Jane Desmond, Ph.D. //
A recent New York Times article on the Covid-19 crisis in India foregrounds the burden on doctors there, not solely in terms of an exhausting overload of patients but in terms of distress coming from a need to ration health care resources: a lack of oxygen to distribute, not enough beds, with some doctors even being attacked by people desperately trying to get their loved ones into a clinic.[1]
For these doctors, the crux here is not just the extraordinary stress we might expect from long hours working under pressure making life-and-death decisions, but what has been termed “moral stress” by ethicist and philosopher Bernard Rollins. In medicine, moral stress can result from an inability to do what one believes is “right” in the practice of one’s profession. It can lead to burnout and depression and, at its most extreme, can even contribute to suicide among health care workers. But although the Covid pandemic has thrust these issues into the spotlight, it doesn’t take a global crisis to trigger moral stress in healthcare workers. Anytime a decision must be made to offer, or to withhold, care due to factors beyond one’s control can add to moral stress.
Is our medical training, medical practice, and our research in the health humanities adequately recognizing and responding to moral stress? Are some populations, specialties, or jobs within healthcare more likely to experience it? Can we imagine future systems of care that alleviate this type of stress among practitioners?
While both M.D.s and D.V.M.s suffer from higher rates of suicide than the general population, the numbers are especially high among D.V.M.’s and within that profession, among women, who now form the majority of graduating veterinarians. For example, recent research estimates that male M.D.s commit suicide about 1.4 times more often than men in the general population, and female M.D.s at 2.27 times the rate of the general female population (American Foundation for Suicide Prevention, afsp.org). Within the D.V.M. profession, these rates are even higher: with men 2.1 times and women vets up to 3.5 times more likely to kill themselves than the general population. Even allowing for differences in how such tabulations are arrived at, the disparate trends are clear.
Those who are charged with caring for us, public health, and animals are in need of care themselves, and they are not yet getting what they need in sufficient ways. While some discussions and programs for promoting mental health in the medical professions focus on discourses of “self-care” and offer useful strategies for countering stress, including work-life balance tips and yoga classes, to address moral stress as a contributor to this crisis means going deeper. It requires proactively addressing the structural causes that help create moral stress in the first place, as well as the gendered components that result in differential impacts of that moral stress.[2]
An unlikely example of moral stress came up recently in conversation with a veterinarian. The question was: What to do about the tiger in the waiting room?
My interlocutor, a board-certified zoological medicine specialist working in the southeast of the U.S., is no stranger to tigers, but usually they are treated in a zoo setting. This patient, though, was driven to the ER by his owner. (“Owner?!?” Yes, remarkably, the laws about owning such large exotic animals like tigers vary widely from state to state, and in some states, with the proper permits you can house a tiger on your property.) Although the owner claimed to have the appropriate permits, based on their conversation, the doctor suspected these papers were not what they were purported to be. Meanwhile, the tiger (technically in the parking lot, not in the waiting room), clearly needed attention. Should she treat the tiger? Call the authorities about a suspected illegal wildlife owner? Was this tiger a danger to humans? Kept in intolerable conditions and should be seized on humane grounds? What was the doctor’s ethical obligation here, and to whom?—the patient? The owner? The larger public? Her clinic? The law?
The doctor treated the tiger. Because this was an emergency situation, her first choice of action was to treat the tiger and relieve suffering, which is part of her oath as a veterinarian. On the other hand, her oath also includes other multiple obligations some of which can conceivably drive different courses of action, such as to protect human health.
And what if the tiger came back again? Was she unwittingly becoming the tiger’s veterinarian and potentially supporting the practice of backyard tiger keeping? Or perhaps indirectly and unknowingly supporting the continuation of a disreputable roadside zoo?
Few of us will have to make decisions regarding tigers, but tackling the issue of moral stress from the vantage point of veterinary medicine can illuminate both the parallels and the differences with human medicine, hopefully throwing into clearer relief how moral stress operates, while acknowledging that the parameters of value for human and non-human animal lives are substantially different. Indeed, they differ across and within communities and are inflected by ethical beliefs shaped by law, religions, philosophy, public discourse, and historical convention.
Take for example a classic case from philosopher Bernard Rollins’ veterinary ethics casebook: “Injured, Unowned Animal.”[3] In this case, a “Good Samaritan” finds a badly injured golden retriever lying by the side of the road, presumably hit by a car. Imagine it is a Friday afternoon at 4 pm, and the vet clinic staff is trying to wind things up to leave for the weekend. Carrying the dog into this nearest clinic, the good Samaritan says he doesn’t own the dog, doesn’t know who does, and can’t pay for the treatment, but is trying to save the dog’s life.
Do you take in the dog, assess, treat, and keep the dog in the clinic to heal, call in weekend staff to oversee his care, and then try to find the owner? Do you send the Good Samaritan to the nearest 24-hour emergency vet clinic that is an hour away? Do you stabilize the dog and send him to the animal shelter the next day? Here the financial and staff timing realities, the veterinarian’s own obligations to others (her family, paying her staff), the moral good of the Good Samaritan’s efforts, and the suffering of the dog all come into play, along with the social valuation placed on that particular species within a specific community. In addition, in contrast to human medicine, there is no insurance, no hospital reimbursable Medicaid, and no public hospital emergency funds to support for care for indigent clients.
