One lesson is that moral distress and ethical challenges may be more frequent and impactful in medical care than previously realized.
An astute observer of the COVID-19 pandemic remarked:
The coronavirus crisis was more novel than we thought, more taxing than we expected – and its consequences will last longer than we anticipated. 1
Hopefully, at the time this is being read, vaccines and public health measures will have muted the horrific impact of the COVID-19 virus. However, this abatement will herald the arrival of post-pandemic consequences of a possible prolonged nature as noted above. There will, no doubt, be many residuals for both the general public and physicians who served on the front lines, including mental health effects.2
There is another enduring impact, with an attendant lesson to be learned, from the pandemic experience that results from its challenge to physicians’ moral and ethical codes. The challenge is one that is represented in terms such as “moral distress,” “moral injury” and “ethical dissonance.”3 The lesson to be discerned is that moral distress and ethical challenges may be more frequent and impactful in medical care than previously realized and bioethical training has a greater need and rationale than ever to move front and center in medical education.
The COVID-19 pandemic presented profound ethical challenges and stresses almost never before seen in U.S. medical care or by its physicians. Basic components of care were hampered by uncertain or short supplies of medications, ventilators and ECMO machines. Decisions on allocations of resources were beyond that of triage training. These decisions on resource allocation defined life or death for patients and carried implications rarely experienced other than on a military battlefield.
Beyond their commitment to treat and care for an overwhelming number of patients, physicians and front-line providers experienced significant threat to themselves, with many contracting the virus and succumbing to it.
The ethical strain was further increased by the frantic search for and implementation of treatments, given no previous clinical pathways. All of these conundrums were complicated by their frequent politicalization. Degrees of duty, decisions on when to bend or stand firm and similar considerations were influenced by an ethical infrastructure that may or may not have been sufficiently developed to buffer such a battering ethical storm.
The concept of moral distress has a long history which, in healthcare, has been most traditionally and extensively discussed in the nursing literature dating from Jameton’s work: described as emanating from knowing the right thing to do, but being constrained from pursuing that course of action.4 Emerging as a concern in physician-provided care, moral distress has been defined as the cognitive-emotional dissonance that arises when one feels compelled to act against one’s moral requirements.5 There is evidence that moral distress is professionally widespread and exists internationally in medicine.6,7,8
Some have attempted to relate this concept to the military and war-time experience of “moral injury” which is characterized as a result of being forced to engage in actions contrary to one’s moral values. It has been described as a residual to a morally injurious event related to perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations.9,10, 11
In medicine, moral injury is similarly described as a response to perpetrating, witnessing, learning about or failing to prevent an act that contravenes one’s moral beliefs and expectations.12,13 It may be seen as the failure to practice to the level of one’s values and commitment. The concept of moral injury has been widely disseminated in various medical publications and seen as a cause for much of current physician discontent and even burnout.14
However, definitions, distinctions and implications of these terms, especially moral injury, are still conflated and confusing when discussed in relation to burnout, post-traumatic stress disorder and even human rights violations.15 There are those who have argued that adopting the military concept of moral injury should be done with great caution, if at all. 16,17,18,19 Further, there is ongoing discussion as to the nature and types of moral distress in general or even, more specifically, whether physicians have an ethical obligation to provide care in a pandemic.20
Nonetheless, what seems to be implied, yet rarely overtly discussed in the moral injury literature, is its relationship to professional ethics, and especially how professional ethics relate to personal moral systems. The pandemic has yielded many relevant ethics-oriented articles, but these appear isolated from the moral injury literature.21,22,23 This is surprising as the concept of moral injury, and even moral distress, rests on ethical and moral foundations.
It would seem that ethicists have an important role to play in educating physicians about the ethical dilemmas in the pandemic and should do so on a consistent basis through educational lectures, town-hall meetings, presence on clinical rounds and one to one consultations. This also relates to our major thesis that greater ethical training is needed in medicine for the future as demonstrated not only by pandemic challenges, but also by those ethical conundrums that occur with regular frequency in daily practice.
In line with Dzeng & Wachter3 we prefer the term and focus on moral distress, which seems less controversial and more relevant. As they note, this term provides a framework for understanding and a path to solutions for its negative effects, especially in regard to bioethical education.
While training in bioethics is certainly part of many medical school and residency programs, there is some question as to its adequacy and availability, especially at the post-graduate level.24, 25 This is notably concerning in light of the moral distress reported in the face of the COVID-19 pandemic.
Bioethical education importantly includes such topics as the tenets of autonomy, nonmalfeasance, beneficence and justice and issues such as confidentiality and informed consent. The changing nature of health care may be accelerating ethical issues overall for the medical profession.26 It may be especially true for some practitioners such as intensivists where challenges are frequent and some specialties such as aesthetic plastic surgery where challenges are inexorable.24
The pandemic has shown us that we need more such training. Further, perhaps it needs to be at more personal and difficult levels such as an analysis of situations like dangers to oneself or betrayal by those in power or those who are trusted to promote ethical practice; all leading to moral distress.
It was noted that a greater role by ethicists may have helped during this pandemic, but more robust ethical training can have future vital impacts. The moral distress perpetrated by the COVID-19 pandemic may well have been less pronounced with greater prior and more conspicuous ethical training and (guided) experience.
Enhanced training would allow a broader and deeper examination of critical issues exposed by, but not limited to the pandemic. Such enhanced training can be instrumental in helping physicians to a personal ethical reconciliation in the face of the same or similar issues. Perhaps as importantly, ethical training in dissecting ethical concerns, provides a framework for confronting such issues whenever they occur. Finally, consistent practice in ethical analysis will make scrutinizing troubling issues more likely, effective and comfortable when needed.
If we truly want to promote physician wellness and if we accept, as many are saying, moral distress and ethical issues belie current physician existential malaise, an increasing moral imperative for enhanced bioethics integration needs to be heeded in medical training.
Dr. Asken is the Director of Provider Well-Being at UPMC Pinnacle in Harrisburg, Pennsylvania. Dr. Goldman is Vice-President of Medical Affairs, System DIO and UPMC Pinnacle Epidemiologist. Special appreciation is expressed to Laurie Schwing, MLS for her help in the preparation of this paper.
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