Beyond Moral Injury: Temporal-Geopolitical Anxiety and the Affective Regime of Care in Taiwan during COVID-19

Beyond Moral Injury: Temporal-Geopolitical Anxiety and the Affective Regime of Care in Taiwan during COVID-19 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Moral Injury: Temporal-Geopolitical Anxiety and the Affective Regime of Care in Taiwan during COVID-19 Yi-Cheng Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8675330/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This article provides a critical examination of the affective experiences of clinicians in Taiwan during the COVID-19 pandemic, challenging the individualized diagnostic framework of "moral injury." While global scholarship has extensively documented the psychological distress of healthcare workers, this study posits that their moral experiences are inextricably intertwined with specific geopolitical anxieties and "affective regimes" of care. Combining ten months of qualitative research and in-depth interviews, the author analyzes how the temporality and spatiality of the pandemic influenced clinicians' emotional lives. The findings indicate that the experiences of Taiwanese clinicians—ranging from the sacrificial fervor of rèxiě (hot-bloodedness) to the strategic dread of being labeled "national sinners"—are not merely psychological reactions to trauma. Instead, they function as a form of "affective labor" mobilized to sustain national "biological citizenship" amidst Taiwan’s structural isolation from the global health community. By exploring the transition from the "affective capital" inherited from the 2003 SARS crisis to the "righteous anger" sparked by pandemic-era misinformation, this article underscores the political significance of emotions. Ultimately, the study advocates for a narrative-oriented, de-victimizing approach that acknowledges clinician subjectivity and addresses the macro-structural tensions underpinning their moral worlds, thereby offering a contextualized alternative to de-politicized trauma narratives. COVID-19 affective experiences moral injury geopolitics Taiwan Introduction In 2022, during the New Year's Day flag-raising ceremony, Taiwan’s Minister of Health and Welfare, Chen Shih-chung, led healthcare workers in singing the national anthem. Among the performances during the ceremony was "Critical Rock," a rock band composed of emergency physicians. One of their songs, "Dear Taiwanese," includes lyrics that state, "Dear Taiwanese, don’t be scared anymore, I will stand here for you, please take good care of us." This performance highlighted the contributions of epidemic prevention personnel to the country and provided healthcare workers with an opportunity to express their feelings, hoping to receive support and care. Critical Rock’s performance bore profound dual symbolism, intertwining the labor of pandemic prevention with the collective destiny of the nation, and also suggesting that the arduous struggles of healthcare workers necessitate the support of the entire citizenry. However, beneath this symbolic solidarity lay a harrowing psychological reality. The COVID-19 pandemic posed an unprecedented mental health threat to healthcare workers globally, characterized by immense pressure arising from unfamiliarity with the virus, clinical uncertainties, and the exhaustion of adhering to high prevention standards over extended periods. Extensive empirical evidence has documented heightened levels of anxiety, depression, and posttraumatic stress disorder (PTSD) among frontline staff (Johnson et al., 2020 ; Mousavi et al., 2021 ; Motahedi et al’, 2021; Le Thi Ngoc et al., 2022 ; Andhavarapu et al., 2022 ; Bayazit et al., 2022 ; Tong et al., 2022 ). Beyond traditional psychological distress, there is an increasing public awareness of the 'moral injury' experienced by workers witnessing patient deaths, while facing their own mortality (Greenberg et al., 2020 ; Shale et al., 2020; Amsalem et al., 2021 ; Čartolovni et al., 2021 ; D'Alessandro et al., 2021; Litam and Balkin, 2021 ; Coimbra et al., 2023 ). This paper contends that the prevalence of these conditions arises from two systemic factors. First, the psychological toll is frequently individualized as a private mental health failure. Second, diagnostic language, such as PTSD, has been depoliticized and stripped of its original context, necessitating political and structural solutions rather than solely clinical strategies. Despite alarming statistics, few studies have critically examined the structural roots underlying the high incidence of mental health issues among healthcare workers. In 2021, Taiwan’s Ministry of Health and Welfare initiated the “Enhanced Mental Health Services for Health-Care Workers in Medical Institutions” program. Observations from various hospital program coordinators suggest that healthcare workers rarely seek psychological assistance. This highlights two issues: the psychological pressure that healthcare workers encountered during the COVID-19 pandemic is not easily defined as an individual psychological problem and healthcare workers are hesitant about accessing institutional psychological interventions. This article explores the affective experiences of healthcare workers during the pandemic without employing traditional mental health terminology. Typically, psychiatric terms refer to individual dysfunction; however, pandemics are collective phenomena. To comprehend the suffering of health-care workers, we must consider the social, cultural, and political dimensions of their experiences. These experiences might not solely pertain to suffering, but may also encompass various affective changes with specific temporal and spatial meanings. Medical anthropologists Be'hague and MacLeish (2020) introduced the term “global psyche,” noting that mental health during the COVID-19 pandemic varied worldwide and was influenced by cultural and political contexts. This highlights the diverse ethical politics that underlie mental health. To provide a necessary supplement to the lived realities and sentiments of healthcare workers during the pandemic, beyond the conceptual framework of moral injury, this article employs the concept of affect to better understand the mental health of health-care workers during the pandemic. This study has two primary objectives: first, to identify new ways to comprehend the challenges encountered by healthcare workers under intense political pressure, and second, to explore resilience and agency in times of crisis. Although discussing resilience and agency might appear optimistic, examining healthcare workers’ narratives during the pandemic aids in understand how these affective changes reflect Taiwan’s unique moral landscape in specific geopolitical contexts. The Dilemma of Trauma Narratives When discussing moral injury, revisiting terms such as trauma and posttraumatic stress disorder (PTSD) is essential. Various epidemiological studies have demonstrated that during the COVID-19 pandemic, healthcare workers experienced significant psychological pressures, including PTSD. These studies, which were primarily based on statistical findings, have emphasized the need to strengthen healthcare workers' understanding of stress, and provide psychological assistance or socio-psychological support to frontline healthcare workers (Carmassi et al., 2020 ; Li et al et al. 2021; Sahebi et al. 2021 ; Andhavarapu et al. 2022 ). Since the term “trauma” was introduced in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association, it has become a significant contemporary reference (Fassin and Rechtman, 2009 ). Farrell ( 1998 ) argues that trauma has evolved from a clinical diagnosis into a cultural lens, used by societies to articulate collective anxieties and interpret historical shifts. Some scholars contend that PTSD is a historically constructed concept (Young, 1997 ; Wessely, 2002 ; Lerner, 2022 ). In other words, it is suggested that PTSD is an unnecessary diagnosis constructed entirely from social and political ideas (Young, 1995 ; Summerfield, 2008 ). Although the term “trauma” existed in ancient Greece, its application as a psychological concept only commenced in the late 19th century. It evolved from “railway spine” in the late 19th century, to “shell shock” during World War I, “war neurosis” in the interwar period, and ultimately to PTSD following the Vietnam War. Notably, after World War II and during the Cold War, nations were reluctant to acknowledge trauma to preserve the heroic image of returning soldiers. Similarly, the Japanese government limited psychiatric diagnoses to maintain the heroic image of soldiers, and Germany reduced compensation for traumatized soldiers. This terminology shifted to sociologists, historians, and writers, particularly in Holocaust research, leading to terms such as collective and national trauma. Psychiatry has only refocused on disaster-related psychological effects with the introduction of PTSD. American sociologist Kai Erikson ( 1976 ) introduced the concept of “collective trauma” in the 1970s. This suggests that even before PTSD became a recognized condition, this widespread psychological state had already garnered scholarly attention, despite many countries deliberately avoiding this issue during the Cold War. Recent research has indicated that PTSD has become increasingly politicized. In Taiwan, trauma following major natural disasters is commonly studied through epidemiological research. Psychiatric researchers often employ epidemiological methods to examine how earthquakes affect mental health, focusing on disease prevalence and the association between demographics, PTSD severity, and comorbidities. Psychiatric