ObjectivesPalliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care.MethodsA literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms ‘moral distress’ AND ‘palliative care’. The review process has followed the international PRISMA statement guidelines.ResultsThe initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed.ConclusionsCognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.

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Aim: This study looks at changes in the knowledge of and attitudes towards substance misuse in medical students in two UK medical schools between years 1 and 4 of undergraduate training. Method: The instrument used comprised 20 questions regarding knowledge, attitudes to training, clinical practice, and stigma. Questionnaires were distributed to 1st and 4th year students. Data was entered onto Microsoft Excel worksheets and analysed using the Excel program. Results: There was an overall response rate of 75%. Knowledge was poor amongst the students, with little improvement seen between 1st and 4th years. Responses to attitudes to training were encouraging from both years of students at both schools. Attitudes to clinical practice demonstrate improvement between the 1st and 4th years. Negative attitudes to substance misuse greatly diminish from the 1st year to the 4th. Conclusions: Education and training in substance misuse are vital in the personal and professional development of medical students, who will become tomorrow's doctors. This study indicates that, while there is a degree of improvement in their knowledge about prevalence and complications related to substance misuse, there is a more clear cut change in attitudes to substance misusers and the value of treatment, as students progress through their years of training. However, an unacceptably high proportion of students still feel negatively about the patient population and about treatment prospects and prognosis.

AimsMoral injury (MI) refers to psychological distress resulting from witnessing or participating in events which violate an individual's moral code. Originating from military experiences, the phenomenon also has relevance for healthcare professionals dealing with wars, natural disasters and infectious diseases. The deontological basis of medicine prioritises duty to the individual patient over duty to wider society. These values may place healthcare professionals at increased risk of moral injury, particularly in crisis contexts where they may be party to decisions to withdraw or divert care based on resource availability.We conducted a systematic review of medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic.MethodWe conducted a systematic review of reports included in MEDLINE, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”. We also searched Google Scholar and Ovid Database and conducted reference searching. We searched for published quantitative primary research as well as advance online publications and pre-print research. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using a seven-item checklist.ResultOur databases search identified 498 records and other sources identified 4 records. We screened 391 records after removing duplicates. 4 reports met our protocol requirements.Three papers used cross-sectional designs. One reported longitudinal outcomes of their sample already described in one of the three papers. Only one study used a MI scoring system validated for healthcare professionals. Others used scoring validated in military populations. These papers reported outcomes from 3334 subjects, with a higher proportion of females. The largest study (3006 subjects) reported MI in 41.3% of their sample. Overall, factors associated with greater MI included: providing direct care to COVID-19 patients; sleep troubles; being unmarried; aged <30 years; female gender; and Buddhist/Taoist faith. Nurses reported a greater severity of MI than physicians. MI significantly correlated with anxiety, depression and burnout. The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up.The average quality assessment score of these studies was 4/7.ConclusionIt is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention during the COVID-19 pandemic and other disaster responses across the globe.

Medical education has changed dramatically since the inception of this journal 50 years ago and is indeed a work in progress: there is now heavy emphasis on the character of the physician, in particular, and professionalism, in general. The subjects of communications skills and the teaching of sincerity, empathy and compassion are relative newcomers to the stage: they are not even as old as this journal itself. Nevertheless, these topics arose in an ancient debate dating from classical antiquity. 'Can we teach virtue?' Plato wondered in the Meno. Not exactly, he concluded. Aristotle believed that acquirement of the virtues enables one to attain the human good, which, in turn, spills over to any profession in which the human being decides to engage. Aristotle, along with his successor, Thomas Aquinas, the 13th century philosopher, argued that the virtues cannot be taught but only acquired, with practice and time, in the real situation.