Physicians and other health professionals caring for seriously ill patients often face difficult decisions about appropriate care for their patients. These decisions can be emotionally laden under the best of circumstances, and become even more challenging under highly stressful circumstances, such as the COVID-19 pandemic. With COVID-19, the numbers of patients who urgently need care, few effective treatments, high risks for disease transmission, and scarcity of critical resources can lead to moral distress.

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“Moral distress comes in when it feels like the kinds of decisions we have to make about care or the kind of care we're delivering really challenges our fundamental beliefs and commitments as medical professionals,” said Rebecca Brendel, MD, JD, a psychiatrist and member of the AMA Council of Ethical and Judicial Affairs and associate director of the Center for Bioethics at Harvard Medical School in Boston. “It’s on a continuum from feeling stressed or challenged all the way to becoming burnt out, having clinical symptoms of post-traumatic stress and, more than that, soul-wrenching questions about what it is that we're doing,”

Here are some of the reasons physicians and other health professionals might be experiencing moral distress as the COVID-19 pandemic continues.

Lack of access to personal protective equipment

Moral distress is prominent when physicians work in a system that puts physicians in a position where they do not have control over important aspects of their professional life, such as access to personal protective equipment (PPE).

“Physicians feel that they have a professional and moral duty to help persons who are suffering, but also feel like they are being let down by a society that’s putting them in harm’s way,” said Dr. Brendel.

COVID-19 is different than other recent outbreak situations, Dr. Brendel explained. With measles, for example, there’s a vaccine so immunized people aren’t at risk. Even in influenza seasons with a less effective vaccine, there is treatment to mitigate symptoms.

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“With COVID-19, physicians who don’t have adequate PPE are expected to put themselves at serious risk in order to treat patients,” she said.

Contagion management and risk to families

Adding to the challenge, physicians and other health professionals know that treating COVID-19 patients means they can also be putting their own families at risk. Going home at the end of a shift doesn’t mean they can leave worry about the disease behind.

“Higher levels of distress related to challenging experiences happen when you can’t have an off button,” said Dr. Brendel. “There’s not been a lot of rest with COVID-19 because when physicians and other health care providers come home, they have to worry that their family could get sick.”

Amplification of health inequities and disparities

“The COVID-19 pandemic is amplifying health care inequities and disparities and that’s also a significant stress for health care professionals,” she said, even if it’s less direct than the risk of disease itself.

For example, in hard-hit New York, hospitals with fewer resources often had the highest caseloads as did “communities of color and lower socioeconomic areas,” said Dr. Brendel. “Those can be secondary things that can add up to why we expect to see a COVID-19 mental health fallout and moral distress beyond what we would see in any bad flu season.”

Even in Massachusetts, where the department of public health was tasked with allocating resources fairly among hospitals, some communities were hit much harder than others.

“Seeing particular communities devastated was a huge challenge,” she said.

Social deprivation between patient and doctor

The pandemic has also deprived patients and physicians of the usual human connection that’s important in medical care. At the Boston field hospital, “you could tell the staff from the patients because the patients just had masks and the staff were in what looked like moon suits with masks and face shields,” said Dr. Brendel. “Imagine the cumulative toll of not really ever seeing the faces and reactions of the people you’re working with and not having that normal human connection with patients or peers.”

“The hospital started printing out stickers of what providers look like without PPE to put on the front of our PPE suits,” she said, adding that there were times she would say to a patient, “You may not be able to tell right now, but I’m smiling.”

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The AMA has created an ethics resource page, "Obligations to protect health care professionals,” that offers expert advice on supporting and protecting staff at health care institutions during a public health crisis. Citing numerous opinions from the AMA Code of Medical Ethicsthe page provides a comprehensive guide to the ethical questions in play.

Additionally, the AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical EthicsJAMA Network™ and AMA Journal of Ethics®, and consult the AMA’s physician guide to COVID-19.

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