By Wes Fleming
Moral injury is a violation of what an individual holds to be morally good and true. The concept arose from research seeking to explain the moral dimension of trauma experienced by combat-exposed veterans. Moral injury entails a unique distress, comprised of evaluative moral judgments that often lead to psychological and spiritual/existential distress.
Recent studies extend beyond military populations to include healthcare providers and first responders. The COVID-19 pandemic presented particularly difficult moral challenges for healthcare professionals. Who should be treated when there are a scarcity of medical resources like ventilators? Who should receive personal protective equipment when supplies are limited? Which staff should risk exposure and who should work from home? Who are considered essential and nonessential workers?
Visitor policies have caused significant moral pain. Most hospitals did not allow families to see their loved ones until they were end of life. Family priests and pastors are still not allowed in to see a patient in many hospitals. This, of course, not only increases my workload as a clinically trained hospital chaplain, but sets me up for having to defend hospital policy — therein lies some of my own moral injury. Yet I understand the reasoning behind these decisions, so I feel the tension and dilemma — the moral paradox engendered by Covid-19. Procedures and guidelines are written to prevent harm, but then cause harm.
These visitor policies remind me of what combat-exposed veterans share regarding their experience with the rules of engagement on the battlefield — the rules are meant to save innocent lives, but they also often put armed personnel in danger. On the hospital front, for instance, an ALS patient was not allowed to see his wife unless he was end of life. Well, he wasn’t dying, but he was days away from losing his voice. He wanted to hold her hand and tell her in person that he loved her one last time. We advocated for an exception to the policy, but we were denied.
That hurt. We suffered a form of moral injury, feeling betrayed by the institution, but I saw the value of the policy, too. Visitors were a significant source of contagion, and patients needed to be protected. Then, on the other side of the moral dilemma, I can’t imagine the moral injury the administrators felt holding the line. I know these directors, and they are caring people.
Following the height of the pandemic, we now face a shortage of nurses, which triggers a new set of moral problems. Some nurses are mandated to work in units they have no familiarity with just because they are RNs. Also, hospitals are hiring traveling nurses who get paid twice as much as the nurses who stayed. Nurses who showed loyalty and worked double shifts when COVID was doing its worst feel betrayed by their institution. But I know that the nursing managers experience moral injury, too, when they are forced to make these decisions.
Research substantiates these observations. Duke University, in collaboration with Chinese researchers, adapted a scale used to measure moral injury in military populations and applied it to healthcare. The study underscores that what nurses and doctors call burnout may actually be moral injury.
One story from the peak of the pandemic illustrates many of these issues. A 40-year-father of three children was allowed into the hospital to be with his wife, who was dying from COVID- related complications. It was a week before Christmas, and as I escorted him from the entrance to the ICU, he told me how they had unsuccessfully tried to keep the virus out of their house. When we arrived, the nurse explained that his wife had died minutes earlier.
The man was shaking as he donned a respirator helmet and surgical gown with the help of the nurse, who gave him strict instructions about entry and exit out of the room. He sat down at the bedside and held his wife’s hand. We could see his lips move as he poured out his heart to her with tears. As the nurse and I observed through the glass, it was like watching a TV show with the volume turned off.
It felt surreal to me, but the nurse said she didn’t feel anything at all. This was a daily, sometimes hourly event. She was more concerned about him not following her directions and risking infection.
When the man came out, he turned to me and asked if he could now see his mother, who was also in the hospital with COVID. But she was not dying, and the policy said that visitors could only see patients who were dying. I called the nurse manager anyway, and she met me in the ICU lobby with the husband and permitted us to go up the back stairwell to see the patient. We found his mother in another negative pressure room behind yet another plate of glass. When she saw him, she got out of her bed and pressed her hand against the glass door – he was not allowed to go in the room. Her other hand covered her mouth as she cried. She had been told of her daughter-in-law’s death. He met her hand with his own and pressed his face against the glass weeping. And they cried together, never touching, communicating through the glass wall.
On this occasion, no nurses attended the moment. They were too busy to take in the experience. Noting the drama from the corner of their eye, they pushed it off, likely to be haunted later.
You can see how the pandemic induced moral injury among all parties in the story. The father wondered if he did enough to protect his family from an outbreak. The visitor policies evoked feelings of guilt and betrayal among staff, patients, and administrators. The overworked and perhaps traumatized nursing staff felt like they were never able to do enough. And the unavoidable need for quarantine and isolation shattered natural human connection — a glass cage that evoked surreality and the absurd.
What can hospital chaplains and church clergy do? In my practice, I am especially alert to hear moral judgments and evaluations coming from patients and staff. I offer them my focused presence, so at least they feel heard. That’s really important. So much moral pain is relieved just through focused presence and empathetic listening — often there are no answers. It’s a moral paradox. I invite people toward acceptance of “what is,” without necessarily condoning the problem or issue. For Christian staff, I lead toward, “not my will but yours be done.” I have also invited staff opportunity to embrace and acknowledge their guilty feelings — to confess their guilt according to some religious traditions — and find forgiveness. Certainly the sacraments comfort our Roman Catholic patients and our priests are quick to respond to a need for mercy and grace
Because moral injury is a part of normal moral processing, we don’t want to eliminate the guilt and anger or treat it like a pathology. Moral injury is a response to moral violation and should be addressed as such with spiritual practices that elicit self-compassion, acceptance, love, forgiveness and understanding
Wes Fleming, BCC, is a clinical chaplain for the Veterans Administration in Syracuse, NY.