Mental health disorders are in vogue, and by that I mean our society pays a lot of attention to quantifying and identifying the social and mental dysfunctions of modern life. It is my belief that most mental health conditions represent ancient helpful survival mechanisms that have become dysfunctional because they clash with modern social systems. Violent trauma often leads to post traumatic stress disorder. Bipolar individuals might just have a physiologically heightened sensitivity to the fact that modern life is absurd and maddening. The morally injured feel genuinely betrayed and guilty.
Moral injury (MI) is largely ignored, and is underrepresented in research. Most related research looks into classical history or literature to connect the dots. The mechanism of MI is the transgression of deeply held beliefs or expectations perpetrated by an authority. Because humans depend for survival on membership, in and validation by family and tribe, the cognitive dissonance between reality and the perception of what should be, can be extremely deleterious. “Unlike post-traumatic stress, which is a result of a fear-conditioned response, moral injury is a feeling of existential disorientation that manifests as intense guilt2.” Warriors from every society and empire have dealt with MI. Agamemnon’s betrayal of Achilles, King Saul’s murderous jealousy against David, and veterans of the Viet Nam Conflict who suffered from the conflict between the momentary demands of the battlefield and their underlying moral beliefs are a few examples.
Health care inflicts MI constantly and my aim is to address this. As patients we are injured every month when we pay an entire mortgage worth of insurance premium and still have to meet a high deductible and an extravagant copay. We are injured when providers demean or patronize us, abuse their power, or inflict unnecessary suffering. For the patient, any action by a health care entity that violates personal sovereignty is morally injurious.
Health care workers suffer injury at the hands of each other: the medication error ignored at the nurse’s station, the doctor who orders unnecessary procedures, and the technician who is forced to carry out morally questionable orders. This regular violation of ethics, winking at incompetence, and hypocritical prosecution of employees ‘outside the clique’ drags down the culture of an organization. Health care workers are so blind to the effects of moral injury that they call their cognitive dissonance ‘professional detachment’ and label the effects they suffer ‘burnout and fatigue,’ rather than guilt and anger. The impact on the healthcare worker of human trauma should not be downplayed: the opportunities to address trauma and suffering are what brings providers into the system. It is when the system itself inflicts suffering that the healthcare worker experiences MI. The taxonomy and definitions of what is wrong with health care are broken in themselves. This is why health care has an impenetrable doublethink professing that sick care is health care. This is the cost of people having ethics or values under a system functionally opposed to those values. Health care workers and patients have to reconcile in their mind a system that both saves lives and ruins them. Am I being too harsh?
The late Donella Meadows, MIT professor and pioneer in systems thinking writes that “…the least obvious part of the system, its function or purpose, is often the most crucial determinant of the system’s behavior4.” Casual observation of health care as a system suggests it is a financial engine also leveraged by the government to control the populace. Big pharma, insurers, and hospital systems do more to keep people addicted and sick than to promote wellness. There are notable exceptions but these are not normative.
No fiat of science or innovation brought about by a technocracy can remove this plank from our eyes. No policy change or regulation enforced by bureaucracy can change the heart of man. This requires serious introspection, dialogue with others, and accountability. There is also drift to low performance in health care, born of intellectual appeasement, which is indeed moral cowardice, defined by Ayn Rand as “fear of upholding the good because it is good5.” Moral injury is rampant in health care because of this banality of evil. Hannah Arendt defined the banality of evil in her 1963 book, Eichmann in Jerusalem. The question is whether evil is radical or simply thoughtlessness, “a tendency of ordinary people to obey orders and conform to mass opinion without a critical evaluation of the consequences of their actions and inaction1.” The idea of health care preventable deaths approaching 400,000 a year as suggested by the Journal of Patient Safety3 is no less horrifying than cremains falling like snow in Nazi Germany.
