Making the ‘least worst’ decisions: moral injury in the COVID pandemic

by Helen Fidler

Acting against your own instincts can lead to stress and burnout but the BMA is here to offer support

Location: UK
Last reviewed: 18 December 2020
helen fidler

You might well feel the last thing we need at the moment is more psychological jargon telling us how miserable we all are.

We already know how we feel, how we have at least twice the risk of suicide compared with the general population and that most of us are suffering from burnout and stress. But why is this?

What exactly is it that is making our roles as consultants so damaging to our mental health and prompting almost one third of us to retire early at present? Why are anxiety, depression and stress the most common reasons for sickness absence in the NHS?

Enter the concept of moral injury: the psychological impact of being made to act against your moral compass or being unable to do what you believe is right.

For doctors, this can stem from being forced to make or act on decisions that we know are not ideal for our patients, and then doing so repeatedly owing to the dysfunctional system we work in.

The subsequent damage that can be done to your conscience as a result of having to make these choices (or obey someone else’s) and an intangible feeling of ‘letting your patient down’ is what is referred to as moral injury.

Just think about yourself in clinic and think of how often you’ve had to apologise to patients for the waiting times, the delay in being seen, the lack of theatre space, or the cancelled procedure. Or imagine, being stuck at home self-isolating when you know your colleagues are desperately over-stretched.

Or having to learn the new skill of providing compassionate care for dying patients in a corridor due to bed shortages, or having no time to ring that anxious relative, and the concept of moral injury will start to make sense to you.

It is what happens when virtuous professionals collide with deeply flawed organisations – we are repeatedly forced to make radically suboptimal decisions for patients and are structurally inhibited from fulfilling our core professional obligations.

Throughout my 22 years as a consultant gastroenterologist, I’ve become used to the responsibility of providing the best care I can for my patients. Although we have always had to be mindful of resources in the NHS it once seemed possible to do so in a timely fashion.

But there has been a gentle slide over the last 10 years or so into an increasing shortfall between what we feel our patients need and what can be provided.

And now the COVID pandemic has blown us out of the water in our efforts to provide high-quality care during a period of significant staffing shortages and underfunding. So, we work harder, write more business cases that often go nowhere, and become increasingly ‘injured’ by the system we work in.

This is then compounded by the other practical concerns of working in a far from perfect NHS: the potential of a complaint arising owing to a resource issue beyond your control; the time consuming nature of Datix reporting every single patient-safety issue; the threat of criminal prosecution affecting our families owing to impossible service demands.

Under-staffing adds strain to the system which can lead to moral injury, while moral injury makes it difficult to retain (let alone recruit) doctors.

With around 30% of consultants retiring early, 43% of appointment panels unable to find someone to appoint, and increasing numbers of us forced to prioritise our mental wellbeing over the career we love, things look to get worse unless something is done soon.

Despite it being an absolute ‘no no’ in medical school interviews, most of us do work in medicine because we want to help people. When that expectation crashes into the brick wall of reality, repeatedly over time, we either leave, become ill, or both.

So, what would a responsible employer do in this situation? The unexamined burden of moral injury must be mitigated.

The NHS Long Term plan aim of ‘backing the workforce’ must recognise this and be properly funded and implemented.

In the short term we need an open dialogue about responsibility without autonomy, the dangers to staff and retention of under-resourced services and the disconnect between what we are experiencing and the expectations upon us.

Bring back doctors’ communal areas where we can share experiences, implement the BMA mental wellbeing charter, and develop a career grade fatigue and facilities charter. It will cost, but not as much as the huge expense of sick leave and locums.

Urgently request honesty from employers about where the responsibility lies and stop the damaging demands for us to work harder and harder for less and less.

It is imperative that staff are informed about moral injury and its dangers and stop being made to feel responsible for things which are beyond our control.

We desperately need to retain our workforce by working in a system that lets us care for our patients properly. No one goes into work to make the ‘least worst decision’ and our patients and our workforce deserve better.

Accessing help

The BMA offers 24/7 counselling and peer support services to all doctors and medical students, regardless of membership. Find out about these and other wellbeing resources.

Sharing your stories

As the consultants committee continues to explore the issue of moral injury, and what can be done to address it, we invite members to share their own experiences.

Having real-life examples of the impact of moral injury can help forward our work on behalf of doctors as we seek better compensation and resources for consultants.

If you would like to share anything on the subject with us, please email [email protected]