Having a keen interest in ethical themes in global mental health and psychiatry, I have been particularly concerned about the long-term impact of the coronavirus disease 2019 (COVID-19) pandemic on the mental health of front-line health care workers (HCWs).  This concern is supported by studies conducted during the early stages of the pandemic.1-3  For example, a study comprising 1257 HCWs conducted at the peak of the pandemic in China found that 71.5% of participants were experiencing symptoms of distress, depression (50.4%), anxiety (44.6%), and insomnia (34%).1  This is not surprising given the extreme working conditions, intractable moral dilemmas and the burden of expectations that HCWs must navigate during the pandemic.

Critical care systems around the globe have been overwhelmed by surges of cases, necessitating the need to ration resources and employ triage decision-making.  While various triage systems and protocols have been developed to diffuse the moral burden of such decision-making in emergency health care, such systems become unfeasible in contexts where there are high surges of cases.  Where immediate decisions are required, the burden of deciding who receives life-sustaining treatment, and who doesn’t, falls entirely onto individual clinicians.  This is a situation that many clinicians have never before encountered.  In addition, the highly infectious nature of COVD-19 necessitates the isolation of hospitalized patients as a public health measure.  HCWs must uphold this isolation and witness their patients dying alone while navigating the distress of loved ones who are prevented from being with hospitalized patients.  Moreover, while HCWs are expected to provide vital care for COVID-19 patients, in many contexts they are doing so without adequate protective personal equipment (PPE) due to global shortages.  They are therefore working in conditions of high risk.  Their own lives are at risk – as evidenced by the high number of coronavirus related deaths of HCWs globally – and they are possibly having to treat their colleagues who contract the virus and possibly witness their deaths, all while knowing that they are placing their families or loved ones at risk of contracting the virus.  Opting to isolate from their families or loved ones, thereby protecting them, means losing a major source of emotional support.

Even in the normal course of events, the health care profession is characterised by extremely stressful working conditions that result in high levels of burnout, a syndrome which has been referred to as an epidemic in health care.4, 5  Burnout was first described, by Freudenberger, as emotional exhaustion resulting from “excessive demands on energy, strength, or resources” and exposure to prolonged and intense stress which may lead to various mental health problems.6  There is growing concern that the emotional distress and trauma experienced by HCWs due to the novel nature, intensity and scale of the COVID-19 pandemic will further increase their risk for developing burnout or other mental disorders.7  Over and above the need to recognise and address the psychological and emotional toll facing HCWs, attention must be paid to a particular kind of trauma that may have long-lasting effects on the mental health of HCWs once the urgency of the COVID-19 response diminishes.

The term moral injury was originally used in military contexts to refer to the long-term psychological distress, including feelings of guilt or shame, arising from involvement in events which violate one’s moral beliefs or are morally challenging, where the nature of the distress experienced is not adequately captured by existing disorder categories or entities such as post-traumatic stress disorder (PTSD).8  Where PTSD is sourced in trauma related to the experience of a threat to an individual’s life, among other factors, moral injury is caused by the experience of a threat to an individual’s moral code or to their beliefs about how things should be.9  More recently, the term moral injury has been applied to the distress experienced by HCWs who frequently find themselves unable to act in accordance with their moral values, and, in particular, in their patients’ best interests, due to resource or institutional constraints.9  In the context of the pandemic, HCWs may be at particular risk of moral injury due to difficulties in processing the fact that their options for acting in their patients’ best interests were severely limited, through no fault of their own.  While moral injury is not a recognised psychiatric entity it could be a contributing factor to negative mental health outcomes.10  The term, which is now appearing extensively in thinking about the long term impact of the pandemic on the mental health of HCWs, therefore warrants more attention10-12.  More specifically, as it has only recently been applied to health care contexts, it requires further conceptual work and, ultimately, research validation, if it is to be used as a therapeutic tool.  However, it seems to effectively articulate something of what HCWs are currently experiencing.

1.         Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. Mar 2 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976

2.         Liu Q, Luo D, Haase JE, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet Global Health. 2020;doi:10.1016/s2214-109x(20)30204-7

3.         Kang L, Ma S, Chen M, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun. Mar 30 2020;doi:10.1016/j.bbi.2020.03.028

4.         Reith TP. Burnout in United States Healthcare Professionals: A Narrative Review. Cureus. Dec 4 2018;10(12):e3681. doi:10.7759/cureus.3681

5.         Dubale BW, Friedman LE, Chemali Z, et al. Systematic review of burnout among healthcare providers in sub-Saharan Africa. BMC Public Health. 2019/09/11 2019;19(1):1247. doi:10.1186/s12889-019-7566-7

6.         Freudenberger HJ. Staff Burn-Out. Journal of Social Issues. 1974;30(1):159-165. doi:10.1111/j.1540-4560.1974.tb00706.x

7.         Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. N Engl J Med. Apr 13 2020;doi:10.1056/NEJMp2008017

8.         Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. Dec 2009;29(8):695-706. doi:10.1016/j.cpr.2009.07.003

9.         Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. 2019. p. 400.

10.       Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ. Mar 26 2020;368:m1211. doi:10.1136/bmj.m1211

11.       Williams RD, Brundage JA, Williams EB. Moral Injury in Times of COVID-19. J Health Serv Psychol. May 2 2020:1-5. doi:10.1007/s42843-020-00011-4

12.       Stoycheva V. For Health Workers, COVID-19 Can Be a Moral Injury Pandemic. Psychology Today Accessed 18 June 2020. https://www.psychologytoday.com/za/blog/the-everyday-unconscious/202004/health-workers-covid-19-can-be-moral-injury-pandemic