Ethical Dilemmas, Moral Distress, and the Risk of Moral Injury: Experiences of Residents and Fellows During the COVID-19 Pandemic in the United States.

The ongoing COVID-19 pandemic has brought numerous ethical dilemmas to the forefront of clinical care, including for resident and fellow physician trainees. In this paper, the authors draw on their own experiences providing frontline COVID-19 clinical care in New York City in their respective roles as an internal medicine resident and later a pulmonary and critical care fellow, and as an associate program director for a pulmonary and critical care fellowship, along with published literature on trainees' experiences in the pandemic, to describe common ethical dilemmas confronted by residents and fellows during the pandemic. These dilemmas are related to personal health risk, resource allocation, health care inequities, and media relations. The authors use a framework of microethics to underscore how these dilemmas are highly contextualized within trainees' institutions, their specific roles, and the patient populations to which they provide care. They argue that frequent ethical dilemmas, compounded by the intense physical and emotional stress of medical training and the pandemic itself, increase the potential for trainees to experience moral distress. Recurrent moral distress may, in turn, put trainees at risk for moral injury with consequences for their mental health and overall well-being. It is imperative to gain a clear understanding of this issue, not only for those trainees who have experienced or are at risk for experiencing personal consequences but also because it may help identify ways to better support the well-being of providers and the care of patients going forward.