Moral injury and Covid-19: praying for the mental health of our front-line

A few years into the American wars in Iraq and Afghanistan, mental health professionals working with veterans began to notice something puzzling: some returning service-members had post-traumatic stress disorder symptoms, but they did not seem to identify PTSD-type events that generated these symptoms.  At the time, conventional wisdom was that a person needed to experience some type of life-threatening event—explosion, car crash, medical scare—to end up with PTSD.  However, these warriors who had nightmares, hypervigilance, emotional disturbances, and social isolation did not seem to be reacting to being under attack; instead, they seemed to be distressed with something touching their core in a very different way.

In an attempt to define this phenomenon, a team led by Brett Litz (a previous boss of mine) published a paper in 2009 outlining what they called “moral injury,” which can occur as a result of “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”  For military personnel, one can imagine the painful choices that can lead to this type of injury—making a mistake that cost your friend his life, watching civilians be targeted, being betrayed by politicians who make dubious wartime decisions, or any number of other catastrophic  events that can take place in the context of war.

It is exactly this type of situation that the world is mobilizing to prevent for our courageous medical professionals who are at the front line of this battle.  This heartbreaking reality has come to pass in Italy, as hospitals do not have sufficient beds, respirators, or other life-saving medical supplies, and, according to reports, are forced to choose who will and will not get medical attention.  Doctors, nurses, and other support staff, who enter the profession to save lives and “first, do no harm”, are powerless to help those in greatest need, and may themselves be the agents of that decision.

In the rest of the world, medical professionals and their family are making tremendous sacrifices—leaving their families for the foreseeable future so that they do not spread the virus to their families and communities, and working with insufficient protection and supplies.  When they have moments to think in the midst of the chaos, they may also feel betrayed by the medical systems or responsible government agencies whose decisions have led them, their families, and their patients more vulnerable.

These are the conditions that, in a clinical way, can be said to engender “potentially morally injurious events.”  But the technical language fails to capture the deeply troubling circumstances that may compel medical professionals to violate their own deeply held moral beliefs in combatting this pandemic.  Doctors, by profession, are accustomed to facing the possibility of death.  They are also trained how to triage and identify those in most urgent need of support, as well as how to cope with sometimes making the wrong decision despite their best intentions.  But we cannot expect them, in addition to the tremendous load they already bear treating the ill, to also have to cope with turning away patients they know will die because there is simply not enough space or resources.

And so, as non-medical civilians, this is just another reason for us to be committed to do our part.  We should stay home, social distance, and do what we can to reduce the rate of spread of the infection.  And as we pray for the health and stamina of the worlds’ hospital workers, we may also add a prayer for their mental health as they make difficult decisions every day, and face unknowable pressure to keep afloat systems that may be teetering even in the best of times.  Let us pray for the mental health of their families who will lose a mother, father, spouse, or child for weeks or months.  And let us also add one more prayer that they not suffer moral injury in this war that they are waging—and let us recognize that the answer to this prayer, if we stay home, may be at least partially within our control.