So what is to be done? Rand states that moral cowardice (and therefore moral injury) is prevented by “an unimpeachable character; one need not be omniscient or infallible, and it is not an issue of errors of knowledge; one needs an unbreached integrity, that is, the absence of any indulgence in conscious, willful evil5.” Doug Cropper was CEO of Inova Fairfax Hospital in Virginia during a Joint Commission accreditation review. When a food service worker was caught falsifying food refrigerator temperatures Cropper was perfectly willing to fire the employee, blow the whistle on the hospital, and turn in all evidence to the Joint Commission. Later Cropper wrote, “the incident was very distressing to me. It was distressing because it spoke to a breach of our commitment to our patients and to each other for total integrity in everything we do. Someone decided it was a ‘minor thing’ to fill in some missing data. Let me be clear about two things. First, it is never acceptable to be less than totally honest about errors or omissions in our work. Second, please know that there are no “minor things” in the daily work we do. As we have observed before, excellence comes from not doing great things nearly so often as it comes from doing our normal daily work with great consistency and careful thoroughness6.” We should all approach our work with the same ethics as Cropper and for God’s sake, if you see something, say something.
When it comes to healing from MI, our modern military and the warriors of old have much to teach us. Veterans never truly had to suffer in quiet from MI, even when there was very little support or conversation. Healing from MI comes from the ability to relate one’s story. Over the last fifteen years of conflict warriors who have spent their career cycling through deployments are the latest generation to reckon with MI. Asynchronous warfare leads to morally ambiguous or stark conflicts with the individual’s understanding of honor and integrity.
Countless support groups, charities, and social organization have developed over the years that allow veterans to tell their story, and speak for the dead. Veteran Service Organizations (VSO) have taken lessons from antiquity and applied them to the problem of MI. Veterans have been encouraged to weave and tell their stories in different contexts. Sometimes spiritualized and sometimes analytical, veterans have used storytelling, writing, art, and activism to contextualize and understand their personal odysseys. Much as I do now, writing this article.
Medicine also needs this awakening. The Society for Participatory Medicine is a step in the right direction, but a more aggressive approach is required. We need to self-identify, identify others, and support each other in this. Perhaps a service organization needs to exist for the burned out and conscience-seared health care professionals, casualties of another kind of conflict. The problem is once you have been seared by MI you are vulnerable to experience it over and over again. As a result, you might commit MI against others, or tolerate it when inflicted upon you. Moral injury might live with you forever: “moral injury makes it hard to transition from memory to the present; it confuses the old self and the new. If the injury is severe enough, it can be almost impossible to see yourself in the present. Instead, you see the person who was capable of making the wrong decision when, years later, you know you could have made a different one2.” Only through the hard work of remembering and telling your story will you process your experience. Tell it to a friend, a clinician, a coworker, or maybe a soldier. Write about it, turn it into art, find a way to use your experience to impact someone else’s life. Nothing formal is required, merely a serious and in depth reckoning of where you have been, and where you wish to go.
- Arendt, H. Eichmann in Jerusalem. New York, NY. Penguin; 1963.
- Gibbons-Neff, T. Why distinguishing a moral injury from PTSD is important. Stars and Stripes Find Out More. March 9, 2015. http://www.stripes.com. Accessed September 12, 2016.
- James, J. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety. 2013;9(3):122–128. http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx Accessed September 12, 2016
- Meadows, D. Thinking in Systems. White River Junction, VT. Chelsea Green Publishing; 2008.
- Rand, A. Altruism as Appeasement. The Objectivist. 1966;01(5)
- Singleton, K. (President and CEO, Inova Health System) 2005, Memorandum to Inova staff, June 1.
A retired Army medic Jesse Eastes is now health care consultant for the Houston Patient-Physician Cooperative. Specializing in economics, he has a master’s degree in Health Care Innovation from Arizona State University. He is a proponent of the idea that economics is health, and holds to the heterodox Austrian School. Jesse is a world traveler and veteran of Afghanistan.