The study, led by Tracy L. Powell of Mount Royal University together with colleagues at the University of Victoria, employed an Interpretive Description methodology, a qualitative approach designed to generate practice-relevant knowledge for applied health settings. Data collection ran from June 2020 to February 2021 and combined in-depth interviews lasting between 45 minutes and three hours with demographic questionnaires, 36 policy and legislative documents, and 34 personal artifacts such as journal entries and emails submitted by participants themselves. Rather than seeking statistical saturation, the team assessed analytic adequacy iteratively, refining interpretations through repeated cycles of coding and team discussion, guided by a relational ethics framework that treats autonomy as socially embedded rather than purely individual.

The participants were predominantly women—26 of 31 family members—ranging in age from 28 to 81, with daughters and wives forming the largest relational groups. The 33 MAiD deaths they described occurred mostly at home, with cancer and neurological conditions as the leading diagnoses, and palliative care was involved in 23 of the cases. Crucially, the researchers found that family members’ experiences were shaped by three interlocking contextual elements: knowing the perspective of the person choosing MAiD, being aware of the suffering that motivated the choice, and managing their own personal beliefs about assisted death. Together, these elements determined how prepared, how accepting, and how morally conflicted family members felt before, during, and long after the death.

Timing of knowledge emerged as a decisive factor. Family members who had long known a relative’s views on end-of-life choices described MAiD as consistent with previously expressed values rather than a shocking rupture. One daughter recalled that assisted dying was “always on our radar,” noting her mother had discussed it long before it became legal. Others described relatives who meticulously planned ahead, even organizing treasure hunts to help family locate medical directives. By contrast, participants who learned of the intention to pursue MAiD only shortly before the decision described feeling, in one participant’s words, hit by a ten-tonne truck—deprived of the time needed to process the decision, reconcile their own values, or address unresolved relational tensions.

Proximity to suffering played an equally powerful role. Family members who witnessed a loved one’s visible deterioration described how the decline transformed MAiD from an abstract possibility into something they could understand as an act of care. Descriptions of a parent becoming a shell of a human being illustrated how tangible suffering made the rationale for assisted death easier to accept, with some participants reporting they became one hundred percent behind the choice as suffering intensified. Conversely, those who were geographically distant or had limited exposure to the decline often struggled with disbelief and resistance. One mother described how her son initially refused to believe his father was dying and began staying overnight to see for himself how his father was managing.

Even among supporters of the decision, moral conflict could run deep and persist into bereavement. Some participants deliberately suppressed their own unease to avoid planting seeds of doubt in their relative’s mind, maintaining outward support while wrestling privately with internal struggle. One husband, despite actively caring for his wife and participating fully in the MAiD process, still described his experience as murder—a stark illustration of how involvement can blur the boundary between supporting a decision and feeling morally responsible for the death. Others questioned whether their own advocacy had unduly influenced their relative, with one son recalling intense turmoil over the fear that his mother had been influenced by him to get approved. The researchers interpret this as relational solidarity: family involvement extends far beyond caregiving into ethical, emotional, and identity-related territory.

The study also exposed systemic friction points. Family members described navigating unfamiliar MAiD processes, advocating for access, and coordinating care, with their burden rising sharply when institutional processes were unclear or clinicians seemed hesitant. When healthcare professionals were knowledgeable and compassionate, participants described the system as integrated and supportive; when information was withheld or questions treated as disruptive, distress mounted. A particularly striking finding concerned palliative care: several participants reported that palliative teams effectively disappeared once a MAiD application was filed, leaving families to fill the support gap precisely when care needs were increasing. Key informants confirmed the value of integration, with one MAiD provider noting that palliative care nurses deliver grief support, stay with the family, and wait for the funeral home—continuity that other services often fail to provide.

Waiting emerged as its own form of suffering. Under the eligibility assessments required by Bill C-14, family members described living in suspension, unable to move forward emotionally while uncertain whether their relative qualified and how long the process would take. One healthcare provider observed that time runs on a different scale for families, who experience procedural delays as five or ten times longer than clock time. Then came the scheduling of the death itself, which participants found profoundly unnatural. One son observed that death is always random until you name a date, at which point it is not random anymore. Others compared the administrative booking process to ordering a pizza or speaking with an airline agent, a transactional framing that left their emotional needs feeling unrecognized at the most consequential moment of their lives.

