Love is sacrifice. There is no greater love than this, to lay down one's life for one's friends. All across the world, healthcare workers are sacrificing for their friends and for strangers alike. They are sacrificing for those who contracted COVID-19 from willful ignorance, from reckless disregard, and others innocently from some unsuspecting source. And yet medical workers treat them all the same, fight tirelessly for their healing. For this and so much more we all owe a great debt of gratitude and honor.
But that is only a small part of what I want to say, and it is to those medical workers I write, I want you to be prepared. Your life is about to change forever, your sense of fairness, justice, and right and wrong may soon suffer so great an upheaval that it leaves you reeling in shock and existentially wounded. Please hear my words. I write them in love.
There is a term, many of you may know, a condition of the soul called moral injury. It is also a condition that many medical professionals already have from years of working in the healthcare industry. For anyone unfamiliar, “Moral injury refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional guilt and shame, and in some cases also a sense of betrayal, anger and profound 'moral disorientation’.” 1
“The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma. Distinct from pathology, moral injury is a normal human response to an abnormal traumatic event.” 2
Moral injury refers to the “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” 3
Said another way, moral injury is “A deep soul wound that pierces a person’s identity, sense of morality, and relationship to society”. 4
There are critical distinctions that need to be made between moral injury, burnout, compassion fatigue, and post traumatic stress. Moral injury is primarily an existential crisis, and while it is often exacerbated and usually accompanied by the physical exhaustion of burnout, the ever narrowing emotional bandwidth of compassion fatigue, and the unconscious and very normal response of stress after trauma, it is more fiendish and perhaps more debilitating than all of the others combined.
Moral injury can be divided into two categories: individual responsibility, that is the perpetration of, or the failing to prevent, harm, and other responsibility where we witness the dereliction of sacred duty and/or betrayal by trusted others.
In this current crisis you are going to be asked to do more than you've ever done, with less than you've ever had, for more people than you could have possibly imagined. Resources will run out soon. At the time of this blog, New York has 5-6 days of critical medical supplies left. Already doctors and nurses are being asked to recycle disposable protective gear, or wear it long after it is safe to use. The decisions being made in boardrooms and political dens are affecting you and your patients in real time. And the stark reality of limited ventilators and other life saving devices is about to have a very real cost in human lives. This is battle field medicine, and no amount of training could psychologically prepare you for this.
Tomorrow, or maybe the next day you will have to choose which patient gets life saving resources. Tomorrow or the next day, another of your peers will fall ill, a victim of recycled masks, of compromised immune systems due to physical exhaustion from endless shifts. The blame may be easy to spot, the mistakes glaring and some even seemingly avoidable, but you will have no time to obsess on that, you will be in the fight of your life, perhaps the fight for your life.
The cumulative effect of all of this, the damage from this perfect storm of ignorance and unpreparedness, will leave your soul wounded. The unfairness, the tragedy, the inequality will fracture your heart, your mind, your spirit. Moral injury fills the vacuum where the illusion of human virtue once was. People will fail you, the system will fail you, your leaders will fail you, and you will be altered in ways unimaginable.
When this over, and it will end, you will be forced to deal with the moral injuries. Some will come from events where you failed, or perceive you did, the decision to give the ventilator to one patient over another. This will lead to toxic, negative, internally directed emotions and cognition like guilt, shame, and lack of self-forgiveness. Other events, those outside your control, administrative or political decisions or inaction that cost lives, will surface as toxic, negative, externally-directed emotions and cognition like anger, inability to trust, and lack of other-forgiveness.
Both types of events are associated with spiritual/existential issues, the loss of "faith", of questioning morality, and until resolved, these internal conflicts can in turn exacerbate social problems like isolation and aggression along with inducing mental health symptoms such as anxiety and depression leading to substance abuse and greatly heightened suicide risk. Doctors are already at one of the greatest risks for suicide, even in non-coronavirus times.
