Dear Editor,
The COVID-19 pandemic is producing a maelstrom of morally distressing and potentially morally injurious events (pMIEs). PMIEs are defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” [1]. Moral distress, which occurs when intensive care unit (ICU) professionals cannot fulfill their moral requirements due to internal or contextual constraints, can fade over time. However, moral injury, a concept originating in military psychology, signifies a durable mental wound characterized by symptoms such as guilt, shame, existential or moral conflict, a loss of trust in goodness, moral detachment and/or moral disorientation [1–3]. A person becomes morally injured if exposed to repeated incidents of moral distress or due to a single egregious violation of morality.
Particularly in public health disasters, it is important to recognize moral injury with ICU professionals apart from post-traumatic stress disorder (PTSD) and the aforementioned moral distress. Moral injury, moral distress and PTSD differ with regard to etiology and consequences (see Table 1). PTSD does not necessarily involve guilt, shame, moral conflict or disorientation. The term “moral injury” signifies a deep mental wound, as opposed to a physiological or characterological disorder. Moral injury and PTSD can, however, be comorbid, and both may lead to avoidance symptoms, substance abuse and increased risk of suicide [3].
Table 1.
| Moral distress | Moral injury | PTSD | |
|---|---|---|---|
| Cause or etiology | Inability to act according to core moral values or obligations due to internal (e.g., a conscientious objection) or contextual constraints (e.g., restrictions on family visits; resource scarcity) | Exposure to repeated incidents of moral distress or due to a single egregious violation of morality | During a traumatic event (e.g., experiencing war, being raped), regular physiological stress responses (hyperarousal, increased epinephrine, increased blood flow to muscles) become amplified, and stimuli reminiscent of the trauma trigger the elevated stress state |
| Symptomatology | Feelings of powerlessness, unfairness, frustration, anger or anxiety | Persisting feelings of guilt and/or shame, loss of trust in goodness, moral detachment, moral disorientation, re-experiencing the MIEa | Unwanted upsetting memories, nightmares, emotional distress or physical reactivity after exposure to traumatic reminders, re-experiencing the traumatic event |
| Understanding | Maybe temporary, episode of distress | Hard to resolve, mental wound | Physiological or mental disorder |
| Consequences | If it dissipates over time, one’s moral framework remains intact. Repeated or persistent distresses lead to professional dissatisfaction, moral injury, decompensation and burn-out | Demoralization, erosion of one’s moral or spiritual framework, self-blame or harm, avoidance of morally conflicting thoughts and feelings, social isolation or alienation | Avoidance of trauma-related thoughts, feelings or reminders, decreased interest in activities, hypervigilance, risky or destructive behavior, and difficulty in concentrating and/or sleeping |
| Examples in ICU practice | An intensivist worries about having compromised the quality of patient care in his daily round as he was only able to examine half of the 45 COVID-19 patients he was responsible for; a fellow describes feelings of unfairness for compromising quality of care for non-COVID-19 patients, some of whom are in a worse condition than COVID-19 patients | A nurse has care duties for more patients than usual and develops the habit of, at the beginning of her shift, apologizing to COVID-19 patients for not being able to provide them with the care she feels she ought to provide due to time constraints; an intensivist described, for the first time in her career, feeling guilty for blaming patients for having caught the virus | When asked which private affairs have recently had an impact on one’s working life, an ICU professional expresses ongoing emotional distress with experiencing abuse as a child |
aMorally injurious event
During the COVID-19 pandemic, ICU professionals who participated in informal interviews and peer support consultations expressed events akin to pMIEs. Professionals described cases in which quality of care and basic care duties were compromised due to being responsible for a large volume of COVID-19 patients. Professionals reported feelings of disorientation, worry, a loss of control and powerlessness. Many professionals explained that because all COVID-19 patients suffer from the same disease and receive similar treatment, and due to restrictions on family visits, patients seemingly become “bodies” without context. Professionals, moreover, sometimes had to act while being confronted with the almost impossible choice between safe working conditions and quality of patient care.
The COVID-19 surge demands from ICUs to commit to long-term mental and moral support, as moral injury and a severe loss of moral integrity does not easily or quickly dissolve. Efforts are needed to prevent harm to individual professionals and substantial turnover in a highly qualified workforce.
First, we recommend ICUs to set up peer support mechanisms that take into account the needs and wishes of professionals. Generally, intensive care attracts perfectionists who may experience moral demands as especially stringent [4]. Peers should encourage professionals to facilitate self-forgiveness and start re-integrating moral transgressions into their moral code and accept that good persons sometimes, out of necessity, act badly. Since guilt and shame are not easily addressed, peers should aim for building long-lasting working relationships.
Second, we advise to stimulate grassroots dialogues on moral requirements in pandemic times. Small-group ethical deliberations help professionals explicate the values and principles at stake and clarify personally felt moral requirements and frameworks. Recognizing the wound is the first step out of moral disorientation and detachment.
Author contributions
All authors contributed to the study conception and design. Acquisition, analysis and interpretation of the data were performed by Niek Kok, Astrid Hoedemaekers, Marieke Zegers and Jelle van Gup. The first draft of the manuscript was written by Niek Kok, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
The research was supported by ZonMw, Project Number 516012513.
Compliance with ethical standards
Conflicts of interest
This manuscript has not been published elsewhere and is not submitted simultaneously for publication elsewhere. There are no relevant conflicts of interest.
Ethics approval
Compliance with ethical standards. Due to circumstances, written consent was gathered by email.
Footnotes
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References
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