Doctors, nurses, and other health care workers in Massachusetts must be suffering from burnout. How could they not be? Our state’s emergency departments are overflowing. Primary care specialists are inundated with requests from patients. An exodus of nurses from the field is putting even more pressure on those who stay. And a recent study found that a doctor would need 26.7 hours in a day to provide appropriate care for their patients.
Yet health care workers in Massachusetts and across the nation say they aren’t burned out. They say they are morally injured. The distinction is vital — and if we don’t recognize how, we could end up making the problem worse.
The concept of moral injury began gaining traction in military settings in the late 2000s as the United States grappled with the psychological fallout of our ill-fated incursions into Afghanistan and Iraq. The term, which was coined by Jonathan Shay and brought into the clinical mainstream by Boston University professor Brett Litz, describes the psychic suffering that sometimes occurs after someone either goes against their own deeply held ethical beliefs (by choice or coercion) or witnesses someone doing the same.
The idea was therapeutically helpful for specialists trying to treat military patients who were feeling the mental and emotional effects not only of suffering harm but of inflicting it. Simply put, moral injury is the pain associated with perpetrating harm.
But a battlefield is a far cry from a hospital, and health care specialists aren’t trained to kill — they’re trained to heal. So why are doctors and nurses dealing with an ailment that is best known for afflicting service members?
As the physician and columnist Lisa Doggett puts it: “We know what our patients need but can’t provide it.”
When they enter the profession, health care workers take on an ethical responsibility to provide high-quality care to the sick and dying. But the American health care system often fails to support them as they do so and in some cases actively hinders their efforts.
Part of the problem lies with the corporatization of hospitals, which drives providers to put financial outcomes ahead of medical ones. The Globe recently quoted a Boston-area doctor who said that medical policies are too often “based mainly on making sure we recoup maximum financial reimbursement for our services.” As a result, she said, “I don’t feel I can take care of my patients safely anymore.”
The slow-rolling collapse of Steward Health Care, which runs eight hospitals in Massachusetts, provided the backdrop for serious lapses in care, none more unsettling than the death of a new mother at St. Elizabeth’s Medical Center last fall. Cost-cutting measures at the hospital led to the repossession of a raft of medical devices, most crucially an embolism coil that could have stopped a fatal bleed in her liver.
Providers involved in situations like this can feel persistent distress in the weeks and months following, but it’s clear that the pain has nothing to do with burnout. Because how do you cope with burnout? You take a vacation, cut back on work hours, meditate, try more self-care. Or just toughen up. None of those actions remedy the problem, which in the case of St. Elizabeth’s, was the absence of life-saving equipment.
Bioethics specialist Keisha Ray argues that calling all such distress burnout incorrectly suggests that it’s simply weakness or a lack of mental fortitude on the part of the provider. Yet the problem isn’t really our physicians, who are among our nation’s most resilient professionals. The problem lies with a system that too often fails them — and in the process fails patients as well.
Let’s listen to our providers when they say they’re morally injured. Just because they’re not burned out doesn’t mean they’re not getting burned.
Joshua Pederson is associate professor of humanities at Boston University and the author of “Sin Sick: Moral Injury in War and Literature.”
