Attention Must Be Paid: More on Moral Injuries in Psychiatry

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

In Arthur Miller’s famous play “Death of a Salesman,” at the end of the first act, the wife of the salesman Willie Loman exclaims to their 2 sons that “Attention, attention must be paid to such a person.” Those sons have become increasingly critical of him as he is failing at his job and marriage. They do not want to follow his desire for them to go into sales. As he is cast aside for more company profits, he has an affair and is caught by his son Biff. His moral injuries escalate with the shame and failure at not following his values. He commits suicide. In so doing, he does leave an inheritance for Biff.

As I have been touching upon moral injuries in recent videos and columns, it would not be hard to connect what happened to such a fictional salesman from the past with what is happening now to real life psychiatrists and physicians. Moral injuries are contributing to our high rate of suicide. Burnout remains at epidemic rates as for-profit businesses maintain control over medicine and patient care. Profits can come become patient care.

Even so, I have encountered what seems to be a paradox. The subject seems more and more relevant to us, yet that attention has waned. I wondered why.

Now that I have finally thought more about moral injuries and examined the literature, it seems like it goes with the territory of being a psychiatrist or any mental health care professional. After all, some degree of personal moral failure seems inevitable, and more or less continuous. For example, if we personally strongly value helping our patients to get better as they are our primary professional ethical priority, what happens to that value when we inevitably fall short some of the time, if not normally a good part of the time? As with teaching. Same with research. Same with administration.

Normalizing the understandable falling short has been tolerable over the history of medicine. Continuous quality improvement is a modern way to reduce falling short. However, when the medical system adds obstacles and barriers that seem unnecessary, even a betrayal of trust, it is harder to feel morally satisfied. We can even feel that we are complicit when we stay in the system to do our best anyways.

One way of coping with that growing disparity between the ideal and actual outcomes is with denying or mentally dissociating its occurrence. Ignore it. Forget about it. That works to a degree, but can gradually eat at our souls. That is why I want to begin a series on moral issues today.

Gratefully, I am not starting from scratch. There was a temporary focus of more attention being paid to moral injuries during the COVID-19 pandemic. Given the many obstacles to our healing, along with all the ensuring losses and trauma, how could that not be so? A leader in the connected fields of psychiatry, religion, and spirituality, Harold G. Koenig, MD, recognized the problem and provided an exemplary summary of the topic right in the middle of the pandemic.¹

Then, relative silence emerged once again, only to now see another rise connected to bearing witness to the current wars.

Attention must be paid to our moral injuries. We will. Stay tuned.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

Reference

1. Koenig H, Al Zaben F. Moral injury: an increasingly recognized and widespread syndrome. J Relig Health. 2021;60(5):2989-3011.