researchers have investigated the prevalence and severity of PTSD following earthquakes. Such research can be challenging due to differences in exposure duration and earthquake intensity (Zhang et al 2007 ; Chang et al 2008 ). PTSD became an important issue after events such as Typhoon Morakot in 2008. More recently, researchers have attempted to explore the relationship between PTSD and COVID-19 (Sahebi et al., 2021 ). As the COVID-19 pandemic emerged in 2020, healthcare workers worldwide encountered immense physical and mental pressure. Some healthcare workers have committed suicide due to stress. Many frontline workers felt helpless during the pandemic and experienced moral injury. Researchers recommended providing immediate emergency assistance to health-care workers, emphasizing that supportive work environments help to reduce “moral injury” (Greenberg et al., 2020 ; Hines, 2021). Shay (1994) proposed the concept of “moral injury” following the Gulf War: Soldiers who participated in the Iraq and Afghanistan wars experienced psychological trauma, prompting Litz et al. ( 2009 ) to systematize this concept, emphasizing that these psychological responses arose from feelings of betrayal during military actions. In pandemic prevention, akin to warfare, the concept of moral injury has been applied to healthcare workers. Traumas often arise not from an illness itself or from moral conflicts in failing to treat patients, but from organizational culture and feelings of betrayal by the authorities. Most research on moral injury has been quantitative and has not fully captured the detailed thoughts and subjective feelings of individuals facing moral dilemmas. In exploring the structural underpinnings of these affective states, Shao-hua Liu ( 2025 ) conducted a critical analysis of how Taiwanese medical professionals navigated the global–local dilemma" during the pandemic. Liu’s examination of medical epidemiologists suggests that Taiwan’s continued exclusion from global health governing bodies necessitated the pursuit of "biological citizenship" through rigorous epidemic control measures as a strategy for achieving international recognition. This geopolitical marginalization imposed a dual burden on medical experts, who were caught between transnational professional principles and the exigencies of nationalistic governance. Although emphasizing moral injury is important, it can be a limiting diagnostic approach. This label risks pathologizing and individualizing psychological issues, potentially undermining an individual’s sense of agency. It may not fully capture the fluid psychological states or the varied meanings of negative feelings when an individual encounters difficulties. Experiences should not be framed solely as moral injuries because exploring the specific context and diversity of an individual’s moral world is crucial. This study adopts a different approach, while examining the negative feelings experienced by Taiwanese healthcare workers during the pandemic. Using a narrative perspective and focusing on the meaning of emotions, this article analyzes the social, cultural, and political significance of emotions. Moral injury may be conceptualized as a conflict between individual conscience and institutional demands. In contrast, putting “affect” as the main concern enables us to address how geopolitics, national identity, and collective memory are jointly woven into clinicians’ embodied experiences. Shifting to Affective Narratives Aiming to provide a nuanced, contextualized perspective that complements existing epidemiological data, this study adopted a qualitative approach, utilizing one-on-one interviews to capture the affective experiences of healthcare workers, supplemented by a literature review. Interviews were conducted with 26 healthcare workers. The participants were aged between 23 and 75 years. Some participants possessed extensive work experience, including work during the 2003 severe acute respiratory syndrome (SARS) outbreak. Most participants aged > 40 years had worked in medical institutions during the SARS 2003 outbreak, with some having frontline care experience. Participants were asked open-ended questions regarding the influence of SARS on their COVID-19 caregiving experiences. This study employs narrative-oriented in-depth interviews to capture information that cannot be obtained through closed-ended interviews, utilizing narrative medicine rooted in Freud’s descriptive symptom approach. The narrative adopts a storytelling format and emphasizes plot development to identify the positions of events within the story. Narrative research, a form of qualitative research, is based on hermeneutic interpretations. By situating events based on relationships with other events in time and space, narrative research identifies the meaning of events, reflecting not only simple realities, but also choices, organizations, and simplifications of reality (Hinchman and Hinchman, 1997 ). Previous research employing the narrative medicine approach have predominantly concentrated on patients' life stories and narratives, garnering attention within the fields of medical sociology (Williams, 1984 ; Frank, 1995 ) and anthropology (Kleinman, 1988 ; Garro, 2000 ). In contrast, the narratives of healthcare professionals have been relatively underexplored. Atkinson ( 1995 , 2017 ) introduced healthcare workers' narratives, examining how they judge, discuss, and approach decision-making when faced with challenges. Pollack ( 2001 ) suggested that physicians' autobiographical narratives could capture the social history of medical development and the culture of medical practices, even highlighting gender perspectives within medical settings. Good and Good ( 2000 ) propose a fictional understanding of medical stories, constructing a recognition of medical reality and historicity. Since Durkheim, anthropologists and sociologists have considered the role of emotions in the body, sensation, emotion, and social change. Philosopher Deleuze ( 1988 ) defined it as the dynamic relationship between bodies, enhancing or diminishing their capacity to affect and be affected by other bodies. The "affective turn" in humanities and social sciences has recently renewed interest in these dynamics. From a certain perspective, affect contrasts with emotion, possessing potential agency rather than a fixed cultural meaning. Affect is perceptible, dynamic, vibrant, and variable, enabling a holistic understanding of the lifeworld. Mazzarella ( 2009 :291) highlighted that contemporary public culture has become more overtly affective; thinking affect offers "a way of apprehending social life that does not begin with the bounded intentional subject while foregrounding embodiment and sensuous life. "In essence, affect points to social and embodied practices rather than individual emotional expressions. This concept aids in rethinking overly individualized psychiatric terminology. Anthropologist Lester ( 2013 ) proposed that trauma narratives create ambivalent agency victimhood, necessitating a re-evaluation of the timeline of trauma. Interpersonal and social relationships are more critical than internal cognitive and emotional issues. She emphasized affect as an embodied cultural model for understanding mental illness, highlighting the importance of considering affect as an embodied practice. In the tradition of political philosophy, fear has long been recognized as a foundational element in collective formation and governance. This perspective traces back to classic thinkers like Niccolò Machiavelli, who famously posited that fear is a more effective tool for maintaining social order than love, and Thomas Hobbes, who argued that the fear of anarchy serves as the very basis for individuals granting legitimacy to a governing body. Sara Ahmed ( 2014 :74) noted that the experience of fear is activated in patriotic declarations against terrorist attacks and serves as a tool for national identity cohesion. Taiwanese psychologist Liu Wen (2021) examined paranoid affect during the pandemic, emphasizing its role in understanding social experiences, contextual situations, and interpersonal relationships. She adapted the concept of "affective practice," advocating for close observation of affect's concrete realization in daily practice, addressing issues of subjectivity and agency. Given Taiwan's geopolitical context, it is imperative to investigate this effect. Geographer Steve Pile ( 2010 :16) states, "Emotional geography ensures there is no split between thought and affect." Expressions of affect relate not only to personal beliefs and values, but also to temporal and spatial contexts. Based on these discussions, this article examines the affective experiences of health-care workers through in-depth interviews, employing "affect" as an analytical framework to comprehend Taiwan's distinctive social and political milieu during the pandemic and to critically reflect on trauma narratives. Research Design and Case Collection This research project was conducted over a 10-month period from August 2021 to June 2022. Crucially, this timeframe witnessed a pivotal shift in Taiwan’s pandemic trajectory: transitioning from a strict 'Zero-COVID' policy toward a strategy of living with the virus and achieving collective community immunity. This period of transition provides a unique vantage point to examine the evolving affective experiences and moral dilemmas faced by healthcare workers as they navigated the systemic reorganization of care protocols amidst escalating community transmission. Given the absence of specific assessment tools for moral injury, and this article ‘s focus on capturing narrative information about the concept, the study utilized semi-open questions to explore clinical workers' awareness, definition, and understanding of moral injury. Additionally, it investigated whether work experiences of moral injury influenced attitudes and decisions in medical practice. Participants’ narratives extended beyond the initially defined scope of moral injury; therefore, the researcher documented their experiences and feelings. This study received ethical approval from the relevant institutional review board (the institution and approval numbers are temporarily withheld). The initial research design involved the recruitment of 30 clinical workers including physicians, nurses, medical technologists, and clinical psychologists. The interviews addressed experiences of moral injury, employing semi-structured questions. The subjective experiences of clinical workers during the SARS and COVID-19 pandemics were analyzed. Ultimately, the study recruited 26 participants (3 supervisors, 15 physicians, and 11 nurses; Table. 