Healthcare Has a Moral Injury

The term "moral injury" is a term originally applied to soldiers as a way to help explain PTSD and, more recently, to physicians as a way to help explain physician burnout.  The concept is that moral injury is what can happen to people when "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." 

I think healthcare generally has a bad case of moral injury. 

Maria Fabrizio for KHN

How else can we explain physicians practicing surprise billing, hospitals suing patients, health plans refusing to pay for pre-authorized treatments, or pharmaceutical companies charging "skyrocketing" costs even for common, essential prescription drugs?  There are people involved in each of these, and countless more examples.  If those people haven't suffered a moral injury as a result, it's hard to understand why. 

Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians.  One physician decried how "the real priority is speed and money and not our patients’ care."  Another made a broader charge: "The health system is not set up to help patients. It’s set up to make money."  He urged that physicians seek to understand: "how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right."

David Oliver, a British physician, has an example of doing that: hospital gowns.  In The BMJ, he argues that "there's no dignity in hospital gowns," noting:

There are sometimes entirely legitimate reasons for using gowns—for example, in critical care or surgery or for some imaging or interventional procedures, where easy access to the whole body is vital. But that’s not the case for most patients for most of their stay. Yet still we use the gowns, or we keep people wearing them well beyond that immediate need.

 Dr. Oliver compares the process of being admitted to the hospital to being jailed -- "people having their possessions bagged up and being forced into standard prison clothing, symbolising the transition from citizen to inmate" -- and pleads "we surely want patients recovering from acute illness or surgery to spend more time in day clothes and shoes to help them regain their independence."

He doesn't want physicians to be part of this moral injury, urging: "Most of all, we as health professionals should be asking why people are wearing them at all."

U.K. physicians have, as a result, launched a #downwiththegown movement, urging the NHS "to put dignity first, and stop humiliating patients at a time when they are vulnerable."  That sounds like something that shouldn't just be limited to hospital gowns, nor only to the U.K.  

In other words, stop inflicting moral injuries on the people who work in healthcare, and start treating the people who receive care with more empathy and in more ways that allow them maintain their dignity.

There are, for example, more dignified hospital gowns available, but they have not become the norm.  Dr. Bridget Duffy, who had been the Cleveland Clinic's first Chief Experience Officer, explained why to NPR two years ago: "Hospitals are not designed for patients."

Think about that: hospitals are not designed for patients.  No wonder what happens to patients in them, and in other healthcare settings, result in moral injuries to the people working in them.  No wonder people receiving care continue to suffer various indignities.

Let's not get caught up in gowns alone.  For example, a new study found that twenty percent of commercially insured people who underwent elective surgeries ended up with surprise bills.  These are patients who have chosen their surgeon, chosen their hospital, yet are still stuck with out-of-network bills, most commonly from anesthesiologists and surgical assistants.

As Karen Pollitz of the Kaiser Family Foundation told Olga Khazan of The Atlantic, "you don’t pick these people. You don’t know them,  You learn their name when the bill comes," referring also to pathologists and radiologists.  

Dr. Karan Chhabra, the lead author of the new study, lamented to Ms. Khazan: "The way we set the system up is really putting patients last.”  In other words, in ways that end up generating moral injury to well-intentioned people.  

Or in the case of those pesky retrospective denials of pre-certificated care, Martha Grimes, director of the Center for Patient Partnerships, asks: "How broken can you get?  How much more laid bare can it be that our health care insurance system is not about health, nor caring, but just for profit?"  It would be hard for anyone involved in issuing those denial to not suffer moral injuries.

And, of course, anyone involved in suing or sending to collections patients who can't pay their share of healthcare charges, no matter how outrageous, must be suffering moral injuries, or must not have a conscience.  

Estimates are that as many as 50% of physicians experience burnout symptoms, and given all of the above and more, I don't understand why it isn't higher.  And I suspect it is at least as prevalent for others working in healthcare.  

If our healthcare system can't even give vulnerable patients something better than the traditional hospital gown, much less refrain from hounding them for money when they are still recovering, well, it has lost its way.  We as patients shouldn't stand for it, and the people working in it should no longer be complicit in the practices it has resulted in.  

Things don't always go well with health care.  Sometimes people don't get better, treatments don't work, mistakes are even made.  We should always, though, seek to allow patients their dignity.  At the very least, we should not allow practices that inflict moral injury to those involved in them.

If we're not careful, our healthcare system's moral injury could prove mortal.