Physician Moral Injury: A Pediatrician’s Personal Story
The Daily Reality of Medical Practice
I struggled to detach the pager from my scrub pants. It was a never-ending battle between the force of gravity, the 3 pagers clipped to the scrub pants waistband, and the pants drawstring. I didn’t have much confidence in the drawstring. I pulled the pants up with one hand, clumsily detached the pager, and read the message. “Please come evaluate Room 16.”
Room 16 was a 2-year-old with a hepatoblastoma. He was finishing a round of chemotherapy in preparation for a planned tumor resection. He had been in the hospital for a few weeks. This last cycle of chemo had dropped his counts, and they were slow to recover. I tightened the drawstring on my scrubs, gowned up, gave my scrub pants one last tug, and walked into the room.
Bright blue eyes silhouetted by a pale bald face stared up at me from the crib. He was awake, a little fussy, and breathing fast. The beeping monitor reminded me he was tachycardic and febrile. I ordered labs, a fluid bolus, and left the room to talk with my attending and review the lab results. We agreed to start broad-spectrum antibiotics and transfuse packed red cells for anemia. I discussed the care plan with his nurse, pulled up my scrub pants, and left to take care of the other issues that were keeping my pagers busy.
When Medicine Hurts Before It Heals
Room 16 was on my mind as I tended to other duties and patients. He was my primary patient. I was halfway through a month of inpatient service which included q4 call. I spent a lot of time in room 16. His tumor was responding to treatment, and it was likely he would have a complete surgical resection soon – his best chance for a cure. The rest of his body, however, suffered as a result of the aggressive chemo. Although I had cared for countless children with similar illnesses, Room 16 unsettled me. It wasn’t fair that one so young was so ill. It wasn’t fair that the treatment for his cancer was worse in the short term than his actual illness.
Understanding Physician Moral Injury and Moral Distress
Physicians have the privilege of helping others during their time of greatest need. That means we have a front row seat to witness the best and worst that life has to offer. Many times we are powerless to stop the worst from happening. This feeling of powerlessness can lead to moral distress and physician moral injury, especially for trainees who enact the treatment plans, witness the side effects, and lack the knowledge and experience to understand the why of the treatment plan or put outcomes into context.
The Weight of Moral Distress in Medical Practice
Moral distress occurs when we know the ethically correct action but are constrained from taking it. Standing at Room 16’s bedside, I felt this acutely. I knew this child needed comfort, needed his parents, needed to be free from pain and fear. Yet the very treatment saving his life was causing his suffering. The system constraints – staffing ratios, treatment protocols, limited family support resources – prevented me from providing the comprehensive care I knew he deserved.
How Physician Moral Injury Shapes Our Practice
Physician moral injury runs deeper. It’s the lasting psychological damage that occurs when we participate in, fail to prevent, or witness acts that conflict with our moral beliefs. While moral distress is situational, moral injury accumulates over time. Each time I administered chemotherapy that made Room 16 sicker, each time I left him alone in his crib to answer another page, I felt I was betraying my fundamental oath to “first, do no harm.” The cognitive dissonance between knowing the treatment was necessary while seeing its devastating effects created wounds in my professional psyche.
Healing from Physician Moral Injury: Finding Solutions
The prevalence of physician moral injury has led to various coping strategies. Building strong support networks of colleagues who understand these challenges is crucial. Regular debriefing sessions, whether formal or informal, help process difficult cases. Mindfulness practices and maintaining work-life boundaries protect our emotional reserves. Most importantly, we must acknowledge that feeling these ethical conflicts doesn’t make us weak – it makes us human. Understanding that moral injury is a system-level problem, not an individual failure, allows us to advocate for structural changes while maintaining our compassion.
Finding Moments of Grace
I returned to Room 16 a couple hours later. His fever and heart rate were down. Overall, he had improved, but he was still awake and restless. His parents were gone, caring for their other children at home. He was alone in his room. He reached for me from his crib. I picked him up, rocked back and forth, and started humming a nameless tune. He laid his head on my shoulder and patted my back in time to the tune. When the patting stopped and his breathing slowed, I laid him in his crib. My pagers were noisy again, and gravity was battling against my scrub pants again. I tugged on my scrubs, grabbed my pager, and left to deal with the next issue.
The Path Forward
While physician moral injury may be an inevitable part of medical practice, in these small moments – a lullaby, a gentle rock, a tiny hand patting in rhythm – we find our healing. While the system may constrain us and treatments may cause temporary harm, our humanity remains our strongest medicine. It’s in acknowledging both our power and powerlessness that we find the strength to continue, to advocate for change, and to provide the compassionate care that drew us to medicine in the first place. The pager will always beep, the pants will always slip, but our commitment to healing – both our patients and ourselves – remains unwavering.