1). The interviews focused on clinical experiences during the pandemic, personal psychological effects, ethical dilemmas, and value conflicts. All participants provided written informed consent. No adverse effects were reported and no participants withdrew from the study. All interviews were recorded and transcribed verbatim, with all transcripts anonymized and encrypted. The research team reviewed and analyzed the transcripts, extracting keywords related to moral injury or other affective experiences. The keywords were contextualized within the participants’ environments, work ecology, and pandemic policies. In this study, the participants’ personal information was anonymized to avoid the potential of institutional pressure. Table 1 Study participants. No. Participant initial Profession Gender Age, years Location of Institution 1 K Retired Internal Medicine Doctor (Supervisor) M 75 Taipei 2 C Attending Emergency Physician M 43 New Taipei 3 L Emergency Resident Physician F 29 New Taipei 4 Y Emergency Resident Physician M 31 New Taipei 5 T Attending Physician, ICU F 53 New Taipei 6 H Attending Emergency Physician M 44 New Taipei 7 Y Nurse, Negative Pressure Isolation Ward F 41 Kaohsiung 8 T Nurse, Negative Pressure Isolation Ward F 41 Kaohsiung 9 C Head Nurse, Internal Medicine ICU (Supervisor) F 44 Hsinchu 10 C Family Medicine Physician M 50 Tainan 11 H Hospice Physician F 35 Tainan 12 C Nurse, Internal Medicine ICU F 41 Hsinchu 13 C Nurse M 29 Taipei 14 L Nurse, Internal Medicine ICU F 30 Hsinchu 15 L ENT Physician, Private Clinic M 49 Taipei 16 N Head Nurse, Professor (Supervisor) F 54 Tainan 17 H Emergency Physician M 29 Kaohsiung 18 C Emergency Physician M 35 Kaohsiung 19 T Emergency Physician M 37 Kaohsiung 20 C Emergency Physician M 37 Kaohsiung 21 H Emergency Physician M 35 Kaohsiung 22 C Nurse, Negative Pressure Ward F 30 Hsinchu 23 H Nurse, Negative Pressure Ward F 29 Hsinchu 24 T Nurse, Negative Pressure Ward F 23 Hsinchu 25 W Nurse, Negative Pressure Ward F 45 Hsinchu 26 H Nurse, Negative Pressure Ward F 25 Hsinchu Rèxiě, Professional Commitment, and National Identity This study included several emergency department physicians, who were pivotal during the pandemic as emergency departments served as the front line of epidemic prevention efforts. All patients, irrespective of their condition or hospitalization requirements, underwent COVID-19 antigen screening at emergency stations, rendering emergency personnel the most experienced in epidemic prevention. Participants frequently utilized the term "rèxiě" (hot-bloodedness) to describe their passion and sense of responsibility toward epidemic prevention work. Rèxiě is the literal Chinese translation of "hot blood," which in English means "passion." The keyword rèxiě was repeatedly mentioned during the interviews, possessing a more embodied connotation. Although healthcare workers' dedication to patient care is self-evident, this professional passion is rarely discussed during routine work, but becomes a shared affective experience during major infectious disease outbreaks. An emergency physician at a New Taipei medical center, who was an intern during the SARS outbreak and now teaches emergency medicine, often emphasized to students: "We think of ourselves as frontline soldiers. Patients with SARS, COVID, or any other infectious disease who visit the emergency room cannot be refused treatment. We must manage and save everyone. This concept is ingrained in the blood of emergency physicians as a matter of professional pride." Dr. C, a resident of the Department of Family Medicine at a medical center in Taipei during the SARS outbreak, shared his experiences: "At that time, I was young and did not have many family responsibilities or significant concerns, so I was not afraid. I did not contemplate much about the potential consequences if I became ill. This passion (rèxiě) propelled me." A second-year resident in the emergency department of a medical center in New Taipei City said: "Initially, I thought it appeared truly admirable, as it seemed exceptionally powerful and exciting. I was filled with passion (rèxiè). Intubation and CBCs were impressive to me, and I felt a strong compulsion to learn how to perform them." Rèxiě implies the embodiment of responsibility and ideals and carries martial connotations. This suggests that medical care is a calling that requires healthcare workers to be at the forefront during a pandemic. Rèxiě also reflects the moral values of frontline clinical workers during epidemic prevention efforts. However, this moral narrative not only highlights the sense of duty that health-care workers feel in fulfilling their "calling" to assist others, but also originates from a collective sense of honor. This collective sentiment not only arises from professionals' recognition of their individual responsibilities, but is also intertwined with emotions shaped by a form of collectivism. Pandemics have exposed the inadequacies of epidemic prevention infrastructure. Healthcare workers obtain less rest during a pandemic. Rèxiě enables clinical workers to temporarily set aside concerns about their working conditions. On one hand, it drives healthcare personnel to dedicate themselves selflessly and unhesitatingly, but consequently, it may also be the reason why they are placed in danger. Therefore, the discourse of rèxiě serves as more than a mere expression of individual professional dedication because it also operates as an "affective regime" that aligns clinical labor with national survival. By interpreting pandemic fatigue through the lens of sacrificial passion, the state and the public effectively mobilize healthcare workers to sustain a form of "biological citizenship, which seeks collective recognition in a structurally unequal world. However, this affective mobilization becomes a dual-edged sword, providing clinicians with a sense of heroic purpose, while simultaneously obscuring systemic deficiencies. When rèxiě is institutionalized as a normative expectation, any deviation is not perceived as a systemic failure, but as a personal moral lapse, marking the juncture at which affective labor can no longer bridge the gap between national representation and the precarious reality of care. These issues are addressed in detail in the subsequent sections. Betrayed by the System: The Structural Drivers of Moral Injury COVID-19 exacerbated tensions in hospitals and led healthcare workers to feel disconnected from the ethical and moral principles they typically adhere to. Some participants noted that the challenges during the pandemic impeded their ability to fulfill their professional responsibilities. These challenges sometimes arose from resource shortages and, at other times, from human factors such as differences in examination and treatment approaches among colleagues and the effects of policies. A typical case of betrayal in a hospital setting occurred in the emergency department of a medical center in Kaohsiung. Physicians expressed anger when they were unable to effectively treat a patient due to stringent infection prevention requirements. "A radiologist noted that the patient's lungs were white, suggestive of COVID-19. Despite the clear symptoms of myocardial infarction and heart failure, a second negative test was required, leading to the patient's death. This is absurd and contradicts our medical oath." Many institutions have strict infection prevention requirements, leading to numerous unreasonable demands during the process of transferring patients between departments. A nurse from a negative-pressure ward at another medical center in Kaohsiung stated: "I think some tests can still be done; it's just that other departments might find it really troublesome. Therefore, additional precautions must be taken. For example, if a patient needs to undergo a computed tomography scan, they must be escorted in protective gear, and security guards control the flow. Emergency procedures will still be carried out, but sometimes they simply ignore you." This process not only results in delays, but also hinders collaboration and communication among healthcare workers when treating patients. Initially, most healthcare workers had a sense of duty and willingness to contribute to pandemic control and treatment. A second-year emergency resident at a New Taipei hospital shared his frustration with the epidemic prevention measures. "I felt I could attend to patients too. However, the hospital's system protected residents by keeping attending physicians outside. I am convinced that we could manage patients while employing appropriate protective measures. However, the hospital did not do so. I