Introduction

Moral injury is a complex term which may be difficult to define (Hodgson & Carey, 2017) but can be explained as the consequence of being forced to do, witness, fail to prevent or comply with something that goes against an individual’s deeply ingrained code of social ethics and or personal morality. Moral injury is not a mental illness but may be a contributory factor for it, resulting in symptoms of anxiety, depression or even posttraumatic stress disorder. It was first described by Jonathan Shay, in his book on Vietnam War veterans ‘Achilles in Vietnam-combat trauma and the undoing of character’ (Shay, 1994). Though moral injury had been initially identified in war veterans, similar situations and ethical dilemmas can also occur in health care settings, hence the term has been borrowed to describe the distress and conflicts experienced by various caring professions working in adverse situations (Williamson, 2018). Moral injury (MI) may lead to feelings of guilt, shame, remorse or even anger. It differs from burnout which also has similar psychological and physical symptoms. However, MI may lead to burnout.Footnote 1

In any acute health care crisis, such as during the current COVID-19 pandemic, moral injury can result given a number of scenarios within clinical settings. There are numerous bioethical choices to be made. These include allocation of scarce resources like ventilators and protective equipment, obeying the institutional and hierarchic rules especially when one is at the bottom of the pecking order, personal safety and the risk to one’s family as a result of performing one’s duty—to name a few. A moral paradox to the Health Care Worker (HCW) is when the principles of altruism, beneficence and self-sacrifice in course of performing one’s duty come in direct conflict with one’s personal well-being (Flew and Priest, 2002). More so in the COVID scenario, where the front line HCW may pose a risk of being a carrier of the virus resulting in infection to their own loved ones. Often the decisions one makes, or are forced to make may evoke feelings of guilt, culpability, powerlessness and distress. There may be a perceived loss of professional integrity and identity. The feeling that one has not done the right thing or failed to prevent something wrong, gives rise to the feeling of being a ‘bad person’ (Greenberg et al., 2020; Williams et al., 2020).

Moral injury in this situation can lead to impaired mental and physical functioning of the individual, including a number of psychosomatic symptoms like insomnia, fatigue, muscular tension, myalgia, headaches and gastrointestinal upset (Dubey et al., 2020). Psychological symptoms of depression, anxiety, suicidal ideas and demoralization are to be expected in this situation. Conventional protective factors like social support, company of friends and means of entertainment have also been restricted; worsening the situation. COVID-19 has actually unleashed a pandemic of global mental ill health.

The current COVID-19 pandemic is at a time when the world is facing an unprecedented war-like situation. The HCWs dealing with the COVID 19 pandemic are especially at a high risk of stress, anxiety, depression and other mental health problems. There is an urgent need to implement interventions that promote mental health in these professionals. Unfortunately, access to formal psychotherapy is often limited, impractical due to time constraints or fraught with stigma. Another issue is the paucity of mental health professionals.

In such troubled times, one looks everywhere for answers, and may even turn to spiritual guidance through the teachings of prophets, saints, spiritual leaders and to the wisdom of the ancient texts to find answers to tormenting existential questions.

Shay (1994) had likened the psychological trauma of Vietnam war veterans to the struggle and distress of Achilles and his soldiers during the long war against Troy. In the Indian epic, The Mahabharata, we have a robust example of moral injury; in the dilemma of Arjuna, the ace warrior of the Pandavas and the prescribed remedy given by none other than the Lord, Sri Krishna in the form of the Bhagavad Gita.

In this article, the authors would like to explore the verses from the Bhagavad Gita to explore the relevance of the advice contained therein to the present turmoil and mental stress experienced by the people at large and more specifically the HCW.

Background: The Bhagavad Gita

The Bhagavad Gita (Gitopanishad) literally means—Song of the Divine. It is revered as holy by the Hindus. It originally appears as an episode in the Mahabharata, the epic story of the battle between cousins, the children of Pandu (Pandavas) and Dhritharashtra (Kauravas). The Pandavas, who had to face persecution and injustice from their own kin, had Lord Krishna on their side as friend, mentor and adviser. He motivates the third of the five Pandavas, Arjuna, to fight, offering himself as his charioteer and guide. Lord Krishna is revered as an avatara or incarnation of Lord Vishnu, the sustainer of the universe in the Hindu holy trinity of Bhramha (the creator), Vishnu (the sustainer) and Shiva (the destroyer).

The ancient wisdom of the Gita imparted by Krishna, which is essentially a friendly dialog between a wise teacher and a disillusioned student, has of late kindled interest as a model for psychotherapy (Reddy, 2012; Pandurangi et al., 2014).

The teachings comprise 700 verses and 18 chapters (25–42) of the Bhishmaparva of Mahabharata, (Sukthanker, 1940; Bhade, 2014). We see, in these verses, how a demoralized Arjuna expresses his ethical dilemma about killing his own cousins and teachers in the battlefield of Kuruskhetra. He expresses his unwillingness to perform his duty as a warrior, of fighting against ‘Adharma’ or injustice. After Lord Krishna’s counsel, he comes a full circle and declares with confidence that his delusion has been destroyed and he is now ready to fight to uphold his Dharma—his duty.

The relevant verses from the Gita (an English translation of the original by one of the co-authors) and their significance in current times of COVID-19 are highlighted as follows.

The Four Concepts of the Gita: The Four Ds

Four concepts from the Gita namely—(1) ‘Detachment,’ (2) ‘Doer and the concept of Self,’ (3) ‘Dharma or Duty’ and (4) ‘Dhyana or Meditation’; the four Ds hold specific relevance and therapeutic potential in offering psychological support to HCWs (also see Table 1).

