Slow Trauma: Reframing Concepts of Moral Injury in Trauma-Informed Ethics Consultation

AbstractAn emerging area of interest in healthcare ethics consultation (HEC) is the potential for moral injury and trauma to surrogate decision makers (SDMs). Introduced by Anani, Lanphier, and Fiester, trauma-informed ethics consultation (TIEC) recognizes that these encounters frequently involve exigent circumstances and the stressful misalignment between the provider's goals and the expectations of SDMs. Moral injuries sustained in HEC can be intensified by perceived feelings of mistrust, fear, betrayal, and failure. Recognizing signs of emotional, physical, and mental distress resulting from prolonged exposure to anxiety can create opportunities for redirection or referral. This article builds on the contributions of Anani, Lanphier, and Fiester by examining a specific kind of moral injury that is likely to be encountered in HEC and the process by which injuries may develop into post-traumatic stress disorder (PTSD). By narrowing the definition of moral injury and distinguishing between fast and slow trauma, it will be argued that trauma arising in HEC is more closely aligned with slow trauma characterized by a cumulative cognitive burden leading to psychological decompensation and identifiable clinical breakpoints. Different from sudden or violent trauma, associated with PTSD, slow trauma is linked to complications of post-traumatic embitterment disorder (PTED); these have separate pathologies with different causes, clinical presentations, and treatment strategies. The pathophysiological model of slow trauma proposed in this article seeks to elucidate a more nuanced understanding of how moral injury, the effects of unrecognized cumulative stress, and risk factors for emotional and cognitive dysfunction can lead to a richer dialogue in TIEC.