Moral injury can occur when surgeons fail to prevent or witness an act that conflicts with their professional values, typically when circumstances result in negative patient outcomes The psychological trauma following these events can lead to second victim syndrome, characterized by guilt and diminished confidence, and if not addressed, can progress to burnout, a condition marked by emotional exhaustion, reduced job satisfaction, and a detached attitude toward patient care.
The concept of “moral injury” was introduced by psychiatrist Jonathan Shay, MD, PhD, in the 1990s to describe the ethics-related psychological damage experienced by Vietnam veterans. In 2009, psychologist Brett T. Litz, PhD, and colleagues formalized this concept, distinguishing it from post-traumatic distress syndrome by emphasizing guilt, shame, and other behaviors stemming from moral conflict rather than just fear.1
“The term ‘moral injury’ captures our attention because it signifies injury. It’s hurt; it's harm,” explained Sunil K. Geevarghese, MD, MSCI, FACS, medical director of transplant perioperative services and professor of surgery, radiology, and biomedical engineering in the Division of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center in Nashville, Tennessee, and a renowned educator and national lecturer on surgical wellness and moral injury. “But part of the challenge here is that we might be upset about any number of things in our lives that do not constitute moral injury, which at its highest level, threatens the surgeon’s identity and his or her relationships with others.”
In fact, moral injury goes beyond mere job-related stress and involves high-stakes ethical conflicts that can result in significant psychological harm.
“I think individuals sometimes use the terms ‘moral injury’ and ‘moral distress’ interchangeably,” said Katherine Fischkoff, MD, FACS, chief of general surgery at NewYork-Presbyterian/Columbia University Irving Medical Center in New York City. “Moral distress is usually a specific incident where you feel that your values are not aligned with whatever the circumstances are in that moment.”
She shared an example of a patient’s family insisting on continuing full care, even though the patient is dying. The surgeon may find that to be morally distressing because they must come in every day and take care of a patient who is suffering and unable to make decisions.
“Moral injury is the bigger, broader piece, where you have multiple events of moral distress that add up to cause a larger, existential misalignment with your job,” said Dr. Fischkoff, who is coauthor of “How Should We Understand Regret as a Moral Psychological Experience that Can Influence Clinical Decision-Making?,” published in the AMA Journal of Ethics.
Moral Distress Among Surgeons
The reported prevalence of moral distress among surgeons and other physicians is inconsistent and varies by specialty.
A survey of neurosurgeons conducted in 2022 revealed that nearly half of those surveyed (47.7%) reported “significant moral distress within the past year,” and managing critical patients without a clear treatment plan was found to be the leading contributing factor for experiencing this psychological anguish.2 “Neurosurgical distress is at its greatest intensity when a neurosurgeon feels obligated to perform futile surgery because of family insistence, surrogate indecisiveness, or medicolegal concerns,” note the study’s authors. Moral distress was linked to 9.8% of neurosurgeons leaving a position, with 26.6% of respondents contemplating their departure from the role.
In a study published in 2020, researchers evaluated data from a mailed survey completed by 2,161 surgeons representing multiple specialties. Using the revised Moral Distress Scale, a tool that measures moral distress in clinicians, the study authors found that 34% of respondents experienced moral distress related to perceived pressure to perform surgery with no clear patient benefit.3
More than half of survey respondents (58%) indicated that they are sometimes or often asked to perform nonbeneficial surgery. The study authors suggested institutions enhance “communication skills that effectively support the emotional needs of patients and families [to] improve the ability to attend to these needs without surgery” in an effort to reduce the incidence of nonbeneficial surgery and moral distress among surgeons.
On the other hand, data quantifying moral injury are scarce, although research suggests it is an emerging issue with profound implications, particularly for surgeons.
“I would be surprised if many surgeons have experienced moral injury,” said Dr. Fischkoff. “I would guess that most surgeons feel very good about what they do, and they feel a great deal of satisfaction when an operation is done well with a good outcome—which is the whole point of our jobs. It’s why we do this. What is important is to figure out how to learn from a bad outcome rather than let it become destructive.”
In fact, adverse patient outcomes can be a significant trigger for surgeons experiencing moral injury.
