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Margaret McKinnon is the Homewood Chair in Mental Health and Trauma and associate professor at McMaster University, and a scientist at Homewood Research Institute. Ruth Lanius is the Harris-Woodman Chair in Psyche and Soma and a professor at Western University. Rakesh Jetly is a clinician-scientist at the Institute of Mental Health Research in the University of Ottawa’s Royal Ottawa Mental Health Centre. Drs. McKinnon, Lanius and Jetly serve as clinician-scientists in their respective clinical and academic settings.

Many people serving in the healthcare and public safety sectors during the COVID-19 pandemic are at risk of moral injury.

That is, they may do, fail to prevent, or witness actions that violate their own moral beliefs or standards, or they may experience a sense of betrayal when they feel inadequately supported by organizations that have an obligation to do so.

Most concepts of moral injury focus on military contexts, but there is increasing recognition that other professions involving high levels of moral stress – police officers, firefighters, paramedics, dispatch workers or corrections guards – may suffer similar forms of psychological injury.

Sometimes framed as the choice between "wrong and wronger,” the weight of such ethical decision-making has been captured classically in the novel and film Sophie’s Choice, where a mother must choose between her two children. Former senator Roméo Dallaire has written movingly about the imperfect and wrenching choices he had to make as the leader of the United Nations Assistance Mission for Rwanda, between obeying his orders from the United Nations, or obeying his conscience as the country’s Hutu majority committed genocide against the Tutsi ethnic group.

Today, in the face of the COVID-19 pandemic, the battle lines have never been more ambiguous for our healthcare professionals and front-line public safety personnel, and the weight of ethical decision-making never more heavy.

Articles, including one recent report in the New England Journal of Medicine, have already highlighted the dire ethical choices faced by underresourced Italian physicians. Should a young man in his thirties with an unclear cancer prognosis receive access to the last remaining ventilator? Or should it be given to an otherwise healthy woman in her sixties? No person should have to endure this, but this calculus is being made.

Similarly, in North America, how could a respiratory therapist, having watched sufferers of COVID-19 die without necessary medical equipment, live life without being consumed by what was lost?

How can our administrators and government leaders make decisions, such as who is redeployed to the ICU and who is redeployed to a relatively safer hospital unit, or how to distribute scarce resources, when those decisions may mean the difference between life and death for front-line personnel?

How can a mental-health professional exude confidence and strength in the face of uncertainty if they’re struggling with their own fears for safety?

These troubling thoughts may touch on deeply held moral and ethical beliefs. My job is to save lives, not decide who lives or dies, would be one such principle. Or adequate medical resources should be available when needed to save the lives of a country’s citizens, and by extension, a country’s guests, such as refugees.

All of these scenarios have the potential for moral injury: a traumatic battle scar that extends beyond traditional conceptualizations of post-traumatic stress disorder (PTSD) to include a profound sense of guilt and shame for one’s actions or inactions.

The other aspect of moral injury – a sense of betrayal or lack of support from trusted individuals with a fiduciary or moral obligation to do so – may occur. Familial transmission by healthcare providers, public safety personnel or other essential workers who might lack critically needed personal protective equipment (PPE) carries the potential for traumatic guilt if a loved one is infected.

Notably, some front-line individuals will emerge from this pandemic with post-traumatic growth – a positive psychological shift following adversity – and recognize new and stronger sides of themselves, as well as of their professional community that were not present previously.

So Canada finds itself at a crossroads. Given our knowledge of moral injury and its potential impact on the brave men and women serving at the front lines of this pandemic, how will we intervene now to provide much needed care and early assistance for this battle injury?

It is increasingly apparent that the antidote may arise, in part, through clear, transparent decision-making by leaders outlining the current stock of PPE and medical equipment, such as ventilators, the known risks of transmission with the PPE available, and the expected rates of death among the public. Such decision making must also incorporate the voices of front-line professionals to provide a sense of control and agency; deciding together how to distribute remaining equipment feels accountable and reasonable.

Together, we can overcome the massive challenge before us, and emerge victorious against this unseen enemy.​

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