Moral distress: When core values are at stake

Throughout the COVID-19 pandemic, physicians may be faced with overwhelmingly difficult decisions. Retired Lieutenant-General Roméo Dallaire will share his perspective on how to approach moral distress in times of crisis and strategies he used in his military career to protect his core values.

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About Lieutenant-General Roméo Dallaire (retd)

Lieutenant-General Roméo Dallaire (retd) is founder of the Roméo Dallaire Child Soldiers Initiative. He's an advocate for human rights, author, government and UN advisor, and former Canadian Senator. Throughout his distinguished military career, General Dallaire served most notably as Force Commander of the UN Assistance Mission for Rwanda during the 1994 genocide. He continues to work to bring attention to the protection of children in conflict, the prevention of mass atrocities, and the struggle that he and many other military veterans face with post-traumatic stress disorder.

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Moral distress: When core values are at stake

Dr. Jillian Horton:

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster. And I'm your host for this series.

As this crisis evolves, some of our health care systems are being flooded with staggering numbers of critically ill patients. Doctors and nurses describe those scenes as war zones and battlefields. And while this experience may be foreign to us, its overtones have sounded all too familiar to Lieutenant General The Honorable Roméo Dallaire.

In today's conversation, it's our intention to highlight powerful emotional and moral lessons learned from General Dallaire's distinguished military career, including his time as force commander of the United Nations Assistance Mission for Rwanda during the 1994 genocide. General Dallaire will also offer us key insights into managing our post-crisis risk of PTSD. General Dallaire, it is a privilege to be speaking with you today.

General Roméo Dallaire:

That's all mine. Thank you very much.

Dr. Jillian Horton:

For anyone who's younger, and perhaps, not familiar with what transpired in Rwanda, could you briefly talk about the absolutely impossible circumstances under which you served there?

General Roméo Dallaire:

I was nearly going to say, I hope they read my book. But I won't say that.

[LAUGHTER]

A UN mission was sent in with the hope of assisting a nation, resolve a civil war, and ultimately, bring peace. We were there simply to assist and to provide a sort of referee job. But ultimately, extremists on both sides, but mostly, on the majority Hutu side decided that they felt peace agreement was not in their favor. And they ultimately commenced a civil war that also incorporated a genocide. Essentially, they decided that by slaughtering all the opposition, they would be able to maintain power.

So what happened was an ethnic genocide in Rwanda. To which, I fear the international community before, during, and even in the ebbing parts, was simply not interested in engaging in providing the resources to-- one, prevent it, two, to stop it, and three, ultimately, to negotiate a much more appropriate solution to the conflict.

That being said, a small force that I had was reduced because of casualties. And we, essentially, witnessed for three months the slaughter of over 800,000 human beings. And the realization that the international community was easy to blame the UN for failing but essentially forgot that every country making up the UN is the UN. And every country refused to provide us with the help we needed to prevent it, let alone, stop the slaughter. And as such, they are all culpable of being complicit in letting a genocide run nearly its full course.

Dr. Jillian Horton:

After I saw your powerful address to health care workers on social media, I had the chance to read one of your books, Waiting for First Light. And it struck me that part of understanding our own experiences is being given the right language to describe them. And we don't have that language in medicine because we don't have experiences on the scale of what you witnessed. How can framing our experiences in military language help us to get through this?

General Roméo Dallaire:

This is an extraordinary question because you absolutely must adopt a completely different lexicon to what is happening around you than a scenario that we are used to in a society like ours that hasn't seen war on its territory since for nearly 250 years, let alone, seen catastrophic failures of the scale that we're talking about. So with that, those who are in the front lines-- because we have front lines. We've got people facing the threat. People who are engaged in trying to stop it, to help the casualties, to reduce the impact of this threat-- they are part of our ensemble.

That is to say, we're all in it. It's not as if it's only them, and we'll see how it works out. We're all part of it. We're all locked in and doing all kinds of restrictions and the like. And so we are in a campaign with a whole bunch of different battles being played out in different hospitals, in different health care centers, in the political structures, where they feel embattled.

And so campaigns are run within the context of a war. And so we're in a war against a threat. We're all in it. There's no exception. And in so doing, we must use that similar atmosphere, that tone to what's going on. Versus a tone of well, let's sort out the problem here in our little local area or in our hospital. And we're achieving the aim.

