CMDFA NSW Conference on Moral Injury

8 MINUTE READ

from Luke’s Journal 2021 | Fire in the Belly 2021 | Vol.26 No.1

The COVID-19 pandemic has thrown many complex moral dilemmas our way, requiring us to make hard and costly decisions. We face the prospect — or current experience — of moral dilemmas, bad moral luck, moral distress, moral residue, and even moral injury. I would like us to think about these things theologically.

Some helpful distinctions 

Moral dilemma
As health professionals, we are pretty familiar with this category. Moral dilemma is when we face a complex situation in which it is either unclear what we ought to do, or there are two (or more) mutually exclusive options between which we must choose (e.g., who gets the ICU bed?). In such cases, if we make a good decision (even if it’s not the only ‘right’ decision), we should feel neither guilt nor shame, even though we may grieve the human cost.

Bad moral luck
This is hard to define, but easy enough to see. It’s where a bad thing happens outside of someone’s control, even if it is the result of their action (e.g., a careful bus driver accidentally kills a careless child). It’s not their fault; it’s just terrible (moral) luck. They rightly feel bad (‘agent regret’), but we need to think very carefully about the perceptions which may arise from that feeling. Specifically, we need to distinguish between wrongs and harms. We wrong someone when we (knowingly) treat them in a way that fails to acknowledge what is owed to them. We harm someone when we injure them (or their psyche or their reputation) in some way. In the above example, the bus driver wronged no one, but they certainly harmed the child. It is entirely appropriate that they feel regret for the harm they have done. But they should not feel guilt for it. Regret needs to be distinguished from guilt. 

Moral distress 
Moral distress is: ‘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 

The origins of moral distress lie in nursing literature, which identifies the following associated elements: 

1. It arises when one believes one knows the morally right thing to do (or avoid doing), but one’s ability to do this is constrained by internal and/or external factors.
2. It comes in two phases. There is “initial distress” at the time of potential action (or inaction); later, there is “reactive distress” or “moral residue” that occurs in response to the initial episode of moral distress.
3. It involves the compromising of one’s moral integrity or the violation of one’s core values.

Moral residue
Moral residue occurs when moral distress is prolonged and has a longer-lasting impact on the affected person.

One paper describes it like this:

“In situations of moral distress, one’s moral values have been violated due to constraints beyond one’s control. After these morally distressing situations, the moral wound of having had to act against one’s values remains. Moral residue is long-lasting and powerfully integrated into one’s thoughts and views of the self. It is this aspect of moral distress—the residue that remains—that can be damaging to the self and one’s career, particularly when morally distressing episodes repeat over time.”² 

Moral injury
Similarly, moral injury may be defined as: “the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code.”⁴ 

It is worth noting that this category was developed in response to the experience of combatants in the armed forces. Shay, who coined the term, included a clear institutional element: “Moral injury is present when:

1. there has been a betrayal of what’s right [in the soldier’s eyes] 
2. by someone who holds legitimate authority 
3. in a high-stakes situation.”⁵ 

Moreover, “Morally injurious events can include acts of perpetration, acts of omission or experiences of betrayal from leaders or trusted others. Unlike post-traumatic stress disorder (PTSD), moral injury is not a mental illness… Moral injury is not limited by context or profession. For example, a recent review found that exposure to moral injury was significantly associated with PTSD, depression and suicidal ideation across a range of professions (e.g. teachers, military personnel, journalists) and across a variety of countries (e.g. USA, Australia, Israel).” 

Moral injury is always pertinent for Christian healthcare professionals, particularly in contexts where hard decisions are having to be made in the context of overwhelming need and allocation of finite health resources. 

Possible responses

The first step is to recognise the importance of truth-telling. People need to acknowledge what they have done, or have witnessed, and the way it has affected them and others. They also need to interpret those experiences correctly: is this an occasion when someone has been wronged, or harmed (or both)? It is important to acknowledge the psychological and emotional impact, and receive appropriate support and counselling — a second, and vital step. 

