treasures in jars of clay: moral injury in healthcare

Rhona Knight looks at how moral injury has become a recognised and growing challenge in healthcare, and how we can begin to face it as Christians.

Do situations at work disturb you? How might you classify them? Do any seem like moral distress or moral injury? These two terms are being adopted in many walks of life in different ways. In 2021, the BMA produced a document on moral injury and distress with its own definitions of the two terms. [1] In passing Motion 296 in September 2021, the BMA noted that moral and ethical integrity is an essential part of wellbeing and morale in the medical workforce. [2] It could also be argued to be an essential part of delivering appropriate healthcare.

We can see some roots of the current interest in moral injury and distress in earlier work on integrity and conscience in healthcare. [3]  Stephen Pattison and Andrew Edgar, for example, spoke into the complexity of this area in their work on integrity in medicine. In their 2011 article ‘Integrity and the moral complexity of professional practice’, [4] they comment that integrity becomes an issue where values, norms and ethos clash with the organisational context or those of other people. They note limitations in the more traditional individualistic view of integrity that sees integrity as deeply held moral principles, congruent with practice. They acknowledge that this form of integrity is often tied up with identity. They introduce another understanding of integrity. This they describe this as ‘the capacity to deliberate and reflect usefully in the light of context, knowledge, experience, and information (that of self and others) on complex and conflicting factors bearing on action or potential action’. In this approach, they argue, there is a need both to respect the moral position of others and for compromise. For them, both types of integrity are relevant in healthcare. However, in the gap between the two, there seems to be significant potential for what is currently being understood as moral distress and moral injury.

moral injury as soul-wounding

Moral injury is often seen as soul-wounding. [5] It is distinct from trauma, though many experiencing moral injury also experience an embodied traumatic response. Much of current moral injury scholarship is rooted in the military. Initially, explorations by Jonathan Shay and others emphasised moral injury arising from betrayal in the chain of command in a high-stakes situation, where soul repair requires institutional reform as well as individual and group therapy. Later understandings, seen in the work of Brett Litz and colleagues, saw a potentially morally injurious experience (PMIE) as ‘Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code. We also consider bearing witness to the aftermath of violence and human carnage to be potentially morally injurious.’ [6]

Moral injury hinged around a discrepancy between moral values and experience resulting in ‘dissonance and inner conflict’. Summarising Litz’s understanding, soldiers were being harmed by doing (through negligence, ignorance, weakness, or deliberate fault) something they perceived as wrong, harming others and self, or by the context of war itself where they were harmed by the environment or their perception of it. [7] Shay and Litz see moral injury within a clinical discourse. Winikka-Lyndon, in his article Mapping Moral Injury, identifies two other discourses. [8] The juridico-critical discourse relates to the compromising of dignity and demeaning of some humans, leading to an acceptance of this demeaning behaviour in a way that changes the norms of society, resulting in some humans becoming seen and treated as of less inherent dignity than others. [9] Examples of this can be found in the writings of Murphy, Hampton, and Bernstein. [10, 11] Structural discourses relate to how society itself is structured in a morally injurious way. We are morally injured by the culture in which we live – we are, therefore, all potentially subject to moral injury. Looking at the work of Carol Gilligan, this form of moral injury is linked to gendered norms where social pressures inhibit authentic development. [12]

is moral injury a diagnosis?

The word ‘injury’ leads us to think of a particular diagnosis with its own symptoms, signs, examination, investigations, management, patient’s perspective, and bio-psycho-socio-spiritual context. Moral injury is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). [13] It appears the reason it was not included was due to a lack of agreement about its nature and measurement. [14] However, I would like to suggest that it is helpful at this time when the term moral injury is being used to describe the experiences of healthcare professionals, to identify more widely accepted symptoms, signs, causes, and predisposing factors that might lead one to consider this as a diagnosis.

■      Symptoms include sustained and enduring negative emotions, such as guilt, shame, contempt and anger, dissonance, diminishment, disillusionment, devastation, disconnection, and spiritual or existential crisis.

■     Signs include compassion fatigue, burnout, vicarious or direct trauma, PTSR/PTSD, anxiety, depression, somatic illness, sleeplessness, and social withdrawal, etc.

■      Causes include perceived betrayal; violation or suppression of deeply held or shared moral values, either by the person themselves, work colleagues or patients; and significant and/or persistent moral distress.

■      Predisposing factors include exhaustion, overwork, personality characteristics, schema, isolation, co-morbidities, and medical specialty

what of moral distress?