Yet the study is far from a portrait of pure distress. Many families described the period before a MAiD death as relationally rich and deliberately meaningful: photo albums shared, favorite meals prepared, engagement toasts written, and what one participant called a living funeral where the dying person could hear the good things people would say about them. On the day itself, participants described intimate, embodied moments of presence—lying on a chest until the heartbeat could no longer be heard. At the same time, many families kept the type of death private, fearing stigma, protest, or religious judgment, with some concealing the circumstances even from close relatives and others attributing the death to the underlying illness. This selective secrecy, the researchers warn, can extend emotional strain into bereavement.

From these findings the team proposes a family-in-focus approach to nursing care that complements rather than replaces person-centred care. Its practical elements include proactive family check-ins, clear and consistent communication about processes and timelines, anticipatory guidance about the emotional complexities ahead, designated points of contact, and access to MAiD-specific psychosocial and bereavement support beginning when MAiD enters the care trajectory and continuing long after the event. The central insight is deceptively simple: active involvement in a MAiD death should never be mistaken for emotional readiness for it. Family members may appear organized and supportive while experiencing deferred grief, guilt, and self-scrutiny that surface only after the death. As assisted dying frameworks evolve internationally, the study argues that healthcare systems must make visible the relational consequences of a legally autonomous choice—for those who remain behind, the death is never only the patient’s own.

Subject of Research: Bereaved family members' experiences of medical assistance in dying in Canada

Article Title: Supporting a Different Type of Death: Experiences of Family Members of Recipients of Medical Assistance in Dying

Article References: Powell, T. L., Stajduhar, K., Prince, M., & Thorne, S. (2026). Supporting a Different Type of Death: Experiences of Family Members of Recipients of Medical Assistance in Dying. Nursing Open, 13(10), Article e70843. https://doi.org/10.1002/nop2.70843

Image Credits: AI Generated

DOI: 10.1002/nop2.70843

Keywords: medical assistance in dying, MAiD, bereavement, palliative care, family caregivers, nursing, qualitative research, relational ethics, end-of-life care, Canada, moral distress, health policy

The article, grounded in the author’s prior service as a counter-intelligence officer as well as in the scholarly literature on moral injury, moral distress and secondary traumatization, makes a deliberately modest but consequential claim. Existing typologies, the author writes, are necessary but insufficient. Some workers—intelligence officers, chaplains, clinicians, forensic investigators, journalists who must absorb atrocity at close analytical range—are structurally required to build deep cognitive and empathic models of harmful people and harmful systems. They must enter, mentally and relationally, into the logic of evil in order to anticipate it, contain it or report on it. That sustained cognitive intimacy, the paper argues, may injure conscience in ways that do not map cleanly onto perpetration, witnessing or betrayal.

Technically, the argument rests on a distinction between exposure and comprehension. Vicarious traumatization research, pioneered in the 1990s by McCann and Pearlman, described how clinicians’ cognitive schemas about safety, trust and intimacy shift after sustained contact with victims’ trauma narratives. Compassion fatigue, a term popularized by Charles Figley, captured the emotional depletion of caregivers. Moral distress research in healthcare, notably the work of Epstein and Hamric on moral residue and the crescendo effect, documented how repeated ethical constraints leave cumulative residue in clinicians. Epistemic moral injury, as Munoz Mosquera frames it, sits at the intersection of these literatures but is not reducible to any of them: the injury is not exhaustion, not schema disruption alone, and not the residue of blocked moral action, but the corrosive effect of being professionally mandated to know evil intimately while remaining unable to act on that knowledge in ordinary moral ways.

