Health care workers scrambled for information and resources as the coronavirus crisis exploded last spring. Yet, facing uncertainty and surging infections, they willingly stepped up to battle the world’s largest pandemic in a century.
Despite that sense of duty, however, many were unprepared for the onslaught of critically ill patients in COVID-19 hotspots like New York and New Jersey. Few anticipated the extreme shortage of protective equipment and health care supplies, nor the confusing and inconsistent response from federal and state agencies.
By late April, it was obvious that health care workers were in trouble as cases of provider depression, anxiety, insomnia, and even suicide mounted. The situation was further aggravated by citizen rallies protesting social distancing and the wearing of masks. Protester signs claiming “COVID-19 is a hoax” added weight to an increasingly discouraged health care workforce.
“This moral injury for frontline providers is a very big deal,” says Carl Heine, clinical education director for emergency medicine in the Elson S. Floyd College of Medicine at Washington State University Health Sciences Spokane.
“There will be a lot of PTSD and grief issues coming out of the pandemic, especially for caregivers who have to make decisions about allocating resources or whether to let patients die alone,” he says. “There’s going to be a lot of guilt and trauma associated with how they are being forced to respond.”
According to the U.S. Department of Veterans Affairs, moral injury is the distressing psychological aftermath of experiencing or witnessing events that contradict deeply held moral beliefs and expectations.
During a public health emergency, health care workers can suffer this intense conflict as a result of a sudden switch in the code of medical ethics.
In ordinary times, health care workers follow the clinical medical ethic—or individual patient care ethic, says William Kabasenche, philosophy professor and ethics education director at the Elson S. Floyd College of Medicine.
“Informed consent and respect for the autonomy of the patient are at the heart of the day-to-day ethics of most health care providers,” he says. “Ideally, we want our interventions to be consistent with the patient’s goals. Some people want full treatment with the highest odds of success while others may decline further treatment for what may ultimately be a terminal illness.”
But during a pandemic when resources like ventilators and N95 masks are limited, Kabasenche says society instead turns to a public health ethic that prioritizes the collective good of the whole community.
“We’re thinking in terms of shared goods and coordinated action that promotes the well-being of as many in society as possible,” he says. “We try to limit the number of deaths that will occur due to scarce resources, but in order to achieve that we may have to set aside individual rights like patient autonomy.”
Kabasenche says health care providers experience moral distress when their normal decisions and work routines are suddenly prohibited—when nurses, for example, can no longer allow patients to have visitors or any kind of direct human touch.
“In ethics, we make a distinction between remorse and regret,” he says. “If I do something that harms you, I should feel remorse and offer an apology. But I still might regret something even if I think I didn’t do anything wrong.
“A health care provider who did her best with the available resources to limit the number of lives lost may feel that she did the right thing. But she may still regret the fact that another person died, or other people were deprived of the chance to be with a loved one who was in the midst of dying.”
Heine, who is also a part-time emergency room physician at Deaconess Medical Center in Spokane, says he is comfortable with bad outcomes if he has stayed true to the individual patient care ethic and done the best he could on every level.
“When we switch to a public health ethic, I can theorize that I am doing the right thing but that does not compensate for my concerns about the very real person in my care that might not get the same individual treatment as in normal times,” he says.
Heine says distress can also arise from society’s expectation that physicians will stay and care for patients during a pandemic despite the danger.
“How lethal does the pandemic need to be before the risk-reward social contract becomes noble versus foolhardy?” he asks. “With PPE shortages and confusing recommendations about what’s appropriate treatment for COVID-19, it’s really tough to know how safe the scene is.
“Firefighters will run into a burning building when the reward is worth the risk—if they have turnouts and the right equipment,” Heine says. “But in some fires, it’s too dangerous to go in, so they decide to fight with external resources only.”
Kabasenche says it’s reasonable for society to expect health care providers to fulfill their end of the contract.
“But it’s also up to the rest of us to try to limit situations that would cause moral distress or injury such as refusing to wear masks or social distance,” he says. “I’d say this is an opportunity for us as a society to recognize how interdependent our well-being and interests are. We need to think as a society and not just individuals.”