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.   

When Hospitals Remove Protections

Dr. Kashif Pirzada wrote yesterday about this graphic from Robbie Meriales from the perspective of a doctor in a hospital in Toronto that's lifting all mask mandates.

"So much truth in this one graphic. 

True story, on a recent shift, I had to run and help a patient who had collapsed on our waiting room floor, short of breath. Hypoxemic. The family was diligent, and tested before coming, and lo-and-behold, they were positive. With some help, got her on a stretcher, I rolled her the acute zone myself, and we got to work stabilizing her. Triple vaccinated, in late middle age, no serious medical conditions, and this thing still got them sick enough to come to us. Another anecdote, right in the middle of summer when these things are not supposed to happen, where I can only say to myself, “what a curse on humankind this virus is”

“Shouldn’t she be in an isolation room?” someone asked. Good question. 

“What’s the point. Isn’t our hospital mask mandate ending soon?” someone else said.

Ah, now we get to the point.

If we were actually following the science, we would have screened her to a separate zone, away from the other patients in the waiting room. She could have infected any number of children, chemo patients, pregnant patients. Instead, we and every patient are now expected to make our own decisions on how to protect ourselves. You could roll into a cancer clinic and cough on every single patient in the waiting room, and not violate policy now.

While many are eager, even celebrating the end of mask requirements in our hospital, they still don’t want to be anywhere near an infected patient outside of an isolation room, of course.

I don’t get it.

Now I’m not about to go on some hopeless career-ending crusade to fight this, when most people don’t even want to think about it anymore... people have moved on, and that is that, I'm repeatedly told

.... but it is profoundly sad to see all the preventable suffering around you, to personally see the public get sicker over time, to see the young people with inexplicable blood clots and strokes, to see the life expectancy numbers continue to plummet, knowing that the only people who will come out of these troubled times relatively unscathed are the tiny minority who are wealthy, well-informed or well-connected.

It is, sadly, almost a certainty that I'll be seeing more patients like the poor woman I had to lift off the floor that night."

Then he asked ChatGPT to write a poem about his experience in the style of the King James version of the Bible:

In sorrow do I witness suffering's reign,
The public's decline, inflicted by this bane,
The young struck by blood clots, strokes untold,
Life's flame grows dimmer, as the years unfold.
Alas, these troubled times, they weigh me down,
More patients, sick and frail, shall soon be found.
But I, a witness, helpless, cannot sway,
For many turn their gaze, move on, they say.

Meanwhile, this is the current signage in Cedars-Sinai Medical Center in LA.

It's amazing to watch Canada be shown up by the States in terms of progressiveness, wisdom, and just basic decency - when it comes to Covid precautions in hospitals at least.