SALT LAKE CITY — Within the span of a week, Dr. Kirsten Doub suffered both a black eye and bloody lip on the job. But it’s not the physical demands of her work, but the emotional ones, that make veterinary medicine so difficult, she says.
Doub, owner of Union Park Veterinary Hospital in Cottonwood Heights, Utah, concurs with a recent study that found veterinarians have high rates of moral distress, the psychological pain that occurs when a person feels compelled to act in a way that is contrary to his or her moral code.
"We are expected to be flawless and to drift off to sleep every night with a free conscience," Doub wrote recently on her Facebook page. And yet, "We are part of a profession plagued with the highest rates of suicide, depression and substance abuse."
The study, published Aug. 6 in the Journal of Internal Veterinary Medicine, was the latest to show that a condition once mainly associated with war veterans is being noticed — and treated — in other professions.
Earlier this year, Dr. Simon Talbot and Dr. Wendy Dean, writing in the health and medicine publication STAT, said physicians are suffering from widespread moral injury because of their inability to offer quality patient care under the bureaucratic constraints of the health care system.
And moral distress and injury among nurses has been a concern for more than a quarter of a century.
In response to the growing awareness of the problem, a Texas seminary established a Soul Repair Center dedicated to research and education about moral injury. At its annual conference Nov. 15 in Denver, participants will participate in workshops to include the effects of moral injury on families, and discuss moral injury in sacred texts.
Moral injury can occur to anybody who has a developed conscience, experts in the field say. But people of faith are uniquely positioned to help sufferers because they are well acquainted with one component of healing: forgiveness.
Another thing that helps sufferers of moral injury or distress is something that anyone who listens well can do.
The cost of 'convenience euthanasia'
In a veterinary practice, moral distress might occur when a client asks the veterinarian to euthanize a pet when the animal’s condition could be treated. “This happens almost daily or at least weekly for most veterinarians. It is one of the main reasons I opened my own hospital,” said Doub, who said she will not perform “convenience euthanasia.”
But moral distress can also result from the reverse situation, according to the study authors. Nearly 8 in 10 veterinarians also report incidents when they believe euthanasia is the best thing for the pet, but the owners refuse and subject the animal to lengthy, expensive and ultimately futile treatment. In many cases, veterinarians may report feeling sad or upset without realizing what is happening on a deeper level: “a conflict between their actions and their personal morals,” authors Lisa Moses, Monica Malowney and Jon Wesley Boyd wrote.
The authors believe that the widespread incidence of moral distress and injury among veterinarians contributes to mental health problems and a suicide rate that is twice the average of the general population. Doub, whose practice now includes former clients of a Utah veterinarian and friend who took his own life in 2012, agrees.
Doub knew another veterinarian and a veterinarian technician who committed suicide. She believes ethical conflicts between pet owners and veterinarians are increasing, in part, because people are living beyond their means and don’t have money saved for emergencies. When an emergency occurs and diagnostic tests and treatment is expensive, they either ask the veterinarian to euthanize the pet, or ask for a payment plan, which they sometimes don’t honor.
Doub’s friend who died by suicide, “had a whole hospital full of cats who were dumped at his practice that he cared for himself. He offered payments and then people wouldn’t pay him back. He hadn't had a vacation in five years."
In health care for humans, moral distress and injury occurs when outside constraints prevent physicians and nurses from providing care that they know a patient needs, according to a study published in 2017 in the journal Psychological Trauma. These constraints could include being compelled to care for more patients than time allows, having to follow a parent's instructions when the physician doesn't believe it's in the best interest of a child, or continue care that does not improve a patient's condition but instead prolongs dying.
The concept of moral injury was originally developed by a Massachusetts psychiatrist, Dr. Jonathan Shay, to describe the trauma suffered by veterans who witnessed or participated in atrocities during war. Shay says moral injury occurs when there is a betrayal of what one believes to be right, either by the person himself or by a person in “legitimate authority."
"Both forms of moral injury impair the capacity for trust and elevate despair, suicidality and interpersonal violence. They deteriorate character," Shay wrote.
A loss to society
Although veterans of combat witness more trauma than the average suburban veterinarian, Rita Nakashima Brock, author of “Soul Repair: Recovering from Injury After War,” said it does not diminish their condition by extending the diagnosis to other professions. On the contrary, it helps to remove a stigma, said Brock, senior vice president for moral injury programs at Volunteers of America.
“I think the way moral injury has moved into other spaces says that it’s a very strong concept, and that other human beings, just like veterans, can be in circumstances that cause them to lose their meaning system," Brock said. "And losing a meaning system is devastating, because it’s about everything you thought was right and good, everything you invested your sense of self in, starts to collapse."
