Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

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We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.

In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

Patient satisfaction scores and provider rating and review sites can give patients more information about choosing a physician, a hospital, or a health care system. But they can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied. Business practices may drive providers to refer patients within their own systems, even knowing that doing so will delay care or that their equipment or staffing is sub-optimal.

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay — wounded, disengaged, and increasingly hopeless.

In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the “disaster zones” where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.

We need leaders who recognize that caring for their physicians results in thoughtful, compassionate care for patients, which ultimately is good business. Senior doctors whose knowledge and skills transcend the next business cycle should be treated with loyalty and not as a replaceable, depreciating asset.

We also need patients to ask what is best for their care and then to demand that their insurer or hospital or health care system provide it — the digital mammogram, the experienced surgeon, the timely transfer, the visit without the distraction of the electronic health record — without the best interest of the business entity (insurer, hospital, health care system, or physician) overriding what is best for the patient.

A truly free market of insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care. These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of health care.

Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, M.D., is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.

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  • death by a thousand cuts – that exactly describes the healthcare I see in my daughter’s medical record. Everyday it was drugs being used in a way that could only harm. Overdoses of Tylenol -seriously over 5,000mgs ordered SCHEDULED for a patient who is charted as having NO PAIN?!? What was the purpose? to destroy her liver? well, it worked! Seeming protocol of refusals to chart any and all side effects? There MUST be a GAG order on side effects. Overdoses of sedatives and narcotics including TAB 12 hour time release morphine GROUND UP into a feeding tube while the patient slept – all without checking vitals that are 70/40? then tanking to 57/20, then fentanyl started?!? The tanking BP called SEPSIS?!? it’s not all the narcotics?! for the “SEPSIS” LOADS OF VANCO that shut down her renal system and drowned her in front of my face! She died with an overdose of a drug in her system she had been refusing for 40 days?!? why does she have to refuse for 40 days?!? stop the freaking order already…why does she have an overdose in her system after 40 days of refusals? Talk about moral injury – reading these medical records – i’m surprised I have not died myself from just not breathing. Yeah if the providers of this kind of medical care have MORAL INJURY, I get it. I have it too now from not understanding that THIS was going on while it was happening. My daughter’s moral injury was “resolved” by this care and the death that soon followed. She entered the hospital with gastric distress and hypotension – she was not terminally ill and only 26. SHE WAS SWEET AND KIND AND WISE AND DESERVING OF STANDARD OF CARE – this can’t be the STANDARD.

    There is NO POINT IN FIGHTING FOR HEALTHCARE if this kind of care is what is being delivered. I believe that NOBODY goes to medical or nursing school to deliver THIS kind of care.

    What would clear it up in California really fast is the abolishment of CALIFORNIA MICRA CAP – it would bring accountability back to healthcare in California and put an end to patient deaths that obliterate all earlier incurred liabilities from disabling healthcare delivery – this would end the financial incentive for unnecessary deaths in California hospitals. Also, making PUBLIC all arbitration cases so that we can all review what is causing the skyrocking death rate by medical errors in this country. Why is it all a BIG SECRET?! Nobody learns anything from past mistakes by keeping it all a BIG SECRET. My daughter’s records showed that mistakes were repeated and repeated and repeated until she was dead. and it looks like there is no medication review process at all going on. Constant dangerous combinations and overdoses of medications and the work flow of safety review and double checks through a series of doctors and pharmacists and nurses to make sure this doesn’t happen – isn’t happening at all.

    Let’s bring back accountability to hospitals- it should NOT be more dangerous to go to the hospital for help then to join a street gang.

    I get it – the hospital front line doctors and nurses are in someway also victims, NOT as sympathetic as my daughter but victims still. However, to stop this THEY have to be brave enough to stand up and say NO. It’s awful the first ones through the wall will get bloodied and lose everything without fanfare. But it has to be done….the situation has sunk so low now we’ve dug through to China as far as human rights violations.

