Intended for healthcare professionals


Sixty seconds on . . . moral injury

BMJ 2019; 365 doi: (Published 26 April 2019) Cite this as: BMJ 2019;365:l1933

Re: Sixty seconds on . . . moral injury

Dear Sirs:
I read the recent article, Sixty seconds on moral injury, with great interest, but also great concern. While not necessarily defending the term burnout, I would suggest that use of “moral injury” in medicine is highly inappropriate. I will briefly summarize why this is so with some salient points which are explored in depth in an upcoming publication. 1

The importation of the concept of moral injury from the military, critical as a psychoemptional impact of war, is misplaced when applied to the practice of medicine and surgery. To suggest any equivalence between what warriors experience and the, albeit very real, stresses of medicine is naïve, at best, and, at worst, demeaning to the men and women who risk their lives defending their countries.

Given the years of extensive research on burnout, it appears to represent some construct of value and it is premature to suggest replacing it with moral injury. Moral injury in medicine is not well-operationalized, researched, nor is the prevalence known.

The concept of “moral distress” has appeared in the medical literature, 2 but this is not moral injury. Ethical challenges and even ethical fractures certainly exist; but they existed before the proposed use of the term moral injury and will continue to challenge medical care.

Proponents of the term moral injury usually assert two other dubious rationales for its use, both of which were represented in the current article. It is not clear that the term burnout blames or puts sole responsibility on physicians, or that it absolves health care systems of any responsibilities. Additionally, there is often a perplexing condescending tone to the discussion of individual approaches to enhancing resilience, or even the mistaken belief that resilience cannot be taught or developed. Multiple examples of effective resilience training do exist in other mission critical domains (military, police, firefighting). Many physicians can benefit from individual resilience techniques.

Introducing questionable terminology serves to obfuscate the real issues of developing strategies to prevent and mitigate physician distress at both the individual and systems level. This tendency can result in additional and more confusing nomenclature such as that recently suggesting that even moral injury may be better supplanted by the term “human rights violations”.3

As stated above, I am not necessarily arguing for unequivocal support for the term burnout for there are legitimate questions about is nature.4 However, I am arguing that, if I may blend the title of the popular movie with the title of this feature, thoughts of adopting the term moral injury for physicians should be gone in sixty seconds.

(1) Asken MJ. It's not moral injury: It's burnout (or something else). Med Economics.
Forthcoming 2019.

(2) Fourie C. Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of moral distress. AMA J Ethics. 2017;19(6):578-584.

(3) Wible P. Not “burnout,” not moral injury - human rights violations [Blog entry]. Pamela Wible
MD [Internet]. 2019 Mar 18 [cited 2019 Apr 29]. Available from:

(4) Schonfeld I. When we say “physician burnout,” we really mean depression. Medscape [Internet].
2018 Jul 3 [cited 2019 Apr 20]. Available from:

Competing interests: No competing interests

07 May 2019
Michael J. Asken
Director, Provider Well-Being
UPMC Pinnacle Health Hospitals
Harrisburg, PA 17101