Friday, June 16, 2023

Moral Injury and Definition Creep

In a class this week we talked about moral injury, but it was presented and discussed as if it meant any time there's a clash of values. One of the examples given was being in university and realizing people in the next bed were having sex. Another explained that people protesting 2SLGBTQIA+ rights are experiencing moral injury, upset that what's acceptable has shifted, which is against their morals. 

Those examples hit me as decidedly not what I understand moral injury to be. So I researched the origin going back to Jonathan Shay and his definition, which he amended from his original to include further research:

"Moral injury is present when there has been (a) a betrayal of 'what's right'; (b) either by a person in legitimate authority (my definition), or by one's self--'I did it' (Litz et al.); (c) in a high stakes situation. Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence. They deteriorate character."

The high stakes part of it can't just be dropped to include every situation or else all coming of age experiences and cultural differences are necessarily injurious. I provided my own example, back in September 2020, in which the province and school boards decided we all had to mask but everyone had to take off their masks at once for a 45-minute nutrition break halfway through the morning (they were just there for four hours of school), and kids weren't allowed to leave the room at the time. They all had to be in a room unmasked together. This was six months before vaccinations were available and at a time when some hospitals ran out of sedatives for intubated patients. It was nuts! I spoke up, over and over and over, and was chastised or ignored. I was struck then with the horrific punch-in-the-gut realization that those in power had a concept of acceptable losses of schoolchildren.   

And now that's everywhere all the time: one or two kids masked in a room without any other mitigations. I added a red horizontal line to Ryan Gregory's annotations in the graph below to show the point at which we decided we had to stop the spread, that first horrible peak. This illustrates that our current valleys are higher than the peak that provoked all those mitigations; we're finally dipping below it for the first time since December 2021. The powers that be have literally decided that we're fine with the deaths and disabilities we once worked hard(er) to avoid.  

This falls under Shay's definition of moral injury as a betrayal, a moral clash, from authority figures, that is causing significant and certain harm to people. It's injurious to us to have to helplessly watch people be put in a dangerous situation, needlessly, especially when they're kids! (This hit me here and here.) 

But presenting the term moral injury as if it's any clash of values waters down the concept. People like that because we want a name for what we're feeling, but being upset or rattled when discovering that people live differently is not the same thing. I worry not just that the term will become meaningless if it starts to apply to everything, but also that it will start to make an injury out of every confrontational situation. I've lived my whole life knowing that many of my peers live by a very different value system. That happens to anyone raised in an equity-centered anti-consumeristic household. And it's bloody annoying when neighbours suggest I really need a new coat despite the old one not yet being worn out! But that's significantly different than being witness to, or being made to participate in, a system in which harm is caused from authorities working with questionable morals. They use a Randian version of utilitarianism that ignores Mill's harm principle. 

The same holds true for the term trauma, which officially refers to, in a nutshell, exposure to (experiencing or witnessing) actual or threatened death, serious injury, or sexual violence. It's not that time your mum yelled at you and it was upsetting. It doesn't mean it doesn't feel crappy that mum lost her temper, but, again, calling it trauma waters down the term and can makes it feel worse than it was. It's like when people used to tell kids whose parents divorced that they were from a broken home instead of just going through a transition to a different type of family structure. It colours the experience and can create a tragedy where there was none. But we can all still be healing from past adversity without being traumatized. Sometimes I think it's as if we just all want to have had the worst possible experience ever in a weird competition with the world, but no matter what happened, if it's the worst thing that happened to you, it's not nothing, even if it's not necessarily trauma. The term seems to make people feel at ease that they need help to cope with experiences, but it's okay to need help anyway

And then, the day after I submitted an assignment on it, after all that digging to find the origins of moral injury, the NY Times posted an article on Shay! The focus is on the moral injury experienced by doctors and nurses throughout the pandemic:

"The physicians I contacted were afraid to talk openly . . . worried they could be disciplined or fired if they angered their employers. . . . Nearly 20% of the 389 E.R. doctors surveyed said they had been threatened for raising quality-of-care concerns. . . . They are noticing how the emphasis on the bottom line routinely puts them in moral binds. . . . 'I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,' Dean says. She notes that the term moral injury was originally coined by the psychiatrist Jonathan Shay to describe the wound that forms when a person's sense of what is right is betrayed by leaders in high-stakes situations. 'Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are part of the betrayal. They're the instruments of betrayal.'"

Exactly! By being made to accept the rules, when we can plainly see the harm they cause, it forces us to betray our morality - or quit. That's the part that's missing from the "any clash of values" definition. Moral injury happens when it's impossible to appease superiors without breaching your own values. 

"Doctors are increasingly the scapegoats of systemic problems within the health care system because the patient is not seeing the insurance company that denied them the procedure. . . . They have to blame someone, and we are the interface of the system."

Fucking insurance companies!! How did they get to be in charge of everything?! They prevent our board from having Corsi-Rosenthal boxes too. It's all about protection against litigation, not Covid. 

Teachers are in that same front-line position. Doctors, and I'll add teachers, "earned the public's trust and derived much of their authority because we're perceived to be 'above the market and pure commercialism.'" Yup. We expect them to work outside of any concern with profit margins or efficiency, but focused exclusively on the human beings in front of them. The needs of people come first. Imposing moral injury on frontline workers was the first step in forced acceptance of a new set of values. Full on privatization of health care and education is the end goal. "Once in charge, these companies start squeezing the doctors to see more patients per hour, cutting staff." We're already looking at losing 7,000 education workers in Ontario due to budget cuts this year. The big question: What are those excess funds of $22 billion Ford's sitting on being set aside for??

So what's wrong with privatizing health care? This obvious problem is that it puts people into debt if they have to choose between rent and a hospital visit. This article in The New England Journal of Medicine also sites underlying issues: 

"It creates the problems of overuse and fragmentation of services, overemphasis on technology, and 'cream-skimming,' and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients."

It sees the patient as an object to sell to, almost a way of moving money around, laundered through insurance companies. That's just the start of the problem. See Klein and McQuaig for more. 

The NY Times article ends with a discussion about doctors forming a union. Education workers have a union, but it's been curiously quiet about many of these issues, also toeing the line from public health when we had to wear surgical masks instead of N95s and when we had to have the kids unmasked for break, adding to our collective moral injury. Follow the rules and stay out of trouble somehow has become their new mantra. Whatever happened to fighting the man

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