  • Thank you for sharing this article. It was indeed an eyeopener. I will not add to my comment because so many previous responses echo my thoughts but perhaps the realization that a problem exists can be a beginning to create the necessary changes in our health care system.

  • Medicine now is a farce. We need for the entire system to crash and burn and start over with the patient and the physician making the decisions.

  • I’m astonished at my doctor’s ability to provide me with superb care 100% of the time. He’s brilliant and genuinely kind. He’ll take enough time with each of his patients, even if that translates into occasionally running late. I would rather he be late and thorough than prompt and inaccurate. I must be fortunate–he’s been my doctor for a decade now and I trust him absolutely.

  • If medicine was purely a science, then it would not be breaking under this pressure. This is just one piece of evidence that medicine is also very much an art. And the business of medicine is not the only thing destroying this art. We need to not be afraid to follow our intuition. We need to not be discouraged from combining our knowledge of the science with our intuition. This isn’t chemistry lab.

  • Code Lavender Team? Really? How perfectly stupid. Also excellent article, thank you. I am looking at similar phenomena in public schools. We need tools to think about ethics problems systemically instead of looking solely at the level of the individual practitioner.

  • Thank you Betsy Tuttle-Newhall, MD for sharing this article. It was my “ah-ha” moment. After 10 years, I have walked away from healthcare, I called it “burn-out,” but that did not encompass my thoughts and feelings. Moral injury is my diagnosis. What I have seen and experienced in my 10 years has shaken me to my core. I no longer want to be part of this “push them in, push them out” mentality, dot your Is/cross your Ts, so as to obtain optimal reimbursement, healthcare professionals incorrectly prescribing medication, incorrect medical histories which no one corrects, bullies/sharks who are allowed and are esteemed to continue to prey. I became a PA to help others. I cannot/will not be part of this. Is it a permanent break? I hope not as my goal is still to care for patients. But for now, I need to heal myself.

    • Claudia and Tim……I HOPE to God people in the “powers that be” are reading these comments. I hate to have to become party of their “system” but sometimes one cannot “fix” their problem and need some help. It is so QUESTIONABLE the information that we are given as patients…..I come home and RESEARCH everything told to me!

    • Indeed the system is unethical. We providers either have to do something to stop it, minimize our contribution or we must stop ourselves. I too left the practice of medicine in 2015 as it’s simply too dysfunctional.

  • A well crafted article that should be on the reading list of every politician and manager working for and within the NHS . Awareness is the first step to preventing / minimising moral injury

  • “In an increasingly business-oriented and profit-driven health care environment”

    Healthcare is not “increasingly business oriented and profit driven”. It is increasingly controlled by government PREVENTING healthcare from being run as a business and be profit driven. Profit is GOOD. Profit is merely the value added for the services and goods you provide minus the cost in resources to provide those services. Being against profits in healthcare means you are against adding healthcare value or wasting precious healthcare resources or both. Government control makes the managing of said resources, i.e., financial considerations, MUCH harder. It is unethical to want to add less value than you are capable and it is unethical to be wasteful with resources that others could make use of. Being against the profit motive for healthcare means you are being unethical.

    Having healthcare be “increasingly business oriented and profit driven” would be excellent and dramatically improve care and quality, while reducing prices. Instead, have a system that is the polar opposite of that, where politicians think they can subvert the laws of economics and pretend taking healthcare resources from one group of people to give to another somehow magically improves healthcare for all. Politicians are increasingly PREVENTING healthcare providers from making business oriented and profit driven decisions, making ALL our lives more miserable.

    Reliance in patient satisfaction scores and provider ratings become irrelevant when people have the power and incentive to spend their own money on their own healthcare, instead of being the pawn of politicians and their crony hospital administrators and healthcare insurance executives. Profits directly measure patient satisfaction and provider ratings. Returning to the free market, returning healthcare liberty to the people is the ONLY way to fix the system currently being broken by politicians elected by voters who think they can ignore the laws of economics. The result is the widespread very avoidable misery we see all around us.