wanted to assist more and gain experience, but we had limited responsibilities inside the consultation room." These protective protocols prevented patients from receiving timely care and posed moral dilemmas for healthcare workers who wished to assist but were unable to participate, leading to a sense of guilt and anger toward institutional management. In fact, this perceived "overprotection" felt by young healthcare workers originated from the experience of the 2003 SARS outbreak. The SARS epidemic inflicted indelible trauma on Taiwan’s healthcare system. During that period, 151 healthcare workers were infected, and unfortunately, 11 succumbed to the disease in the line of duty. This tragedy revealed severe deficiencies in infection control training and protection mechanisms for young physicians within the medical system during that era. Consequently, the government immediately initiated a fundamental reform of medical education that same year, introducing a comprehensive Post-Graduate Year (PGY) training program. This system aimed to strengthen the foundational infection control capabilities and adaptive resilience of every clinician through general medical training before they entered specialized fields. Simultaneously, the medical community established stricter "protection strategies," particularly for medical interns and residents. The sense of profound frustration and "institutional betrayal" experienced by healthcare workers during the pandemic was not merely an individual emotional response but a consequence of the fundamental conflict between professional ethics and the logic of medical governance. When physicians were compelled to witness patients succumb to conditions such as myocardial infarction due to administrative delays and stringent testing requirements, it highlighted a tragic reality where "infection control administration" overshadowed "clinical rescue," directly contradicting the medical oath. This sense of betrayal is rooted in structural interventions driven by economic efficiency and risk aversion: departments engaged in patient-shuffling to minimize their own administrative "trouble," while the "overprotection" of young doctors—although historically grounded in the trauma of the 2003 SARS deaths and the subsequent PGY system—evolved into a strategy to prevent the loss of "expensive human capital.” For young clinicians, being restricted from high-risk areas not only impeded their professional development but also engendered profound guilt and anger, as they were unable to fulfill their professional values during a crisis. Ultimately, when the healthcare system treats its workers as "sterile components" to be preserved for operational capacity rather than as moral subjects, these efficiency-driven interventions become the structural drivers of moral injury. SARS as an Affect Capital As previously mentioned, the SARS experience propelled reforms in Taiwan's medical training system. Moreover, for the healthcare professionals who experienced that epidemic, it facilitated the accumulation of a form of 'affective capital' used to confront the challenges posed by COVID-19. The 2003 SARS outbreak ranked among the most severe infectious diseases globally, with a high fatality rate, particularly affecting regions in Asia, including China, Hong Kong, Taiwan, and Singapore. In Taiwan, the SARS outbreak represented a pivotal turning point in the evolution of epidemic prevention policies. The Taiwan Central Epidemic Command, along with medical graduates, gleaned substantial insights from their experiences during the outbreak. Healthcare workers with prior SARS experience were less apprehensive of the COVID-19 pandemic, leveraged their experience, and delivered timely responses. The organizational efforts undertaken over the past two decades have been imparted to younger personnel, who are now better equipped to comprehend the concerns and needs of frontline workers and to make empathetic decisions regarding work distribution. As an illustrative case, a study conducted at a major tertiary hospital in Taiwan during the 2003 SARS outbreak revealed that nearly 75% of healthcare workers experienced significant psychiatric morbidity (Chong et al., 2004 ). This immense psychological pressure stemmed from feelings of extreme vulnerability, the perceived threat to life, and the persistent uncertainty surrounding the highly contagious virus (Chong et al., 2004 ). Hospital staff were forced to navigate heavy workloads and social isolation while facing the constant risk of infection without prior precedent. This profound collective trauma, however, eventually crystallized into a form of 'affective capital' within their professional careers, serving as a foundational reservoir of resilience when confronting the later challenges of COVID-19. Dr. C, a general practice resident working at a medical center in Taipei, recounted the frustration of being assigned to a fever screening station without adequate experience during the SARS outbreak: "It was absurd to place the critical responsibility of protecting the hospital from patients with SARS on family medicine residents instead of thoracic, internal, or infectious disease specialists.” Nearly two decades later, Dr C became the senior attending physician. In confronting the COVID-19 pandemic, he believed that excessive worry was unwarranted, and had confidence in the government's prevention policies. Taiwan's initial experience with a large-scale, unfamiliar, infectious disease epidemic was with SARS. In response, the central government established new public health systems and medical education guidelines, and provided general medicine training through post-graduate training programs. Furthermore, the government implemented new institutional infection control procedures. Consequently, Taiwan’s response to COVID-19 was better than to SARS, with healthcare workers demonstrating greater preparedness and courage. A head nurse at Hsinchu Regional Teaching Hospital, who was a new nurse during the SARS 2003, shared the following: "We retrieved paper regulations from the SARS period, read and adapted them to our unit, and prepared to go inside, reviewing cases with colleagues." An emergency physician at a New Taipei medical center highly endorsed the post-graduate year training program: "SARS influenced this pandemic's response. The post-graduate program, often criticized, ensured that all physicians in Taiwan understood general medicine and were prepared to assist during emergencies." The narratives of the participants who experienced the SARS outbreak, suggest that when initially confronted with an unknown virus, healthcare workers may feel fear largely due to institutional inadequacies. However, after 20 years of improvements in the medical system and training protocols, novices have now become leaders. Fear and anger from the past evolved into affective capital in the context of the new pandemic. This transformation of past trauma into "affective capital" demonstrates how collective memory functions as a stabilizing force in pandemic governance. The legacy of SARS is not merely a technical repository of protocols, but a lived "affective archive" that anchors current actions in a historical narrative of survival. This capital enables clinicians to overcome the paralyzing effects of radical uncertainty by enacting a form of resilience that is predicated on beliefs about institutional progress. However, such affective capital is inherently conditional and demands reciprocal accountability from the state. When clinicians draw upon their memories of SARS to bolster their courage, they are not just performing duties, but reinforcing a social contract. Consequently, when policies appear politically motivated rather than scientifically grounded, the sense of betrayal intensifies, as it threatens the integrity of the affective capital invested in national defense. Fear of Becoming a “War Criminal” Despite the enhanced sense of security under more comprehensive prevention systems compared to during SARS, clinicians still experienced fear during the COVID-19 pandemic, often concerned they might become a "breach in prevention" or even a "war criminal." This pressure was unique to Taiwan's initial zero-tolerance policy, which aimed to position Taiwan as a model for pandemic control, placing moral pressure on healthcare workers so as not to undermine national achievements. A dedicated ward nurse in Hsinchu said the following: "I tell others I work at a hospital but don't want to mention that I care for critically ill patients to avoid trouble." A fourth-year emergency resident doctor in New Taipei City said: "Everyone was cautious, fearing becoming a breach in prevention. Taiwan is quick to assign blame, so we had to be very careful, fearing not just illness but also being seen as a war criminal." The term "war criminal" is a strong phrase. War metaphors appear to have frequently been used and readily accepted in Taiwan's pandemic response. Some scholars have suggested avoiding the association of pandemic prevention with war metaphors to prevent nationalism, racial discrimination, resource injustice, authoritarianism, and conspiracy theories (Panzeri et al., 2021 ; Musolff, 2022 ). However, war metaphors are unavoidable in specific geopolitical contexts, such as when mobilizing prevention efforts. Taiwanese healthcare workers feared being labeled "war criminals," reflecting Taiwan's persistent war threat since World War II. During the early stages of the pandemic, due to its geographical proximity to China, where the first cases of the COVID-19 were identified, coupled with long-standing political tensions, Taiwan’s strict epidemic