No, you're not. You're just one small part of the whole ensemble. And as such, you can gain strength by knowing everybody's in it with you. Or you could feel overwhelmed by saying, how are we going to get out of this? Because we're all caught in it.

Dr. Jillian Horton:

You were sent to Rwanda with totally inadequate supplies. And you talk about the UN start from zero system, where you are required to figure out what you need, and order it, and hope that it comes instead of having it provided. And as a result, you were totally under-resourced. And I found myself thinking about the parallels between that experience and health care workers caring for patients with inadequate, or in some cases, no personal protective equipment. What moral guidance would you give to doctors and other health care providers about their duty both to others and self when they are faced with this same mismatch?

General Roméo Dallaire:

It's very interesting that in the video you referred to earlier on when I spoke about supporting the first responders, the health care personnel, a minister got back to me from our government rather displeased that I mentioned that there probably won't be enough resources. And that it's going to exacerbate some of the moral and ethical dilemmas that the first responder, the medical people, the doctors are going to face when they're going to be-- potentially, if not-- overwhelmed, but certainly, in the midst of the full weight of the crisis. And it was a reaction of, well, this is not a very positive statement.

Well, the first thing is, is that you've got to tell the troops the truth. And I think that what is essential for the medical staffs, the doctors, and so on is to recognize that they are in the front lines. When they will not have all the resources needed, they're going to have to make choices that are going to be even more complicated because of the lack of resources.

And the near isolation that that creates to the individual-- in having to save a life or not being able to save a life, or seeing a life that he couldn't save, or alleviate the pain and the suffering of people because they know that either resources are somewhere else or they're simply just not been planned for or not acquired in due course-- that is going to bring about a near sense of guilt of saying, I'm there to do that, but I don't have it. I've been doing everything I can, and it's not enough.

And so many years back when I came back from Rwanda, I was told, you did what you could, and nobody can expect more. That provided zero solace. Zero. Because you saw them. You smelled it. You touched it. You felt it. You lived it. You heard them cry. You could see in their eyes the pain and the suffering. And so the fact that you did everything you could will not alleviate the potential sense of guilt that it didn't happen.

That's where it is crucial. That the profession and that the teams do not let people isolate themselves. That they sense that they are part of an ensemble. That it is a big scenario in which they're playing a part. And that their part, it may be not always successful. Other parts, may the same be in certain circumstances.

But they're working within the construct of a massive involvement. And that they cannot hold themselves responsible or guilty for not having all that is required. Nor should they even hold themselves accountable for saying, well, doing all the best I can, just wasn't enough. No. That's wrong.

You must communicate with colleagues. You must exchange. You've got to be communicating constantly between yourselves to sustain these pressures, sustain these stresses. And to be able to not let this sense of both rage-- on one side-- and of a sense of near guilt take hold because we need you for the long haul. We don't need you as a casualty in the early parts of it or in the throes of it because that's just going to weaken the whole team.

And that's why you must be able to exchange with colleagues. And you've got to face the fact that this is of such significance. That you are pulling your weight. Then, that's what we can only hope for in this time of crisis.

Dr. Jillian Horton:

You share a story early on in Waiting for First Light that struck me as oddly familiar. Your executive assistant on the mission commented that you had concern and kindness to direct towards everyone other than yourself. And medicine is also a profession where we are not known for self-care. We have a high suicide rate, and a tendency to be martyrs, and to brand people who try to set boundaries as inferior. How is that going to be a liability to us?

General Roméo Dallaire:

Anybody who's part of an organization or profession, particularly, when they wear a uniform-- and you, guys, wear uniforms of varying types, of course-- or work within a very organized structure, hierarchical, or whatever, you come to realize that your organization is often very Darwinian. It doesn't tolerate not being able to give 100%. It has a serious problem with anybody that might be suffering that is not overtly physical but maybe psychological, and as such, is not able to perform to a 100%.

And so what is direly, direly important is that we don't need commanders, leaders, heads, doctors who are in the most responsible positions to enter a role of-- as you say-- martyrdom or risk-taking that will put them in a position of not being able to sustain the whole campaign. You will lose some battles. But losing some battles doesn't mean you lose the campaign. And it certainly doesn't mean you lose the war.

