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How Healthcare Is Causing 'Moral Injury' to Doctors

Discussion in 'Doctors Cafe' started by Mahmoud Abudeif, Mar 23, 2019.

  1. Mahmoud Abudeif

    Mahmoud Abudeif Golden Member

    Mar 5, 2019
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    Pressured Into Situations That Violate Their Beliefs

    Being a physician is not like any other job.

    Doctors witness suffering among people they've come to care for. They're intimately involved in decisions involving life and death, pain and suffering, and quality of life. Many of the situations they face involve wrenching, frustrating ethical quandaries.

    At the same time, physicians are overworked, pressured with productivity targets, and stymied by regulations and rules. Today's healthcare system often prevents physicians from being able to deliver the care that they feel is right and best for the patient.

    The impact of dealing with feelings of dismay and helplessness over not being able to "just be a doctor," and the inability to resolve frustrating ethical dilemmas in a positive way, assault a person's emotions and psyche.

    Some have called it a "moral injury" that is being inflicted upon physicians.

    "Working in healthcare is not like working at Google or some other corporation," says Carol Bernstein, MD, a psychiatrist at New York University's Langone Medical Center. "Physicians are dealing with people who are really frightened and scared. You're trying to help them, trying to make them better. That's why many doctors think of this profession as a higher calling."

    "Physicians talk about the corporatization of medicine, with the imposition of all the guidelines and regulations," says Bernstein. "It makes doctors less able to deliver the care they want to deliver, which contributes to burnout and stress, which harms physicians and their relationships."

    Moral Instead of Physical Injury

    The concept of moral injury arose in relation to military situations, in which soldiers in time of war were required to participate in situations that violated their own moral and ethical codes. Jonathan Shay, MD, PhD, psychiatrist in Colrain, Massachusetts, described a form of moral injury that occurred when service members were forced to do something that violated their own ideals, ethics, or attachments.

    Soldiers could experience the moral injury effect simply from witnessing or learning about acts that breached their own moral beliefs and expectations, according to Michael D. Matthews, PhD, professor of engineering psychology at the US Military Academy in the Department of Behavioral Sciences and Leadership.

    What Situations Create Moral Injury?

    Situations that violate a physician's ethical belief in doing no harm and hamper the goal of making a patient well may lead to damaging emotional distress. Often for physicians, the challenges of trying to deliver the care they believe is best are counterbalanced by the relationships they have with patients, which is most important to doctors, says Bernstein. "That makes it worth the sacrifice," she says.

    "However, physicians often get burned out because there's no way to balance those sacrifices. How this situation affects an individual doctor is highly variable and depends on what resources the person comes in with, what their home life is like," says Bernstein.

    Ethical quandaries that arise on the job can also lead to moral injury — quandaries made all the more difficult by regulations, legalities, and the threat of consequences if a physician tries too hard to defend or promote his or her views.

    Physicians Report Their Difficult Dilemmas

    In Medscape's Ethics Report 2018: Life, Death, and Pain, more than 5200 physicians told us about their frustration over and reactions to ethical dilemmas in which they had participated. Some accepted these issues as part of the tough calling they had followed; others remained upset and disturbed.

    "There's no question that ethical issues will always be present for physicians," says Becca Brendel, MD, JD, associate director of the Center for Bioethics at Harvard Medical School and vice-chair of the American Psychiatric Association's Ethics Committee. "As technology changes and there are a rapidly increasing number of options for treatments to keep people alive, physicians are often stymied from doing what's right."

    In Medscape's Ethics Report, physicians described their toughest ethical dilemmas, which included the inability to relieve a patient's pain or suffering due to family control and goals that were not always noble (such as involving inheritance); inability to help suffering patients who were asking to die; quandary over keeping a less-than-competent physician from performing procedures for fear of retaliation; inability to save a child because the parents wanted to try "their own" treatment; and watching a patient die a preventable death because he or she refused to have a blood transfusion when needed.

    "The worst experience I had was caring for a patient with ALS," said one physician. "Because of regulations involving medications, I could not do the best job of relieving her suffering. It was horrible to watch her gasp for air, miserable and unable to control her functions. I know she wouldn't have wanted to stay that way, but she couldn't speak for herself; and her family wanted us to do whatever we could to prolong her life, no matter the quality of that life. We met with them many times, but they would not budge. It was hard to put it out of my mind."

    Said a critical care physician: "I saw a family who insisted on all treatment for a 95-year-old who was intubated, struggling and obviously in pain. The family wanted her alive, and it had something to do with money. The hospital ethics committee and legal team got involved, but the family threatened to sue. I'm supposed to 'do no harm,' but I couldn't stop this."

    "I have performed abortions because I had to, even though it was against my beliefs," said one ob/gyn. "I basically liked my job, but I found another place to work where I didn't have to do that."

    "Physicians have used terms like 'moral regret,' 'moral residue,'" Brendel says.

    Serious Decisions That Weigh Heavily

    "Because so many dilemmas have life-and-death consequences, they're very serious decisions that weigh heavily on physicians as professionals and, more generally, as people," says Brendel. "They create a great deal of tension. Physicians take on a very critical responsibility to put patients' health interests first."

    Medical ethical dilemmas become increasingly tougher because often there are few right or wrong answers.

    "Sometimes it takes a while for physicians to get used to the fact that the multiplicity of variables makes situations far more complex than they may have been used to in other settings," Brendel says. "When you're learning medicine, there's a very clear path: If you have an illness, here's the treatment or here's the set of options for treatment," says Brendel.

    But there may not be a clear path in the real medical world. "There's never or rarely going to be an answer that makes everyone happy," says Brendel. "As physicians, we need to learn how to deal with some of our moral concerns that don't get included in the process."

    "Doing work with ethics is not about finding one answer, or the one right answer, but about developing an array of ethically allowed options," she said.

    What Can Help Prevent Moral Injury?

    Bernstein says that this emotional injury to physicians can only stop when our current healthcare system changes, when there's a noticeable difference in the unremitting pressure on physicians and the constant stumbling blocks that prevent them from delivering the kind of healthcare that they feel will be best for patients.

    The ethical elements that can lead to distress and moral injury can be elucidated by a better understanding of the role of bioethics. Physicians need more education and training in making ethical decisions, says Brendel.

    "Awareness and education are very important," says Brendel. Still, she says, even within ethics courses, you can't learn everything you need to know. Many medical specialty organizations, including the American Psychiatric Association, have an ethics committee where members can call in with ethical questions and get guidance from the committee, she says.

    Ethics education has become a requirement in medical school and in postgraduate medical training, says Brendel. Even beyond that, many states have ethics training requirements for maintaining a license.

    "If a physician didn't feel like these weighty challenges affected them, then something is wrong," says Brendel. "But the challenges shouldn't become so weighty that physicians are stuck with them."


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