Limited life saving resources, the desire for personal safety over patient care, outright mistakes, administrative decisions with dire consequences, even co-workers playing God will all wound your soul, but the greatest existential crisis that you may face, will be why must the innocent suffer. This virus preys on the vulnerable, the weak, the defenseless. The ones who need us most. Where is the fairness, the justice in the universe? Where is God? If God exists, why doesn't He intervene?
There are no easy answers. There may be none you find satisfactory. But for your own well being, for the care of your soul wounds, let me offer what I believe is the only true inoculation against, and the only cure for moral injury: hope.
If you are reading this as a Christian, than you will perhaps appreciate what I am about to say, but in the event you do not believe in God, or the Christian God, please consider the thoughts to follow objectively. Every code seems nonsense without the key, a jumble of words and phrases with no meaning. If your universe seems dissonant, confusing, and indecipherable, (or when it does after this is all over) let me humbly offer the Key.
First you must realize you are not alone in this, hundreds of thousands of medical professionals are going through or will go through the same things. Secondly, I believe in a God who suffered in every way, bore every burden any human would ever suffer, and understands intimately your moral crisis, your soul wound. Feeling alone in this is an inescapable prison, but knowing you are not alone, that others, most importantly that God understands, is the beginning of comfort, the first glimmer of that hope.
The Christian bible says “Not only that, but we rejoice in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope,” Romans 5:3,4
Scripture makes many promises, and perhaps none as seemingly unfathomable as this: “suffering produces hope”. The promise that for the believer, good will come from our afflictions.
As I've written about before, I spent 16 weeks at a field hospital near Mosul, Iraq. There I saw the worst humanity can do to the most innocent among us. Children targeted by drone strikes, hunted by snipers. One night I carried five children to the morgue. It leaves you breathless, concussed. It shakes your faith. No easy answers come in those moments, no words of comfort for others come easy either. And yet something in us holds fast. Words form on our tongue that are not our own…
"…rejoice in your sufferings, know that suffering will produce endurance, and endurance character, and character will produce hope."
This passage is saying that when Christians suffer, they have a strength that is not their own, in their weakness they find God's grace, His great power, holds. When they would run in fear or in despair, when they would curse sacrifice and live for themselves instead, His nature in them holds. When in the midst of their worst physical, mental, even existential crisis, He never leaves them, hope is produced and that hope holds. For the Christian hope is not an abstraction, it is a person, His name is Jesus Christ.
Christianity is much more than a path to follow, a philosophy to obey, it is the transformation of our very nature by God Himself living in us. The power and the intimacy this affords us becomes such great confidence in the darkest hour. For the Light of the world is in us and even death could not extinguish Him.
My prayer for you is this: Fall to your knees as you fight this wretched demon COVID-19, or perhaps it has already knocked you to your knees, and cry out for God of the universe to give you the hope of Jesus. He promises to work all things together for the good of those who love Him. He is infinitely able, and His love for you both unfathomable and unstoppable.
Love is sacrifice. There is no greater love than this, to lay down one's life for one's friends. Jesus calls you friend, He laid down His life for you. So that you could live this life with the same power that raised Him from the dead and destroyed the sting of death, the power of the grave forever.
Let His perfect love casts out all fear. Let Him start to heal those soul wounds. Let Him be your peace in this storm, your shelter from more moral injury, from fear itself.
Keep your chin up and wash your hands. Love you all. Xoxo
1. Litz, Brett T.; Stein, Nathan; Delaney, Eileen; Lebowitz, Leslie; Nash, William P.; Silva, Caroline; Maguen, Shira (December 2009). "Moral injury and moral repair in war veterans: A preliminary model and intervention strategy". Clinical Psychology Review. 29 (8): 695–706.
2. Molendjk, Tine (2018). "Toward an Interdisciplinary Conceptualization of Moral Injury: From Unequivocal Guilt and Anger to Moral Conflict and Disorientation". New Ideas in Psychology. 51: 1–8
3. Litz, et al. 2009, p. 697
4. Silver, D. (2011). Beyond PTSD: Soldiers have injured souls. Truthout.org (9/3/11). Retrieved from http://www.truth-out.org/news/item/beyond-ptsd-soldiers-have-injured-souls
