In his latest Launch Pad column, Adam Talbot (Manchester, UK) writes about moral injury in vascular surgery, suggesting steps that could be taken to prevent it.
Vascular surgery often places surgeons in high-pressure situations where the right course of action is clear, but systemic constraints prevent its delivery. This dissonance is increasingly recognised as moral injury, a psychological harm distinct from burnout.
The British Medical Association (BMA) defines moral distress as the experience of knowing the ethically appropriate action to take but being unable to act due to external constraints.1 When this distress becomes prolonged or is caused by serious ethical breaches, it can result in moral injury, a deeper, long-term psychological impact that erodes professional integrity and mental wellbeing. In a 2021 BMA survey of UK doctors, 78% reported experiencing moral distress, and more than 50% said the term moral injury reflected their experience. These findings spanned specialties, and they highlight a widespread challenge across the health service.
For vascular surgeons, this may arise when patients with chronic limb-threatening ischaemia (CLTI) present too late due to delays in referral or diagnostics, when urgent revascularisation is postponed due to lack of theatre access, or when decisions are made based on bed availability rather than clinical priority. These situations are not rare; they are becoming routine.
Intraoperatively, moral distress can occur when surgeons encounter unforeseen complications or deviations from the expected course of surgery, where they are aware of the optimal intervention but lack the means or opportunity to effect it. A surgeon might encounter an unexpected anatomic variation or an unanticipated technical complication that prevents the desired outcome. Despite following all the established protocols, the surgeon may feel a profound sense of failure, as they are aware that the result falls short of both clinical expectations and their personal standards of care.
This sense of powerlessness is particularly damaging when it occurs in the context of an emotionally charged situation such as limb loss. Surgeons, driven by a deep sense of responsibility and a commitment to achieving the best possible outcome, may experience guilt or moral distress when they are unable to fulfil the duty they perceive to the patient. These intraoperative moments, though often beyond the surgeon’s control, can lead to long-term moral injury, especially in the absence of avenues for reflection or support.
The culture of vascular surgery, which historically values decisiveness and perfectionism, may further compound the issue. Surgeons may be less likely to speak openly about emotional distress or seek help, fearing judgment, loss of credibility, or other consequences. Over time, unaddressed moral injury can contribute to low morale, detachment, depression, or even thoughts of leaving the profession altogether.
To prevent moral injury in vascular surgery, organisational change is essential, not just personal resilience. The BMA 2021 report recommends increasing staffing and resourcing, especially in key areas like CLTI, to reduce systemic delays that contribute to ethical conflict. It also calls for simplified bureaucracy, enabling faster patient pathways and clearer clinical decision-making. Equally crucial is the cultivation of an open, supportive culture. Surgeons need safe forums to voice concerns, such as Schwartz rounds or facilitated peer discussions, embedded as protected elements of job plans.2 Finally, improving access to wellbeing resources, from counselling to occupational health support, offers early psychological relief that can head off longerterm moral injury.
We cannot eliminate all pressures, but by taking moral injury seriously, and addressing it through practical methods, we can begin to protect our colleagues, our patients and the standards of care we are committed to uphold.
I would like to thank Mr R Chandrasekar for suggesting the topic of moral injury in vascular surgery. Please see ‘The Countess Technique of Vascular Anastomosis’. His innovative work in advancing vascular surgical techniques continues to inspire improvements across our specialty.
References
- British Medical Association. (2021) Moral distress and moral injury: Recognising and tackling it for UK doctors. London: British Medical Association
2. The King’s Fund. (2025) Schwartz Center Rounds®. Insight and analysis, The King’s Fund. Available at: https://www.kingsfund.org.uk/insight-andanalysis/projects/schwartz-center-rounds (Accessed: 1 August 2025).
Adam Talbot is is a specialty trainee in vascular surgery based in Manchester, UK and education representative for the Rouleaux Club—the vascular trainees’ association for Great Britain and Ireland.
