How Threats to Health Care Professionals' Core Values Lead to Moral Injury

Introduction: Threats to Core Values

In the late 1990s, my colleagues and I started noting a rising tide of what we then called physician dissatisfaction.  One small clue was that physicians I met at meetings seemed to be responding to polite questions about their well-being with less enthusiastic responses.  In the early 2000s, publications begin appearing about health care professionals' dissatisfaction (1-3). 

To better understand what was causing this dissatisfaction, we interviewed doctors and health professionals, and found that US physicians feared their core values were under threat(4).   We postulated that several aspects of American health care dysfunction caused such threats, and set about trying to better characterize and understand them.  Since then, we have been discussing health care dysfunction and how it threatens core values on Health Care Renewal.

Health Care Professionals Whose Core Values are Threatened May be Morally Injured

We were focused on what produced threats to core values, but not so much on how these threats affected health care professionals, other than by producing dissatisfaction.

Meanwhile, others focused on that dissatisfaction, and then on health care professionals' burn-out, but not so much on its systemic causes.  In 2012, we noted the first report on burnout by Shanefelt et al(5), and we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing it. Instead, the literature often characterized burnout as a lack of health care professionals' resilience, or even the result of some sort of psychiatric disease affecting them.

However some physicians were trying to understand how health care professionals' angst derives from health care dysfunction.  In 2018, Dr Wendy Dean and Dr Simon Talbot wrote an article in StatNews entitled "Physicians' aren't 'burned out.' They're suffering from moral injury." They wrote:

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

Rather than burnout, they suggested that physicians are suffering from moral injury:

The term 'moral injury' was first used to describe soldiers’ responses to their actions in war. It represents 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.' Journalist Diane Silver describes it as 'a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.'

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Moral injury is a consequence not of some sort of personal failing, or lack of self care.  It is the consequence of a bad system.  They cited some aspects of health care dysfunction, including

Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

 World War I - Battle of the Somme


Thus

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of 'death by a thousand cuts.' Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Dean and Talbot noted that instead of addressing moral injury, large health care organizations seem to blame health care professionals for their own burnout, and hence make them the targets of interventions meant to improve burnout:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses 'information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water' in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the 'disaster zones' where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

The Resonance of  Moral Injury

Dean and Talbot have continued to raise the alarm about moral injury.  They have expanded on their original writing by noting that health care organizations' focus on flaws of health care professionals as causes of burn out are a kind of "gaslighting"(6)

'Gaslighting' refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system.

The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity.

Scene from Gaslight with Charles Boyer and Ingrid Bergman

They asserted:

A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system.

Health care professionals, often blamed for their own burnout, found that the concept of moral injury resonated.  By mid 2019, Dr Dean, writing again in StatNews, wrote:

we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.

The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.

But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.

By early 2020, the concept of moral injury appeared in the main stream media, that is, the Washington Post, in an article that agreed that moral injury

resonates with clinicians across the country. Since they penned an op-ed in the online health news site Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

The article ended with this from an emergency department physician:

He said many people frame burnout as a character weakness, sending doctors messages like, 'Gee, Keith, you’ve just got to try harder and soldier on.' But [Dr Corl] said the term 'moral injury' correctly identifies that the problem lies with the system. 'The system is flawed,' he said. 'It’s grinding us. It’s grinding good docs and providers out of existence.'

Those further interested in understanding and addressing moral injury should see to the Fix Moral Injury website.


Discussion

In retrospect, it seems that Health Care Renewal has been trying to describe the causes of moral injury since 2004. Thus our work complements that of Dr Dean and Dr Talbot.

Our 2003 article(4) identified five aspects of health care dysfunction that threatened core values, and hence we now realize could cause moral injury:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

Since then we have come upon many instances in which health care professionals' core values were under threat, likely generating moral injury.  We found cases in which top health care leadership took actions that ignored or directly challenged core values, that is, mission-ignorant or mission-hostile management.
 
 A major reason was the rise of  "generic managers." Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.

In other words, health care is now in the grip of "managerialism," as characterized in   an article that in the June, 2015 issue of the Medical Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest.  Some recent examples:
-  A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent  money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc
Here are more examples.

Dean and Talbot cited hospital systems and health insurance companies putting short-term revenue ahead of patient care as a cause of moral injury.  They also noted badly designed and implemented electronic health records and litigation risks as causes. But managerialism is rampant among health care organizations.

So we have identified shocking cases of leaders of various health care organizations who put self-interest ahead of the quality of care, or the integrity of health care education and research.  These organizations were not just hospitals and health insurance companies; but also academic medical centers, and medical schools; pharmaceutical, biotechnology and device companies; and lately, especially in the US, government and government agencies (look here).  (Also see our tag list for links to particular companies and organizations, eg, DHHS, Pfizer, UPMC, UnitedHealth, etc)

Organizational leaders enabled, directed or implemented actions like deceptive marketing and public relations, promotion of propaganda and disinformation,  manipulation and suppression of research, generation of conflicts of interest, and even crime and corrupt actions, including bribery and kickbacks, and fraud.  

And yet, despite these widespread actions generating moral injury, while health care professionals muttered under their breath about the behaviors of health care organizational leaders, there has been so little open discussion that it appears such discussion is taboo- we call this the anechoic effect.  Of course, failure to openly discuss the problem resulted in failure to craft any workable responses.

So appreciating that moral injury of health care professionals is a final common pathway of such extreme health care dysfunction adds even more urgency to our task.  To address health care dysfunction, we must address what health care professionals may see as severe problems, but which they seem afraid to talk about, much less challenge.  

As long as those with a vested interest in maintaining the current system can dismiss their critics as lacking resilience, in need of therapy, and just plain weak, their criticism will be blunted.  However, we must make those with such vested interests face the moral consequences of a dysfunctional system that has provided them with such personal advantages.


References

1. Haas JS. Physician discontent: a barometer of change and need for intervention. J Gen Intern Med 2001;16:496–7.

2. Shanafelt TD, Bradley KA, Wipf WE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–67.

3. Steinbrook R. Nursing in the crossfire. N Engl J Med 2002;346:1757–66.

4. Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).

5.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; 172(18):1377-1385. doi:10.1001/archinternmed.2012.3199 (link here)

6. Dean W, Dean AC, Talbot SG. Why 'burnout' is the wrong term for physician suffering. Medscape - Jul 23, 2019. (link here)

7.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.