Moral Injury Links Medicare Advantage Physicians To Combat Veterans

What can I do? Where can I hide from all this and not be found? What wings would take me high enough? How deep a hole would I have to dig? My shame for the evil I have done consumes me… I am soaked in blood-guilt, polluted, contagious… I am a pollutant, an offense to gods above. (Euripides, 416 BCE)

Several years ago on the occasion of Veterans Day, I wrote about the concept of moral injury in an article entitled “A Civilian Speaks to Veterans.” A piece, by Professor of Religion Kelly Denton-Borhaug, that appeared in TomDispatch, alerted me to the work being done by her on this issue at Moravian University in Bethlehem, Pennsylvania. There, Dr. Denton-Borhaug is Program Director of Peace and Justice Studies and also Co-director of the Moravian University Humanities Fellowship.  She states:  

“Moral injury is not a psychological pathology.  It is the destruction of a person's moral center within the context of war.”  

So I should not have been surprised to find the above concept applied to Medicare Advantage, wherein doctors are forced to deal daily with life threatening situations whose outcomes are decided not by medical professionals but by profit-driven insurance companies (private corporations, hedge fund managers, or Ollie's Plumbing and Heating). In the June 2024 edition of The Retiree Advocate, Jaisri Lingappa explains this phenomena in an article entitled “Is Medicare Advantage Creating a Crisis of Conscience for Your Provider?”  Lingappa posits:

“Moral injury is the distress health-care providers feel when their personal ethos to heal suffering and, above all, do no harm conflicts with a corporate mandate to generate profits. In a seminal 2018 article (1) and their subsequent book on this topic (2), Dr. Wendy Dean and co-author Dr. Simon G. Talbot explained how moral injury among healthcare providers is analogous to veterans experiencing “anxiety and avoidance caused...by shame and guilt associated with perceived immoral conduct.” Importantly, moral injury is not the same as burnout. Recommendations for relieving burnout – e.g. time off, reduced hours, encouraging relaxation through meditation or hobbies – do not relieve the moral injury that providers feel when pressured to be the instrument of systems that betray their deeply held moral beliefs.”

A later article, “Reframing Clinician Distress: Moral Injury Not Burnout” by  Dr. Harold G. Koenig and Dr. Faten Al Zaben, looks at the symptoms exhibited by soldiers, physicians, and health care workers that demonstrate their commonality and their points of divergence, as shown in the Venn diagram at the beginning of this article. In the conclusion to their article, Koenig and Al Zaben provide an additional aspect of MI:

“We have also noted that MI occurs in first responders and others exposed to severe trauma that may have involved actions that transgressed moral beliefs or values, although regrettably, little research has been done in this regard.”

This quote brings to mind an article I wrote six years ago, “The Traumatization of Our Police,”  in which I expanded on an article, “The Police Are Traumatized,” by Alex Kelly, former editor at Truthdig. Kelly reports that,

“…police work is inherently traumatizing. Whether they ever have cause to reach for their guns or not, police officers are constantly subject to threats of violence. It is part of the water in which they swim. Left untreated, the consequences of trauma can be disastrous. Lengthy exposure disrupts normal brain functioning. It undermines our ability to think clearly and carefully and regulate our emotions. And it makes us more suspicious, less trusting and even paranoid. It increases the likelihood that we will respond to stressful experiences aggressively.”

But Kelly also mentions that few police officers avail themselves of treatment for their stress. In many cases involving their contacts with the public, police officers are caught between solidarity with their fellow officers, police department management, and their own personal moral center. By getting psychological help, officers risk breaking with other officers, those whom they depend upon to assist and protect them. Therein, the double bind, which leads to moral injury.

Three videos below on moral injury as understood in the cultures of the military, the police and health care practitioners.