Coronavirus: the moral wound of health workers

Every health worker, who works in the emergency-urgency area, has a very high level of what we psychologists call resilience , that is, the ability to respond to potentially traumatic events .

This is a skill that every operator has developed over the years of their profession dealing with emergencies, bereavement and particularly serious situations.

The coronavirus emergency has entailed levels of complexity that go beyond any previous situation. This has had a powerful emotional and psychological impact on frontline healthcare professionals .

The difficult ethical choice

One of the critical issues that has characterized the work of health workers in these months of pandemic has had to do with the dilemma of making an ethical choice . Not being able to guarantee all coronavirus positive patients intubation and access to intensive care, which patient to admit to the intensive care unit and which to refuse?

In this regard, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (Siaarti) has published a text aimed at colleagues. On the basis of this, the resources, not accessible to everyone, should be reserved for those who were most likely to survive and, secondly, for those who could have more years of life saved.

This indication has changed the health paradigm that provides for equality of care , regardless of age or probability of survival. To an ethical, political question are added powerful psychological implications . It is legitimate to think that being faced with deciding who to give a chance to survive, intubating the patient, and who not, can represent an emotionally overwhelming condition for the healthcare worker.

The psychological consequences of treatment choices

Surely it happens in the medical profession that we have to deal with difficult choices but the coronavirus emergency has placed doctors in front of this further level of complexity by not having resources for everyone and asking them, in some cases, the question of who to save and who to leave. to die.

Facing the choice of denying someone care to save someone else, due to the lack of resources of a system unable to guarantee assistance to all its citizens, can be a challenge to our morality .

Faced with this dilemma, doctors, despite having received the support of the Siaarti document, have not been freed from the burden of decision-making. Consequently from the emotional implications linked to the impossibility of providing adequate treatment to all patients with consequent loss of human life.

It is not yet clear how similar events may have impacted on operators but it is legitimate to assume that some of them may experience a certain level of moral suffering , what in the literature is called moral injury .

The moral injury of health workers

A recent study published in the British Medical Journal (Greenberg, Docherty, Gnanapragasam & Wessely, 2020) has indicated moral injury as one of the mental health risks of operators engaged in the covid-19 emergency.

Most of the research on moral injury has been conducted with the military and war veterans. This is because the nature of war and combat create situations in which people can live experiences that strongly clash with their own moral code or with the values ​​of civil life.

Think for example of killing an enemy fighter, or engaging in or witnessing acts of disproportionate violence, or even feeling euphoria and excitement in killing someone.

Although the term has therefore been applied mostly in the military context, extending its use to the health sector can provide valuable information on the experiences of health workers. In fact, they had to make difficult decisions relating to people’s life and death. Sometimes they felt they should and could have saved a patient’s life but were unable to do so.

What is meant by moral injury ?

The moral injury involves damage to their conscience when a person commits, or witness fails to prevent acts that transgress their own moral beliefs, their values or their own code of ethics (Litz et al., 2009). Or it can involve a deep sense of betrayal when you feel inadequately supported by others in positions of power who have an obligation to do so.

In traumatic or unusually stressful circumstances, people can therefore perpetrate, fail to prevent or witness events that contradict deeply ingrained moral beliefs and expectations. The moral injury is the psychological result, behavioral, social, spiritual and sometimes that can result from exposure to such events.

Examples of events that can cause moral injury include:

  • Having to make decisions that affect the survival of others;
  • Doing something that goes against your beliefs (act of commission: for example, causing harm to others;
  • Not doing something in line with your beliefs (act of omission: for example, failing to protect people, by mistake or inertia);
  • Be witnesses of an act that violates one’s moral code (witnessing acts contrary to one’s beliefs);
  • Experiencing betrayal by trusted others (for example, not feeling protected by superiors).

Moral injury and negative emotions

What happens when an act that was, or at least seemed to be, crucial and justified in a moment of extreme criticality is re-analyzed in the light of a violation of one’s values ​​and deep moral convictions?

Emotions are generated which may include guilt , where the person feels distress and remorse about that event (for example, “I did something bad”); shame , in which the person blames himself for the behavior and generalizes it to a negative sense of self (for example, “I’m bad for what I’ve done”). A person who experiences betrayal may feel anger , resentment, and impair the ability to trust others.

Another distinctive emotion in the case of moral injury is the inability to forgive oneself which can lead people to believe they do not deserve to feel better, as if they were serving a sentence for the wrongdoing. A person’s life becomes filled with self-loathing and self-punishment, to the point of destroying one’s sense of self as a loving and worthy human being.

One can feel unworthy, unforgivable, and irreversibly damaged (Farnsworth, Drescher, Nieuwsma, Walser & Currier, 2014).

Moral injury and psychopathology

These thoughts and emotions can contribute to the emergence of mental disorders such as depression and post-traumatic stress disorder . The moral injury has also been associated with higher rates of self-injury and suicidal ideation (Bryan, Bryan, Morrow, Etienne & Ray-Sannerud, 2014).

It is known that the injury moral also be manifest as physical disorder : are common muscle tension, headaches , gastrointestinal disorders and sleep, as well as feelings of fatigue and frustration.

It is safe to assume that moral injury also has an impact on an individual’s spirituality . For example, an individual may have difficulty integrating what has happened with their faith, eliciting doubt about the spiritual beliefs they previously held.

Moral Injury and Post-Traumatic Stress Disorder

It is important to note that not all individuals exposed to potentially traumatic situations necessarily develop post-traumatic stress disorder . Exposure to events potentially capable of inducing moral injury does not automatically lead to the emergence of this condition.

Although there may be overlap in symptoms between moral injury and post-traumatic stress disorder, they are two distinct conditions. Moral injury is often associated with post-traumatic stress disorder where the situations that cause moral injury are traumatic events per se for the individual.

As such, they trigger post-traumatic stress disorder symptoms, characterized by intrusive memories, avoidance of people or places that somehow recall the event, and emotional dysregulation.

Unlike post-traumatic stress disorder, moral injury is not a mental disorder; nevertheless it represents a dimension that deserves to be investigated.

Addressing the psychological distress of health professionals

It is legitimate to think that in this moment, in which health workers can catch their breath after months of sleepless nights and exhausting shifts, the reality of everything that has been experienced can re-emerge into consciousness.

Even if the epidemic has not disappeared and therefore we cannot speak of a real phase of demobilization, that is to say the phase in which the emotional impact of what has been experienced arrives, this can be the moment. in which one comes to terms with a war that was mostly fought in the secret rooms of hospitals.

By virtue of this, it is important that, among therapists dealing with trauma, the ability to recognize and not ignore the risk that some operators on the front line in dealing with the covid-19 emergency may have developed moral injury become widespread .

It can be difficult for patients to share certain morally harmful events due to the feelings of guilt and shame associated with them. Therefore, therapists should be sensitive enough to pay attention to internal conflicts related to the violation of deep moral values. They must try to offer health workers the care necessary to allow them to return to normal individual, occupational and social functioning.


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