The term distress is often a symptom of something deeper. One of the early writers in the area of moral distress in the context of medicine was the nursing philosopher Andrew Jameton. He notes that moral distress occurs when ‘one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. [15, 16] He distinguishes between initial and reactive distress. Initial distress ‘involves feelings of frustration, anger, and anxiety people experience when faced with institutional obstacles and conflict with others about values’. Reactive distress ‘is the distress that people feel when they do not act upon their initial distress.’ [17] He also identified and gave examples of how to address this distress: immediately, in the short term and long term. [18] The BMA defines moral distress as ‘the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action…The individual suffering from moral distress need not be the one who has acted or failed to act; moral distress can be caused by witnessing moral transgressions by others.’ [19]

I would like to broaden this out and suggest moral distress is a term used to describe embodied feelings, such as uncertainty, discomfort, anxiety, and concern, that have a moral dimension or root to them. I suggest that typically, moral distress can arise in the context of the workplace when you are in a situation where you are observing, considering or preparing to implement decisions where you are: unsure or uncertain what is the right thing to do – eg facing moral dilemmas, or unable to do what you believe needs to be done – eg due to lack of resources or value conflicts. It can also arise when you are considering enacting a decision that is against your core values or reviewing a past action or inaction that you now consider may have been morally or ethically wrong. Moral distress is, therefore, an everyday part of the life of someone working in healthcare. Unprocessed, I suggest long term and repeated moral distress can result in moral injury.

management of moral injury and distress

There is no current validated treatment for moral injury. [20] Evidence-based psychotherapies for trauma are being used, acknowledging that moral injury and trauma often co-exist. Adaptive disclosure employs mechanisms of moral repair, including a secular confession, which leads to compassion, forgiveness, and reparation. Acceptance and Commitment Based Therapy (ACT) promotes non-judgmental acceptance of internal experiences and committed action toward value-congruent behaviour. Joshua Knabb outlines a faith-based version of ACT for Christians, [21] reflecting how the six processes of ACT can be related to the Christian faith as psychological flexibility that emerges from walking with God in love. Through watchfulness, endurance, the contemplative transcendent self, and practising the presence of God, psychological pain, and suffering can be accepted, leading to committed, value-congruent action in response to the call of God.

James 5:13-20, which concludes, ‘Therefore, confess your sins to one another and pray for one another, that you may be healed,’ seems key. If the moral injury we experience is as a result of our own wrongdoing, we can confess and receive forgiveness and healing. We are also encouraged to talk with others openly and honestly as we seek God’s call in the mess. But what of the sins we find hard to receive forgiveness for, and what of the moral injury where the causes are more organisational, complex, or less clear-cut? And how might moral injury and distress be prevented?

affective equipoise

Equipoise is a term describing perfect balance. It is often used rationally – for example, in clinical trials. Affect is about things that relate to, arise from, or influence feelings. In using the term affective equipoise, I am acknowledging the interdependent, embodied nature of emotions. Affective equipoise is an embodied equipoise of body, mind, and spirit arising from being deeply rooted in God (Psalm 1). From a place of affective equipoise, we recognise our brokenness and the brokenness of other people, the church, and the world, in a way that may stir us but does not shake us. Affective equipoise enables us to notice, name, lament, and accept that things are as they are. At that point of acceptance, it is what it is. There is a pause. It is not passive but there is no immediate intuitive or longer-term reactive striving arising out of our sinful nature and disordered attachments, where our protest arises from our own brokenness.

Instead, there is a pause that notices, names, laments, but then accepts and then asks, ‘What then, God? What is your invitation to me in moving from contemplation to action?’ [22] One place we can see affective equipoise in the life of Jesus is with the woman caught in adultery. She is morally injured. She is aware that she has broken God’s law; she is being demeaned and shamed by the crowd in a society that sees women of less value. What does Jesus, who sees this, do? In a way that reminds us of Jeremiah 17:13, he is silent, bends down and writes in the dust. Jesus lives and ministers from a place of deep-rootedness, dwelling, and oneness with the Father [23] – a place of affective equipoise.

treasure in jars of clay

When we are: rooted like the tree in Psalm 1, connected like the vine in John 15, and dwelling in and indwelt by God as in John 17, we are in a place of affective equipoise, equipped to face and manage the moral distress and potentially morally injurious experiences that would assail us. As we reflect thankfully, praising, revering, and serving God, giving ourselves wholly to God and seeking freedom from things that would draw us away from God, we increasingly inhabit an embodied awareness of living in the loving gaze of God; of knowing ourselves as loved sinners, being aware of personal sin and the sin of the church and world; of being with Christ in the Holy Week journey. In their use of the Ignatian Spiritual Exercises, the writings of Joyce Huggett and the Lectio 365 app highlight these ways of being with God and dwelling in God’s word. From this place, we are more able to discern and enact the call of God – from contemplation to action in the day-to-day warp and weft of life. This resonates with faith-based ACT for Christians but takes it further. It is not just about how to journey through suffering, moral distress, and moral injury – it is about a way of being that is so rooted in God that, while we may be stirred by PMIEs, we will not be completely shaken by them (2 Corinthians 4:7-18). [24] ›