Triage Trauma and Moral Distress

October 1, 2020

Mental health providers who battle a pandemic may find that it unsettles their deepest sense of self.

COMMENTARY

Mental health caregivers have all too often had to work in situations where patients’ needs far outstrip available resources. It is akin to the triage experienced at times in emergency rooms, on the battlefield, or by clinicians dedicated to the care of underserved populations.1 The chaos and uncertainty generated by the COVID-19 pandemic mirrors historical reports of other global traumas, times when difficult decision making occurs amid great uncertainty, and tragic choices must be made.2 Making such choices can leave indelible effects on the human psyche.3

The aftereffects of triage-like situations are often insidious and may remain hidden for years, sometimes expressing themselves somatically, psychologically, and behaviorally. Sadly, the COVID-19 pandemic has also challenged caregivers, as well as patients and their loved ones, forcing difficult triage choices. Experience reminds us that we need to be prepared for the aftermath of triage’s trauma.

Traumatic flashbacks, feelings of unconscious or dissociated survivor guilt or shame, and experiences of depression are common. Efforts to treat this posttraumatic spectrum of suffering, while often helpful if not curative, can also often fail, leaving clinicians concerned about what they have missed, how might they have been more helpful.

Much is written about the models and ethical issues raised by working with such individuals. How to help them remains a mystery. Clinicians are often left saying, “We’ve done the best we can, and it simply wasn’t good enough.”

Perhaps such self-flagellation and despair are the result of working from a limited perspective on the etiological components web of chance, causation, choice, and helplessness that entraps the individual in their suffering. Witnessing, experiencing, or perpetrating traumatic events does not only affect normative cognitive expectations; it also challenges an individual’s sense of self and fundamental expectations of their values. It can assault their moral self: a sense of meaning and what is right and wrong, not simply as ethical choices, but as elements of their own inherent constitution and agency.

Moral integrity represents the depth of an individual’s inner core, not a simple dichotomy of right and wrong. As such, when a person’s moral integrity is jeopardized in some fashion, they lose touch with their inner identity. It may lead to overestimating or disowning personal agency as a protection against the aloneness and helplessness inherent in triage-limited decision-making. As a result, many of the components of posttraumatic suffering and chronic grief (such as guilt, remorse, shame, or considering oneself infallible) are experienced in a far deeper way, since the sense of meaning and existence are in jeopardy. Denial of uncertainty, compartmentalizing helplessness, and experiencing life-long anticipatory mourning are possible consequences. And when resilience is necessary, an inability to grieve helplessness and vulnerability can lead to culturally sanctioned, socially toxic prejudices.

Caregivers and patients suffering from moral injuries are different from those who are not. Moral injury means that an individual's self-definition is on the line. Efforts to mitigate their post-traumatic spectrum symptoms may only provide partial remedy for their problems. Individuals suffering greatly may become angry, blaming caregivers, in an effort to retain an illusion of control. They frequently experience feelings of doom greater than depression.

The aftermath of COVID-19 will likely leave many with posttraumatic spectrum and chronic grief. Many will also likely suffer from moral distress. “Did I do enough?” “I failed to take proper precautions.” “My god failed me.” Such cries of distress are likely to be misunderstood unless we recognize that they may well be expressions of existential moral suffering. Unaddressed, moral suffering may be a prelude to toxic resilience: dehumanization and destruction of members of a historically demonized and marginalized minority.4 Moral distress also may prompt self-destructive behavior, as in “deaths of despair” from suicide, excessive risk taking, and looking for quick fixes or anesthesia via compulsive drug use.5

Who can address such suffering? An initial step is to connect with those who have made triage decisions. Clinicians should make sure that they are not left with the choice of either feeling alone or being treated generically. Care providers must address a fundamental wish of perfectionism in themselves in order to be available to help those saddled with triage responsibility. While observing boundaries, at times self-disclosure of one’s own failures, fears and regrets in life can be helpful. As members of a supportive medical and mental health community, we need to be prepared to do no less during and after this pandemic.

Addressing moral distress is different. Post-triage trauma, confessions of regret are not enough. It is vital to recognize that there is a good deal of judgment inherent in decision making under conditions of uncertainty and limited resources. The key is to avoid both perfectionism and denial of responsibility, idle self-righteousness, and nihilism. Such insight can only be achieved in a safe space for conversation. As we recover and hope, it is vital to make time and resources available to treat not only checklist post-traumatic stress spectrum mental health symptoms, but also the larger, more persistent changes in personality and perception of self that constitute moral injury.6

Dr Bard is has been a faculty member of Harvard Medical School Department of Psychiatry Medical since 1976. He is co-founder, co-director and vice president of the American Bioethics Culture Institute, the American Unit of the International Network of the UNESCO Chair [Haifa] in Bioethics, Inc. Dr Bursztajn is co-founder of the Program in Psychiatry and the Law at Harvard Medical School and president of the American Unit of the UNESCO Bioethics Chair (Haifa). He is coauthor of Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

References

1. Bursztajn HJ, Gutheil TG, Brodsky A. Ethics and the triage model in managed care hospital psychiatry. Psychiatric Times. 1998;15(9):33-40.

2. Calabresi G, Babbitt P. Tragic Choices. Harvard University Press; 1996.

3. Modell, AH. Other times, other realities: Toward a theory of psychoanalytic treatment. Harvard University Press; 1990.

4. Haque OS, De Freitas J, Viani, et al. Why did so many German doctors join the Nazi Party early? Int J Law Psychiatry. 2012;35(5-6):473-479.

5. Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Pap Econ Act. 2017;397‐476.

6. Tanaka G, Tang H, Haque OS, Bursztajn HJ. Preserve Enduring Personality Change After Catastrophic Experience (EPCACE) as a diagnostic resourceLancet Psychiatry. 2018;5(5): e9.