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Burnout remains a major unresolved and worsening problem for anesthesiologists (Anesthesiology 2024;140:38-51). In one recent survey, 67.7% of respondents reported high risk for burnout (emotional exhaustion and/or depersonalization), and 18.9% reported burnout syndrome (emotional exhaustion, depersonalization, and low sense of personal accomplishment (Anesthesiology 2024;140:38-51). Perceived lack of support at work was by far the strongest factor associated with burnout (OR 9.2; 95% CI, 7.0 to 12.1), followed by staffing shortages (OR 1.96; 95% CI, 1.57 to 2.43). The survey authors emphasized the role of human-centered design (“a design and management framework to develop solutions to problems by involving the human perspective in all steps of the problem-solving process”) for solutions to enhance anesthesiologist well-being and the crucial role of organizational leadership to support health care workers (Anesthesiology 2024;140:38-51; asamonitor.pub/4bRxrgE). Our aim is to expand the discourse around burnout in anesthesiologists by introducing the concept of moral distress and moral injury as underrecognized, pernicious phenomena that both feed burnout and emanate from it.

Numerous commentators outside of anesthesiology have shifted focus toward moral injury and away from burnout when characterizing clinician distress (Fed Pract 2019;36:400-2; BMJ Qual Saf 2018;27:766-70; BMJ 2019;366:I4774). Burnout, they explain, places blame and responsibility for solutions on individual physicians, while moral injury attributes clinician distress to “broken” systems rather than “broken” individuals (Fed Pract 2019;36:400-2; BMJ Qual Saf 2018;27:766-70). Some argue that focusing primarily on individuals prevents identification of systems-related drivers of chronic workplace stress that fuels clinician distress (BMJ 2019;366:I4774). Others propose that clinician distress should be viewed as a continuum that begins when systems and individual factors lead physicians to transgress their moral codes, resulting in cognitive dissonance experienced as primarily moral distress and moral injury, rather than burnout, per se (BMJ 2019;366:I4774; JAMA 2020;323:923-4; J Gen Intern Med 2020;35:409-11; Nurs Ethics 2023;30:960-74). Dean and colleagues propose that a significant percentage of what is regarded as burnout is actually moral injury (JAMA 2020;323:923-4). Because secondary burnout is a late consequence of primary moral injury, individualistic approaches to burnout (interventions to develop resilience, resourcefulness, and adequate/sufficient self-care) may delay identification of earlier phases of clinician distress (JAMA 2020;323:923-4; Nurs Ethics 2023;30:960-74).

Physicians have prima facie obligations to promote patient autonomy as a function of primary respect for persons, to promote the health and well-being of individual patients (beneficence), and to minimize harms as weighed against benefits (nonmaleficence). Moral or ethical dilemmas occur when there is more than one correct action, but the actions seem incompatible with each other such that the moral agent (i.e., the physician) cannot satisfactorily choose both/all actions at the same time (Principles of Biomedical Ethics. 8th ed, 2019). An example is when clinicians feel distress around decisions to continue or withdraw life-sustaining treatment in a critically ill patient. Resolving such dilemmas is integral to medicine, but conflicting allegiances to patients, institutions, society, and the self may compel physicians to transgress their moral code by making decisions that run counter to full realization of patient autonomy or welfare (JAMA 2020;323:923-4; J Gen Intern Med 2020;35:409-11; Nurs Ethics 2023;30:960-74). A classic example for anesthesiologists is observing an inexperienced/inexpert surgeon having difficulty with a complex operation. Should the anesthesiologist contact a more senior surgeon/the surgeon’s chief to come assist or avoid embarrassing the surgeon and undermining their ability while letting them continue to struggle (also preventing criticism of oneself)? Such moral dilemmas can create moral distress, which “occurs when individuals believe they are unable to act in accordance with their ethical beliefs due to hierarchical or institutional constraints” (J Gen Intern Med 2016;31:93-9; Nursing Practice: The Ethical Issues. 1984). Put another way, with moral distress, there is a correct action that is difficult to accomplish. Like “death by a thousand cuts,” chronic, repeated moral distress and betrayals of one’s moral conscience can result in moral injury. In the modern era, moral injury was first used to describe psychological trauma experienced by many Vietnam War Veterans (J Relig Health 2021;60:2989-3011). It has been differentiated from post-traumatic stress disorder and variously defined as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” and “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society” (Clin Psychol Rev 2009;29:695-6; asamonitor.pub/3WPaPsT). While certainly not all chronic work stressors cause transgression of an anesthesiologist’s moral code, anesthesiology does have a unique constellation of conditions that drive moral distress and moral injury. The identification and role of these factors in leading to burnout among anesthesiologists has not been clearly defined.

While surveys of anesthesiologists in practice and training cite lack of support at work as the strongest factor causing anesthesiologist burnout, the reports do not elaborate on what exactly lack of support means (Anesthesiology 2024;140:38-51; Anesthesiology 2021;134:683-96; Anesthesiology 2019;131:668-77). We posit that lack of support at the institutional and departmental levels may contribute more directly to moral injury than to burnout as a primary phenomenon. Moral distress occurs when decisions made in the best interests of the patient may conflict with institutional or leadership priorities. With corporatization of health care and a “no margin, no mission” culture, institutional financial incentives can be pitted against best medical practice (Bus Prof Ethics J 1993;12:39-50). Many anesthesiologists find production pressure from the institution and surgeons to be morally distressing, sometimes forcing a choice between taking the time to provide optimal care or providing what they consider suboptimal care by taking shortcuts on the preoperative evaluation and/or using more efficient but less efficacious or safe anesthetic techniques, just to save time.

Disruptive surgeon behavior and communication failures in the OR are associated with an increase in malpractice claims for both surgeons and anesthesiologists (Br J Anaesth 2021;127:470-8; Ann Surg 2019;270:84-90). In an institutional culture that tolerates surgeon incivility (bullying, sarcasm, condescension), moral distress for anesthesiologists can arise when they opt to restrict communication with a verbally abusive surgeon rather than speaking up or asking clarifying questions with the intention of optimizing patient care. Abusive behavior also creates clinician distress that negatively impacts professional identity and diminishes professional worth.

Another important and common potential source of moral distress in anesthesiology is obtaining informed consent on the same day as elective surgery. The pressured context in which complex, nuanced information must be conveyed to stressed patients begs the question of whether consent is truly informed and voluntary (asamonitor.pub/3yGBhe3; asamonitor.pub/3VbrUuH). Anesthesiologists may experience cognitive dissonance when asked to obtain consent under time-constrained circumstances from a very anxious, nervous, or fearful patient/surrogate. Oftentimes, health literacy or language barriers may preclude optimal comprehension of the proposed anesthetic plan and its risks, benefits, and alternatives, as well as understanding of a lengthy and complex informed consent document. With respect to voluntariness, patients may feel coerced to just sign the consent form because preparations for surgery have already been made, the surgeon is waiting, and they need to sign consent for anesthesia if they want the procedure. Anesthesiologists can experience substantial moral distress around whether they are acting in the patient’s best interests.

In conclusion, anesthesiologists must be aware that it is often the psychological distress associated with the deep soul wound of moral injury, rather than just burnout, that may lead to physician frustration, emotional exhaustion, detachment, low sense of personal accomplishment, and disillusion in their practice.