prevention measures assumed a nationalistic character. A resident doctor in the emergency department of a medical center in Kaohsiung was restricted from returning to work at the hospital after visiting relatives in China during the Lunar New Year. The hospital implemented stringent quarantine measures, heightened level of precaution regarding the initial site of the outbreak. The doctor expressed the following: "What I felt more keenly was that people would start saying that these viruses were brought over from there. For a long time, Taiwan has been in a delicate and somewhat tense relationship with China. Being caught in the middle of one’s identity, hearing these comments can sometimes be uncomfortable." During the COVID-19 pandemic, the public was advised to avoid using war metaphors. However, the statements of the participants in this study indicated that war metaphors are difficult to avoid. Clinicians who apply war narratives to their own circumstances reflect on their fear of war. This fear was not solely directed at the virus, but also at the palpable threat of war under regional political tensions. War metaphors can deepen the effects of discrimination but can also serve as a driving force for stricter epidemic prevention measures. The dread of being labeled a "war criminal" reveals how pandemic governance in certain political contexts transcends clinical management to become a project of national security. This "affective state of exception" illustrates that a breach in prevention is perceived not merely as a medical error, but also as a geopolitical failure that jeopardizes national prestige. In this context, the "war metaphor" is not a mere linguistic choice but a reflection of tangible political stakes. When clinicians internalize the possibility of being deemed "war criminals," they are navigating a space where they are mobilized as frontline buffers against perceived external threats. This fear indicates that the negative feelings experienced are fundamentally linked to the nation’s precarious standing, where affective labor becomes a mechanism of state security, further blurring the boundaries between medical ethics and national loyalty. Resonance of Suffering: Doing More for Patients and Families During the early stages of the pandemic, "even as the 'Zero-COVID' policy compelled everyone to be hyper-vigilant to avoid becoming a breach in prevention, with few cases of COVID-19 in Taiwan, healthcare workers did not feel a heavy labor burden. Workers would often go beyond their normal caregiving duties and voluntarily offer additional services. This motivation sometimes arose from their experiences or from witnessing similar struggles, creating psychological resonance. Dr. M, an emergency critical care physician, made video calls instead of in-person meetings. "During my time caring for patients with COVID-19, there was a case where a patient was very breathless before intubation and managed to speak to their family through a video call. After intubation, the patient experienced cardiac arrest due to low blood oxygen levels. Although the heartbeat was revived, the patient remained in a vegetative state. I managed to arrange a video call, allowing the husband and brother to speak to her, encouraging her to keep fighting." Such practices indicate that regulatory frameworks often restrict medical actions. Healthcare workers typically do not use remote communication to explain conditions. However, isolation as a key measure against COVID-19 led to the establishment of remote consultation regulations. Healthcare workers’ experimental actions sometimes embody resistance and breakthroughs against existing systems. Two nurses working in a negative-pressure ward at a medical center in Kaohsiung were interviewed. These nurses had experience dealing with infectious diseases and recalled encountering severe anxiety when they suspected contracting tuberculosis. One nurse stated, "An X-ray showed abnormalities, and we suspected tuberculosis. I had to undergo a test and was extremely fearful. Despite my extensive experience with infectious diseases, the prospect of explaining this to my family kept me awake at night." During the pandemic, the nurse cared for a Ukrainian patient with no family support and assisted in establishing a social media page to locate his family: "We even created a Facebook page for him to connect with his mother. He spoke limited English and was mentally ill. He had attacked the captain of a ship and was quarantined in accordance with COVID-19 protective measures. Hearing his mother's voice and connecting with her helped him to calm down." Another nurse from the same negative-pressure isolation ward recounted her experience caring for foreign caregivers. As the foreign workers were in isolation and had no family to care for them, the nurses voluntarily took turns purchasing Indonesian food. "We would buy some Indonesian food from nearby vendors who cooked and sold their dishes. This made them very happy, as they were reminded of home." Many patients have experienced loneliness and homelessness during the COVID-19 pandemic. Healthcare workers can provide additional services beyond medical care to provide patients with a sense of home. This form of empathy, in which healthcare workers go beyond usual duties for their patients, is precisely the unique aspect revealed in this study., showing that the affective experiences and moral values of healthcare workers are closely intertwined. Although the pandemic imposed physical and mental stress on healthcare workers, their resilience may manifest through a pronounced display of empathy, serving as a compensatory strategy for their negative emotions. Silenced Grievances Taiwan’s pandemic trajectory shifted significantly in May 2021. The community infection rate had remained nearly zero for an extended period; however, airline crew members and quarantined hotel staff contracted COVID-19 in late April, leading to an increase in the number of community infection cases in May. The number of infected individuals surged, prompting Taiwan to elevate its alert level to level three. Frontline healthcare workers encountered immense physical and mental pressure under stringent isolation measures and hospital care protocols. They reported feeling compelled into silence, with the hospital's zero-infection policy primarily aimed at preserving healthcare workforce capacity. Workers were subjected to constant moral pressure, perceiving an unspoken prohibition against social behaviors, and any positive diagnosis implied disloyalty to hospital policy. A dedicated ward nurse at a regional teaching hospital in Hsinchu described a pronounced sense of detachment from early pandemic enthusiasm: "I only know that I felt very sad. It is not exactly sadness but negative emotions, such as frustration and helplessness. It felt like an endless situation with no end in sight, which made me feel annoyed." This sense of interminability reflects disillusionment with the once seemingly effective zero-infection strategy. As the pandemic response evolved into a prolonged battle, the mindsets of clinical workers underwent significant transformations. Unlike the initial fear of becoming a breach in the pandemic prevention efforts, healthcare workers under extreme stress sometimes expressed a desire to test positive to obtain a break. One nurse shared: "I am not sure if it is similar for others, but persons around me are generally unhappy. Some, like me, just want to test positive to get a break, even though it burdens our colleagues." Another nurse who worked at the same hospital described the intense workload and restrictions: "The pressure was so intense that we spent seven out of eight working hours inside, only emerging to handle orders. We often had lunch as late as 5 PM or 6 PM and this was repeated daily. We encountered many restrictions and had no outlet to relieve stress, even as our supervisors kept reminding us not to eat out or gather, which made us feel even more constrained." Young nurses responsible for caring for patients with COVID-19 in negative-pressure wards were predominantly in their twenties. Many were unmarried and did not have the responsibility of caring for children, making them more likely to be assigned night shifts. However, as the pandemic progressed, they gradually began experiencing physical and mental exhaustion. Another nurse from the same unit as the two previously mentioned earlier was reprimanded by her supervisor after testing positive for COVID-19. During the interview, she displayed her phone showing how her illness was publicly disclosed in the team’s social media group, raising questions about her adherence to health management protocols. "One morning, I had breakfast outside, and my supervisor immediately assumed I contracted COVID-19 there. They announced my illness in a group chat, blaming me for not adhering to the rules. I felt targeted and angry." Under immense pressure, young nurses resorted to clandestine gatherings as a coping mechanism. However, dedicated ward supervisors also faced pressure to maintain operational capacity, reflecting the broader challenges in risk management under pandemic policies. These policies were influenced by Taiwan's unique geopolitical context, which necessitated strict measures. A key reason these feelings could not be openly expressed was that these clinicians believed they were powerless to alter the situation and therefore saw no necessity to do so. First, they felt unable to challenge the hospital's hierarchical organizational culture. Furthermore, they maintained the belief that the pandemic would eventually subside and that normality would be