Department of Emergency Medicine, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
Departments of Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA.
Anthropol Med. 2021 Jun;28(2):223-238. doi: 10.1080/13648470.2021.1929831. Epub 2021 May 31.
Opioids, a set of potent pain medications, have numerous known deleterious side effects, ranging from constipation to respiratory depression and death, and yet they are routinely prescribed and administered in biomedical settings. Situated against the backdrop of the US opioid epidemic, this paper examines how the iatrogenic and inadvertent harms and complications caused by opioid administration in clinical settings are experienced by clinicians as forms of moral injury. 'Moral injury' describes a moral agent's experience of perpetrating or being unable to prevent events that are at odds with their moral beliefs and social expectations. This concept powerfully extends Illich's notion of clinical iatrogenesis, which refers to harms experienced by patients; instead, 'moral injury' indexes forms of harm that extend beyond patients to those providing them care. Using an analytic auto-ethnographic approach based on more than a decade of clinical practice in urban hospitals in the Midwestern and Northeastern United States, the authors describe interactions with patients on opioids whose treatment trajectories are fraught with iatrogenic complications, and explore how biomedical institutions and systems further harm vulnerable patients who receive and are addicted to opioids. Though anxious to avoid harming their patients, clinicians are disempowered by hierarchical systems of medical decision-making, which hinder their ability to always act in what they feel are the patient's best interests. This paper highlights the emotional/affective distress and ambivalence experienced by physicians when making decisions about whether to administer or prescribe opioids. Ultimately, the paper demonstrates how iatrogenesis and moral injury are concomitantly produced through cascades of decision-making and local health systems, rather than individual clinical decisions alone.
阿片类药物是一组强效止痛药，具有许多已知的有害副作用，从便秘到呼吸抑制乃至死亡不等，但它们在生物医学环境中仍被常规开具和使用。本文以美国阿片类药物流行的背景为背景，研究了临床环境中阿片类药物管理导致的医源性和意外伤害和并发症如何被临床医生体验为道德伤害。“道德伤害”描述了道德代理人实施或无法预防与其道德信仰和社会期望相悖的事件的经历。这一概念有力地扩展了伊里奇（Illich）的临床医源性概念，后者指的是患者所经历的伤害；相反，“道德伤害”则是指那些超出患者范围，延伸到为他们提供护理的人的伤害形式。本文使用了一种基于作者在美国中西部和东北部城市医院超过十年临床实践的分析性自传体方法，描述了与接受阿片类药物治疗的患者的互动，这些患者的治疗轨迹充满了医源性并发症，并探讨了生物医学机构和系统如何进一步伤害接受和成瘾阿片类药物的脆弱患者。尽管临床医生急于避免伤害他们的患者，但等级制度的医疗决策系统使他们失去了权力，这阻碍了他们始终按照自己认为对患者最有利的方式行事的能力。本文强调了医生在决定是否给予或开具阿片类药物时所经历的情绪/情感困扰和矛盾心理。最终，本文表明，医源性和道德伤害是如何通过决策和当地卫生系统的级联产生的，而不仅仅是个人临床决策。
