Moral injury is distinct from, yet related to, two other concepts common in medical discourse: moral distress and burnout. (See Table 1.) Although individual experiences may not always fit neatly into one category, their differences remain important for distinguishing methods for intervention and repair.
Andrew Jameton coined the term “moral distress,” characterizing it as “1) psychological distress of 2) being in a situation in which one is constrained from acting 3) on what one knows to be right.”14 Moral distress is the immediate result of participating in or witnessing a morally troubling situation. For example, a nurse might experience it when a doctor asks her to administer a treatment she finds objectionable. Moral distress might linger a few hours after the inciting event, but if her individual sense of the good remains intact, it often resolves.15 However, repeated or severe violations may leave a moral residue, which can accumulate and lead to moral injury.16,17
Whereas the nursing literature often focuses on moral distress, physicians commonly describe their work-related exasperation as “burnout.” Definitions vary somewhat, but burnout is generally understood as a combination of emotional exhaustion, depersonalization or cynicism, and a sense of reduced personal accomplishment.18,19 The prevalence of burnout among doctors varies widely, with more than half of U.S. physicians reporting at least one symptom.18,20
The diagnosis of burnout is not made uniformly; a recent meta-analysis found wide heterogeneity across indices used, as well as across score cutoffs within the same tool.20 Although moral distress and moral injury are not the only causes of burnout, moral injury can contribute to its core symptoms. The inability to practice medicine in a way that coheres with one’s moral expectations is distressing. Doubts about one’s abilities to carry out the good can lead to ineffectiveness and a reduced sense of personal accomplishment. Perhaps most significantly, moral injury can lead to cynicism, depersonalization, and disengagement.
But moral injury is not itself burnout. The fact that so many doctors are concerned about the possibility of burning out suggests that they are not yet emotionally numb. By contrast, physicians who burn out are no longer distressed at the violation of deeply held moral beliefs, because they are beyond feeling. The detachment and depersonalization associated with burnout can be viewed as the absence of distress or moral investment altogether.
We offer a heuristic describing the interplay among moral awareness, distress, injury, and burnout. (See Fig. 1.) We argue that they exist on a spectrum. Moral distress, if sustained, is a common cause of clinician moral injury. If unchecked, moral injury may lead to burnout.21 In practice, the progression is often uneven, and there can be movement back and forth along the continuum. A singular morally distressing event may be so injurious that it leads swiftly to burnout.22 In others, the same event might trigger only moral distress. While not perfect, this continuum is helpful for considering interventions before burnout. Moral distress can be mitigated and moral injury thwarted if the inciting circumstance or event is removed. Addressing moral injury to prevent burnout is more difficult. It requires attending both to the organizational climates and structures that lead to ethical violations and to the clinician’s ruptured moral identity.