Moral injury was identified by health care professionals (HCPs) as a driver of occupational distress prior to the COVID-19 pandemic, but the crisis expanded the appeal and investigation of the term.1 HCPs now consider moral injury an essential component of the framework to describe their distress, because using the term burnout alone fails to capture their full experience and has proven resistant to interventions.2 Moral injury goes beyond the transdiagnostic symptoms of exhaustion and cynicism and beyond operational, demand-resource mismatches that characterize burnout. It describes the frustration, anger, and helplessness associated with relational ruptures and the existential threats to a clinician’s professional identity as business interests erode their ability to put their patients’ needs ahead of corporate and health care system obligations.3
Proper characterization of moral injury in health care—separate from the military environments where it originated—is stymied by an ill-defined relationship between 2 definitions of the term and by an unclear relationship between moral injury and the long-standing body of scholarship in burnout. To clarify the concept, inform research agendas, and open avenues for more effective solutions to the crisis of HCP distress, we propose a unified conceptualization of moral injury and its association with burnout in health care.
CONTEXTUAL DISTINCTIONS
It is important to properly distinguish between the original use of moral injury in the military and its expanded use in civilian circumstances. Health care and the military are both professions whereupon donning the “uniform” of a physician—or soldier, sailor, airman, or marine—members must comport with strict expectations of behavior, including the refusal to engage in illegal actions or those contrary to professional ethics. Individuals in both professions acquire a highly specialized body of knowledge and enter an implied contract to provide critical services to society, specifically healing and protection, respectively. Members of both professions are trained to make complex judgments with integrity under conditions of technical and ethical uncertainty, upon which they take highly skilled action. Medical and military professionals must be free to act on their ethical principles, without confounding demands.4 However, the context of each profession’s commitment to society carries different moral implications.
The risk of moral injury is inherent in military service. The military promises protection with an implicit acknowledgment of the need to use lethal force to uphold the agreement. In contrast, HCPs promise healing and care. The military promises to protect our society, with an implicit acknowledgment of the need to use lethal force to uphold the agreement. Some military actions may inflict harm without the hope of benefitting an individual, and are therefore potentially morally injurious. The health care contract with society, promising healing and care, is devoid of inherent moral injury due to harm without potential individual benefit. Therefore, the presence of moral injury in health care settings are warning signs of a dysfunctional environment.
One complex example of the dysfunctional environments is illustrative. The military and health care are among the few industries where supply creates demand. For example, the more bad state actors there are, the more demand for the military. As we have seen since the 1950s, the more technology and therapeutics we create in health care, coupled with a larger share paid for by third parties, the greater the demand for and use of them.5 In a fee for service environment, corporate greed feeds on this reality. In most other environments, more technological and therapeutic options inevitably pit clinicians against multiple other factions: payers, who do not want to underwrite them; patients, who sometimes demand them without justification or later rail against spiraling health care costs; and administrators, especially in capitated systems, who watch their bottom lines erode. The moral injury risk in this instance demands a collective conversation among stakeholders regarding the structural determinants of health—how we choose to distribute limited resources. The intermediary of moral injury is a useful measure of the harm that results from ignoring or avoiding such challenges.