I I remember the exact moment when I realized the enormity of the Covid-19 crisis. In the days before the pandemic was even called a pandemic, I was sitting in a hastily organized gathering of high-level colleagues from the hospital. We were reflecting on how we might respond if the terrifying scenes emerging from northern Italy were replicated in our hospital. An intensive care consultant stood up and said: “People have to understand that we are entering a war zone; we have to adapt accordingly.” There was a moment of stunned silence in the room. To someone else, these words might have seemed melodramatic, but to this wise and respected physician, they struck a chord.
With the latest figures from the UK government showing that there has been nearly 150,000 deaths where Covid-19 was mentioned on the death certificate, it is understandable why some people liken the pandemic to a war. In fact, daily life on the NHS is now peppered with military language: front line, golden command calls, redeployment, buddy systems. As a psychiatrist, the term that has resonated with me the most is “moral damage.”
Moral damage can be defined as distress that arises in response to actions or inactions that violate our moral code, our set of individual beliefs about what is right or wrong. In the medical literature, moral injury has historically been associated with the mental health needs of military personnel, arising from their traumatic experiences during active duty.
Non-pecuniary damage is generally thought to arise in high-risk situations, so it is not surprising that the term has gained traction in healthcare settings during the course of the pandemic, as healthcare personnel have faced extreme and sustained pressure at work. In many ways, working at the NHS for the past year has felt like a circus acrobat of sorts, contorting ourselves to balance several competing realities: the desire to provide high-quality care to all of our patients in the context of limited resources, looking after our own health needs along with those of our patients, trying to make peace with the responsibility we feel towards our loved ones while still maintaining our duty of care to patients.
If we fail to deliver, especially in high-risk situations where we think things should have been done differently, it can shake us to the core. Our moral code transcends the relatively superficial responsibilities of our professional role: it gets to the heart of who we are as human beings. If we feel like our core values have been attacked, it can leave us devastated and disappointed.
Many people who have suffered moral damage describe a sense of helplessness and betrayal. The latter is often cited by health personnel in connection with the government’s handling of the pandemic, whether due to inadequate supplies of PPE, the perception that the shutdown could not be entered soon enough, or the pay cut in real terms for many NHS staff.
There is a genuine fear that once the dust begins to settle on the pandemic, there will be an exodus of NHS staff who will be too shattered by their experiences over the past year to continue in their role.
It is important to recognize that moral damage is not a mental illness. Most people who suffer moral damages will recover without the need for formal help. However, research tells us that moral damage may be associated with the development of serious mental health problems such as depression, post-traumatic stress disorder, and suicidal behavior; this is more likely to happen if people feel unprepared and unsupported.
We know that moral damage can result in several powerful feelings, mainly shame, guilt, and anger. We can often tell if someone is feeling angry, but it can be much more difficult to recognize those people who have been overwhelmed by shame or guilt. There may be a tendency for these people to disconnect from those around them and deviate from the task at hand. The danger of not recognizing when people are struggling is that there may be a delay in getting the right help. Like many health problems, the longer mental distress is left unaddressed, the more difficult it will be to address. I’ve lost count of how many times people have told me it’s “okay” when it turns out it’s not.
From what we know so far, it appears that a tiered support system that allows people to make sense of their experiences can be beneficial for those who have suffered moral injury; most will benefit from the simple act of a supportive conversation with someone they trust. while others will require the expertise of specialized mental health services.
It’s also worth keeping in mind that, in addition to causing injury, trauma can also be responsible for growth. For some of us, facing the challenges of the pandemic has helped us increase our sense of competence and professional confidence. While it is unclear exactly why some of us will be hurt but others will prosper, we know that we can foster professional growth by optimizing our levels of preparedness and support before, during and after high-risk situations.
We have been waging war against Covid-19 for more than a year. We are not soldiers, or heroes, or angels. We are healthcare professionals who do everything possible to do the job for which we have been trained. But we can’t do it without the right support and resources. We have a moral duty to minimize the risk of moral harm to healthcare personnel. Not only because we want a sustainable workforce and an effective healthcare system, but also because it is simply the right thing to do.
George is Digismak’s reported cum editor with 13 years of experience in Journalism