Joshua Parker: Moral injury and burnout are not the same

Joshua Parker argues that we need to recognise the distinct experiences of doctors’ work related suffering

In recent months, the medical community has seen a growing debate about whether burnout among doctors should be redefined as “moral injury.” Until recently, this conversation had been confined largely to the US, but in April 2019 the president of the Royal College of Physicians, Andrew Goddard, added his voice to those who think that burnout is better described as “moral injury”. He noted that we need to make it clear that healthcare staff are “injured” by the overstretched system.

This is an important topic, but I’d argue that rebranding burnout as moral injury is inappropriate. It conflates their separate causes and fails to recognise the distinct experiences of doctors who experience work related suffering.

Imagine a soldier shoots dead a child whose body is laden with explosives. How might this soldier feel on returning home and holding their own children? The impact of such situations on an individual’s wellbeing and selfhood is profound. This kind of act, its violation of what is right and its reflection on you as a good (or bad) person, epitomises moral injuries. The betrayal of what is good fractures moral identity. It is these kinds of events that lead to moral injuries. It is easy to see why the concept of moral injury was developed in a military context.

The philosopher Nancy Sherman, who has worked extensively with the US military, describes moral injuries as “experiences of serious inner conflict arising from what one takes to be grievous moral transgressions that can overwhelm one’s sense of goodness and humanity. The sense of transgression can arise from (real or apparent) transgressive commissions and omissions perpetrated by oneself or others, or by bearing witness to intense human suffering . . . In some cases, the moral injury has less to do with specific (real or apparent) transgressive acts than a generalised sense of falling short of moral and normative standards befitting good persons and good soldiers.”

It’s true that doctors can experience moral injuries. I’d hope that doctors generally have a strong sense of what is good and right—a moral identity—and hold themselves to high professional standards. Medicine is intimately connected with human wellbeing and operates at the fringes of life and death. Inevitably, doctors witness a range of human pain, hardship, and misfortune daily. Moreover, what doctors do, fail to do, or see others doing, and how this affects patient care and outcomes, could be perceived as a grievous moral transgression. This all threatens doctors’ moral identity and can leave them susceptible to moral injuries; but how does this line up with what we mean when we talk about burnout?

The Royal College of Psychiatrists defines burnout as “a syndrome of emotional exhaustion, involving the development of negative self concepts, negative job attitudes, and a loss of concern and feeling for patients.” The causes of burnout are complex but include factors like excessive workloads, long hours, not being given rotas in advance, commuting distance, loss of hospital amenities, and so forth. It is the recognition of the harm that these working conditions inflict—and a sense that for many doctors they may be worsening—that has driven a lot of the medical community’s recent focus on burnout.

While the impact of these working conditions should not be underestimated, none “overwhelm one’s sense of goodness and humanity.” These kinds of workplace struggles are not rooted in deep transgressions of what is right and pose no threat to an individual’s moral identity. A cause of burnout they may be, but moral injuries they are not.

It’s true that the demands of the system can push doctors away from providing the kind of care that they believe is best for their patients. This too is recognised as a cause of burnout. Being unable to fulfil your moral duties to your patients—“falling short” in Sherman’s terminology—is likely to erode your sense of moral self. When the system upends doctors’ sense of right and wrong they suffer a moral injury, not burnout. This is not because burnout and moral injury are interchangeable, but because burnout has been used inappropriately to describe what is better viewed as moral injury. The system may cause burnout; for example, by imposing relentless pressures and making doctors feel like just another component on a conveyor belt. Yet when the system operates as a bulwark to doctors acting according to their conscience, their ensuing sense of despair is closer to moral injury than burnout.

Even if they can share causes, the two remain phenomenologically distinct. The prevailing feeling in burnout is emotional exhaustion with its sequelae. Moral injury, on the other hand, is associated with profound distress and intense emotions of shame, guilt, or self-loathing.

Moral injuries and burnout usually have different causes and are experienced in distinct ways. Our response to them must also differ. As burnout results from how individuals are treated by a system, doctors’ experiences of burnout could be drastically reduced by system reorganisation. Incidentally, this is contrary to resilience, which has justifiably received a strong backlash for its emphasis on individuals making changes to their lifestyle or mindset.

In contrast, no amount of system change could prevent all moral injuries. Even working within a perfect system, doctors could not escape bearing witness to the suffering of others. Moreover, they will continue to face situations that threaten their moral identity because doctors face dilemmas that aren’t the result of the system. The onus for moral injury cannot be entirely put back on the system. While organisations should be able to offer staff support, the response to moral injury has to start with the individual and be focused on healing the moral wounds of medical practice.

The idea that burnout and moral injuries are somehow interchangeable is simply false. They have different causes, are experienced differently, and require different solutions. Doctors’ wellbeing matters and is in urgent need of remedy. To make progress we must take a fine grained approach, thinking carefully about the nature of doctors suffering and how to fix it.

Joshua Parker is a GP trainee at Macclesfield District General Hospital and an education fellow in ethics and law at Wythenshawe Hospital. In his non-clinical role, he teaches medical ethics. Twitter @joshp_j

Competing interests: None declared.