COVID-19 and experiences of moral injury in front-line key workers

Abstract

The COVID-19 virus outbreak was declared a pandemic by the WHO on 12 March 2020. Whilst the infection mortality rate is not fully understood, it appears to be considerably higher than that of other recent pandemics (e.g. H1N1 pandemic, mortality rate 0.02%) [1]. Furthermore, several groups of people, such as the elderly and those with some pre-existing medical conditions, appear to be particularly vulnerable to the disease [1,2]. International evidence, and the public health messaging put forward by Public Health England, suggests that COVID-19 may place a substantial demand on an overstretched National Health Service (NHS). A lack of specific resources—such as a lack of beds in Intensive Care Units, essential medicines and ventilators—and increased demand on the NHS may mean that front-line workers, such as clinicians, paramedics and other care staff, may be unable to provide adequate treatment to all patients, as seen in Italy [3]. Additionally, current guidance recommends that anyone who is showing signs of a potential COVID-19 infection (e.g. new persistent cough, fever), or who lives in a house with someone who shows such signs, must self-quarantine at home [2] meaning that some clinicians will be unable to return to their ‘front-line’ responsibilities at a time when their colleagues are working exceptionally hard. As a result of these exceptional challenges, lives will inevitably be lost that could, in other circumstances, have been saved. Non-clinical professionals in other essential roles, such as the justice system, media workers, social workers, etc., may also feel the profound effects of being required to perform already highly challenging duties in a more constrained manner which may lead to risks being more difficult to manage. How such events will impact front-line, key worker teams remains unclear, but it is likely that many will experience a degree of moral distress and some moral injuries [4]. Moral injury is defined as the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code [5]. Morally injurious events can include acts of perpetration, acts of omission or experiences of betrayal from leaders or trusted others. Unlike post-traumatic stress disorder (PTSD), moral injury is not a mental illness. Although experiences of potentially morally injurious events (PMIEs) can lead to negative thoughts about oneself or others (e.g. “I am a monster” or “my colleagues don’t care about me”) as well as deep feelings of shame, guilt or disgust. These, in turn, can contribute to the development of mental health problems, including depression, PTSD and anxiety [6]. Moral injury is not limited by context or profession. For example, a recent review found that exposure to moral injury was significantly associated with PTSD, depression and suicidal ideation across a range of professions (e.g. teacher, military personnel, journalists) across a variety of countries (e.g. USA, Australia, Israel) [6]. Currently, there are no manualized approaches to treat moral injury-related mental health difficulties. In fact, some standardized treatments for PTSD (e.g. prolonged exposure) may potentially be harmful and worsen patient feelings of guilt and shame. Some emerging US evidence suggests that Adaptive Disclosure (where forgiveness is received from a benevolent moral authority) may be helpful [7]. UK clinicians also report using an amalgamation of validated treatments (e.g. compassion-focused therapy, schema therapy, etc.) to treat patients affected by moral injury [8]. Much of the research in moral injury at this stage has been carried out in military personnel and veterans. However, several potential risk factors for moral injury have been identified [9,10] that may be applicable to other professions during the COVID-19 Pandemic (Table 1): Potential risk factors for moral injury Potential risk factors for moral injury Front-line key workers, such as healthcare providers and emergency first responders but also other non-healthcare-related staff (e.g. social workers, prison staff), may be especially vulnerable to experiencing moral injuries during this time. A lack of resources may mean they are unable to adequately care for those they are responsible for which may result in great suffering or a loss of life. A lack of resources, clear guidance or training may also mean staff perceive that their own health is not being properly considered by their employers and feel at increased risk of disease exposure. Similar challenges may also be experienced by other essential workers such as supermarket workers or delivery drivers, who routinely would not have considered themselves as providing critical services to the public. It is important to note, just as not all individuals who experience trauma necessarily develop PTSD, exposure to PMIEs does not automatically result in moral injury. Nonetheless, the following practical recommendations may be beneficial: Fr