While psychological support and counselling are helpful, they do not address guilt and shame especially well. That, I suspect, is because moral distress and moral injury are real spiritual phenomena as well as psychological/existential experiences, and need an appropriately differentiated response. Church communities ought to be places where spiritual support can be found, and people pointed to the grace of God in the gospel. 

While the gospel is the best ‘spiritual therapy’ I know, we also need to be careful. While we might seek spiritual care as a means of dealing with distress, it is unlikely to ‘work’ if it is only a ‘therapeutic strategy’. However, we also need to recognise the diverse riches of what spiritual care offers us, and discern what kind of response will be most appropriate for the case at hand. 

In cases of bad moral luck, people need to be able to articulate their ‘agent regret’, and lament the harms that have been done and their role in them. However, they also need to recognise that guilt is not appropriate. Lament will also be helpful in cases of moral distress, moral residue and moral injury, but in these situations, there may also be appropriate guilt for wrongs committed or permitted. This guilt needs to be confessed, and the forgiveness of the gospel received (after appropriate remedial actions). Concurrently, they may need cleansing and transformation by the Spirit. Finally, institutional factors need to be identified and, where appropriate and possible, dealt with, to avoid unnecessary repetition. 

Conclusion

As health professionals, we will all face situations that challenge our moral compass. Various feelings and perceptions may arise from the conflicts and pressures associated with this, and it is important to recognise the benefits of a multi-faceted response. Psychological, emotional, social and spiritual care can work together to help a person process and move through experiences of moral dilemma and distress.

A video of this talk is available to members of CMDFA. If you are not a member and would like more information please call the CMDFA Office on 02 9680 1233.

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Footnotes

1. Christine Sanderson et al., “Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature,” Clinical Ethics 14, no. 4 (2019): 195, https://doi.org/10.1177/1477750919886088 
2. Stephen M. Campbell, Connie M. Ulrich, and Christine Grady, “A Broader Understanding of Moral Distress,” American Journal of Bioethics 16 (2016): 2.
3. E.G. Epstein and S. Delgado, “Understanding and Addressing Moral Distress,” Online Journal of Issues in Nursing 15, no. 3 (2010), https://doi.org/DOI: 10.3912/OJIN.Vol15No03Man01
4. Victoria Williamson, Dominic Murphy, and Neil Greenberg, “COVID-19 and experiences of moral injury in front-line key workers,” Occupational Medicine 70, no. 5 (2020): 317, https://doi.org/10.1093/occmed/kqaa052
5. Shay, 2011, 183, cited in Joseph Wiinikka-Lydon, “Mapping Moral Injury: Comparing Discourses of Moral Harm,” Journal of Medicine & Philosophy 44, no. 2 (2019): 179.
6. Williamson, Murphy, and Greenberg, “COVID-19 and experiences of moral injury in front-line key workers,” 317.

References

• Campbell, Stephen M., Connie M. Ulrich, and Christine Grady. “A Broader Understanding of Moral Distress.” American Journal of Bioethics 16 (2016): 2-9.
• Epstein, E.G., and S. Delgado. “Understanding and Addressing Moral Distress.” Online Journal of Issues in Nursing 15, no. 3 (2010): Manuscript 1. https://doi.org/DOI: 10.3912/OJIN.Vol15No03Man01
• Sanderson, Christine, Linda Sheahan, Slavica Kochovska, Tim Luckett, Deborah Parker, Phyllis Butow, and Meera Agar. “Re-Defining Moral Distress: A Systematic Review and Critical Re-Appraisal of the Argument-Based Bioethics Literature.” Clinical Ethics 14, no. 4 (2019): 195-210. https://doi.org/10.1177/1477750919886088
• Wiinikka-Lydon, Joseph. “Mapping Moral Injury: Comparing Discourses of Moral Harm.” Journal of Medicine & Philosophy 44, no. 2 (2019): 175-91.
• Williamson, Victoria, Dominic Murphy, and Neil Greenberg. “Covid-19 and Experiences of Moral Injury in Front-Line Key Workers.” Occupational Medicine 70, no. 5 (2020): 317-19. https://doi.org/10.1093/occmed/kqaa052