Moral injury and the four pillars of bioethics.

Healthcare providers experience moral injury when their internal ethics are violated. The routine and direct exposure to ethical violations makes clinicians vulnerable to harm. The fundamental ethics in health care typically fall into the four broad categories of patient autonomy, beneficence, nonmaleficence, and social justice. Patients have a moral right to determine their own goals of medical care, that is, they have autonomy. When this principle is violated, moral injury occurs. Beneficence is the desire to help people, so when the delivery of proper medical care is obstructed for any reason, moral injury is the result. Nonmaleficence, meaning do no harm, has been a primary principle of medical ethics throughout recorded history. Yet today, even the most advanced and safest medical treatments are associated with unavoidable, harmful side effects. When an inevitable side effect occurs, the patient is harmed, and the clinician is also at risk of moral injury. Social injustice results when patients experience suboptimal treatment due to their race, gender, religion, or other demographic variables. While minor ethical dilemmas and violations routinely occur in medical care and cannot be eliminated, clinicians can decrease the prevalence of a significant moral injury by advocating for the ethical treatment of patients, not only at the bedside but also by addressing the ethics of political influence, governmental mandates, and administrative burdens on the delivery of optimal medical care. Although clinicians can strengthen their resistance to moral injury by deepening their own spiritual foundation, that is not enough. Improvements in the ethics of the entire healthcare system are necessary to improve medical care and decrease moral injury.