Moral injury and the four pillars of bioethics

Introduction

Moral injury occurs when a person experiences an immoral event that disrupts their fundamental moral integrity. Injuries can be self-inflicted by intentionally doing something wrong or come about as collateral damage through observation of a real or perceived action that violates an internal sense of right and wrong. Those suffering from moral injury have a disruption of their sense of morality, with consequences impacting their capacity to behave in a moral manner. The injury reduces their capacity to think of themselves as a moral, good person (Yan, 2016).

The term moral injury was introduced initially to describe the reaction of military veterans to the participation in or observation of profound ethical transgressions occurring during wartime (Shay & Munroe, 1999). The diagnosis of moral injury in veterans relies on the presence of three factors: a betrayal of what is right, which is carried out by someone who holds legitimate authority (e.g. a leader), and occurs in a high stakes situation (Shay, 2014). The diagnosis of moral injury, however, has not been limited to those exposed to the atrocities of war. It has also been evaluated in refugees, health care workers, and adolescents transitioning to adults (Chaplo et al., 2019). In these diverse groups, while moral injury is recognized as a distinct entity from other psychological conditions, such as post-traumatic stress disorder, the diagnosis relies on poorly defined, generalized criteria, which is very similar to that used for combat veterans. While symptom scales have been developed for military personnel, adolescents, and refugees, no specific diagnostic criteria exist for health care workers (Chaplo et al., 2019; Koenig et al., 2018; Nickerson et al., 2018).

The optimal treatment of moral injury, just like the diagnosis of moral injury, remains unclear. Proposals to treat moral injury in medical professionals include participation in support groups, building up personal character, and personal reflection by keeping a diary. The inclusion of standard treatments for post-traumatic stress disorder in veterans suffering from moral injury has also been proposed.

A maxim of medicine is that a correct diagnosis is half the cure. In the case of moral injury as it specifically applies to medical professionals, we propose that a violation of the four pillars of bioethics forms the foundation of the diagnosis. We propose a framework for moral injury in health care based upon the four pillars of bioethics (Beauchamp, 2006). These pillars are patient autonomy, beneficence, nonmaleficence, and social justice. They serve as an effective foundation for evaluating moral behavior in medicine. Our framework clarifies the meaning of moral injury in medicine. When a physician, nurse, or other health care provider participates in, or witnesses a violation of, one or more of these core principles, moral injury occurs. Treatment strategies focused on repairing the breach of these principles of morality in health care may be the best way to heal the injury. Improving the recognition of and reflection upon the moral stressors that clinicians encounter in their practice may prevent moral injury from progressing further. This framework will help more clearly define moral injury in medical professionals, allowing the development of treatment specific to those working in health care.

Patient autonomy

The principle of respect for autonomy holds that each person with capacity has the right to make their own decisions, and providers have a moral obligation to respect this right. In the clinician-patient relationship, patient autonomy can be especially vulnerable. This principle is often at the forefront of ethical concerns in health care (Entwistle et al., 2010); (Stammers, 2015).

Compromising patient autonomy can result in moral injury, regardless of whether or not the perceived event is a true violation. For example, children presenting to the emergency department may openly voice a desire to not get an injection or an intravenous line. Although it is recognized that the decision of the legal caregiver overrides that of a young child, the perception of compromised autonomy can result in moral injury. Although the reason for the injection or intravenous line is medically indicated, the action nevertheless is against the will of the child. Logically, we know children will cry and object to many medical treatments. Still, whenever possible, it is recommended to obtain consent from both the child and the parent. Consent to treatment requires permission from the legal representative of the child, and if possible, assent from the child as well (Tait & Hutchinson, 2018). The accumulation of such experiences that challenge the clinician’s duty to respect patient autonomy may eventually lead to moral injury.

