Moral Injury Epidemic

Moral Injury Epidemic

“When COVID swept the planet, a moral injury crisis arose as ethically wrenching dilemmas became the new normal.” “ In an atmosphere of rationed care, doctors, nurses and other health care workers must admit a few patients and turn many away”, to die. https://www.scientificamerican.com/article/moral-injury-is-an-invisible-epidemic-that-affects-millions/
Moral injury is a specific and devastating trauma that arises when people face situations that deeply violate their core values. Such violations of morality can result in shame, guilt, and hopelessness, raising the risk of substance abuse, depression, and suicide. When society allows the uncontrolled spread of a deadly virus, millions are afraid they may become infected and transmit the virus to their family.

How did we arrive at this point of moral degradation?

For thousands of years, physicians took oaths to always act in the patient’s best interest when providing care. At the heart of medical ethics, this moral code was passed down through the centuries and reaffirmed by The World Medical Association (WMA) in 1949 and again in 2006. Additionally, the WMA specified:” A physician shall not allow his/her judgment to be influenced by personal profit or unfair discrimination,” and “shall not receive any financial benefits or other incentives solely for referring patients or prescribing specific products”.

Ethics ran headlong into The HMO (Health Maintenance Organization) Act of 1973.
The passage of this act set the stage for the undermining of long-established medical ethics. The HMO Act was designed specifically to reduce costs, by charging patients a monthly fee for a set package of health care. The Act was passed with the knowledge that there had been no systematic analysis done to show that it would not negatively impact health care. Nonetheless, the Government gave millions of dollars in direct financial assistance to develop the HMO which was designed to be a profit-making business.

This HMO economic arrangement put physicians' and other healthcare providers’ financial interests into conflict with the needs of their patients. The monthly pot of money must provide for profit, salaries, wages and health care. If too much is spent on the patients, there is less available for profit and wages. So began the Health Insurance, Corporate Medicine assault on medical ethics. By 1980 this Wall Street strategy had crystallized into a worldwide approach to health care.

In 1980 the World Bank Acts---

Publishing a new healthcare sector policy in 1980, The World Bank advocated reducing public health infrastructure and opening the door to rampant privatization of health services and pharmaceutical supply. https://documents1.worldbank.org/curated/en/649631468138271858/pdf/40968ocr.pdf
This policy was adopted by the US government. The Federal Government’s share of public health expenditures plummeted from 60% in 1968 to 10% in 1983, where it has remained for forty years. This silent war on our Public Health Infrastructure carried out under both Democratic and Republican administrations has drained hundreds of billions of dollars from our Public Health Services, jeopardizing the health, safety, and welfare of the population. Since 2009 alone, some $150 Billion has been defunded, along with the loss of some 60,000 jobs.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695931/
Tragically the Medical Profession succumbed to the rise of Corporate Health Care by betraying their core medical ethic and became complicit “stewards” of an economic system that puts profits before people—The AMA’s (American Medical Association) Principles of Medical Ethics:V11, gives the following ethical guidelines for physicians: “Mitigate possible conflicts between physicians financial interests and patient interests by minimizing the financial impact of patient care decisions and the overall financial risk for individual physicians.
https://www.ama-assn.org/sites/default/files/media-browser/principles-of-medical-ethics.pdf
We have experienced four decades of HMO’s negative effects on health care while they became the darlings of Wall Street earning billions of dollars for investors as health care was rationed by: denial of service, restricted benefits, cost cutting, patients dumping, overworked and underpaid staff, and plunging physician’s incomes. http://www.mbc.ca.gov/Publications/Newsletters/action_report_1998_04.pdf
The author D.H. Lawrence (1880-1930) appears to have anticipated these horrors, when he wrote: “The mosquito knows full well, small as he is he’s beast of prey. But after all he only takes his bellyful, he doesn’t put my blood in the bank.”

