When Systems Collide: The Moral Injury Crisis in Healthcare

I’ve written about moral injury in healthcare before, most notably in my review of If I Betray These Words by Dr. Wendy Dean and Dr. Simon Talbot, which remains one of the most urgent calls to action I’ve encountered.

Their book profiles clinicians across the United States tough, resourceful, and deeply committed professionals, who find themselves trapped between the patient-first values of the Hippocratic oath and the business imperatives of a broken healthcare system. This tension is the very essence of moral injury in medicine.

Sadly, in Australia, not enough is being done to support our own healthcare workers who are sounding the alarm about the conditions under which they’re now forced to operate. And this reality struck me with renewed force after returning from the General Practice Conference & Exhibition (GPCE) in Melbourne.

Dozens of doctors, particularly those from Emergency Departments, came to our stand. Not to talk shop. Not to network. But to share. And what they shared was raw. Familiar. Urgent.

Many told me they knew exactly what moral injury felt like. Some had left high-pressure hospital environments hoping to escape the impossible ethical demands, only to encounter a different strain of moral compromise back in General Practice understaffed, overburdened, and under-supported. The system is not just strained it’s in crisis.

Nurses, too, approached with their stories. Their language was often slightly different moral distress, but the emotional weight was the same. The grief of not being able to do what they knew was right. The exhaustion of watching suffering go unaddressed. The despair of being silenced by bureaucracy, budget constraints, or burnout.

It's early days for moral injury education in Australia and with a growing cohort of multidisciplinary skills pushing for better prevention in multiple systems, not just healthcare, it is sure to emerge as a key consideration in mitigating psychosocial hazards.

I first became aware of Moral Injury during my chaplaincy training and like others have activeley endeavoured to grow my skill set in this area particularly the healing aspect which is deeply relevant to chaplaincy. We know that pastoral narrative therapy, community connection and forgiveness are some of the tools that appear to help people heal. But it's still early days in research in this area.

That said, Moral injury isn’t new. In fact, it’s ancient.

Humans have long wrestled with the emotional and ethical toll of being unable to act in accordance with our values, whether in war, religion, philosophy, or medicine. From Achilles' grief and rage in The Iliadto Shakespeare’s Macbeth, from Thomas Aquinas' moral pain to the diagnostic debates of the DSM, the language may shift, but the wound is familiar.

As the healthcare system evolves (and in many ways, deteriorates), we must stop pretending that moral injury is a fringe concept. It’s embedded in the very fabric of caregiving under pressure. The question now is whether we’ll finally name it, and act to prevent it and help those harmed to heal.

How Business Metrics Are Wounding the Healing Professions

Medicine has long been held as a noble calling. Those who pursue it understand the sacrifices, the sleepless nights, the relentless study, the missed birthdays. But they also believe something deeper: that their efforts will matter. That in easing suffering, they’ll find purpose.

And for generations, they did. Until something broke.

As Talbot and Dean write in modern American healthcare, and in growing pockets across global health systems, many physicians now find themselves caught in a profound and painful contradiction: a system that asks them to heal, while rewarding them for doing the opposite.

This is where moral injury begins.

What Is Moral Injury in Healthcare?

Coined and explored by Dr. Wendy Dean and Dr. Simon Talbot, moral injury is not the same as burnout. Burnout implies that the problem lies within the individual, too weak, too tired, too incapable. Moral injury shifts the lens back to the system.

Moral injury happens when physicians are forced, time and time again, to act against their own ethical code. When they must deny a necessary test because of insurance constraints. When they’re told to prioritize patients based on coverage, not criticality. When corporate executives overrule clinical judgment to protect profits.

It’s not just demoralizing. It’s wounding.It eats away at the very reasons many entered medicine in the first place.

“This is a bottom-up examination of our diseased healthcare system… in which physicians are the heroes—mostly.”— Kirkus Reviews on If I Betray These Words by Dr. Wendy Dean

Five Signs the System Is Breaking People:

These aren't abstract complaints. They show up in exam rooms and emergency departments every day:

1. Documentation over care – Physicians spend more time clicking boxes than listening to patients.

2. Overloaded schedules – More patients, less time. Faster consults, fewer connections.

3. Staffing by spreadsheet – Hiring and firing decisions made by business analysts, not patient needs.

4. Ethics overridden by executives – Boardroom decisions that ignore frontline medical realities.

5. Shareholder interests above public health – Community wellness is compromised in favor of quarterly gains.

What Happens When the Conflict Is Too Much?

Some physicians try to escape, switching specialties, moving to smaller practices, even leaving medicine altogether. Others spiral into despair. Depression, isolation, and tragically, even suicide.

Each of these losses is personal. But they’re also systemic.

Because when a healer is broken, a whole community loses its hope.

We Can’t Heal This with Yoga Classes

Addressing moral injury in healthcare demands far more than resilience training or mindfulness apps. These tools may help individuals cope, but they don’t touch the root cause.

We need deep, systemic reform, including:

1. Reclaiming the humanitarian mission at the heart of healthcare institutions

2. Putting doctors at the table for decisions that impact patient care

3. Prioritizing outcomes, not margins

4. Creating environments where ethics aren’t optional

5. Fostering open, protected dialogue between staff and leadership

Healthcare executives aren’t the villains. They’re under pressure too—navigating insurance systems, regulations, investor expectations. But healing this broken relationship starts with acknowledging that doctors and executives are operating from fundamentally different moral frameworks.

Only when that truth is understood can the real work begin.

Why This Conversation Matters for All of Us

Moral injury in healthcare doesn’t just affect physicians. It impacts every nurse, allied health worker, administrator, and every patient.

Every time a clinician is forced to turn away from what’s right, trust is eroded. And when trust disappears from healthcare, what’s left?

As we face rising mental health challenges, inequities in access, and a growing workforce exodus, the question of how we care for our caregivers becomes not just moral, but urgent.

Let’s stop pretending this is about individual resilience.Let’s start designing systems worthy of the people who work within them—and the people they serve.

Further Reading:If I Betray These Words: Moral Injury in Medicine and Why It's So Hard for Doctors to Put Patients First by Dr. Wendy Dean and Dr. Simon TalbotAvailable at: www.fixmoralinjury.org/book

Join the Conversation:If you’re a healthcare worker, a policymaker, or a patient who believes we must do better, subscribe and stay engaged. Together, we can raise the alarm, build alliances, and push for care systems that honor the sacred trust at the heart of medicine.