Silent Burdens: Ethical Distress and Psychological Impact Among Medical Residents During the COVID-19 Pandemic in Brazil: a phenomenological qualitative study

Abstract Background. Ethical analysis of the COVID-19 pandemic has centred on triage and allocation. Far less is known about the everyday ethical experience of frontline medical residents. This study set out to describe that experience from residents’ own accounts. Methods. In this single-centre phenomenological qualitative study we used the Inductive Process to Analyze the Structure of Lived Experience (IPSE) to analyse semi-structured interviews with 33 medical residents at the Hospital das Clínicas, University of São Paulo (HCFMUSP), a primary COVID-19 referral centre, between July 2020 and January 2021. Interviews were conducted, transcribed and coded in Portuguese. Reporting follows the COREQ and SRQR criteria. Results. Six interrelated themes describe a movement from institutional fragility to moral injury: institutional absence, intergenerational and hierarchical tension, ambiguity of responsibility, ethical loneliness, the quiet compromise, and moral injury. Residents repeatedly made morally significant decisions in isolation, without relational spaces for shared deliberation or recognition. Hierarchical asymmetries silenced moral dissent. The cumulative moral residue described in these accounts crystallised into lasting moral injury. Residents consistently identified the absence of structured institutional support as what was missing. Conclusions. The ethical difficulty residents described lay in ordinary clinical decisions taken without guidance, within a hierarchy in which disagreement carried a cost, and with no one to deliberate with. In these accounts moral suffering arose from the relational conditions of the work rather than from the resilience of individual clinicians, and what remained afterwards was described as damage to moral identity rather than as fatigue. Medical ethics appears here as a practice enacted within clinical work rather than applied to it from outside, which places structured support for moral deliberation within crisis preparedness rather than after it.