Discussion Paper: Moral Injury

CMDFA Ethics Management Team (EMT)

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from Luke’s Journal 2020 | Ageing Gracefully | Vol.25 No.3

Doctor sitting in a hospital corridor.

Moral injury has been defined as the “ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction, or decision that conflicts with their own values.1

Moral distress is found to correlate with burnout, consideration or intention to leave a position or workplace and non-alignment with workplace ethical climate. Nurses score significantly higher on moral distress measures than doctors. The EMT (Ethics Management Team) is aware that the subject is always pertinent for Christian healthcare professionals, for example in the context of progressive legalization of abortion and euthanasia, but that it has greater significance at the moment because of the COVID-19 crisis. This is particularly the case in places where hard decisions are having to be made in a context of overwhelming need and allocation of finite health resources.

The EMT proposes to investigate Moral Injury as its initial project. A sub-committee has been appointed with this in view, to undertake the work and provide further reports. We would like to introduce the topic to our members and nurses to facilitate discussion and mutual support. Sometimes just a simple understanding of the issue can be helpful for coping. Moral injury has frequently been categorised as post-traumatic stress disorder, and this has not been helpful for dealing with it.

Moral injury is an event that violates deeply held moral beliefs or values. It can cause a profound psychological distress that results from actions, or lack of them, which deeply impacts one’s moral code.2 It may be something I have done, deeply personal and not necessarily known to any person other than myself. It may be something I have done that involves others, even without them ever knowing. It may be something that has been done to me or I have witnessed done to others. It may be something that I have been compelled or obliged to do by others with the power to enforce it, or because they did not support me as they ought. It may at times simply be the failure or inability to give good bedside care. It is more than “just” a traumatic event. It is also something more than “just” guilt although this may be involved. Even when the event involves no actual physical describable trauma, it is still a violation and it needs to be recognised as such, as part of recovery.

Recognising/acknowledging the reality/truth of what happened, that it was more than just a traumatic or tragic event, that it ran in opposition to deeply held morals, that it was the result of a deliberate, non-accidental, course of action that was in conflict with those morals – even if it seemed there was no other course of action when it might have been the lesser of two evils – still requires defining for recovery to occur.

In view of the serious consequences of moral distress on the healthcare professional, it is important that it is addressed and support accessed. While it is not always possible to eliminate all situations that cause moral distress, there are ways to mitigate their impact. The EMT would like to help CMDFA members to understand moral distress and provide guidance to those who experience it.

Further reading:

Canadian Medical Association Covid-19 and moral distress

Concerns raised about Covid-19 and moral distress

https://www.bioedge.org/bioethics/concerns-raised-about-covid-19-and-moral-distress/13482

Covid-19 patients need not die alone

https://www.bioedge.org/bioethics/covid-19-patients-need-not-die-alone/13483


 
Members of the Ethics Management Team  
Rev Dr Andrew Sloane, NSW, Chair
Dr Megan Best, NSW
Gabrielle Macaulay, NSW, NCFA Rep 
Assoc Prof Anna Walsh, NSW, legal member 
Dr Joseph Thomas, QLD
Dr Lachlan Dunjey, WA
Dr Rohit Joshi, SA
Dr Kuruvilla George, VIC, CMDFA Board Rep
Ian Gowlett, retired RN, NCFA Board 


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References

  1. Sanderson, C., Sheahan, L., Kochovska, S., Luckett, T., Parker, D., Butow, P., & Agar, M. (2019). Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature. Clinical Ethics, 14(4), 195–210. https://doi.org/10.1177/1477750919886088
  2. Williamson, V., Murphy, D., & Greemberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational medicine (Oxford, England), 70(5), 317-319. doi:10.1093/occmed/kqaa052

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