restored. If someone could not endure the circumstances, the only option was to leave. This shift from passionate dedication to desperate longing for infection marks the limit and eventual disintegration of national affective mobilization. When the "Zero-COVID" policy transformed from a public health goal into a mechanism of "moral surveillance," the affective atmosphere of the clinic shifted from collective honor to the dread of punishment. The reprimands of supervisors and public shaming in social media groups reflect a governance logic that prioritizes biosecurity over individual subjectivity. Under this regime, the clinician’s body is instrumentalized as a "sterile resource" to maintain national capacity; any sign of illness is interpreted as both a professional and moral betrayal. This "enforced silence" not only masks systemic vulnerabilities but also inflicts a profound moral injury—clinicians realize they are not cared-for subjects in the eyes of the state, but rather biopolitical components required to function in a vacuum, devoid of personal needs or human limitations. Righteous Anger: Imagining Justice and Public Interest Clinicians’ positions and affective experiences during the pandemic varied hierarchically. Unlike frontline practitioners facing institutional oppression, senior healthcare workers with SARS experience often express anger over public issues, which this article terms "righteous anger." This affective reaction arose from senior workers workers’ experiences and empathy for frontline workers' struggles, reflecting their sense of justice in public policies. This section highlights another type of response, empathy, which is more radical. The Taiwanese government established a command center for the pandemic, and daily press briefings served as a singular communication channel. While some criticized this centralization of power, the majority of healthcare workers interviewed supported national policies and expressed anger at key opinion leaders who opposed them. During the pandemic, many discussions were held regarding vaccines and many influencers claimed that the government's promotion of vaccinations was detrimental. Dr. L, who experienced quarantine at Hoping Hospital during SARS, dismissed the opinions of those influencers. "They do not hold the position, so they do not bear the responsibility. Some already have a specific stance, and as long as they are supported by certain media outlets, their voices are heard. But to put it bluntly, what do they really know? Do they believe infectious disease specialists are incompetent?" Taiwanese society is highly politically polarized, and many influencers express extreme views in the media, complicating the public’s ability to discern the accuracy of professional opinions. Dr. L continued, "I think the media thrives by creating chaos. Initially, they criticized the AstraZeneca vaccine, rendering it worthless. However, many individuals receiving the BioNTech vaccine do not realize that the second dose can be more potent. The media brainwashed them into thinking that getting the AstraZeneca vaccine would be deadly, but they would understand when they receive the second dose of BioNTech." The world has been presented with a completely different media landscape during the COVID-19 pandemic, with numerous studies and discussions on misinformation and post-truth-era epidemic prevention. During the 2003 SARS outbreak, the media was perceived to have considerably complicated Taiwan's epidemic prevention efforts. Retired pulmonologist Dr. K, who served as the executive director of a crisis management center at a medical facility during SARS, stated that his most vivid memory of the anti-epidemic experience was dealing with the media. At that time, a resident physician caring for SARS patients traveled to Japan and was diagnosed with the infection upon return. The Japanese media questioned the physician’s professionalism, stating that he had traveled despite exhibiting fever symptoms, potentially spreading the virus to the Japanese populace. Dr. K publicly defended the resident physicians against the Japanese media ‘s criticisms, stating: " These health news reporters had no substantial material to work with, so they simply resorted to sensationalism. The most alarming aspect was the media's reckless reporting." Although some criticized Taiwan's government for establishing a command center during the COVID-19 pandemic, citing concerns over centralized power and a lack of diverse perspectives, Dr. K commended this approach. Therefore, the health department is completely transparent. They allow questions until there are none remaining. They provide answers daily, irrespective of the questions, and regardless of the media outlet you represent." Dr. K's narratives reflect his full support for the government[s initiatives and are based on the concepts of fairness and justice. However, each individual’s concept of justice varies and is influenced by their personal histories and social roles. Professor N, a nursing professor at a medical school in southern Taiwan, offered a contrasting perspective of command centers. Professor N was interviewed in 2021, when the Omicron variant began to spread. She disagreed with the command center's overly centralized approach, stating: Increasing evidence has shown that Omicron is not severe; however, every day, 40 or 50 people are sent to medical centers. I do not understand; we have always said that it was not necessary." Having experienced previous infectious disease outbreaks, Professor N understood the pressures encountered by frontline healthcare workers in hospitals and advocated for a more flexible response to the evolving pandemic. Her responsibilities included ensuring continuous communication, sufficient supplies, and an adequate workforce. She recounted that in January 2020, she had not anticipated taking certain actions. When COVID-19 was first reported in Taiwan, some N95 masks ordered from foreign suppliers did not arrive. She later discovered that other units intercepted the masks. After reading a story about a resident physician in New York who resorted to using a gun to seize supplies, she decided to personally retrieve the supplies from customs. "It was really outrageous. Sometimes we realize that we are not so different from New York,’ she said. The righteous anger described in this section was also experienced by Dr. L, who was dissatisfied with certain influencers deliberately opposing government policies; Dr. K, who clashed with journalists during the SARS outbreak; and Professor N, who was frustrated with pandemic prevention policies during the COVID-19 outbreak. This anger pulsed among healthcare workers during the pandemic, prompting them to go beyond the call of duty. Their actions reflect a philosophy of action that transcends traditional moral standards, and the pandemic provided individuals with space to reimagine justice. This "righteous anger" functions as an affective mechanism for defending professional boundaries and expert authority in an era of polarized misinformation. Unlike moral injury which arises from a sense of powerlessness, this anger originates from a position of institutional seniority and "affective capital" accumulated through previous crises, such as SARS. It reflects a transition from passive compliance to an active "scientific citizenship," wherein clinicians feel compelled to safeguard the public interest against what they perceive as the "epistemic chaos" engendered by media and political influencers. By dismissing critics as irresponsible "outsiders," these senior professionals are not merely endorsing the state; they are asserting that true justice in public health must be rooted in clinical responsibility and specialized knowledge rather than populist rhetoric. However, Professor N’s experience with intercepted supplies demonstrates that this anger challenges the state’s bureaucratic inefficiencies. Ultimately, righteous anger serves as a catalyst that prompts clinicians to "reimagine justice" by reclaiming the agency to define what constitutes a rational and ethical response, thereby transforming their emotional frustration into a proactive philosophy of action that transcends conventional moral frameworks. Discussion: Beyond Trauma – The Geopolitics of Affect This article contends that the experiences of Taiwanese healthcare workers during the COVID-19 pandemic have transcended the individualized diagnostic framework of "moral injury" or "trauma." Instead, these experiences should be understood through what this study terms the “geopolitical affective regime." As Anderson ( 2009 ) suggests, affective life is not merely a personal interior state but an "object-target" for biopolitics and security environmentality. In Taiwan, this biopolitical target was specifically shaped by a "double bind" of existence: the need to perform as a global model of health excellence, while navigating structural isolation from the international community. 1. The Temporality of Affect: From Capital to Betrayal Taiwanese clinicians’ affective journeys revealed how temporality shapes moral experiences. In the early stages (2020– 2021), the pandemic response was fueled by the "affective capital" inherited from the 2003 SARS trauma. This capital transformed past fear into a "heroic narrative" explicitly linked to national survival. However, unlike the romanticized resistance often criticized by Scheper-Hughes (1993), the "Team Taiwan" sentiment represented an "affective mobilization" where clinicians voluntarily ceded individual rights for the sake of national "biological citizenship.” However, as the pandemic transitioned from the "Zero-COVID" ideal to the large-scale community outbreaks of May 2021, this capital began to deplete. The analytical shift here is critical: the exhaustion felt by clinicians was not merely a result of physical workload, but a "rupture of the affective contract." When policies shifted and resources became strained, senior clinicians’ “righteous anger” functioned as an emotional critique of institutional management. This anger indicates that emotions are not just markers of victimhood but also tools for social critique, reflecting a demand for professional accountability that transcends psychological support. 