During my career I have cared for veterans of many wars.  Some had visible injuries and scars because of their service while many more had unseen and undocumented wounds.  I felt honored as a physician and a fellow human when veterans shared feelings, experiences and undocumented injuries with me.   We, as healthcare providers as well as fellow citizens, now acknowledge those unseen or invisible wounds more readily than several decades ago.  Psychological, emotional, and spiritual injury can occur to any of us.  Initially coined in Worl War I, “shell shock” was used to describe a constellation of physical and psychological symptoms as the result of combat.  Eventually the terminology, post-traumatic stress disorder or PTSD, evolved to describe what some soldiers experienced as the result of military service.  Whether a front-line combatant, a pilot, or a nurse caring for wounded soldiers, some service members experienced PTSD. 

Only through recognition of the effects of trauma on members of the military has the medical profession and society come to acknowledge and finally accept the impact of trauma on human experience.  The Greek poet, Homer, demonstrates the impact of trauma on characters in both the Iliad and the Odyssey.   A moral injury can occur along with PTSD, but they are not the same.  Dr Jonathan Shay discusses the concept of moral injury in his book Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994).  In essence, a moral injury can occur when a person is in a high-stakes situation, and he/she believes a person (or entity) in authority has not done what is perceived as morally right.  Therefore, a moral injury is broader than what is described as PTSD and includes the spiritual, emotional, social, and cultural impact of trauma. 

We as health care providers may experience a moral injury when an individual or entity in authority hinders us from doing what we percieve is best for the health of a patient.  Guilt and shame may be two of the feelings we then experience.  Providers may lose trust in their healthcare leaders as well as healthcare institutions in positions of authority (health insurance companies and health care networks).  As a result of this perceived moral transgression, anger and resentment may build over time, which can lead to unhealthy behaviors.  Chronic frustration and a sense of not being heard can lead to apathy about patient care and a loss of purpose as a healthcare provider.

Recognition of my own limitations and what I have control over as well as deciding when to “make a stand” is something I try to live by in my practice.  I am not perfect.  None of us are.  However, it is in our shared experiences and imperfections that we can truly empathize with another human being.  We all do not serve in the military, but we all experience some type of trauma in life.  Thanks to the recognition of “shell shock” and PTSD in members of the military, we, as humans, can hopefully acknowledge and better understand trauma and moral injury.  Only through understanding and acknowledgement of moral injury in others can we identify it in our patients, colleagues, and even ourselves. 

One of the most beneficial treatments for PTSD and/or moral injury is sharing.  Sharing one’s experiences with trauma and/or moral injury with others nurtures the healing process.  Denial, hiding or suppressing feelings and experiences will eventually lead to a variety of problems including feelings of isolation and unhealthy coping behaviors.  We as humans benefit from social interactions whether in good or bad times.   Similar to the benefits of 12-step groups, veterans who share can benefit from the “purging” of feelings and experiences into a group who listens without judgement.  By honestly sharing the group as a whole can benefit from the experiences of the individual. 

I encourage all providers to take a few extra moments to listen to those who may have a moral injury.  Although your story may have different subjects, locations and events, you can benefit from the communal experience of grief, sorrow, and moral injury.  We as humans share the joys and excitements of life but when it comes to the at times difficult part of living—the sorrow and the grief—we often refuse to take part in the shared healing.  Veterans can teach us much about community and what it truly means.  They live, train, and die together.  The rest of us do the same things however we are usually not in life-or-death situations.  Sharing and listening with empathy are the best ways to experience this human life.  Look for commonalities between you and your patients.  As a provider, you may find that deep down your heart and soul are speaking to you through the mouth of one of your patients.  Many veterans over the years have helped me recognize and acknowledge many of my own buried emotions and experiences.

References:

• Homer — The Iliad and The Odyssey
• Dr. Jonathan Shay — Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994)