We Are Not Okay: Moral Injury and a World on Fire


Keisha Ray, PhD

Publish date

We Are Not Okay: Moral Injury And a World on Fire
Tag(s): Top read essay
Topic(s): Editorial-AJOB

The following editorial can be found in the April 2024 issue of the American Journal of Bioethics.

After giving the name “burnout” to the experience of being overworked and undervalued and the physician and patient suffering that comes from it, many clinicians have sought to elucidate further what exactly is wrong with the practice of medicine. While “burnout” may adequately capture the emotions of many clinicians practicing medicine within systems designed to value profit over wellbeing, one that creates as many inequities as it purports to cure, within the past few years, the term “burnout” has seemed to not fully capture the experience of practicing medicine in the 21st century.

While burnout is more closely associated with exhaustion and not being able to handle the demands of practicing medicine, it suggests that the problem is internal; that a person is weak, and if they had more mental fortitude then they would be able to practice medicine without issue. But if more than one-half of physicians report some form of burnout, then perhaps the problem is not that these very smart and very dedicated people are not mentally tough. Moral injury, however, looks beyond the self. It names the conflict that often arises from “conflicted allegiances—to patients, to self, to employers.” Moral injury was first used to describe soldiers whose moral and ethical beliefs conflicted with their duties as soldiers. Based on its origins, however, anyone can experience moral injury just as anyone can experience burnout, regardless of profession. Moral injury is the result of our deeply held beliefs conflicting with our occupational duties; it’s a conflict between our internal selves and our external environments. And as the world around us continues to demand our labor despite the world around us seemingly being on fire, I recently have been asking, can bioethicists experience moral injury and what would that look like for bioethicists?

Although we take different routes, many bioethicists practice bioethics because we are passionate about helping people, making observations about how the world around us affects our health and wellbeing. Bioethicists generally, have a concern for the least well-off among us. In general, we want to do some good. But when physicians cannot help a patient have better health outcomes because what the patient needs are resources like proper housing, a well-paying job, child care, and other things that they cannot provide in their position as caregiver, they feel defeated and may question their role in health care or if they can ever really help their patients. Similarly, bioethicists have our own instances of defeat and helplessness. When our bioethical work and the tools and talents available to us to help people offer no solace to the hurting, and we know it, we feel defeated and aimless. But if moral injury occurs “when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs,” then moral injury is an inevitable part of the job for bioethicists. How could it not be?

While a concept of moral injury based on the four broad ethical principles in health care—autonomy, beneficence, nonmaleficence, and social justice—has been suggested, the focus has remained on health care providers; in particular how witnessing violations of ethics makes them susceptible to harm, or moral injury. And while many bioethicists like myself don’t specifically work with patients and are not clinicians, our work is on the human condition. We often ask “What does it mean to be human and what does it mean to violate our humanity? What do humans need to lead a life of wellness and happiness?” To answer these broad questions and the endless specific questions they inspire, many of us apply the four biomedical principles—autonomy, beneficence, nonmaleficence, and justice—to our work. We also often create our own principles as well, by which to do bioethical work examining the human condition. Furthermore, as an applied field of study, we often take these principles, use them to call out instances of human rights violation, and offer practical solutions.

To do the kind of evaluation of the world that bioethics requires, bioethicists have to 1) have our own set of values and principles that we apply to ourselves, our work, and to others around us; and 2) we have to be hyperaware of the non-ideal world in which we live, raise families, mentor, support friendships, play with our pets and all of the things that make life worth it for us as well as do our bioethical work. This is to say that bioethicists are a principled group and every day, especially lately, we see violations of these principles, violations of humanity of the deepest kind and yet we are asked to keep working. We are asked to keep drawing conclusions about how people ought to be treated while watching ongoing violations of life. But we are asked to keep working. Keep teaching our students about ethical principles. Keep putting out research that shares our ideas on how we ought to treat each other. Keep mentoring students. Keep applying for grants to fund our research. We are asked to keep going as if every part of the world isn’t challenging the very nature of what it means to be a bioethicist. And for better or worse, we do.

Pandemics, war, military conflicts, political turmoil, discrimination at all levels of social life, inaccessible health care, horrible treatment of immigrants, gun violence, and so many other issues around the world that don’t make it onto our radar are the backdrop of our everyday bioethical work. Yet, we keep showing up. We keep pointing out abuses of humanity and continue to do our best to be truth-tellers in a world that often feels like it would prefer us not to be.

At some point, though, it will become too much (For many, it has already become too much). We will succumb to the injury of seeing our principles violated and televised for the world to see and feeling like it is only getting worse. Because at the heart of moral injury is our own humanity. We can only take so much. We can only keep working for so long amid tragedy, violence, death, and destruction without a light at the end of the tunnel. Being a human in a world ablaze makes us susceptible to moral injury, regardless of profession. We have our principles, sure, but hopefully, first and foremost, we are human. Moral injury began as a way to describe professional duties conflicting with personally held beliefs. Still, there’s something universal about this conundrum in the same way that burnout is universal. This is because moral injury captures the absurdity of our modern world. That we are required to live our lives as if everything is wonderful and as if equality has been achieved is absurd. But because of our work and those principles we have worked to cultivate, bioethicists especially know that it’s not. This is true, much in the same way that the best comedians are eternally sad, because to be funny and call out a senseless world requires a high level of hyperawareness and sensitivity to other people’s pain. But this is true of so many other people, too. I know there are teachers, engineers, landscapers, custodians, restaurant workers, and people in every profession who know that the world is not ok and they are not ok either.

Moral injury gives name to a feeling that I have been having lately as I’m asked to show up to work and my life as if there aren’t people who didn’t wake up today because of violence, disease, and greed. I’ve celebrated holidays and my own professional accomplishments, but I can’t escape that lump in my throat, that nagging feeling that this is all meaningless given the state of the world. After all, my principles won’t feed the starving, shelter the bombed, free the captive, or care for the sick. I don’t have the answer. I do not know what we are supposed to do about our perpetual moral injury. I do find some comfort in the origins of moral injury—calling out a broken system rather than broken individuals. I am not broken; I am just a bioethicist and a human forced to work and live within a broken world.

Keisha Ray, PhD

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