The ethical bind

This is the 4th and final newsletter in this current series, drawn from the work behind my book Caring Costs - Addressing the cost of caring in healthcareand the wicked problems facing the health workforce. I hope this series has been helpful.

We can see what our clients and communities need.

We can also see that sometimes the system doesn't adequately fund or staff our services in line with our evidence-based training, the research or what our practice wisdom would recommend.

We can be left with impossible choices that do not feel like we actually have a choice. Stretch beyond what is sustainable, or step back and watch someone go without.

That bind has a name. It is one of the wicked problems I write about in Caring Costs. The research literature calls it moral injury.

The squeeze you are working inside

In my book, Caring Costs, I describe this “squeeze” as the most painful of the wicked problems. The choice between over-functioning to compensate for the system or stepping back and watching your clients go without the care they need is not a fair one. The consequence of that impossible choice is now showing up across the workforce.

We were trained to make a meaningful difference inside systems that increasingly make it difficult to do so and asked to practise in trauma-informed ways while the systems around us can be traumatising to ourselves and our colleagues.

What the research shows

Moral injury was first described by Jonathan Shay in his work with combat veterans. He observed that some forms of distress arose when a person was betrayed by someone in legitimate authority, in a high-stakes situation, in a way that violated what they knew to be right. Over time, this eroded the capacity to trust.

The concept has since been extended to healthcare. Dean and colleagues (2024) proposed a unified definition. Moral injury arises when a system's policies and practices, or the actions of those in authority, undermine the professional obligation to put the person you work with first. They argue that moral injury and burnout are related but distinct. Burnout locates the problem in the individual, which leads to solutions like well-being programs and self-care strategies. Moral injury locates the problem in the system and calls for structural change.

Chronic understaffing, business models in tension with person-centred care, and the burden of compensating for systemic failures by overworking, produce moral injury in healthcare workers, according to Rabin and colleagues (2023). Phoenix Australia’s report for the Department of Veteran Affairs (Metcalf et al., 2022) frames it as knowing what care a person needs and being unable to provide it due to obstructions beyond our control.

The picture is consistent. The bind is structural. The cost is internal and personal.

The shift

What you are feeling during your working week is your professional skills and values responding to conditions that are out of step with what you were trained to deliver.

Moral injury is what happens when caring about doing right by clients collides with what the system is asking them to do. When you over-function, the system runs on your unpaid labour. When you do not, you carry the weight and trauma of watching someone go without adequate support. Either way, the cost lands inside you. Naming this as moral injury, rather than a personal failing, shifts the question from "what is wrong with us?" to "what is being asked of us, and who can we talk to about it?"

Consider the following:

If you sit in senior leadership or governance:

1. Where are we making space for addressing the ethical challenges being experienced by our teams, rather than only the symptoms it produces?

   For example, do reports name the ethical strain on staff, or only the burnout and turnover numbers?

2. What would it look like to treat moral injury as a system signal, rather than a wellbeing issue to be managed?

   For example, treating patterns of staff distress as data about the system, rather than as a problem to be addressed through individual wellbeing programmes.

If you supervise or lead a team:

1. How often does my team raise the gap between what they know is needed and what they can actually deliver, compared with workload or efficiency?

   For example, is the ethical strain a standing item in supervision, or does it only surface when someone is close to leaving or requests support?

2. What signs of moral injury am I missing in my team, because they look like high performance?

   For example, is it the team member who is 'never sick', who carries the most complex caseload without complaint, or who takes on what no one else can?

If you work directly with clients:

1. When did I last face the choice between doing more myself and stepping back to let the gap show? And did I name it, or carry it on my own?

2. Where do I have someone I can talk to about this, rather than carry it alone?

   For example, a trusted colleague, a leader, a supervisor, or a peer outside your immediate team.

If you are early in your career:

1. When I cannot deliver what my training says a client needs, am I assuming the gap is my inexperience or lack of skill, when it may be the system?

   For example, am I looking at undertaking more professional development or seeking more supervision to 'fix' the problem, when this is not the issue?

2. What patterns of over-functioning am I starting to build in my effort to meet expectations or prove myself?

   For example, am I taking work home in the evenings, skipping breaks, or saying yes to extra responsibilities I am not yet ready for?

3. Who is the person I can talk about this with when carrying it on my own starts to feel like the only option?

Where to start

1. Call it what it is. Naming the bind as moral injury, in supervision and in team meetings, shifts it from a private weight to a shared concern. Burnout language asks you to self-regulate and manage the issue alone. Moral injury language lessens the risk of internalising and asks the system to account for itself.

2. Notice the over-functioning pattern. The unpaid follow-ups, the after-hours liaison, the small ways you cover what the system will not fund. This is not dedication to be praised. It is information about where the system is failing to hold its weight.

3. Protect the witness function. Where you cannot fix the bind, document it. Workforce data, supervision notes, incident reports, and submissions to consultations. It only becomes visible to those who can change it when it is named in writing.

4. Make space for the response. Moral injury does not resolve through better time management. It needs colleagues, supervision, and conversations where you can speak about what you are witnessing without rushing to fix it.

You were trained to make a difference. The wound, when it comes, is the cost of caring inside a system that does not yet care back.

Name it, share it, and refuse to carry it alone.

Want to read more?

Amy Edmondson's The Fearless Organisation offers a framework for creating workplaces where people can speak about what is not working, without it being treated as a complaint or a performance issue. For clinicians, it gives language for why naming hard truths feels risky and what makes it possible. For leaders, it provides practical ground for building team cultures where moral injury can be raised, rather than carried alone.

References

• Dean, W., Morris, D., Manzur, M. K., & Talbot, S. (2024). Moral injury in health care: A unified definition and its relationship to burnout. Federal Practitioner, 41(4), 104–107. https://doi.org/10.12788/fp.0467

• Metcalf, O., Davis, B., Forbes, D., O'Donnell, M., & Phelps, A. (2022). The current status of moral injury: A narrative review and rapid evidence assessment. Phoenix Australia. Centre for Posttraumatic Mental Health. Report prepared for the Department of Veterans' Affairs.

• Rabin, S., Kika, N., Lamb, D., Murphy, D., Stevelink, S. A. M., Williamson, V., Wessely, S., & Greenberg, N. (2023). Moral injuries in healthcare workers: What causes them and what to do about them? Journal of Healthcare Leadership, 15, 153–160. https://doi.org/10.2147/JHL.S396659[Veri

• Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090

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