The ever-increasing death toll from COVID-19 isn’t the only thing that has been hard on physicians during the pandemic. Many doctors have also had to confront ethical challenges, leading some to wonder whether their actions still point true north on their moral compasses.
“The difficulty with the pandemic is that is not a single event, but an ongoing event. ... So there may be more peaks and valleys of anticipation, heroism, honeymoon, disillusionment and reconstruction,” according to Mark Thomas Hughes, MD, MA. He is an internist and palliative care physician at Johns Hopkins Medicine, a core faculty member in the Berman Institute of Bioethics there, and assistant professor of medicine at John Hopkins University School of Medicine.
Physicians practicing in this milieu are susceptible to moral distress because they may not be able to do what they think is the right thing to do in a given situation due to some restraint—for example, having to ration limited resources, see patients virtually or postpone preventive care.
“This then has an impact on their moral integrity,” Dr. Hughes said. “If the clinician feels moral distress, this then may lead to moral injury, resulting in emotional upset or resentment. It may entail loss of empathy or numbness. Or it may progress to lasting moral residue with feelings of guilt or shame or even burnout.”
The COVID-19 pandemic is bringing new medical ethical questions to the forefront. The AMA is your source for guidance on ethical issues like triage and resource allocation during COVID-19.
What can help
“Emotional regulation is a key for addressing not only personal distress, but moral distress,” Dr. Hughes said, adding that the social resilience model aims to keep people in the “resilience zone,” regulating the flow of sympathetic activation and parasympathetic release.
“One of the keys in understanding resilience is, in any given moment, we have the freedom to choose our own attitude. ... In any given set of circumstances, we can choose how we will react to the situation and what meaning we will attach to the event,” said Dr. Hughes in remarks recorded for the November 2020 AMA Sections Meeting.
”Our ability to be resilient is dependent on the situation,” Dr. Hughes said.
“If we are tired or sleep deprived or physically worn down, we may be less able to accommodate to the stressful event and more likely to be pushed out of our resilience zone,” he added. “So there are daily rituals that clinicians can undertake to maintain and bolster their resilience zone.”
Dr. Hughes advised the following.
Check in with yourself and colleagues about how things are going. This “provides an opportunity to take a pause in the action, allows us to catch our breath,” he said. “It’s not necessarily to fix the problem, but at least acknowledge what's going on.”
Be mindful of what you can control. One of the things you can control, again, is how you choose to look at things.
Find ways to connect people to their purpose or calling. “It may mean tapping into the driving force that gives our life meaning, especially those that are in the helping professions,” Dr. Hughes said.
Leverage knowledge and skills to build self-efficacy. This is another area where physicians can control their fate.
Remind people they are not alone. “It may mean partnering with a coworker and telling each other, ‘I've got your back,’” he said.
Provide psychological first aid. Your interest in a colleague’s situation can help mitigate acute distress and instill hope.
Seek and offer peer support opportunities. Some health care organizations have teams of peers who can be called upon to help clinicians process a triggering event.
“At Johns Hopkins,” Dr. Hughes noted, “we've created moral resilience rounds, which is a Zoom session for health care workers to get together to talk about ethically challenging situations.”
Dr. Hughes’ advice on physician well-being was part of a larger talk he gave about ethical challenges during the pandemic, which included guidance for conducting end-of-life conversations with patients and their families.
To learn more about Johns Hopkins’ moral resilience rounds, explore the AMA STEPS Forward™ module, “Success Story: Virtual Gatherings Build Moral Resilience During Crisis."