“Do you mean there’s no way for me to get my medication?”
A young college student, visibly angry and saddened, looked at me across the Zoom video psychiatry appointment.
“ADHD drugs are in short supply, and I’m not sure when it will end.” “I know it’s frustrating,” I sighed audibly.
“So, what do we do now?” The patient stares at me, hoping that I can help him get around the barrier. But I’m afraid I can’t.
“There are a few options, all of which are pretty bad,” I told him. “You can call a bunch of pharmacies and tell me which ones have it in stock and in what doses. I can then send prescriptions for whatever you require. You can also wait until the pharmacy where you usually get it restocks the medications, but I know you need it to function, especially at school, so that may be out of the question. We can also discuss temporarily switching medications.”
Switching is neither a simple nor a beneficial change. This patient, like many others I see, had to try several medications before finding one that was affordable and didn’t have too many side effects (like insomnia, lack of appetite, and additional anxiety). Even if he decides to try switching, there’s no guarantee that the new medication will be available. The scarcity has spread to other prescriptions, including Adderall, Ritalin, and Concerta, and his new one might be next.
My patient appears disheartened as he listens to my list of unsatisfactory possibilities. I take responsibility for it. “I’m very sorry,” I apologise for the fourth or fifth time today.
I didn’t have a name for what I was feeling until the epidemic introduced it into my vocabulary: moral damage. Nobody warned me before I got into this job that the powerlessness that comes with working in mental health is essentially a chronic moral damage.
The phrase arose in the context of the military and war in order to reflect a specific experience of veterans from PTSD. Moral harm happens when people are subjected to stressful situations and either perpetuate, fail to avoid, or witness acts that violate their own values and moral views. The psychological, behavioural, social, and spiritual suffering we experience subsequently is referred to as the harm portion.
Triggering events in the military include situations in which officers must make decisions that influence the survival of others, as well as situations in which someone fails to execute a duty during a traumatic occurrence. We explored moral harm in health care during the early pandemic in terms of resource allocation issues such as masks or ventilators, or seeing significantly more than the (already tough) projected quantity of suffering and death. We recently addressed it as a possible effect of the Dobbs judgement for OB-GYNs. Despite the fact that few studies have examined the incidence of moral harm in health care, a study comparing military veterans sent to war after 9/11 and health care professionals during the pandemic found that the general prevalence rates of possible moral injury were comparable.
The health care employees, on the other hand, reported higher incidences of moral injury from others rather than themselves. This implies they were more likely to agree with statements like “I am concerned by witnessing others’ immoral behaviours” rather than “I am troubled by acting in ways that broke my own principles and beliefs.” An example would be knowing that patients should have family members present when dying in the hospital but being unable to do so due to COVID-related hospital regulations. This regulation may go against their own ideas about how people should die, but they are helpless to change it. The gap between others and self may be connected to the belief that health care employees labour in a broken system and may feel deceived by others as a result, such as society, government, or hospital authorities.
As an outpatient psychiatrist, I’m always apologising for circumstances beyond my control. If there isn’t a lack of ADHD medications, it’s insurance refusing other vital medicines. Or a patient who is unable to locate a therapist. They may change jobs (or, worse, be fired), and insurance changes or increased expenses may prevent them from seeing me. As a result, they now have to locate a new psychiatrist while dealing with a pandemic and a severe scarcity of mental health experts. I wish them well despite being sick to my stomach and injured.
But it’s not simply impatient. When I was in residency, we were cautioned that our first two years, which were mostly spent inpatient psychiatry, would be significantly more difficult, and they were correct. We saw patients who repeated returning to the hospital because there was no social assistance to transport them to appointments or help them pay their meds. There were also patients who had to wait days, even weeks, in the emergency room only to be admitted to the inpatient ward because we didn’t have enough beds to accommodate everyone who required it. My attendings informed me that I only needed to go to my third year of training, where I’d be primarily outpatient, to observe that individuals do improve. That is correct: it is one of the highlights of my profession and the reason I picked it. However, they failed to inform us that even if people improve, the system does not.
It may be helpful to think of moral harm in medicine as the difference between telling someone “We tried everything we could” and “We did everything we could in a dysfunctional system with all the required resources.” We are all unwilling agents of the system. I am frequently shouted at or sobbed at, and as an empath, I take it all. I realise that my patients’ reactions during my visits aren’t about me, but it doesn’t make it any less painful. To feel like I’m doing anything, apologising is sometimes all I can do. Perhaps it’s my way of reminding them that I’m still a nice guy attempting to be a good doctor.
My reaction, on the other hand, is usual. Moral harm frequently causes us to blame ourselves and feel guilty, as well as to be furious, disgusted, and even humiliated. These negative ideas about ourselves and others may not necessarily indicate that we have mental health problems, but we may begin to observe stress reactions such as changes in our sleep, overworking, turning to alcohol to cope, and social isolation. While moral harm is not a mental health diagnosis in and of itself, it is a risk factor for developing depression, PTSD, suicide ideation, and burnout. As physicians, we already have greater rates of depression and burnout than other similar groups, and this is only adding to the mix. In fact, higher moral injury ratings were associated with worsening severity of symptoms, including suicidal ideation, in one research of health care professionals with COVID.
Aside from the harm to the individual health care worker’s mental health, there is a risk of moral injury, which might force people to abandon the industry completely. Losing personnel would simply exacerbate a system that already has restricted access, particularly for mental health specialists. According to the Health Resources and Services Administration, by 2030, demand for psychiatrists would outpace supply by 6%, resulting in a shortfall of almost 18,000 psychiatrists. This figure does not include unmet need owing to impediments to getting mental health care, or the increase in mental health problems related to COVID-19, which has added to the strain and demand on mental health practitioners. Access is already a challenge, but when the present personnel goes due to moral harm, the patients who are left without treatment will eventually suffer.
Naming what I’ve been going through as moral harm is beneficial, and it’s truly the first step towards dealing. Many of us, including the majority of my health-care professional patients and me, are ready to talk down to ourselves and blame ourselves at these instances. Instead, we must halt, identify our feelings and suffering, and practise self-compassion. To do so, we must learn to replace our negative ideas with the methods we communicate with someone we care about—a friend, family member, or even a younger version of ourselves. Our professions are already difficult enough without us complicating matters by pulling ourselves down.
At the same time, sharing our experiences with moral harm is one of the few options open to us as people. Medicine is not a vulnerable area, and as a result, we frequently feel alone in our experiences and sentiments. True self-care for moral harm requires making decisions with the aid or counsel of others when feasible, including seeking support in distressing talks (or afterwards). We can digest our experiences and hear alternative ways to think about or create sense from what we experienced together, in either organised or informal ways, when disturbing occurrences occur. We don’t have to endure alone.
Even writing it all down has helped me.
Erin Balsa is a highly skilled and knowledgeable health journalist with a passion for educating the public on important health and wellness topics. With extensive experience in both traditional and digital media, Erin has established herself as a trusted voice in the field.