    The good news, the US is still the freest healthcare system in the world, which is why the US has the very best medical outcomes in the world and basically the only place where medical innovations occur. The rest of the world has made the unethical choice to prevent medical innovators from finding the ways to add value to healthcare patients while consuming the fewest resources because they’ve made the unethical decision people shouldn’t have healthcare liberty because ignoring the laws of economics is popular, though clearly unethical. Since the rest of the world has made it illegal to make to innovate, the rest of the world’s medical system depends on the US for nearly every single advancement.

    • Wow them are some alternative facts. There are a lot of dead people who might disagree with you. The US has the worst outcomes of any developed nation, and it is much more expensive too. See we already pay almost 10k a year per person, with the worst outcomes. Just run the numbers, this is the kind of backwards, and alternate fact opinion that got us to this position.

    • While I don’t disagree with your comments about excessive government imposition or innovation, I don’t share your virtual worship of profits.
      Profit motive/ self-interest is the “invisible hand” of Adam Smith that ensures innovation and competition in a free market. Such self-interest is usually considered amoral, neither good or bad. But it is only within a free (efficient) market that price and value accurately reflect each other, whereas you would equate the two regardless of context. For most goods and services a free market spurs our economy for the good of society. In some areas, like roads , defense, clean air and water, public health, and schools we as a society have decided that unbridled free markets don’t adequately serve the public good. Most people, especially if they are ill, believe this is the case with healthcare. As a consequence, third party payment is the norm. Interposition of a third party disrupts supply and demand (that’s its purpose) such that market forces are no longer at work. Sadly, but necessarily, profit motive promotes workarounds and gaming the system. Examples of profiteering abound- oncologists selling chemotherapy for substantial increases in income; ER fees and balance billing that skyrocket Blame Emergency Rooms for the Out-of-Control Cost of Health Care ; huge variations in prices (like rabies treatment), just to name a few.

    • You write as if you’ve never been without insurance and are probably making a six or seven figure income. Try living in the real world for a change.

    • You write as if you’re making a six or seven figure income and have never been in the position of worrying about insurance. Try living in the real world for a change.

    • free-ist? US healthcare is the MOST expensive per soul. Besides it is definitely NOT a free market system. HEALTHCARE, at least in California, enjoys FREEDOM from consequences under California MICRA CAP law. It is THE industry that enjoys the MOST government protections from accountability, by law. Secrecy, under the guise of patient privacy laws, allows harm to happen over and over and over again without the public ever finding out about it. Democracy dies in darkness and so do patients – the deaths are horrific, agonizing and terrifying – or at least my daughter’s unnecessary death was. : ( Cruelest most unkind death imaginable drowned in her bed begging for her lungs to pump out while hopped up on vasopressors w the unnecessary fluids and nephrotoxins just escalating – HOLY SHIT Im sorry nobody would be allowed to execute someone on death row this way. Although, I think American healthcare may have the ability to provide good outcomes, who benefits from these abilities is very much driven by financial interests. Let us be honest, the industry wouldn’t need protections like CA MICRA CAP law if it was doing a GOOD job for most people. To say accountability for “errors” would kill the “business” means you shouldn’t be doing business that way, not we need a GOVERNMENT SHIELD FROM ACCOUNTABLITY so we can continue to operate this way. eeesh this healthcare business environment isn’t good for anyone….it’s morally injuring the entire country, doctors and nurses included. I praise the doctors for speaking out against being forced to practice this way, it is selfless and brave to speak out in this profession. BRAVO for caring – thank you for being brave enough to feel despite all that it may cost you. it gives me hope.

  • Maybe we should go back with the old hospital system of nonprofit. Or, get rid of insurance companies and going to fee for service. Those of us in healthcare might need to decrease our prices though. But I agree with this article something needs to change.

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