2. The Spatiality of Affect: Geopolitical Dreads The anxiety associated with becoming a 'breach in prevention' or a 'war criminal' highlights the spatial dimension of affect. This spatiality is also reflected in the various levels of spatial deployment: for example, healthcare workers must serve as defensive sentinels for their medical institutions to achieve 'zero-infection,' while regional designated hospitals must bear the responsibility of maintaining zero infections across their entire administrative jurisdictions. Ultimately, these efforts are directed toward consolidating Taiwan's image as a “world model” for pandemic control. In Taiwan’s unique geopolitical situation, the 'war metaphor' is not a rhetorical choice but a reflection of tangible existential threats. The clinician’s body became a literal national border. This study finds that the 'moral injury' often reported in Western literature—typically centered on the inability to provide care—is, in Taiwan, reconfigured as a 'geopolitical moral burden.' Clinicians were pressured to maintain an image of national perfection in order to secure Taiwan’s global standing. 3. Reimagining Justice Ultimately, overemphasizing "trauma" or "PTSD" risks depoliticizing the clinician's experience, reducing structural and geopolitical tensions to a psychopathological condition. By shifting the focus to affect politics, we can observe how the moral worlds of individuals are inextricably intertwined with collective nationalistic mobilization. The "righteous anger" and "tactical fear" described by participants are not symptoms to be treated, but a philosophy of action that reimagines justice within a "post-truth" and polarized landscape. For Taiwan's democratic sovereignty, the lesson is clear: Fostering a resilient medical profession requires more than individualized psychological services; it demands recognition of the geopolitical stakes that shape the affective worlds of those on the front line. Conclusion: Toward a Temporal-geopolitical and Contextual Approach to Affect The primary objective of this study was to move beyond the limiting narratives of individualized trauma to a more nuanced and context-sensitive interpretation of the affective challenges faced by healthcare workers. These findings suggest that clinicians’ experiences during the COVID-19 pandemic cannot be encapsulated in purely psychological or psychiatric terms. Rather, they are deeply embedded in the specific temporal and spatial logic behind Taiwan’s pandemic governance. As this research illustrates, the affective states of clinicians—ranging from the sacrificial fervor of rèxiě to the strategic dread of being labeled a "war criminal"—are not merely internal reactions to stress but are responses to a state striving for global legitimacy in a structurally unequal world. This study demonstrates that "moral injury" often discussed in academic literature must be contextualized within the highly politicized nature of epidemic prevention. While slogans of "global solidarity" prevail in health governance, the pandemic has reified borders and exacerbated geopolitical tensions. In Taiwan, when bureaucratic or political performance eclipses professional integrity, the resulting sense of erosion is not just clinical burnout but structural tension. However, these affect-laden experiences are not exclusively negative; they also embody a form of resilience. By viewing negative affect as a potential site of resistance or "righteous anger," we can recognize the agency of clinicians who seek to reimagine justice amid institutional inadequacies. Consequently, this article advocates for a narrative-oriented, de-victimizing approach to clinician well-being. By avoiding the tendency to equate suffering with a passive victim identity, this approach restores healthcare professionals’ subjectivity and dignity. To be effective, support interventions must transcend individualized psychological treatment and address the institutional and geopolitical factors that underlie clinician distress. Establishing healing spaces through independent third-party entities can provide a sanctuary in which the complexity of these affective worlds is acknowledged without being pathologized. Ultimately, understanding the affective politics of frontline care is not only a matter of mental health but also a necessary step toward fostering a more robust and ethical foundation for healthcare systems in an era of globalized epidemics. Declarations Conflict of interest: The author has no conflict of interest. Ethics approval (The institution and approval numbers are temporarily withheld.) Funding This research was supported by a grant from [Anonymized for Peer Review]. Author Contribution Yi-Cheng Wu is the sole author of this article. He was responsible for all aspects of the study, including the conceptualization and research design, conducting qualitative interviews and data collection, performing the literature review, and drafting and revising the final manuscript. References Anderson, B. (2009). Affective atmospheres. Emotion, Space and Society, 2(2), 77–81. https://doi.org/10.1016/j.emospa.2009.08.005 Ahmed, Sara. 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Young, A. (1997). Suffering and the origins of traumatic memory. Daedalus , 126(1), 245–260. Zhang, W., Lee, L. C., Connor, K. M., Chang, C. M., Lai, T. J., and Davidson, J. R. (2007). Symptoms of neurasthenia following earthquake trauma: re-examination of a discarded syndrome. Psychiatry research, 153(2), 171–177. https://doi.org/10.1016/j.psychres.2006.04.021 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8675330","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610009411,"identity":"37008e95-5679-45f7-b78f-d515182f9ad6","order_by":0,"name":"Yi-Cheng Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYHAD5gMQ+gBhlTAGWwJMC2MDkVp4DIjTYs7ef/BxZZsdg8GNnK+bbrYxyPHdSGB/zINHi2XPYWbDs23JQC25227ntjEYS95IYGzGp8XgRjKbZGPbAQYzqJbEDSAtOfi03H/M/hOiJecZSEs9YS03mNkYoVrYQFoSDAhpsexJNpZsOJfMY3/mmdntnHMShjPPPGyc/QePFnP2gw8/NpTZyUm2Jz+7nVNmI893PPnAxxn4HAYiGNkYYEEkAeI24NEA1cKAzx2jYBSMglEwCgAF7FIWnUoDogAAAABJRU5ErkJggg==","orcid":"","institution":"Mackay Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yi-Cheng","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2026-01-23 05:39:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8675330/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8675330/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106092940,"identity":"ddb5ef74-5adf-4d7e-8a13-94b8d2fefd4d","added_by":"auto","created_at":"2026-04-03 11:31:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":784699,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8675330/v1/eadd1623-2564-4fb5-ae2d-8d3d1695d115.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Moral Injury: Temporal-Geopolitical Anxiety and the Affective Regime of Care in Taiwan during COVID-19","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2022, during the New Year's Day flag-raising ceremony, Taiwan\u0026rsquo;s Minister of Health and Welfare, Chen Shih-chung, led healthcare workers in singing the national anthem. Among the performances during the ceremony was \"Critical Rock,\" a rock band composed of emergency physicians. One of their songs, \"Dear Taiwanese,\" includes lyrics that state, \"Dear Taiwanese, don\u0026rsquo;t be scared anymore, I will stand here for you, please take good care of us.\" This performance highlighted the contributions of epidemic prevention personnel to the country and provided healthcare workers with an opportunity to express their feelings, hoping to receive support and care.\u003c/p\u003e \u003cp\u003eCritical Rock\u0026rsquo;s performance bore profound dual symbolism, intertwining the labor of pandemic prevention with the collective destiny of the nation, and also suggesting that the arduous struggles of healthcare workers necessitate the support of the entire citizenry. However, beneath this symbolic solidarity lay a harrowing psychological reality. The COVID-19 pandemic posed an unprecedented mental health threat to healthcare workers globally, characterized by immense pressure arising from unfamiliarity with the virus, clinical uncertainties, and the exhaustion of adhering to high prevention standards over extended periods.