The paper develops four candidate mechanisms through which this injury might be produced. The first is instrumentalized empathy, in which empathic and relational capacities—the very capacities ethics requires people to preserve—are conscripted as tools of the mission. An intelligence professional who deploys what the literature on negotiation calls tactical empathy is, in a sense, weaponizing a moral capacity, and the author suggests that this instrumentalization may itself degrade the self. The second mechanism is sustained cognitive intimacy with evil: the long, deliberate study of cruel actors, which risks normalizing the logic of cruelty from the inside. The third is mandatory compassion suppression, in which institutions require workers to switch compassion off in circumstances where it would naturally arise, producing a rupture between professional identity and moral character. The fourth is relational duplicity under moral mandate: maintaining false relationships, cover identities or strategic deceptions for extended periods, which strains the truth-telling virtues that moral traditions from Aristotle to Aquinas have treated as constitutive of integrity.

What gives the article its distinctive texture is the way it frames these mechanisms theologically, through what the author calls pastoral inversion. Drawing on Emmanuel Levinas’s philosophy, particularly the concepts of le visage (the face) and le tiers (the third party), Munoz Mosquera argues that ethics traditionally begins in the encounter with the face of the Other, which commands a response. In professions that require knowing evil intimately, this structure is inverted: the professional must study the face of the perpetrator analytically while remaining obligated, simultaneously, to the third party—the victims, the public, those the work is meant to protect. This double obligation, held under conditions of secrecy and operational constraint, generates what the author identifies as a specific moral geometry of harm, one that pastoral caregivers need new vocabulary to address.

To anchor that vocabulary historically, the paper reaches into Christian intellectual traditions. It invokes the Thomistic concept of veracitas, the virtue of truthfulness associated with Thomas Aquinas, to analyze what sustained professional deception does to a person ordered toward truth. It draws on the ascetical and confessional precedents of the tradition, including the Spiritual Exercises of Ignatius of Loyola and the apophatic mysticism represented by The Cloud of Unknowing and analyzed by scholars such as Denys Turner and Andrew Louth, to construct what the author calls a structure-over-content model of care. The insight is elegantly practical: when a trauma survivor cannot disclose the content of what they know—because of classification requirements, legal exposure or protection of others—caregivers can still work with the structure of the wound, using apophatic, or negative, approaches that attend to what cannot be said rather than demanding that it be said.

The article does not stop at theory. It offers a five-domain taxonomy intended to organize the phenomenology of epistemic moral injury for future empirical work, along with four-step interim guidance for clinicians and chaplains who may already be encountering cases that fit the pattern. It also lays out a research agenda: the field now needs psychometric instruments capable of distinguishing epistemic moral injury from perpetration-based and betrayal-based presentations, validation studies across occupational groups, and intervention trials that test whether structure-over-content pastoral approaches outperform disclosure-dependent models for populations bound by secrecy. The author is explicit that these are proposals, not findings; the paper is a conceptual and theoretical contribution, written from the author’s personal professional experience and published literature, without primary data collection.

The broader significance of the proposal lies in how it repositions the boundary of trauma science. Post-traumatic stress disorder centers on fear-based fear circuitry and life threat; moral injury, as developed by Jonathan Shay, Brett Litz, Shira Maguen and colleagues in the military mental health literature, centers on transgression—of one’s own morals, or of others’ morals toward oneself. The Moral Injury Outcome Scale Consortium’s 2022 work in Frontiers in Psychiatry consolidated the syndrome around feelings like guilt, shame, betrayal and spiritual struggle. If Munoz Mosquera is right, a subset of suffering professionals experiences none of these pathways yet still presents with the hallmark cluster: alienation, loss of trust, meaning collapse and spiritual dislocation. Naming their wound would matter clinically, because interventions built around processing perpetration-related guilt may fail people whose guilt is epistemic—guilt about what they know, understand and can never unknow.

The paper also carries an implicit institutional challenge. If epistemic moral injury proves to be a real and distinct phenomenon, then intelligence agencies, courts, hospitals, media organizations and faith communities bear responsibility for the moral formation of the people they task with dark knowledge. Structured chaplain interventions for moral injury in veterans, already tested in trials by Koenig, Ames, Antal, Cenkner and their colleagues, suggest one template; the paper implies that similar structures—supervision that treats the knower as morally exposed, rotation practices, confession-adjacent safe spaces, and care models that do not require disclosure—should be designed for secret-keeping professions. The wound of knowing, the argument concludes, is real precisely because knowing is never morally neutral: to understand evil with intimacy is to let it touch the self, and a science of trauma that ignores that touch is describing only part of the human cost.