Nonmaleficence

The principle of nonmaleficence is captured by the Latin maxim, primum non nocere: “above all, do no harm.” It has been estimated that medical error is the third leading cause of death in the United States (Makary & Daniel, 2016). While the potential to reduce these errors is debated, common preventable harms include medication adverse events, central line infections, and thromboembolisms (Nabhan et al., 2012). With increasing ability to treat patients comes increasing opportunity to harm patients as systems become more complex. Most clinicians are very aware and regularly reminded of these statistics, however, the seemingly futile efforts to try and reduce the incidence of these harms is troublesome and can contribute to moral injury. Bureaucratic and administrative interference, well intended or not, can hamper efforts by physicians and nurses to decrease harm, leading to moral injury and a sense of powerlessness.

Beneficence

With the many opportunities to harm a patient in mind, we must also remember that patients come to clinicians in search of improvement or restoration of their health, which leads to the principle of beneficence. The commitment to helping others is the driving force amongst health care workers and to accomplish this goal there must be a net benefit over harm (Gillon, 1994). Decisions on diagnostic pathways, treatment plans and societal policies all must balance the benefit versus harms, and these balances also must be made in context of the patient’s values.

Beneficence, when compromised, creates numerous conflicts in medicine that can result in moral injury. When the cost of proper medical care exceeds the ability of an individual patient to pay, beneficence can be compromised. Pharmaceutical pricing is a common cause of this moral compromise. For example, many patients with atrial fibrillation will benefit from changing their warfarin prescription to a newer, direct oral anticoagulant such as apixaban. However, the up-front price of the newer medication prohibits them from changing, even though the total financial cost of the newer medication is estimated to be lower due to fewer medical complications (Gupta et al., 2018). Beyond the financial impact, the negative impact upon the patient’s health can be devastating. Compromising the principle of beneficence occurs when the patient is unable to take the best medication because of financial limitations. Although the medical complications from the older medication will ultimately cost more money, the hard reality is that patients will take the cheaper medication because they cannot afford the up-front costs of the newer, better medication.

Social justice

The final pillar of bioethics is social justice. Justice demands that limited resources be distributed fairly, and that patients not be discriminated against due to any number of demographic variables such as race, religion, gender identity, sexual orientation, age, or cultural background. Moral injury occurs when these ideals conflict with the hard reality of medical care where discrimination does occur, primarily along socioeconomic lines.

These complex socioeconomic disparities cause moral injury because clinicians know what their patients need and find the economic barriers to needed care to be illogical, unnecessary, and capricious. They know that not getting that nursing home bed placement will result in a bad outcome, often at a much higher cost. They know that not getting a patient with a substance use disorder necessary treatment will ultimately cost more to society, although the health care plan may save money. They have seen first-hand the elderly family member decide they would rather die than leave a large medical bill for their surviving relatives. Witnessing these events on a regular basis doesn’t cause burnout, it causes moral injury.

Medical professionals working in medical systems and countries that rely on privately funded insurance may also experience a constant violation of the principle of social justice. For example, one study comparing a population with universal medical insurance found disparities in the care given to racial and ethnic minorities to be greatly decreased or even eliminated (Chaudhary et al., 2018). A similar study found that universal medical insurance ameliorated socioeconomic disparities in mortality (Veugelers & Yip, 2003). Medical professionals working in private medical insurance systems who know about and trust such research studies may experience a persistent low-grade violation of their bioethics. This, over time, may progress to symptomatic moral injury. The primary means of addressing such issues would be meaningful involvement in improving the larger health care system.

Conclusion

Moral injury occurs when there is a disruption in an individual’s sense of personal morality and capacity to behave in a just manner. It is a common occurrence in medicine because of ongoing violations of bioethics that have become an intrinsic part of the healthcare system. The prevention of moral injury is accomplished by decreasing violations of the four pillars of bioethics whenever possible. Patients deserve autonomy, and we can give this to them. Although we cannot always help our patients as much as we would like, we can always help them in at least some way. We can be vigilant when taking measures to increase patient safety and decrease harm. With a firm understanding of the basic principles of bioethics, medical professionals can become more adept at identifying and reflecting upon moral violations in the workplace. This recognition helps prevent recurrent moral injury, decreases burnout, and can help to heal previous injuries.

Data availability

No data are associated with this article.