For the past month and maybe longer, I have been waking up with pressure in my chest. It worsened in December and continued to worsen in the new year. I had identified it as anxiety, but felt it was of a different quality than my run-of-the-mill anxiety. This feeling was more anguished.

During the first week of January, I volunteered at a clinic, where I saw patients, assessed, and treated psychiatric illnesses. My daily job is inpatient psychiatry, and I enjoy seeing outpatients in this clinic for individuals without insurance at the beginning of each month. This particular week, all my patients were Venezuelan immigrants. The pressure worsened in the days that followed.

Then, Renee Good was shot and killed by an ICE agent in Minnesota, and the pressure worsened. It occurred to me that the feeling was moral injury, not anxiety. It took several incidents and a lot of introspection to identify what I was actually feeling.

Defining moral injury

The psychiatrist Jonathan Shay initially described moral injury, which he coined to describe the experience of veterans. It aimed to describe an injury that can occur if someone takes part in, cannot prevent, or witnesses an event that goes against their values. It has been recognized to be ubiquitous in medicine.

The Pitt, a television show currently airing, is a good example of this type of workplace trauma. In The Pitt, doctors, nurses, and hospital staff appear to accumulate a lifetime of moral injury over a 15-hour shift. A casual viewer may not recognize this while watching, but as a physician viewing this show, I found myself uncomfortable and emotionally triggered, realizing that it was being depicted accurately, hour by hour, as the show develops.

I am very familiar with moral injury acquired over my career in medicine. I have felt it in emergency rooms, my office, and in bathroom stalls, just praying no one would walk in and hear me crying. It starts for me with a pit in my stomach, an increase in my heart rate, and a desire to escape. It is a familiar feeling, one I can best describe as bone-tired exhaustion, while you try to fight back tears and your heart ticks along at what feels like a breakneck pace. After the initial realization, the aftermath can take months or even a lifetime to deal with, and it accumulates with injury after injury, adding up over the years.

I had always associated moral injury with my work. I had never really applied it to the other facets of my life, and perhaps, other than during COVID-19, there had not been another time in my tenure here on earth that had encapsulated it as well as the current time.

The ethical canary

Upon reading a bit more about it, I found that in 2000, it was further discussed in the literature as an “ethical canary,” showing that moral injury on a wider scale is like a canary in a mine. I like that metaphor, being from West Virginia. It suggests that the concept of moral injury and distress can draw attention to sensations and times when systemic changes are needed. I think we certainly are on a precipice of something looming in this nation, and I suspect so many people are waking up with the same ache in their chest as I am.

The problem is that I think so many of us, including myself, are operating in a learned helplessness mindset, feeling like nothing we do could make a difference. I know that for me, this is mired in my privilege and lifelong tendency to lean on it and use that as an excuse to allow other people to do the work. Of course, I vote, but that is not enough.

Systemic violence and silence

Renee Good was shot in the head in front of her wife, only a few miles from where George Floyd was also killed in broad daylight five years ago. Black and brown people have always understood that a minor traffic stop could end in their mortality, but for so many of us in this country, that isn’t our experience.

Violence against women, especially white women, has always gone on, but it is so often hidden behind bedroom doors and family secrets. Everyone saw this violence in broad daylight, and the officer topped it off by calling her a “fucking bitch.” As a woman and a female physician, I have heard this insult hurled at me too many times to count. It is a sort of macabre rite of passage for women.

The swift reaction of some individuals in the media to discredit her and mar her name was another injury. The likes of which we are all familiar with: If a Black or brown person is felt by the media to need discrediting, then they dredge up their list of names and qualities to butcher their reputation. More injury. One could argue that I, as a white woman with money and all the privilege that entails, am late to these revelations, and you would be correct. All the reading and study and work that I have done to attempt to deprogram myself from the tenets of white supremacy, I am really only at the beginning of the work.

I think that the escalating violence over the last year and the ability to match patterns alerted me that we were always heading toward open violence against anyone who doesn’t obey. Knowing it was coming doesn’t make it sting less. We are here now, and I am woefully unprepared with answers; however, just identifying what the ache is has helped me to more fully understand the situation. Perhaps someone reading this will have a better understanding of the dread many of us wake up with.

Courtney Markham-Abedi is a psychiatrist.