In discussion with first year veterinary students at my university, during my “Contemporary Issues” course unit on ethics, most decide that, if placed in such a position, they would not turn the dog away but will stabilize and treat the injuries enough to hand the dog off to the local shelter. But once this unique case is dealt with, soon the conversation turns to the larger structures that land the veterinarian in this position of moral stress in the first place. These include the need to develop a network of donors to help pay for indigent/unowned emergency care; the potential for cooperation between shelters and local vet practices so there is a protocol in place for transfers, and even the cultivation of a network of local news reporters who can publicize the donation of medical care made by the clinic, and help raise funds, all while helping to find the owner.
Developing creative collaborative community-based strategies can feel empowering, and hopefully lessen that gap between what the doctor feels is “right” and what she can realistically do on a sustainable basis in these situations. Ultimately this can help lessen the mental and emotional stress of doctoring.
The key here is systemic coordination and redefinition of whose problem/responsibility the provision of care is. In the human medicine field we see this emerge in debates about how to structure a national health care system that is equitable and effective. On the global stage, the pandemic-driven crises reveal the maldistribution of healthcare resources among countries and among populations within them. The more closely a health-care system can align with the ethical values of the doctors who work in it, presumably the less the moral stress. Restructuring that alignment is a political act of social revisioning, and the Covid crisis, which has laid bare so many inequities as well as the demands on medical workers, may provide a heightened opportunity for change.
In the meantime, helping our students by giving them the concept of “moral stress” to work with can be a powerful tool. Naming and analyzing a structural problem can be both a political act and a way to help envision a pathway toward redress. We’ve seen this across the U.S. this summer as the protests for racial justice in the wake of George Floyd’s murder, along with the deaths of so many others, helped make the concept of “systemic racism” widely available to some who may have previously understood racism not as a social and political structure, but as a set of individual actions or attitudes to be avoided or overcome.
When we approach the epidemic of healthcare workers’ burnout and even suicide not as an individual “failure” to thrive but as an outcome due, at least in part, to analyzable social/political/and economic structures that necessarily produce moral stress, we may be able to imagine new effective structures. We may empower medical professionals to see that the cause/source of their stress and burnout does not lie solely in their own inabilities to resolve the tensions between what they believe is “right” and what is “possible” in any patient’s case, but, rather, to see it as a systemic problem that needs, and can respond to, collective action.
And meanwhile, what of the tiger in the waiting room? Yes, there’s hope there too. Legal interventions designed to set Federal standards for ownership and care of such exotics are being developed. These would get rid of the widely divergent state laws that make it relatively easy to keep a tiger in some states, and make enforcement more uniform. If backed up by money and personnel for criminal investigations, along with a shift in public discourse, we might put an end to backyard tigers, and my vet colleague would no longer find one waiting at her clinic.
Calling on doctors—whether M.D.s or D.V.M.s– to use their medical expertise to advocate for structural changes in healthcare may seem only to enlarge the already expansive obligations we place on them. But, in the long run, such collective action may benefit them by reducing moral stress, burnout, suicides, and departures from the medical fields. And, ultimately, it would result in better health for all—doctors and their patients.
[1] Nytimes.com/2021/05/18/world/asia/india-covid-doctors-medical-workers.html, accessed Aug. 4, 2021.
Of course, India is not the only place where this distress about the rationing of care during the pandemic has occurred. Italy earlier confronted this problem and, in the United States, equitable access to care has been a critical issue in some communities with, for instance Native American reservation hospitals being especially hard hit, although the fears of running out of beds in large cities has largely been averted so far. Mark Walker, “Pandemic Highlights Deep-Rooted Problems in Indian Health Service,” The New York Times, 9/29/20, updated May 21, 2021.(https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html.)
[2] For a sample of articles from the popular press, research publications, and professional resources, see the following: Suzanne Tomasi, et.al., “Suicide Among Veterinarians in the United States from 1979 through 2015,” Journal of the American Veterinary Medical Association, 1/1/2009, Vol. 254, No. 1: 104-112; Jamie Ducharme, 12/20/2018, “Veterinarians face Disproportionately High Suicide Rates, Study Says,” Time.com/54855521/veterinarians-suicide; and Melissa Chan, “Here’s Why Suicide Among Veterinarians is a Growing Problem,” 9/12/19, Time Magazine (https://time.com/5670965/veterianian-suicide-help). See the organization for veterinarians, “Not One More Vet,” nomv.org., and also a robust suite of mental health resources focused on wellbeing, available through the AVMA website (www.AVMA.org). Regarding physician mental health and suicide see: “10 Facts about Physician Suicide and Mental Health,” available at American Foundation for Suicide Prevention, www.afsp.org; and Marya J. Cohen, “Doctors die by suicide at twice the rate of everyone else. Here’s what we can do,” The Washington Post, Oct. 6, 2020.
[3] Bernard E. Rollins, An Introduction to Veterinary Medical Ethics, Theory and Cases, second edition Blackwell Publishing, 2013.
Photo credit: Blake Meyer via Unsplash.