But if you irresponsibly put yourself at risks by thinking that going flat-out and not ensuring that you're sustaining yourself in an appropriate way, then yeah, the people might think you should be doing a bit more. But you cannot because it's not just today you got to worry about. You got to be there next week. You got to be there in weeks to come. You're going to have to keep that thing going.

And as such, taking the hero-ish type of position, that win a couple of medals. No. That's not the way to do it. Not within the realm of responsibility that you have. Because what you ultimately will be held accountable for is taking decisions that have put you in jeopardy. And as such, you're abandoning the people that need you. The people that still haven't come to your door that will be needing you all the more into the future.

And so how you fight that is by the institution-- the individuals in the institution-- of recognizing that they must be there for the long haul. And they've got to sustain this thing. And the only way to do that is to ensure that they take decisions that are, yes, responsible, of course. But that they commit themselves to the extent that they can work it for the long haul and be capable of sustaining the pressures, and strains, and the ethical decisions, and wearing down that that will have over time.

If they're not doing that, then the central conclusion to that is that they weren't very professional about it. Professional means not just taking care of today. A profession means ensuring that you've got an eyeball out to the future also. And you're anticipating, and you've got foresight on what's still coming down the road.

Dr. Jillian Horton:

You talk so compellingly about re-entering the world after your time in Africa, and the discord between what you'd seen, and the absurdity of abundance in the life that you came back to. Can you make some predictions for physicians working through this crisis about what those transitions might feel like? And how we need to try to handle them?

General Roméo Dallaire:

It was uncanny that I'm in the midst of a genocide and waist-deep in bodies, with the smell, and the gore, and the destruction, and the pain, and suffering, and so on, and the depravities of resources, and what we've seen on the ground. And yet I took a small one-hour flight out of Rwanda, and I'm in Nairobi in a bustling town as if nothing's happening. And people are looking at it from a detached perspective, trying to be objective, and wanting to help, but not really living it.

And so there is going to be a shock. It's going to be a shock that all of a sudden, you're going to walk out of the environment in which you are under so much stress and so much demand to see that other people are simply doing their thing. And that doesn't necessarily push you to want to explain what has happened because you come out of that with a feeling that they just won't understand.

They've never been in combat. They've not been there. They've not smelled, and touched, and felt, and heard what is happening. And so how do you describe that? And do you want to describe it again? Do you want to relive it with them? And so you internalize this. And that's going to be nearly fatal.

In fact, one of the great causes of suicide is the fact that we internalize it, and isolate themselves, and ultimately, we self-destruct. There is an absolute critical need to find a reference out there. And references will come to you from peers mostly. Peer support. People that you've known. People you trust. People you've seen who are willing them to listen.

And that you know they'll listen. And they won't ask a bunch of stupid questions and won't interrupt. And just let you vet. And let the pain out, and the rage out. And let it live in the presence of another human being. And that that other human being is simply listening, smiling a bit, crying a bit, but listening, and letting you grasp the truism of an outside world that will never really understand that you hope you will be able to inculcate some elements of what happened.

And that they have enough empathy and skills to be able to assist them in, at least, comprehending that you're injured. That you're hurting. That you're a walking wounded. That it's been honorable to work on those-- and to be hurt. And that there is not a shame there. And worse, there's no stigma in having lived that. And if that can be passed on by that community around through the family, and community, and professionally, then you're going to build strength. Because they won't feel as if they're the only one that's hurting, and as such, isolate themselves, and ultimately, make some pretty stupid decisions.

Dr. Jillian Horton:

You have concerns about the mental health of our profession after this is all over, and how that actually may be the phase where we are going to incur the most casualties. How else can we, as a profession, begin to mitigate that risk right now?

General Roméo Dallaire:

In the part of the leadership of your organization, the professional collegial milieu that you have, there is an absolute need of being very conscious and making people very conscious. That when this overt enemy is defeated, the effects of the war may raise exponentially on you, and on your team, and on the demands of you. Because the wounds that have been acquired during the campaign, you don't necessarily feel them to their full strength because you're going flat out, and your professional instincts often take over as they should. And they can fill the time.