Fast Forward to the ACA (Affordable Care Act) of 2010—

One of its chief goals was to “reduce the cost of health care” by giving “financial incentives” to providers for the “Value” they provide in health care. A value-based payment incentive was to be established by bundling payment for certain types of care. Forbes Magazine, advertised as ‘The Capitalist Tool’ stated, “Bundled payments are just price controls by another name—and as such will yield subpar care by encouraging insurers and providers to put their own financial interests above the medical needs of patients.” https://www.forbes.com/sites/sallypipes/2014/09/22/the-bungling-of-bundled-payments/?sh=7cc952d1c60f
The ACA was passed with very little known about its effectiveness or risks to Patient Care. https://www.rand.org/health/key-topics/paying-for-care/value-based-purchasing.html
Once again it is all about cost-cutting. But now with the so-called “Value-Based Purchasing”, it is no longer about making profits for corporations, but spending less government money -it is about getting more for the Government’s shrinking dollars going to health care spending for Medicare, Medicaid, and Social Security Disability. The politicians want to “save” money, which in reality means to redistribute money, but the economics is similar. With some ten trillion dollars in tax cuts for the rich over the last two decades, the US treasury has less available for social services as politicians continue to redirect a trillion dollars per year to the military--war industry without concerns that it is “costing the government too much”. https://zcomm.org/zmagazine/a-letter-of-thanks-to-our-wealthiest-1-percent/

The Tax Reform Act of 12/2017 will suck an estimated thirty billion dollars out of Medicare... Bundled payments will shrink and the giant vice of shrinking payments, combined with rising costs (hospital profits, rising prices for supplies, drugs, medical equipment, etc.,) will inevitably squeeze the lifeblood out of both the patients and the healthcare providers.
Tragically this became a reality in 2020 with Covid-19, when the elderly were allowed to die as the state of Arizona rationed health care using “Crisis Standards of Care,” to decide who lives and who dies. https://www.newsweek.com/arizona-activates-emergency-plan-ration-dwindling-health-care-resources-1514653

This policy was founded upon the ethics promoted in the Journal of the American Medical Association (JAMA).

The Journal of the American Medical Association (JAMA) called for “A Framework for Rationing Ventilator and Critical Care Beds during the COVID-19 Pandemic”. https://jamanetwork.com/journals/jama/fullarticle/2763953 JAMA accommodated itself to this brutal betrayal of the people’s health. The journal advocated a policy to ration and deny care that will fall most heavily on those over 60 years of age. The JAMA article of March 27, 2020, recommends who should be DENIED care:
1) Those least likely to survive treatment. Statistics show that the death rate increases over the age of 60. (the elderly, with higher risk for minorities)
2) Those with other medical conditions. More common over age 60. (the elderly, with higher risk for minorities)
3) Those who are working and “intrinsically more worthy” will be given priority and those who are retired will be denied. (the elderly)
4) Those who are younger will be given priority and the elderly will be denied.
5)
The exsanguination of medical ethics has helped bring us to this dangerous moment in history.

We have witnessed a craven transformation of medical ethics when physicians and other health providers are clamoring to sign up for “Value-Based Bundled Care”. The AMA has betrayed their ancient oath as healers, in service to an economic system that puts profits before people.

The Covid pandemic President Biden declared was over, and the lifting of all restrictions against its spread, have killed a quarter of a million US citizens in 2022, 95% are age 65 and older. Our parents and grandparents continue to die, while vaccine-evasive and transmittable Covid variants constantly emerge as the pandemic has become one of the leading causes of death in the US. Moral injury continues to spread across the land. We have been led into a partnership with Dracula.

How do we escape from this public health catastrophe of Moral Injury?

“Unless your employer hires more staff or supplies more resources, chances are you’ll have to keep making decisions that violates your ethics, compounding your trauma.” The causes of Moral Injury require “systemic solutions on a much broader level”.
https://www.scientificamerican.com/article/moral-injury-is-an-invisible-epidemic-that-affects-millions/
This is the road to cure, and prevention.

1/10/2023
Dr. Nayvin Gordon.
Dr. Gordon is a Family Physician who has written many articles on health and politics. He can be reached at gordonnayvin [at] yahoo.com
Dr. Gordon is a California Family Physician who writes about health and politics. He has been published on various platforms including The Mercury News, Counterpunch, Z magazine, Countercurrents, Scoop Independent News, Anderson Valley Advertiser, Socialist Viewpoint, Multiracial Unity Blog, Scientific American, The Oakland Tribune, The Journal of Family Practice, American Family Physician and Dissident Voice, and others.