Table 1 The four Ds of the Bhagvad Gita
Full size table

For the original verses from the Gita, please see “Appendix 1.”

Detachment

Many HCWs have reported feeling let down as a result of working with insufficient resources, personal protective equipment and staffing (Greenberg et al., 2020; Williams et al., 2020).

In the Gita, we find Arjuna experiencing a similar feeling of sorrow at having been placed in apposition where he has to inflict injury to his own kin. Krishna’s introduction of the principle of Detachment can be of great relevance to HCWs. He tells Arjuna to recognize that all emotions are just fleeting sensations of mind and ask him to engage in Karma Yoga stating “Yoga Karmasu Kaushalam” meaning detachment, yet excellence in works is Yoga. The important thing to note here is that detachment does not mean running away or shrugging away responsibility. It just means being detached from the consequences of the action that is performed to the best of one’s ability, whatever the circumstances one is placed in.

“Vested you are with the authority to perform**

But not seek your action’s fruits in any form

When by the fruits of actions you aren’t motivated

From discharging your duties, you never get deviated 2.47

Perform your every action in this Yogic way

all attachments Arjuna, you must throw away

From accomplishments and loss find your release

Then you shall attain the Yogic poise and peace". 2.48 (Also, see “Appendix 1”)

Doer-Ship: The Concept of the Self

Moral responsibility for the choices one is forced to make can lead to moral injury especially when one feels helpless that the decision-making is not one’s own but conformity to protocol, authority or political correctness. Where there are such moral paradoxes, the advice of Krishna becomes relevant and is very valuable. Krishna introduces the concept of the individual ‘Self’ as being part of the universal Self or cosmos and the interconnectedness of oneself to all things both sentient and insentient (living and non-living). This helps to reduce one’s sense of alienation and paradoxically, also one’s ‘ego.’ We are all important but not indispensable; we are all interconnected in a cosmic web and not isolated. We are not the doers, but instruments of a higher power. This frees us from doer-ship.

“The knower of the true principles of existence

Knows that he is not the cause of his subsistence.5.8

He is not the doer of works, but his work is done.”4.20 (Also, see “Appendix 1”)

Dharma or Duty

For the COVID ‘warriors’ including the HCW, doing one’s duty is not a new concept. Fighting sickness and disease, in adverse circumstances, trying to save lives is considered to be the mission of healing professionals. This duty often comes in direct conflict with self-preservation and the risk of infection to family and loved ones. Fast tracking of new medical students and residents to overcome man power shortages has created situations where the competency and mental health of newly appointed employees are to be monitored with utmost care (Greenberg et al., 2020).

In these individuals, exposing colleagues or patients to danger due to either inexperience, indecisiveness or while working beyond the expected or normal competency is an inevitable result leading on to further distress and guilt.

The concept of Dharma or Duty of the Gita as explained by Krishna to Arjuna can offer solace to the ‘corona warriors’ who have experienced moral distress while performing their duty. Krishna tells Arjuna that for a warrior the most appropriate thing was to defend the integrity of his duty. Krishna also tells Arjuna to not have the guilt of defective action and never abandon one’s duties by stating that making mistakes is a natural phenomenon.

“Your Dharma—moral duty you must consider

And from it, you most definitely mustn’t falter.2.31

Even if defectively done, as all actions are cloaked with defect

Just as the fire is masked by its own smoke’s effect.” 18.48 (Also, see “Appendix 1”)

Dharma does not mean just duty; in this context, it has a wider scope and meaning. It means upholding ethical principles to the extent one can, while giving one’s best efforts in fulfilling one’s mission; without the sense of doer-ship and with detachment from the results of the action; which may result in saving someone’s life or regrettably sometimes letting death happen.

It is only in such performance of duty that one can attain a sense of accomplishment and happiness. This thought finds an echo in Viktor Frankl’s book “Mans Search for Meaning” (Frankl, 1962).

Frankl explains that without a mission, one loses the will to live and life becomes meaningless. A mission, he says is not some grand purpose, it is just something that only you as an individual can do, based on the peculiar circumstances you are placed in. It need not be perfect, it need not be grand and it may be defective. To have tried to do something to the best of your abilities, even in adverse circumstances, is what makes the difference. That is Dharma according to the Gita.

Dhyana or Meditation

Meditation, as a spiritual practice, has shown to significantly reduce stress and improve the general mental health, mindful attention and self-efficacy in patients with acute respiratory illnesses (Barrett et al., 2018).

As a cognitive corollary of the physical wellness mediation provides, a realistic, bold and detached outlook focused on one’s duties to oneself and others without fear, guilt or panic could foster a healthy protective immune response in human body. This may have a potential to promote a positively modulated psychoneuroimmnological response of the human biological system (Bonneau et al., 2007).

Some verses recommending meditative practices from the Gita are highlighted as follows (Also, see “Appendix 1”).

“Shunning all external touches they concentrate,

focusing at the center between eyebrows, they meditate

controlling the life force entering and leaving the nostril

Their inhalation and exhalation, they equalize by their will 5.27

Step by step one must gradually turn inwards

And think of nothing else that is outwards

With the intelligence focused in concentration

One must engage in the Self’s meditation.” 6.2

Conclusion

The message of the Gita is universal. The religious and the secular, the Hindu and the non-Hindu alike can derive solutions from it for addressing moral injury and ethical dilemmas. Almost all religions of the world endorse doing one’s duty, rooted in righteousness and submission of all one’s actions and their results or consequences; even be it death to the highest power. The secular can draw inspiration from the concept of the universal interconnectedness of all things and the wisdom of doing what one can do to the best of one’s ability while accepting what one cannot change.