When Healing Hurts: A Doctor’s Struggle with Moral Injury in U.S. Health Care

In the winter of 2011, I walked away from fifteen years of training in surgery and psychiatry, working in both rural and urban emergency rooms, and as a private practice psychiatrist, to manage research funding for the U.S. Army in regenerative medicine and hand and face transplants. I was exhausted and frustrated that, on too many days, no matter the delivery structure – academic, state-funded, or private practice – it was nearly impossible to get my patients the care they needed. I grieved for the only career I’d ever wanted and had worked so hard to achieve, but being complicit in a system that borrowed my credibility and exploited my patients’ vulnerability to serve its own purposes was nonnegotiable. I had to leave but one question lingered: Resourceful and resilient in every other area of my life, why couldn’t I make this doctoring thing work?

Four years later, I began exploring that question in earnest, after learning about a Midwest physician’s death by suicide. Physician colleagues across the country in various specialties and practice structures eagerly told me, informally and in confidence, about their work experience and their distress. Repeatedly, I heard the same refrain: “I signed up to work long hours and to see impossibly difficult things. What I didn’t expect was how hard it would be to get my patients the care they need.” These colleagues rejected burnout as an inaccurate description of their experience because the term implied individual susceptibility to the pressures of the job but said nothing about the endless, maddening challenges built into systems of care that made it hard to uphold their oaths.  They needed different language, but what?

Discovering "Moral Injury": A Term for the Crisis in Our Health Care System

One steamy spring day about a year into this journey, I heard a research psychologist on NPR talking about his work with military veterans who suffered a different kind of invisible wound from post-traumatic stress. They had a compromised sense of their moral integrity, rather than their sense of physical safety. He called it, “moral injury.”

The term, first used with combat veterans, refers to the perception of betrayal by a legitimate authority in a high stakes situation that causes one to transgress deeply held moral beliefs. 

The veterans with moral injury felt like they lost their moral compass. In health care, the deeply held beliefs referenced in the definition are the oaths we take to put patients first. The description of moral injury sounded like what I had heard from colleagues who described a conflict between carrying out their oath to heal and keeping their jobs in a profit-driven system. Caught between conflicting demands, these doctors, like soldiers, were questioning their moral core. 

One of the first colleagues I ran this concept past was Simon Talbot, a reconstructive plastic surgeon who specializes in hand surgery. We met because of a shared interest in hand transplants, but our vantage points in medicine were very different. Simon was a surgeon, and I was a psychiatrist. He worked in academic medicine, and I walked away from a private practice. He left New Zealand after medical school, so he was steeped in publicly funded universal health care. And, whereas I come from a long line of salesmen and plumbers, medicine is in his blood — his great grandfather, grandfather, father, uncle, and twin sister were doctors; his mother and her mother were nurses. We talked between sessions at a transplant conference in 2016 about how medicine changed us. We soon concluded that, if our experiences were so similar, despite our many differences, then we probably were not the problem, the system was the culprit. Moral injury struck him, too, as an accurate descriptor of his experience.

Our conversations might have gone nowhere except that when I returned home, my physician husband’s stable congenital heart condition suddenly and rapidly deteriorated. The local physicians, who were also my husband’s colleagues, were inexplicably paralyzed. They dragged their feet about making plans to transfer him and I watched, helpless and imploring them to intervene, as a terrifying critical illness almost ended tragically. They finally sent him to a teaching hospital two hours away and he recovered fully, but I was deeply puzzled and vowed to understand why those local physicians, who I knew were good people, took so long to act in their patient’s best interest. It turned out that a new corporatized mindset was behind their delays, keeping every justifiable dollar from leaking out of the health system. Those physicians had to play brinksmanship with my husband’s life or risk their jobs.

A few months later, armed with firsthand experience of the impact on patients, Simon and I laid out our concept of moral injury to a group of academic surgeons. We proposed that the demand-resource mismatches of burnout contributed to clinician distress, but the policies and management practices running counter to our oaths, and heedless of patient best interests, was most of the problem. Physicians are skeptical scientists, to the core. We expected they would approach this new idea with reservations and poke holes in the concept. If they did, it would only make our planned paper stronger. Instead, almost in unison they paused, raised their eyebrows, and then rattled off story after story of how moral injury fit their experience. They unanimously urged us to publish it.

Many months and many rejections later, STAT News published our paper. Immediately, emails, direct messages, and calls flooded in. Most were some version of, “This is the language I’ve needed for years.” We waited for interest to die down, but instead, it grew and spread beyond health care, to social workers, veterinarians, teachers, public defenders, and others who felt the language also applied to them. So, in the fall of 2018, we established a nonprofit organization, Moral Injury of Healthcare, to change the narrative of occupational distress. Dozens more articles, research papers, a book (If I Betray These Words), and two podcasts have followed, and “moral injury” is now a widely used descriptor of occupational distress. But the systemic and cultural changes that form the core of solutions are meeting resistance at many levels of leadership.

Clinicians commit years to learning their professions, during which it is ingrained that patient needs always take priority. In exchange for their courage and persistence, they want the autonomy and latitude to provide excellent care and comfort, in accordance with their training. Moral Injury of Healthcare aims to change the environment so that it is easier for patients to get good care, and for the health care workforce to provide it in a sustainable way.

Wendy Dean is the co-founder of Moral Injury of Healthcare and co-author of If I Betray These Words.