Subject of Research: Epistemic moral injury as a proposed fourth category of moral injury arising from mandated professional knowledge

Article Title: Epistemic Moral Injury: The Wound of Knowing

Article References: Munoz Mosquera, A. B. (2026). Epistemic Moral Injury: The Wound of Knowing. Pastoral Psychology. https://doi.org/10.1007/s11089-026-01369-w

Image Credits: AI Generated

DOI: 10.1007/s11089-026-01369-w

Keywords: moral injury, epistemic moral injury, trauma psychology, pastoral care, Levinas, apophatic theology, compassion fatigue, vicarious trauma, moral distress, chaplains, counter-intelligence, empathy

The American Board of Pediatrics recently announced a plan to alter pediatric subspecialty fellowship training, moving toward a competency-based framework that would, for neonatal-perinatal medicine, condense what has traditionally been a three-year fellowship into a shorter pathway. Proponents of such reforms point to workforce shortages, the financial strain of prolonged training, and evidence that clinical competence can be demonstrated and certified through entrustable professional activities rather than time served. The board’s stated goal, articulated in its 2026 announcement on ensuring readiness for practice, is to advance competency-based subspecialty training so that physicians enter independent practice sooner without sacrificing skill. For a field grappling with persistent recruitment challenges and rising demand for neonatal intensive care, the appeal is obvious.

Yet Kukora and her colleagues argue that this framing overlooks something fundamental: professional identity formation, often abbreviated as PIF in the medical education literature. Drawing on decades of scholarship, including the influential schematic model developed by Richard and Sylvia Cruess and colleagues at McGill University, the authors describe professional identity formation as the process through which trainees internalize the values, behaviors, and norms of medicine, gradually coming to think, feel, and act like the physicians they are training to become. This transformation does not occur through the mere accumulation of procedures or checklists. It unfolds within what educational theorists call a community of practice, an immersive social environment in which novices learn by participating alongside experienced mentors, absorbing not only explicit teaching but also the hidden curriculum of daily clinical life.

Neonatal-perinatal medicine presents a particularly demanding context for this transformation. Neonatologists care for infants at the very margins of viability, make life-and-death decisions under profound uncertainty, and navigate emotionally charged relationships with families in crisis. The ethical terrain is notoriously difficult: decisions about initiating, withholding, or withdrawing life-sustaining treatment; the interpretation of aggregate outcome statistics for individual counseling; and the negotiation of family-centered care in settings where evidence is often incomplete. The authors emphasize that the entrustable professional activities defined for neonatology, the specific tasks considered essential for independent practice, are themselves deeply rooted in professional identity formation. Competence in these activities presupposes mature moral reasoning, the capacity to experience and manage distress, and the resilience to sustain a career in an emotionally punishing environment.

The literature on moral distress in neonatology underscores why this matters. Studies by Prentice, Janvier, Gillam, and colleagues have documented high levels of moral distress among neonatal clinicians, the anguish that arises when providers know the ethically appropriate course of action but feel constrained from pursuing it. Repeated episodes of moral distress leave behind what Epstein and Hamric have described as moral residue, a cumulative erosion that contributes to the crescendo effect of escalating distress over time. Compassion fatigue, secondary traumatization, and burnout are well documented among neonatologists, and physician burnout has been linked in multiple studies to increased medical errors and worse patient outcomes. Professional identity formation, the authors argue, is one of the key mechanisms through which clinicians develop the meaning and purpose that buffer against these occupational hazards. Research by Toubassi and colleagues has explicitly linked professional identity formation to well-being, suggesting that a coherent sense of professional self is not a luxury but a protective factor.

