Each healthcare professional, who works in the emergency-urgency area, has a very high level of what we psychologists call resilience, i.e. the ability to respond to potentially traumatic events.
This is a capacity that each operator has developed in years of profession having to do with emergencies, mourning and particularly serious situations.
The Emergency from Coronavirus has led to levels of complexity that go beyond any situation previously lived. This had a powerful emotional and psychological relapse on health professionals engaged on the front line.
The difficult ethical choice
One of the critical issues that characterized the work of healthcare professionals in these months of Pandemia has dealt with the dilemma to operate one ethical choice. Not being able to guarantee all Patients positive in the Coronavirus Intubation and access to intensive care, which patient hospitalization in intensive care and which to refuse?
In this regard, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (Siarti) has published a text aimed at colleagues. Based on the resources, not accessible for everyone, they should be reserved for those who were more likely to survival and, secondly, to those who could have more years of life saved.
This indication has changed the health paradigm that provides for theEquality of careregardless of age or probability of survival. To an ethical, political question, are added powerful psychological implications. It is legitimate to think that finding themselves in the face of deciding who to give a chance of survival, intubating the patient, and who is not, can represent an emotionally overwhelming condition for the healthcare professional.
The psychological consequences of the treatment choices
It certainly happens in the medical profession of having to deal with difficult choices but theCoronavirus emergency He placed the doctors in front of this further level of complexity by not having resources for everyone and placing them, in some cases, the question of who to save and who to let die.
Face the choice to deny someone to save someone else, due to the lack of resources of a system not able to guarantee assistance to all its citizens, can represent one challenge for our morality.
In the face of this dilemma, the doctors, despite having received the support of the Siarti document, were not freed from the burden of the decision -making process. Consequently, from the emotional implications related to the impossibility of providing adequate treatment to all patients with consequent loss of human lives.
It is not yet clear how similar events may have impactful on operators but it is legitimate to assume that some of them can experience a certain level of moral sufferingthe one that takes the name of Moral Injury.
The moral injury of healthcare professionals
A recent study published on British Medical Journal (Greenberg, Docherty, Gnanapragasam & Wessely, 2020) indicated the Moral Injury as one of the risks to the mental health of the operators engaged in the Covid-19 emergency.
Most research on Moral Injury It was conducted with the military and war veterans. This is because the nature of war and combat create situations in which people can experience experiences that clash strongly with their own moral code or with the values of civil life.
For example, we think of the killing of an enemy fighter, or by committing or witnessing acts of disproportionate violence, or even trying euphoria and excitement in killing someone.
Although the term was therefore applied mostly in a military context, extend its use toHealth area It can provide valuable information on the experiences of healthcare professionals. In fact, these had to make difficult decisions relating to people’s life and death. Sometimes they believed that they should have and could save the life of a patient but were unable to do it.
What is meant for Moral Injury?
The Moral Injury It involves damage to one’s conscience when a person commits, testifies or cannot prevent acts that transgress their moral beliefs, their values or its ethical codes of conduct (Litz et al., 2009). Or it can involve a deep sense of betrayal When you feel inadequately supported by others in a power position that have the obligation to do it.
In traumatic or unusually stressful circumstances, people can therefore perpetrate, not be able to prevent or attend events that contradict deepestly rooted beliefs and moral expectations. The Moral Injury It is the psychological, behavioral, social and sometimes spiritual consequence which can derive from exposure to these events.
Examples of events that can cause Moral Injury they include:
- Having to make decisions that influence the survival of others;
- Do something that goes against their beliefs (Commission act: for example, cause damage to others;
- Do not do something in line with their beliefs (deed of omission: for example, not to be able to protect people, by mistake or inertia);
- Be witnesses of an act that violates its moral code (attending acts contrary to one’s beliefs);
- Experiment with the betrayal by other trusted (for example, not feeling protected by superiors).
Moral Injury and negative emotions
What happens when an act that was, or at least seemed to be, crucial and justified in a moment of extreme criticality is reassembled in light of a violation of one’s values and deep moral convictions?
