Moral Injury in Health Care: A Unified Definition and its Relationship to Burnout

Moral injury had been discussed by health care professionals as a cause of occupational distress prior to COVID-19, but the pandemic expanded the appeal and investigation of the term. Moral injury incorporates more than the transdiagnostic symptoms of exhaustion and cynicism and goes beyond operational, demand-resource mismatches of corporatized systems.

Moral injury describes the frustration, anger, and helplessness associated with existential threats to a clinician's professional identity as business interests erode their ability to put patients' needs ahead of corporate and health system obligations. We propose a framework that combines 2 moral injury definitions. An individual who experiences a betrayal by a legitimate authority has an opportunity to choose their response. Moral injury arises when a superior's actions or a system's policies and practices undermine one's professional obligations to prioritize the patient's best interest. Perceived as inescapable, the resignation or helplessness of moral injury may present with emotional exhaustion, ineffectiveness, and depersonalization, all hallmarks of burnout. Both moral injury and burnout can mediate and moderate the relationship between triggers for workplace distress and the resulting psychological, existential, and physical harm.

Moral injury is increasingly recognized as a source of distress among health care professionals. It emerges from structural constraints on the ability of health care professionals to deliver optimal care and stand up for patients, their oaths, and their professions. A unified definition of moral injury must be integrated into the framing of clinician distress alongside burnout, recentering health care on ethical decision making rather than profit.