And I used to make my guys work till they drop so that they didn't dream. They didn't have time to think. They just slept. And then, bingo, they're back into it. But as this campaign goes down, and as we look at transitioning into the post crisis, then all that adrenaline is going to disappear. And it happens fairly fast. All what you've seen, all those wounds that were cut open in your minds, and so on are now going to start to hurt, which is different than simply when they happened.

And because of that, it's going to ask for more support, more help. So just as foolishly as we saw governments at the end of the war cut all resources and everything, particularly for people. And I remember after Afghanistan, when I was in the Senate defense committee saying, hey, when Afghanistan ends, that's when the real number of casualties will start appearing. And that's exactly what happened.

And so preparing yourself for a second round. That the first round is defeat the enemy. The second round is to bring you back to a level that you can sustain, and ultimately, evolve into a new future. And that means being able to handle those wounds. And those wounds need professional help. You can't do it alone. It's Impossible.

And so the entity, the corporate body, the sisterhood, brotherhood of the profession, be it just colleagues, be it also those who can be close to you that love you and that are willing to sustain the impact that this have and seeing you all of a sudden hurting overtly. Because the operational demands of the job won't be the same, yet the impact of the injuries will have escalated. And so that's when you become exceptionally vulnerable.

And so you prepare people for that. You said there's going to be another round, and that round. So where are the tools to be able to handle bringing those walking wounded back down to a certain level of normality? They'll never forget what happened. But then they live with it and continue. That's what you got and work towards.

Dr. Jillian Horton:

General, you talked about how the experience of being in Rwanda made you care more about humanity. What kind of social change or transformation might you predict coming out of this experience for us on the other side?

General Roméo Dallaire:

I think this can evolve into an extraordinary transition for us into a far more mature society. That we've all been in this together. And we've all hurt to varying levels. But we've all lived it. And it's not going to disappear.

And so it's a reference point that our society can refer to and say, did we grow with this? Or did we fail? Or did we fall apart? Or in fact, did we have the right leadership? And will the future leadership be able to handle such scenarios because of the experience of this?

I think that's one significant overriding element. There are two-- however-- groups in our society that I think are going to take on a different perspective. And I hope we're smart enough to realize it. The first one-- and not necessarily in the order.

But the first one that I want to speak to is the youth under 25. This enemy is attacking the older people. The younger people are not being attacked in the same scale. Yet it is an opportunity for those who are young to hold the generations between the 25 and the 70s accountable for doing things right.

And they should be engaged, and committed, and vocal, and pulling all the revolutionary skills they have of the communications world-- social media [INAUDIBLE]-- to keep the pressure on. They can come out as a new leading force within our society. So that's really, really important.

And the second one is women. The front lines are just chockablock with women. They are fighting that battle in the majority. And so it is an opportunity for the male-dominated societies that we still have to realize that there's no way that that can continue. That the women must be perceived as a full-fledged, totally committed, and willing to take casualties to keep our society going just as much as men, and probably, better in certain circumstances than men are.

And so there is an opportunity with this. That women grow within our society. Not that they are not themselves having to grow, but that their stature, that their ability to sustain our society will grow with this. And that the society will adjust.

We could shave 25 years off of the gender problems and the glass ceilings with this experience if we're smart enough to realize it. And I do hope that the men come to the full realization. And that women use this as a pivot for their future.

Dr. Jillian Horton:

General Dallaire, I am so honored and--

[INTERPOSING VOICES]

--profoundly moved and uplifted after speaking with you today.

I'll stay at it and keep me in mind as you start thinking about the post crisis, as I want to be engaged. And I'm talking with the political people. But I think I can be maybe of assistance of helping people explain what the hell is happening to them, and how they can evolve into the normalcy after being injured on this campaign.

And before we go, I also want to extend my deepest thanks and gratitude on behalf of my colleagues everywhere for your wisdom and for your service to our country.

I'm just an old soldier. Thank you very much.

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon.

Moral distress: When core values are at stake

About Lieutenant-General Roméo Dallaire (retd)

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About Lieutenant-General Roméo Dallaire (retd)

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Related resources

Provincial physician health programs

Physician profile: Dr. Sang and the 2021 National Physician Health Survey

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COVID-19 learning series

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Moral distress: When core values are at stake