As I write these words, COVID-19 is sweeping through New York City and wreaking havoc around the globe. No other event in recent memory has so deeply disrupted daily life in North America and the ordinary function of the U.S. healthcare system. For many physicians, this pandemic has upended the experience of practicing medicine in the United States.
We face risks to our physical health that most of us might never have anticipated. However, other injuries threaten us, too. Among them is what some call "moral injury." For those of us who survive or avoid infection, moral injury is likely to have the most lasting effect on our well-being.
The term "moral injury" evolved to illuminate the experiences of combat veterans. According to Pediatric Emergency Care, it identifies the deep, lasting emotional injury one may sustain as a result of "having witnessed and/or participated in acts ... [inconsistent with] one's moral beliefs."
The language of war heavily populates the communal conversation around the COVID-19 pandemic. We physicians, nurses, respiratory therapists, first responders and others form the "front line" in a "battle" against the disease. There are concerns surrounding our armor — personal protective equipment (PPE) — or lack thereof. U.S. Surgeon General Jerome Adams has even signaled devastation to come with references to Pearl Harbor and Sept. 11, 2001, as CNN reports.
Given the enormous societal effort required to confront the challenges presented by COVID-19 and the losses we anticipate, the analogy is appropriate. I wonder, however, how many of us recognize how apt the comparison between combat exposure and the healthcare professional's experience of the pandemic is likely to be.
The rationing of medical care
The New England Journal of Medicine (NEJM) recently published a deeply thoughtful article, "Fair Allocation of Scarce Medical Resources in the Time of COVID-19." In it, Dr. Ezekiel J. Emanuel and his co-authors spell out clear and logical ethical priorities, thereby offering support to those facing the vast, ever-changing complexities on the ground. "The choice to set limits on access to treatment is not a discretionary decision," they state, "but a necessary response to the overwhelming effects of a pandemic."
The fact that this approach is necessary does little to mitigate its impact on those of us who must implement it. After all, we are sentient human beings who chose to enter medicine in order to heal and not harm. "The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated," write the authors of "The Toughest Triage — Allocating Ventilators in a Pandemic," also in the NEJM. An Italian journalist writing for the Boston Globe offered proof, describing "anesthesiologists weeping in the hospital hallways [in Lombardy, Italy] because of the choices they [were] going to have to make."
4 Steps to address moral injury
These realities beg the question: How can we soften the impact of moral injury on physicians and other healthcare givers in the time of COVID-19? I would suggest four steps we can take.
1. Start talking now
To begin with, we can start to talk now about what moral injury is and how we and our teammates will experience it. The NEJM article by Emanuel et al. provides a clear and meaningful discussion of the ethical principles and priorities we may need to fall back on to make decisions regarding resource use. A deeper understanding of those principles and how they apply in this situation may support us emotionally and spiritually as we make decisions unlike any most of us have had to make before. Opening the conversation can establish a shared vocabulary for discussing these exceptionally hard experiences as they unfold.
2. Develop clear boundaries around roles
In Italy, once rationing of resources — particularly ventilators — demonstrated the potential to become a necessary reality, a group of physicians and ethicists united to develop a method for decision-making under these circumstances. The two NEJM articles referenced above echo their recommendation that the responsibility for making these choices should not rest on the patient's clinical caregivers. Rather, respected clinicians and ethicists not directly involved in the patient's care must shoulder that burden, allowing direct caregivers to retain their role as the patient's advocate.
3. Advocate for societal support
In a recent editorial published in the New York Times, a New York psychiatrist praised legislation in that state "immunizing health care providers for medical decisions they make in the course of providing care to victims of the pandemic." The extreme nature of the disease and its prevalence together with the lack of PPE "is putting doctors and nurses under severe stress when they are called to perform CPR with virtually no chance of success, endangering themselves — and their families— in the process. I have never seen these health care providers so upset."
He advocates for the rapid development of similar legislation in every state, and I agree. Forcing physicians on the COVID-19 frontline to silently debate between protecting their team's and their own health and avoiding civil or even criminal charges is inhumane and immoral. The law and U.S. society can do better.
4. Anticipate the need for psychological care
Conversations about physician mental health and suicide in the U.S. have exploded in recent years. Now is the time for action. Even those of us not at the epicenter of the developing pandemic in the U.S. find ourselves experiencing significant anticipatory grief. We simply can't help but imagine ourselves in our colleagues' shoes. Every state, hospital and medical society must anticipate that physicians, nurses and other healthcare workers of every variety will require mental healthcare, potentially for quite some time to come. As we prepare ourselves for the coming months, we will do well to prepare for these needs, too.