The COVID-19 pandemic has been unprecedented as such an event has not happened on such a global scale since 1919, with the Spanish Flu. At the beginning of the pandemic, we sometimes heard muzzled voices of health care providers who experienced sheer horror due to the quickly escalating demand for urgent care, ICU beds, and ventilators.
It is important to note that these incidents were happening on an unprecedented scale due to the quickly escalating demand for urgent care, ICU beds, and ventilators — all three of which have seen unimaginable numbers as patients continue coming in waves from different parts of the country.
We have had more than 50 people per hour being admitted into hospitals with respiratory symptoms at some points.
Many policies and procedures were “thrown out the window,” for lack of better words, during the pandemic. We saw situations where we disregarded previous protocols, where health care providers were forced to reuse personal protective equipment. This was a clear violation of health and safety standards.
We saw care providers make do with homemade masks instead of using medical-grade masks, items that pre-pandemic were readily available and frankly quite inexpensive to purchase. We heard the news of many states frantically begging the government to intervene and provide the much-needed aid.
We heard of heroic efforts made by prominent individuals to help charter planes to bring PPE from other countries. I still remember watching the New England Patriots plane landing with much-needed PPE and the heavy security presence as they guarded the precious cargo. I believe they had 1.2 million N95 masks from China.
So, in this article, I pose the question of moral injury.
What exactly is it, and how is it relevant to the COVID-19 pandemic? The idea of moral injury is not new, but it is truly relevant in the context of COVID-19.
“Moral injury” is a term that comes from military medicine, and it refers to the emotional pain caused by witnessing, participating in or bearing responsibility for an event that causes serious physical harm.
It can happen during wartime or when someone has been exposed to traumatic situations. Moral injury is not about guilt. It is more like a wound than an infection. It can fester for decades without treatment before manifesting as PTSD or depression. Many physicians and other frontline workers experienced a moral injury due to the pandemic, policy changes, and inconsistencies in care. I am not blaming anyone but rather highlighting the repeat emotional and physical trauma care providers went through.
The moral distress that many health care providers are experiencing has left them feeling deeply distressed by their inability to “save” everyone they see, despite doing everything in their power.
In the face of this kind of moral injury — which I am using as shorthand because we have no other word for what these people experience — one might ask: What good am I? How does my healing matter? What do you say when someone says: “Why should I live if my baby died?”
Imagine knowing that the patients you care for will get poor treatment compared to another cohort of patients.
Through the grapevine, shared experiences of physicians worldwide, and even some news reports, we heard stories about how physicians were forced to make terrible decisions. They were forced to decide who gets to live or die based on life expectancy, comorbidities, and, unfortunately, in some cases, politics.
As a physician who swore the Hippocratic Oath, these actions arguably violate the oath core to the physician’s identity. However, we were on the battlegrounds of a deadly COVID-19 pandemic — a battle that has killed over 3.8 million individuals in a short period of time. We might never know the true numbers as patients sometimes died in their homes before diagnosis, or in many countries, the systems to keep track of deaths were grossly inaccurate.
What the COVID-19 pandemic has taught us is that these types of events will happen again. The implications are global, and we need to be prepared for future outbreaks.
We live in a global world where travel is easy and relatively simple. I am not trying to be a pessimist, but there is a chance that another pandemic will occur in our lifetime.
As responders on the frontlines, it is important to remember our own mental health and well-being as caregivers to continue doing this work with integrity. For those of you who experienced trauma, I implore you to seek help. It would be best if you talked to someone skilled. Sometimes, verbalizing and journaling the pain you witnessed is needed. One needs to offload these thoughts not to fester and cause us problems physically or mentally.
I will be remiss to discuss “the elephant in the room.” The fact is moral injury, for many of us, was present pre-pandemic. We struggled with providing the gold standard for health care for our patients when in many cases, individuals did not have sufficient insurance coverage, or in some cases, they did not have coverage at all. The pandemic affected the most vulnerable in our society. And in a modern world, I am saddened that this is still a common occurrence.
History will look back at us to comment on how we handled this pandemic. Let us learn from it. It’s everyone’s collective responsibility to do their part as many times our actions or lack thereof can adversely affect others.
The pandemic has shown us how the best of human intentions can turn out to be the worst. Addressing moral injury is our collective responsibility so that we do not repeat mistakes and create more harm in a world already ravaged by COVID-19. It is my hope, as a health care provider, advocate for social justice, and conscientious resident of this planet — we do better next time.
Tomi Mitchell is a family physician.
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