Emotions that can include a sense of guilt are generated, where the person feels anguish and remorse for that event (for example, “I did something bad”); Shame, in which the person blames himself for behavior and generalizes him to a negative sense of himself (for example, “I am bad for what I did”). A person who experiences treason can experience anger, resentment and compromise the ability to trust others.
Another distinctive emotion in the case of Moral Injury It is the inability to forgive themselves who can induce people who believe they do not deserve to feel better, as if they were to serve a sentence for the transgression committed. The life of a person is filled with self-contempt and self-to-enter, up to destroying his own sense of self as a loving human being and worthy of being treated.
You can feel unworthy, unforgivable and damaged irreversiblely (Farnsworth, Drescher, Nieuwsma, Walser & Currier, 2014).
Moral Injury and Psychopathology
These thoughts and emotions can contribute to the emergence of mental disorders Like depression and post-traumatic stress disorder. The Moral Injury It has also been associated with higher rates of self-injurious behavior and suicidal ideation (Bryan, Bryan, Morrow, Etienne & Ray-Sannerud, 2014).
It is known that the Moral Injury also manifest itself as physical disorder: There are common muscle tensions, headache, gastrointestinal disorders and sleep, as well as feelings of tiredness and frustration.
It is legitimate to assume that the Moral Injury also have an impact on the spirituality of an individual. For example, an individual may have difficulty integrating what happened with his faith, elecing the doubt about the spiritual beliefs he had previously.
Moral Injury and post-traumatic stress disorder
It is important to note that as not all individuals exposed to potentially traumatic situations necessarily develop a post-traumatic stress disorder. Exposure to events potentially capable of inducing Moral Injury It does not automatically involve the emergence of this condition.
Although there may be an overlap of symptoms between Moral Injury And post-traumatic stress disorder They are two distinct conditions. Often the Moral Injury is associated with post-traumatic stress disorder where the situations that cause Moral Injury These are traumatic events for the individual.
As such, they trigger a symptomatology from post-traumatic stress disorder, characterized by intrusive memories, by the progress of people or places that somehow recall the event, and from emotional disreguling.
Unlike post-traumatic stress disorder, the Moral Injury It does not fall among mental disorders; Nonetheless it represents a dimension that deserves to be investigated.
Face the psychological distress of healthcare professionals
It is legitimate to think that at this moment, in which health workers can resume breath after months of sleepless nights and massacred shifts, the reality of everything that has been experienced can re -emerge to consciousness.
Even if the epidemic has not disappeared and therefore we cannot speak of a real phase of demobilization, i.e. the phase in which the emergency finishes comes the emotional impact of what has been experienced, this may be moment when you deal with a war that mostly has been fought in the secret rooms of hospitals.
By virtue of this it is important that, among the therapists who deal with trauma, the ability to recognize and not ignore the risk that some operators engaged at the forefront of facing the Covid-19 emergency may have developed the Moral Injury.
It can be difficult for patients to share certain morally harmful events due to the feelings of guilt and shame associated with them. Therefore therapists should be sensitive enough to pay attention to internal conflicts linked to the violation of deep moral values. They must try to offer health workers that care necessary to allow them to return to a normal individual, working and social functioning.
Bibliography
- Bryan, Ao, Bryan, CJ, Morrow, EC, Etienne, N., & Ray-Sannerud, B. (2014). Moral Injury, Suicidal Idea, and Suicide Highs in A Military Sample. Traumatology. Advance Online Publication. http://dx.doi.org/10.1037/h0099852
- Farnsworth, JK, Drescher, KD, Nieuwsma, Ja, Walser, RB, & Currier, JM (2014). The Role of Moral Emotions in Military Trauma: Implications for the Study and Treatment of Moral Injury. Review of General Psychology18 (4), 249-262, https://doi.org/10.1037/gpr0000018
- Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely S. (2020). Managing Mental Health Challenges Faced by Healthcare Worldrs During Covid-19 Pandemic. British Medical Journal;368: M1211 DOI: 10.1136/BMJ.M1211
- Litz, BT, Stein, N., Delaney, E., Lebowitz, L., Nash, WP, Silva, C., & Maguan, S. (2009). Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Interventions Strategy. Clinical Psychology Review ; 29 (8): 695–706.
