War in Ukraine and moral distress: experiences of a British GP

[摘要] Disaster responders operating in humanitarian contexts — such as healthcare professionals deploying to and practising in active war zones, refugee camps, and the ground zero of famines, earthquakes, and devastating hurricanes — often experience a plethora of negative emotions because of perceived or actual transgressions of their core ethical principles.Gustavsson et al describe this ‘moral distress’ as a stress reaction triggered by the responder being unable to discharge their deeply held moral values in various situations during disaster responses, such as when the individual is hindered from taking what they believe to be the morally required action because of external obstacles (including being associated with or affected by the morally questionable actions and decisions of others), contextual limitations (including the absence of the required equipment, medications, or specialist facilities to deliver the morally required outcome), and personal failings of the individual’s character (akin to weakness of will or moral akrasia).1 While moral stress is a normative response to the ethical challenges frequently experienced by disaster healthcare responders, the subsequent emergence of moral distress is dependent upon the intensity, duration, and frequency of the moral challenges giving rise to moral stress. Without successfully identifying and managing moral distress, harmful secondary consequences may subsequently emerge in affected responders including both those of a moral concern — such as moral residue, moral numbness, and moral detachment — and those of a psychological nature — such as work exhaustion, compassion fatigue, and professional burnout. These impacts may be deep, enduring, and impede the responder’s ability to address future moral, professional, and personal challenges.1PROVIDING HEALTH CARE DURING THE RUSSIAN INVASION I am a British GP and have been providing care to internally displaced people in eastern Ukraine — people whose lives have been unexpectedly inverted due to the Russian invasion and subsequent occupation that began on 24 February 2022 — for the previous 7 weeks with a UK-based medical NGO. I have been working with national and international humanitarian colleagues to provide mobile primary health clinics in Poltava City, the wider Poltava Oblast, and Trostyanets’ and its surrounding villages in the neighbouring Sumy Oblast. While Poltava has largely avoided significant Russian aggression, its city and wider region now accommodate tens of thousands of internally displaced people (IDP) who have fled from the neighbouring regions of Sumy, Kharkiv, Donetsk, and Luhansk Oblasts that have been heavily targeted by invasion and bombardment. This immense influx of people has placed enormous strain on the existing health system that was already over-stretched and under reform prior to the war.2 Our work in these areas aims to relieve this additional pressure by providing primary health care to IDP with chronic diseases, acute minor illnesses, and psychological consequences of participating in, sheltering from, and finally escaping violent hostilities. Meanwhile, the medium-sized town of Trostyanets’ was occupied by the invading Russian army for a 1-month period before liberation by Ukrainian forces.3 Its sole hospital and most of its primary health clinics were destroyed, while many of its health professionals fled the hostilities, meaning residents that survived occupation, and those now returning to what remains of their homes, have enormous physical and mental health needs that the health system cannot yet satisfy. Our work in Trostyanets’ and its surrounding villages is therefore to partially replace essential health care while the local system undergoes reconstruction. My moral predisposition leans towards a practical utilitarianism designed to maximise human flourishing and eradicate meaningless suffering while respecting human rights and avoiding repugnant conclusions. Motivated by this ethical framework, my experiences of practising in this intense humanitarian context have generated multiple episodes of substantial moral distress. This article will outline a few of them, and briefly describe the relevant situation, ethical challenges, and resulting moral distress.

[学科分类] 卫生学