“One of the most powerful examples of a major complication that could result in moral injury is interoperative death, meaning a death in the midst of an operation, whether it is an emergent case, trauma case, or an elective procedure,” said Dr. Geevarghese. “There are most certainly complications in every surgeon's career that could have this kind of effect but may not be as stark as death. It could be bleeding after an operation; it could be liver failure after a liver resection; it could be the failure of whatever the intent of the procedure is that you are doing. I think it's important to realize the common denominator is that the complication itself can happen even if you do the right thing for the right reason at the right time.”
In addition to adverse patient outcomes, institution-driven constraints that limit the provision of optimal care and observing unethical conduct by colleagues can also result in moral injury, especially if there is a pattern of these events and behaviors.
“I think it is important to realize that moral injury isn’t a diagnosis,” he said. “It is not codified as a psychiatric disorder by the American Psychiatric Association in the DSM-5-TR [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition], but it is most certainly an event that occurs and has a major impact on our psyche.”
Why Are Surgeons Vulnerable to Moral Injury?
While many healthcare providers grapple with moral distress and moral injury, surgeons are uniquely positioned to experience the psychological repercussions of these events due to the invasive nature of their work.
“As surgeons, we enter into these unspoken, high-risk contracts with our patients to provide high-quality care,” explained Dr. Fischkoff. “And unlike other specialties, I would argue, surgeons have a different connection to their patients in that we have a direct impact on their outcome. We are one of the few specialties where we are, if something goes wrong on our end, directly responsible for that outcome.”
In an article cowritten by Dr. Fischkoff and published in the November 2023 issue of the Journal of the American College of Surgeons, the authors noted: “Surgeons live and practice an intense form of applied ethics. Several unique features of the surgeon-patient relationship distinguish surgical ethics from general medical ethics. These include the relational proximity of surgeons to their patients, the harm inflicted on patients as part of surgery, and the surgeons’ unique power to rescue patients.”4
More recently, in an article published in the AMA Journal of Ethics, Dr. Fischkoff described the psychological distress experienced by surgeons within the framework of regret: “Surgeon regret is a powerful experience that shapes a surgeon’s sense of self, future interactions with patients, and intraoperative decision-making. While all physicians are exposed to complex and formative moral experiences, surgeons have a unique exposure to regret and moral injury, given the invasive nature of their relationship with their patients and the highly interdependent “surgical contract” they form with their patients.”5
Dr. Fischkoff concluded the article by noting that while regret is an unavoidable experience for surgeons, it is beneficial to view these episodes as an opportunity for professional growth.
“The only surgeon who never has complications is a surgeon who never operates,” wrote the authors, quoting a common aphorism. “By confronting regret, surgeons can develop the resilience needed to continue providing compassionate, confident care in the face of inevitable challenges.”
Early career surgeons are particularly susceptible to experiencing moral injury due, in part, to their limited clinical experience and a lack of fully developed coping mechanisms. In an article published in the Annals of Surgery earlier this year, Dr. Geevarghese and colleagues conducted a literature review of moral injury in healthcare, along with an analysis of surgical career pathways and outcomes reporting data.1
Based on their findings, the authors suggested that “protective equity” accumulates over the duration of a surgical career, while vulnerability follows an M-shaped curve with peaks in both early and late careers. Protective equity in this context refers to the respected and often distinguished professional reputation of a senior surgeon based on a consistent pattern of successes and positive outcomes.
“Early in your career—when you haven't developed all the credibility that you will have at the mid-career stage—is a period of vulnerability, when you are more vulnerable to moral injury,” explained Dr. Geevarghese. “As you develop protective equity, which you might think of as a kind of ‘bank account’ of credibility driven by great outcomes, your esteem within the practice and within your referral base grows. This protective equity can shield surgeons from experiencing the adverse effect of morally injurious events.”
Unfortunately, protective equity can fade over time, leaving later career surgeons feeling as vulnerable as their early career colleagues. “Concerns regarding cognitive and technical competence arise resulting in a second peak of vulnerability, resulting in the potential for increased sensitivity to moral injurious events,” said Dr. Geevarghese.
