Moral injury and the four pillars of bioethics

Thomas F Heston,Joshuel A Pahang

doi:10.12688/f1000research.19754.1

Abstract

Health care providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians particularly vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments all are associated with unavoidable, harmful side-effects. When an inevitable side-effect occurs, not only is the patient harmed, the clinician also suffers a moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While moral injury occurs routinely in medical care and cannot be entirely eliminated, clinicians can decrease the prevalence of injury by advocating for the ethical treatment of patients, not only at the bedside, but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the healthcare system as a whole are necessary in order to improve medical care and decrease moral injury.

Highlights

Moral injury occurs when a person experiences an immoral event that disrupts their fundamental moral integrity
While moral injury is recognized as a distinct entity from other psychological conditions, such as post-traumatic stress disorder, the diagnosis relies on poorly defined, generalized criteria, which is very similar to that used for combat veterans
In the case of moral injury as it applies to medical professionals, we propose that a violation of the four pillars of bioethics forms the foundation of the diagnosis

Summary

Introduction

Moral injury occurs when a person experiences an immoral event that disrupts their fundamental moral integrity. Improving the recognition of and reflection upon the moral stressors that clinicians encounter in their practice may prevent moral injury from progressing further This framework will help more clearly define moral injury in medical professionals, allowing the development of treatment specific to those working in health care. Moral injury occurs when these ideals conflict with the hard reality of medical care where discrimination does occur, primarily along socioeconomic lines These complex socioeconomic disparities cause moral injury because clinicians know what their patients need and find the economic barriers to needed care to be illogical, unnecessary, and capricious. They know that not getting a patient with a substance use disorder necessary treatment will cost more to society, the health care plan may save money They have seen first-hand the elderly family member decide they would rather die than leave a large medical bill for their surviving relatives. The primary means of addressing such issues would be meaningful involvement in improving the larger health care system

Conclusion

Findings

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