by Matthew Wynia, MD, MPH, FACP
Featured in the Aug-Oct 2021 Colorado Medicine Colorado Medicine.
It’s become a truism that the pandemic has elevated public awareness of ethical issues in medicine and public health. Triage of scarce resources in disasters, the ethics of quarantine and isolation, the legal and ethical legitimacy of mask and vaccination mandates – these are no longer just public health ethics classroom exercises, they are topics of dinner-table conversations worldwide and the subjects of wrenching real-world decisions by leaders.
Longstanding racial, ethnic and geographic health disparities have also been exacerbated by the pandemic, leading to heightened public awareness of historical and structural injustices in U.S. health care. The racial justice protests of 2020 didn’t focus much on excess deaths among minorities in the US health care system, but they could have. And more people now recognize systemic injustices as intertwined, with health disparities intersecting with structural injustices in policing, education, transportation and other domains of American life.
For many health system leaders, this recognition has prompted a difficult acknowledgement: racial, ethnic, geographic and disability-related health disparities cannot be solved by “cultural competence” initiatives aimed at individual clinicians. Just as frontline clinicians have long struggled to help their patients facing various barriers to good health – over which individual clinicians have little or no control – many leaders are now struggling to figure out their roles in remedying structural problems in payment, geographic distribution of resources, transportation, employment and other barriers to the wellbeing of historically disadvantaged communities, because these factors lie outside the traditional purview of the health care systems they lead.
In the meantime, the fact that professional ethics calls on frontline clinicians to put patients’ interests ahead of our own was probably already widely known, but it was also mostly theoretical for many patients. The pandemic changed that too, as the news filled with stories and images of doctors and nurses, often haggard and broken but labeled as “heroic.” But this dynamic also poses a challenge for health system leaders, with many predicting a mass exodus of clinicians in the coming months and years.
Similar to the complex challenge of addressing health inequities, many leaders are coming to realize that addressing the challenge of rising moral distress and burnout among clinicians cannot be solved using an approach focused on bolstering individual resilience. Clinicians being ground down by packed schedules, resource shortages, and EMRs tailored to billing rather than patient care might not find enough solace in free yoga classes at noon on Wednesdays. But do individual health system leaders really have the leverage to change the core functionality of available EMRs, or the rates at which their communities choose to be vaccinated, or payment models that reward volume over value?
With the complex challenges confronting health system leaders, it’s no surprise that they are experiencing moral distress and burnout, too. Moral distress arises when someone knows the right thing to do, but is constrained by external forces and can’t do it. It arises most often from power dynamics – and while moral distress can be alleviated by naming it and recognizing its effects, it is solved only by effective advocacy to improve underlying conditions.
As I write this, I can almost hear frontline clinicians muttering that their system leaders are paid quite well for bearing these burdens. But so are many clinicians who burn out nevertheless. In health care, remarkably, there is little relationship between one’s level of remuneration and the experience of burnout.
The bottom line is that health system leaders, like clinicians, need to learn how to recognize, analyze and act on the ethical challenges they face. Today more than ever, they need to create safe spaces for talking about the painful experiences of the last year, to share creative practical interventions, and to practice the skills of ethical leadership.
Matthew Wynia, MD, MPH, FACP, directs the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. He co-directs the Aspen Ethical Leadership Program, a selective-admission program for exploring and developing skills for managing ethical challenges facing health system leaders. The next cohort of leaders meets Oct. 3-6, 2021; more information is at: bit.ly/AELP2021