This first decade of my career as a millennial physician is starting to look as fragmented on my CV as it has felt in reality, chasing even a modicum of the stability that the physicians of my father’s generation took for granted. Meanwhile, the chaos engendered by market forces like vertical and horizontal integration across insurance and hospital systems, private-equity-backed buyouts of physician practices and surgery centers, and now just about every four years, profound alterations to governmental policies regulating an industry that now represents 17.6 percent of our GDP, or 4.9 trillion dollars (approximately 14K per person) has given me what amounts to career whiplash. I’ve been employed, self-employed, and now an independent contractor, in for-profit and nonprofit and religiously affiliated systems, in the Deep South, the Midwest, the Midatlantic, and the Rocky Mountain West. There is no safe space. My eldest child has lived in four states in her twelve years, and we are actively looking for our next home. This time, we’ve expanded our search abroad in the hopes that a system that doesn’t call patients “customers” may be at least a little bit insulated from at least the worst that a pure business mindset brings to health care.

In the ten years since I completed my residency training, burnout has become one of the most powerfully resonant buzzwords to capture what feels like a pivotal moment in medical practice. I don’t remember if we had any formal teaching about burnout when I was in medical school, nor would I have been able to stay awake discussing such frivolous topics in my workhorse of a residency when basic bodily functions — sleep and sustenance — took up so much of my “personal” time. Now there is a more recent push to reframe “burnout” because it lays the problem, and by extension the solution(s), at the feet of the sufferers to do even more (yoga, or meditating, or healthy eating, or exercise) when by definition they already feel like ashy husks barely clinging to the desiccated threads of their humanity. Instead, maybe this movement is better thought of as the accumulation of moral injury, which happens when the values, goals, and priorities of the system in which we work feels deeply at odds with our individual moral code. Moral injury is the subjective psychological state of emotional distress from witnessing or perpetuating behaviors that violate our internal ethical framework for how the world should ideally be. In medicine, this happens to every doctor every day. Each time we witness or deliver care that doesn’t meet the standard for how we would want our family members treated or the care we would expect for ourselves, moral injury results. It might be just a scratch or a scrape, but it can still sting. It still violates our integrity the same way that the most innocuous cut or insect bite can be the nidus for necrotizing fasciitis. What starts off as a mild hurt, no big deal, evolves into drastic pathologic changes across a multitude of autonomic and emotional systems.

Frankly, I don’t think moral injury really captures it either. I’m no moral philosopher, but I remember fragments of my collegiate “Intro to Ethics” class, and in particular the choices posed by utilitarianism, in which the stated goal was always to do the most good by the most people (though some utilitarians get very excited by the inclusion or lack thereof of nonhuman sentient creatures). The problem was that alterations in knowledge, especially of future outcomes, could change the moral orientation of current actions. For instance, diverting a runaway bus from killing an innocent child in the middle of the road, and sacrificing three adults on the bus to do so, changes if the child is a future inspirational leader or a future sociopathic totalitarian autocrat, or if the dictator or the saint is the grownup on the bus instead. I walked away from ethics feeling like no one had any better answers than my basic gut check, which I now know is influenced by whether or not I smell flowers or garbage in my immediate environment and my overall tolerance for risk, which may or may not be related to my genetic dopamine receptor polymorphisms.

So, professing ignorance of all but rudimentary canonical knowledge of virtues or antithetical cardinal sins, I think the best way to capture the ethical conundrum of modern medical practice is along the lines of Catch-22 or Sophie’s Choice, in which there really is no decision for the burned out practitioner that is devoid of profoundly negative ethical and emotional ramifications. It’s learned helplessness, the Psych 101 rat-in-the-electrified-cage. If you quit, or retire early, you stand to leave your colleagues that much more understaffed and stretched to meet the needs of the system, your patients with impaired access to care, a dearth of knowledge or underutilized skills and expertise, not to mention the “wasted” investment in your education and training, or the internal feelings of failure and disappointment. If you stay, you continue to sacrifice yourself and your loved ones for a system that quite literally profits from human suffering — the more people suffer, the more medical care they require and seek, the more procedures they undergo, and the more money is made, and the more you personally suffer, the more grams or drops or microns of productivity have most likely been squeezed out of you.

It’s interesting that both of those novels have war as the backdrop, and yet maybe it fits since modern medicine has become decidedly militaristic in its dedication to “fighting” disease and “eradicating” infection. One of the only places where as much suffering is witnessed (and then carried by the survivors) is the battlefield. But while the military has created almost shockingly progressive curricula for resilience that focuses not only on stress‑inoculation, but also on proven cognitive aides like mindfulness and cognitive flexibility, social cohesion and mentorship, post‑traumatic growth, shared purpose and even spirituality, medical training is too invested in its coldly rational, scientifically authoritarian self‑image to allow contamination by any of that soft science mumbo‑jumbo, even when the hard science demonstrates concrete utility and benefit to empathy and compassionate care. And so we doctors are forced to bear witness to the systemic perpetuation (perpetration) of suffering that we feel morally helpless to mitigate, for myriad reasons:

• because there’s not enough time and there’s another patient waiting
• because there are always too many patients and not enough time
• because we were on call or finishing notes and haven’t slept, eaten, or exercised
• because we are torn between our obligation to our patients and our obligation to our families and friends and communities

I had the CFO of my former company, a private practice anesthesia partnership, tell me when we were negotiating with the hospital for either financial support or drastic alterations to efficiency, that I had a “moral obligation” to provide care regardless of whether or not I was paid to do so. Mind you, her assertion stood even though she knew intimately that more than 90 percent of our surgical volume was elective. This is exactly the moral argument that has prevented doctors from effectively utilizing collective action, bargaining, unionization, and strikes, to press back against the demands of a consumer-oriented for-profit health care industrial complex. Because we fear the suffering of our patients in a way that even the administrators intimately familiar with our work do not, just like the politicians who order military engagements have rarely fought on battlefields. And that fear becomes the yoke wrapped around our necks. Either we suffer, or our patients do, in this no-win zero-sum game we all find ourselves playing, while someone slices off a fat piece of that 4.9 trillion-dollar pie to watch us compete in our martyrdom and self-effacement.

Moral turpitude is a legal term that references behavior that is “inherently base, vile, or depraved, and contrary to the accepted rules of morality.” I cannot think of anything that so eloquently and accurately describes the network of insurance preauthorizations and denials that delay and complicate care, nor a pharmaceutical industry that ratchets up prices of essential life‑saving medications like epinephrine or albuterol, or a system that insists that we go to battle every day against human suffering stripped — by a system that sees us as no more than a means of production — of our most basic armament: the value of our own humanity.

Shannon Meron is an anesthesiologist.