A person's identity is "profoundly moral" and people usually automatically behave in ways that reflect that inner code, she explained. But then you can have an experience that causes you to fail to do the right thing, even if you want to do the right thing.
For example, Brock once had a conversation with a man who was fleeing the World Trade Center on 9/11 and saw an older man trip and fall, and he didn't stop to help him. When he looked back, two other people had stopped. Later, he began to doubt his capacity to behave morally because of the experience, she said.
“In the aftermath of that, you start thinking, what do I believe, how could I have done that, how can I trust myself to be a good person?” she said.
When moral distress or a moral injury afflicts a person in a profession, it not only hurts the individual, but society. A doctor, for example, may come to believe that she's not a good doctor anymore, after experiencing repeated moral distress, and disillusioned, leave the profession.
"It's not just the loss of their career; it's a major loss to society," Brock said.
'An ancient concept'
Nancy Ramsay, director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas, said moral injury is “an ancient concept with a new name.”
History shows that even ancient cultures struggled with moral injury. “We know that, in the Hebrew Bible or the Christian Old Testament, when there were battles, men didn’t go right back to their towns. They had a process of ritual cleansing, or a year of penance before they could participate in sacraments again. War changes people’s lives forever,” Ramsay said.
Moral injury is different from post-traumatic stress, however, she said. “They can occur together, but they’re not the same." Post-traumatic stress occurs in the aftermath of an event in which a person thought they were going to die. “It actually changes chemicals of the brain; it has physiological consequences."
Ramsay describes moral injury as the result of either perpetrating, failing to prevent, or witnessing an act that betrays your moral standards. People may also suffer moral distress or injury by being witness to the aftermath of an event.
“Suddenly, you realize there’s a capacity for destructiveness that went beyond the scope of your imagination,” she said.
As for the difference in moral distress and moral injury, Ramsay said, “Think of them on a continuum. Moral distress is uncomfortable, but it’s not the kind of devastating, life-changing trauma of moral injury. Moral injury, some people write about as if the world changes. The scope is more profound. Neither is comfortable, but moral stress is not as serious in its consequence,” she said.
To help educate faith leaders on the scope and treatment of moral injury, Brite's Soul Repair Center offers seminars and conferences for people of all faiths, and other seminaries — to include Iliff School of Theology in Denver, Eden Theological Seminary near St. Louis, Missouri, and Boston University's School of Theology — are addressing moral injury in their program offerings.
Some hospitals are trying to help physicians and other health care providers with a caregiving program called "Code Lavender." But writing in STAT, Talbot and Dean said that's not sufficient.
"What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. .. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based and financially responsible decisions," they wrote.
As for veterinarians, the authors of the new study called for more instruction on ethical conflict and self-care in veterinary school.
"Regardless of the explanation, training in recognizing, naming and navigating ethical conflict as part of veterinary professional education could start to address the problem," the report said.
Steps to healing
Repairing a moral injury is as important as healing a physical injury, said Brock of Volunteers of America, because “Human beings can’t live without a meaning system.”
One of the most important parts of recovery is being able to talk about what happened with a benevolent person who cares about you, Brock said. “Once you begin to do that, you can start to process the story, to think about it from different angles.”
Eventually, she said, “You have to build a new moral system that is adequate to that experience. You're not well if you put it away and try not to think about it and just keep going."
Ramsay agrees that being able to talk frankly to someone who will listen without condemnation is critical to those wrestling with moral struggles. And doing so leads to another step — repentance and self-forgiveness.
Being able to safely say out loud what has happened, and explore the context of the action, helps people to look honestly at whether they could have done anything differently. It helps them distinguish between fault that they own and/or fault that belongs to another, or even to realize that the action that troubles them was simply the inevitable outcome of an incredibly complex and difficult situation.
“That may not take away being haunted by what they saw and what they did, but hopefully it helps the process of remembering and mourning this life-changing experience,” she said, adding that people who have religious faith may benefit from being able to confess their actions to a spiritual leader.
And whether or not people are religious, doing volunteer work or other good deeds may be both reparation and a source of healing. In addition, some people may find relief through a physical practice, such as meditation or yoga.4 comments on this story
People who are suffering from a moral injury, either from their professional work or something they did in their personal life, might be able to take comfort in knowing that they’re not fundamentally broken, that their suffering is indicative that their conscience is working perfectly well.
“You can’t have moral injury without a conscience. Your conscience is working perfectly well," Brock said. "But what happened is, your conscience has become ungrounded from any meaning system that makes your conscience feel that it’s active and doing the right thing. That’s why you’re so miserable.
"It’s not a pathology; it’s a normal, human response to abnormal conditions. But it is a profound kind of suffering,” she said.