I retired from my pediatric cardiology practice almost two years ago, and I keep circling back to one of the final days of my career. For a long time, I told myself I had simply burned out, worn thin by the pace and the paperwork. Only with time and reflection have I realized I didn’t step away because I was tired, I stepped away because of deep moral injury.

I remember the day in snapshots: a busy clinic afternoon, two patients waiting in exam rooms, my pager buzzing on the counter.

“We need you to review an echocardiogram. Seventeen-year-old. Suicide attempt. Possible organ donor.” On the echo screen I saw a good heart, a potential match for a dying recipient in another city, a chance to turn one family’s worst nightmare into another family’s hope.

When everything converged

I called the transplant center reaching the transplant nurse. They needed a cardiac catheterization to confirm that the donor heart function was adequate. No cath, no heart. I then called one of my adult cardiology colleagues: “Would you be willing to do a donor heart cath on this young man? It could make the difference for a patient waiting for a transplant.”

She agreed, and there was more back-and-forth (questions, criteria, risk calculations). For a while it wasn’t clear if the pieces would come together but they did. The heart was accepted. The transplant would go forward. In a landscape where so many things feel like loss, this was a clear win: life emerging out of tragedy.

Then my phone rang again. This time it was a colleague from a nearby clinic where I had done outreach 22 years, building a panel of about 250 children and families, some of whom we now in adulthood. We were renegotiating the outreach contract between that center and my home institution.

“I’m so sorry,” my colleague said. “The contract is dead. Your institution insisted on a fee we just can’t afford. We can’t continue the outreach. It’s over.”

In the span of a few hours, I had cared for clinic patients who had no idea what else was happening, coordinated the donation of a young man’s heart for transplant, and learned that countless clinical relationships were ending because of a financial decision I hadn’t been told about by my own leadership.

By that point in the day I was exhausted and chose to wait to hear from leadership about their outreach decision. It was six days before they contacted me to share the details.

When joy and devastation arrive together

You might think coordinating that gift of life would have filled the emotional space of the day. Instead, my inner landscape was filled with grief for the 17-year-old and his family, gratitude and relief that his heart would help someone else live, pride in the teams that made the transplant possible, and a deep sense of rightness about that part of the work.

Layered on top was shock and grief as years of outreach were erased with a single contract decision, anger that those patients were losing a familiar cardiologist and continuity of care, rage and hurt that my own institution had made this decision without my knowledge, leaving me to hear it first from a colleague across town, and a profound sense of being abandoned and expendable by the very system I had served so faithfully.

This was emotional whiplash with the best possible outcome for one situation and the worst possible outcome for another. A moment of medicine at its best, inside a system behaving at its most transactional. That day was the tipping point. A few days later I announced my retirement.

Naming what happened: moral distress and moral injury

At first, I interpreted that day through my usual lens of wondering what I could have done differently. Then I began to find language that fit the experience better: moral distress, moral injury, institutional betrayal, enforced patient abandonment. Moral distress happens when we know (or believe we know) the ethically right thing to do, we are willing to do it, and we are prevented from doing it by forces we can’t control.

The transplant story ended well despite the moral stress: negotiating with systems more focused on risk than on meaning, knowing that if a cath couldn’t be done the heart would be wasted, carrying the weight of families on both sides. The deeper wound, though, was moral injury. The institution I served was acting in ways that violated my core commitments, to patients, to community, to partnership with me as a physician.

A developmental lens: learning from Kegan and Garvey Berger

My understanding of this rupture in the moral fabric of my work was aided by exploring the tenets of adult development, especially Robert Kegan’s constructive-developmental theory and Jennifer Garvey Berger’s Changing on the Job: Developing Leaders for a Complex World. Both authors describe how adults can move through different “meaning-making” stages. Two forms of mind helped me make sense of that day: the self-authoring and self-transforming mind.

Self-authoring leaders have a strong internal framework of clear goals, values, and principles that organize their decisions. They focus on consistency, coherence, and execution and have a sense that their role is to “author” and protect a particular narrative about what matters, often financial and strategic priorities. In the contract negotiation, my institution’s leadership was operating in a very self-authoring way: “We have a financial framework. These are our terms. If the other institution can’t meet them, the contract ends. It’s unfortunate, but it’s consistent with our principles.” From their vantage point, this likely felt disciplined and principled.

Self-transforming leaders also have values and principles but see any single framework as partial. They view systems, relationships, power, and history as intertwined and regularly ask, “How do these stories fit together? Whose perspective is missing? What might we need to rethink, even in our most cherished beliefs?” That’s where I found myself living. I didn’t just see a contract. I saw 22 years of accumulated trust with a community, 250 patients whose lives were woven into that outreach, and the juxtaposition of a life-giving transplant with a life-draining administrative decision on the same day. I saw a health care system increasingly comfortable dropping long-term relationships rather than re-examining its financial assumptions.

My narrative was not “I shouldn’t have let one day push me into retirement” but rather “That day revealed a culmination of misalignments and unaddressed moral distress. Resigning was an act of self-preservation and truth-telling.” Naming what happened reduced the shame and stopped me from mislabeling moral injury as simple burnout.

So, when someone says, “It’s just business,” part of me now hears: “This is the story we are choosing to privilege.” To a largely self-authoring system, this is about principles and margins. To a more self-transforming clinician, it is about identity, covenant, and the kind of story we are telling with our actions.

Leaning into healing

Healing from moral injury is not the same as “recharging.” Burnout says, you’re depleted, rest. Moral injury says something essential to your sense of rightness has been violated. For me, healing has included:

• Grieving: The 17-year-old who died, the grace of his heart helping another patient live, the loss of outreach relationships with no closure, and the version of myself who believed institutional loyalty would always be reciprocated.
• Sorting responsibility: Distinguishing what was truly mine that day from what belonged to transplant policies, contract negotiations, and financial frameworks I did not control.
• Reclaiming vocation outside the system: Continuing to walk with physicians through moral distress and leadership challenges as a coach and creating spaces where my way of seeing systems is an asset, not an inconvenience.
• Practicing forgiveness without erasing accountability: Slowly releasing my grip on the hope that the past will change, seeing leaders as humans caught in their own stories, and choosing not to carry resentment in my body, while still telling the truth and keeping boundaries.

An invitation

Maybe you have had similar experiences such as creating the best possible outcome for a patient and still ending the day feeling hollow, watching a program you poured yourself into disappear because “the numbers don’t work,” or seeing your institution make decisions that are financially coherent but morally devastating.

If so, I invite you to:

• Name what is really happening (moral distress, moral injury, developmental mismatch, grief).
• Get curious about the stories in play: the one leadership is living and the one you are trying to live.
• Find people who can hold the complexity with you such as colleagues, therapists, coaches, and spiritual directors.
• Separate “I am broken” from “this is breaking me,” and remember that walking away can, at times, be an act of integrity.

The paradox of that day (the coexistence of profound good and deep harm in the same 24 hours) is only one example of what health care workers face daily in systems increasingly driven by corporatization and commodification of care. We must not abandon compassionate communication about what moral injury is. Becoming self-transforming leaders will help us create a morally sustaining, integrity-restoring culture of care, the living opposite of moral injury.

Susan MacLellan-Tobert is a pediatric cardiologist.