Takeaway
Moral injury can arise when there’s a tension between business goals and clinicians' mandate to serve patients. Encouraging transparency and commitment to reconverging these goals may improve understanding and lessen distress among hospital administrators, healthcare professionals, and patients.
Passion in the Medical Profession | May 19, 2025 | 3 min read
By Christos Georgiades, MD, PhD, Johns Hopkins Medicine
Is providing excellent patient care still the primary mission of healthcare institutions?
Not long ago I was witness to a disillusioning experience. A leadership member at a healthcare institution delivered a “State of the Union” address to an audience of faculty and staff. The speech lasted for about 45 minutes, but the only statement my mind retained was: “. . . Henceforth, the priority of this department will not be the welfare of patients.”
There was of course a qualifying statement, yet the shock value of this proclamation was tremendous. More than anathema, it was proof of what we suspected for some time: that there’s divergence of purpose between healthcare institutions and healthcare professionals. The cumulative effect of such experiences goes beyond what most people call “burnout” and to a far more deleterious state: “moral injury.”
Burnout
Burnout is variously defined by authors as “anxiety, cognitive impairment, and diminished functional capacity,” or “exhaustion, cynicism, and decreased productivity” and is unfortunately rather common in healthcare. Luckily, it’s by and large reversible. Changes to one’s daily routine, better remuneration, improved work-life balance, more time off, changing geographic location, and/or improved interpersonal relationships, to name a few, can mitigate or eliminate the consequences of burnout.
Moral injury
But this isn’t what was experienced or caused that day. Rather it was moral injury. Moral injury is an entirely different beast than burnout, and far more hazardous to both healthcare institutions and professionals. It’s caused by “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs.” In other words, forcing someone to act in a way that’s against their own ethical standards. The moral wound it leaves behind is permanent and consequential.
It often goes something like this: healthcare professionals dedicate their life to taking care of the sick; people who come to them psychologically prostrate in absolute trust. It’s both an awesome and a dreadful responsibility. Then suddenly the world around these healthcare professionals changes. Productivity, financial solvency, profit and loss statements, balance sheets, and reimbursement are terms that have ascended to the top of the ladder of priorities. As a result, the relationship between those who deliver healthcare and those who run the economy of the institution has flipped. In the past, the model would have clinicians provide healthcare services and expect the administrators to “sell” those services in a way that keeps the institution solvent. In the new, flipped model, the administrators dictate to clinicians the scope of healthcare services acceptable so that the institution remains solvent. And when this divergence of purpose boils over the limit which healthcare workers find morally acceptable, moral injury sets in.
What can an institution do to prevent moral injury?
Consider this: clinicians are deluged with mandatory training courses, online educational modules, etc. The objectives? To reduce noncompliance with regulations, minimize institutional risks, and legally shield the institution. In other words, to make clinicians see healthcare delivery from the point of view of administrators.
What about making administrators see the delivery of healthcare from the clinicians’ point of view? Administrators could be exposed to the potential consequences of their actions/policies on the quality of healthcare delivery. Should they be asked to take equivalent training sessions? What happens when they prioritize capital spending on the most profitable equipment instead of the most needed? What are the consequences of them prioritizing named brick-and-mortar expansion instead of focusing on clinical competency?
Moral injury’s serious consequences include a permanent loss of loyalty to the institution and in extreme cases, medicine in general, and detachment from the noble ideas that attracted one to join medicine in the first place. Clinicians cannot and should not be expected to steer away from their professional priority. This leaves administration with the responsibility of preventing moral injury by realigning its primary objectives and reconverging with those of clinicians: focusing on providing excellent patient care.
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This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.