discussions with family members, and appropriate professional counseling and assistance.
There are also ways to mitigate moral dilemmas through the healthcare system. For example, moral distress is increased if physicians are asked to make bedside rationing decisions. The system should instead create clear guidelines about resource allocation. The constraints of guidelines will free physicians from an improper role as gatekeeper, permitting them to stay in the role of an advocate for their patients.
We would argue that, beyond guidelines, institutions should look for ways to prevent physicians and healthcare teams from developing moral distress, including programs to promote well-being that are based on best practices and sound research. The treatment of moral injury is complex, time consuming, and difficult. It is in everyone’s best interests to create a system that minimizes moral distress and moral injury.
Casey Jo Humbyrd, MD, MBE, FAAOS, is from the Department of Orthopaedic Surgery and Berman Institute of Bioethics at Johns Hopkins University.
Charles Carroll IV, MD, FAAOS, is an associate clinical professor of orthopaedic surgery at the Feinberg School of Medicine of Northwestern University in Chicago. He serves as the coordinator for ethics in clinical practice for The Journal of Bone & Joint Surgery and was the chairman of the Ethics Committee for AAOS from 2011 to 2015. He has an active hand surgery practice in Middleburg, Va.
Jill Fahlgren is an executive coach and founder of The Possible Life, Inc., as well as executive coach and lead facilitator for Kellogg School of Management's Alumni Career and Professional Development Services.
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