Moral injury and the four pillars of bioethics

Health care providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians particularly vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments all are associated with unavoidable, harmful sideeffects. When an inevitable side-effect occurs, not only is the patient harmed, the clinician also suffers a moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While moral injury occurs routinely in medical care and cannot be entirely eliminated, clinicians can decrease the prevalence of injury by advocating for the ethical treatment of patients, not only at the bedside, but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the healthcare system as a whole are necessary in order to improve medical care and decrease moral injury.