Against this backdrop, the prospect of condensing fellowship raises a series of ethical concerns. First, there is the problem of time itself. Identity development is longitudinal and cannot be reliably compressed without consequence. Qualitative longitudinal research on how residents develop virtues suggests that character formation in medicine depends on sustained experience, reflection, and mentorship over time. A trainee who spends fewer months in the neonatal intensive care unit has fewer opportunities to witness and internalize how seasoned clinicians handle uncertainty, communicate bad news, repair errors, and honor the values of family-centered care. Second, the authors point to the discontinuity problem in medical education, a topic recently analyzed in the New England Journal of Medicine by Warm and colleagues. Shortened, fragmented training pathways risk disrupting the continuity of relationships, between trainees and mentors, and between trainees and the patients and families they follow over weeks and months, that make deep learning possible.

Third, the perspective highlights the hidden curriculum, the informal and often unspoken lessons trainees absorb from their environments. When institutions signal that training is primarily a throughput problem to be optimized, trainees may internalize a transactional view of their profession. Conversely, when programs deliberately protect time for reflection, ethics education, and relationship-building, trainees are more likely to develop the habits of moral attention that neonatal practice demands. Ethics education in neonatology, as recent work in NeoReviews by Sullivan and colleagues illustrates, increasingly integrates theory, multimodal teaching methods, and even artificial intelligence innovation, but it requires protected space within the training structure to take root. A compressed pathway that crowds out these formative experiences may produce technically competent graduates who are nonetheless underprepared for the ethical weight of their role.

The authors are careful to acknowledge the legitimate pressures motivating reform. The pediatric subspecialty workforce faces genuine shortages, and neonatal intensive care admissions in the United States have risen steadily, according to National Center for Health Statistics data covering 2016 through 2023. Burnout and workload concerns have prompted serious discussion of hours-based scheduling in neonatology, and some have argued in the Journal of Perinatology that the field should indeed move to two-year fellowships. A companion critical appraisal by Vergales and colleagues examined the American Board of Pediatrics’ proposed two-year pathway in detail, questioning whether the required competencies can realistically be achieved in the condensed timeframe. The debate is thus not between reform and stagnation, but between competing visions of what fellowship is ultimately for.

What distinguishes the Kukora paper is its insistence that the answer must be framed in ethical rather than merely operational terms. The authors argue that it is an ethical imperative for neonatal-perinatal medicine fellowship programs to nurture the evolving professional identities of their learners, because those learners will guide future innovation and progress in the field while providing ethical, family-centered, high-quality clinical care. If professional identity formation is foundational to every essential entrustable professional activity in neonatology, then any reform that undermines it risks compromising not only individual careers but the profession’s core mission. The stakes, in other words, are borne ultimately by newborns and their families, who depend on physicians trained not just to perform interventions but to deliberate wisely about when interventions serve the patient’s best interests.

The perspective closes with a call for the pediatrics community to take these risks seriously before implementing the new pathway. Rather than treating identity formation as an intangible byproduct of training, the authors suggest it should be treated as an explicit outcome to be protected and measured, alongside clinical competence and procedural skill. As the American Board of Pediatrics moves forward with competency-based subspecialty training, the challenge will be to design programs that achieve efficiency without hollowing out the human and moral development that makes a neonatologist more than a technician. The paper’s central message is stark: how the profession trains its future members will shape, for better or worse, the care that the smallest and most vulnerable patients receive for decades to come.

Subject of Research: Ethical implications of condensing neonatal-perinatal fellowship training for neonatologists' professional identity formation

Article Title: Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship

Article References: Kukora, S. K., Gray, M. M., McLean, C. K., & Krick, J. (2026). Threats to neonatologists’ professional identity formation: ethical implications of condensing neonatal-perinatal fellowship. Journal of Perinatology. https://doi.org/10.1038/s41372-026-02899-0

Image Credits: AI Generated

DOI: 10.1038/s41372-026-02899-0

Keywords: neonatology, professional identity formation, medical education, fellowship training, American Board of Pediatrics, moral distress, medical ethics, neonatal-perinatal medicine, competency-based training, burnout, family-centered care, Journal of Perinatology