\u003c/p\u003e \u003cp\u003eExtensive empirical evidence has documented heightened levels of anxiety, depression, and posttraumatic stress disorder (PTSD) among frontline staff (Johnson et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Mousavi et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Motahedi et al\u0026rsquo;, 2021; Le Thi Ngoc et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Andhavarapu et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bayazit et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tong et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Beyond traditional psychological distress, there is an increasing public awareness of the 'moral injury' experienced by workers witnessing patient deaths, while facing their own mortality (Greenberg et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Shale et al., 2020; Amsalem et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Čartolovni et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; D'Alessandro et al., 2021; Litam and Balkin, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Coimbra et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis paper contends that the prevalence of these conditions arises from two systemic factors. First, the psychological toll is frequently individualized as a private mental health failure. Second, diagnostic language, such as PTSD, has been depoliticized and stripped of its original context, necessitating political and structural solutions rather than solely clinical strategies. Despite alarming statistics, few studies have critically examined the structural roots underlying the high incidence of mental health issues among healthcare workers.\u003c/p\u003e \u003cp\u003eIn 2021, Taiwan\u0026rsquo;s Ministry of Health and Welfare initiated the \u0026ldquo;Enhanced Mental Health Services for Health-Care Workers in Medical Institutions\u0026rdquo; program. Observations from various hospital program coordinators suggest that healthcare workers rarely seek psychological assistance. This highlights two issues: the psychological pressure that healthcare workers encountered during the COVID-19 pandemic is not easily defined as an individual psychological problem and healthcare workers are hesitant about accessing institutional psychological interventions.\u003c/p\u003e \u003cp\u003eThis article explores the affective experiences of healthcare workers during the pandemic without employing traditional mental health terminology. Typically, psychiatric terms refer to individual dysfunction; however, pandemics are collective phenomena. To comprehend the suffering of health-care workers, we must consider the social, cultural, and political dimensions of their experiences.\u003c/p\u003e \u003cp\u003eThese experiences might not solely pertain to suffering, but may also encompass various affective changes with specific temporal and spatial meanings. Medical anthropologists Be'hague and MacLeish (2020) introduced the term \u0026ldquo;global psyche,\u0026rdquo; noting that mental health during the COVID-19 pandemic varied worldwide and was influenced by cultural and political contexts. This highlights the diverse ethical politics that underlie mental health.\u003c/p\u003e \u003cp\u003eTo provide a necessary supplement to the lived realities and sentiments of healthcare workers during the pandemic, beyond the conceptual framework of moral injury, this article employs the concept of affect to better understand the mental health of health-care workers during the pandemic. This study has two primary objectives: first, to identify new ways to comprehend the challenges encountered by healthcare workers under intense political pressure, and second, to explore resilience and agency in times of crisis. Although discussing resilience and agency might appear optimistic, examining healthcare workers\u0026rsquo; narratives during the pandemic aids in understand how these affective changes reflect Taiwan\u0026rsquo;s unique moral landscape in specific geopolitical contexts.\u003c/p\u003e"},{"header":"The Dilemma of Trauma Narratives","content":"\u003cp\u003eWhen discussing moral injury, revisiting terms such as trauma and posttraumatic stress disorder (PTSD) is essential. Various epidemiological studies have demonstrated that during the COVID-19 pandemic, healthcare workers experienced significant psychological pressures, including PTSD. These studies, which were primarily based on statistical findings, have emphasized the need to strengthen healthcare workers' understanding of stress, and provide psychological assistance or socio-psychological support to frontline healthcare workers (Carmassi et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Li et al et al. 2021; Sahebi et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Andhavarapu et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince the term \u0026ldquo;trauma\u0026rdquo; was introduced in the fourth edition of the \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e by the American Psychiatric Association, it has become a significant contemporary reference (Fassin and Rechtman, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Farrell (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1998\u003c/span\u003e) argues that trauma has evolved from a clinical diagnosis into a cultural lens, used by societies to articulate collective anxieties and interpret historical shifts. Some scholars contend that PTSD is a historically constructed concept (Young, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e1997\u003c/span\u003e; Wessely, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Lerner, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In other words, it is suggested that PTSD is an unnecessary diagnosis constructed entirely from social and political ideas (Young, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Summerfield, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the term \u0026ldquo;trauma\u0026rdquo; existed in ancient Greece, its application as a psychological concept only commenced in the late 19th century. It evolved from \u0026ldquo;railway spine\u0026rdquo; in the late 19th century, to \u0026ldquo;shell shock\u0026rdquo; during World War I, \u0026ldquo;war neurosis\u0026rdquo; in the interwar period, and ultimately to PTSD following the Vietnam War. Notably, after World War II and during the Cold War, nations were reluctant to acknowledge trauma to preserve the heroic image of returning soldiers. Similarly, the Japanese government limited psychiatric diagnoses to maintain the heroic image of soldiers, and Germany reduced compensation for traumatized soldiers. This terminology shifted to sociologists, historians, and writers, particularly in Holocaust research, leading to terms such as collective and national trauma. Psychiatry has only refocused on disaster-related psychological effects with the introduction of PTSD.\u003c/p\u003e \u003cp\u003eAmerican sociologist Kai Erikson (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1976\u003c/span\u003e) introduced the concept of \u0026ldquo;collective trauma\u0026rdquo; in the 1970s. This suggests that even before PTSD became a recognized condition, this widespread psychological state had already garnered scholarly attention, despite many countries deliberately avoiding this issue during the Cold War. Recent research has indicated that PTSD has become increasingly politicized. In Taiwan, trauma following major natural disasters is commonly studied through epidemiological research. Psychiatric researchers often employ epidemiological methods to examine how earthquakes affect mental health, focusing on disease prevalence and the association between demographics, PTSD severity, and comorbidities. Psychiatric researchers have investigated the prevalence and severity of PTSD following earthquakes. Such research can be challenging due to differences in exposure duration and earthquake intensity (Zhang et al \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Chang et al \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). PTSD became an important issue after events such as Typhoon Morakot in 2008. More recently, researchers have attempted to explore the relationship between PTSD and COVID-19 (Sahebi et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs the COVID-19 pandemic emerged in 2020, healthcare workers worldwide encountered immense physical and mental pressure. Some healthcare workers have committed suicide due to stress. Many frontline workers felt helpless during the pandemic and experienced moral injury. Researchers recommended providing immediate emergency assistance to health-care workers, emphasizing that supportive work environments help to reduce \u0026ldquo;moral injury\u0026rdquo; (Greenberg et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hines, 2021).\u003c/p\u003e \u003cp\u003eShay (1994) proposed the concept of \u0026ldquo;moral injury\u0026rdquo; following the Gulf War: Soldiers who participated in the Iraq and Afghanistan wars experienced psychological trauma, prompting Litz et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) to systematize this concept, emphasizing that these psychological responses arose from feelings of betrayal during military actions. In pandemic prevention, akin to warfare, the concept of moral injury has been applied to healthcare workers. Traumas often arise not from an illness itself or from moral conflicts in failing to treat patients, but from organizational culture and feelings of betrayal by the authorities. Most research on moral injury has been quantitative and has not fully captured the detailed thoughts and subjective feelings of individuals facing moral dilemmas.\u003c/p\u003e \u003cp\u003eIn exploring the structural underpinnings of these affective states, Shao-hua Liu (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) conducted a critical analysis of how Taiwanese medical professionals navigated the global\u0026ndash;local dilemma\" during the pandemic. Liu\u0026rsquo;s examination of medical epidemiologists suggests that Taiwan\u0026rsquo;s continued exclusion from global health governing bodies necessitated the pursuit of \"biological citizenship\" through rigorous epidemic control measures as a strategy for achieving international recognition. This geopolitical marginalization imposed a dual burden on medical experts, who were caught between transnational professional principles and the exigencies of nationalistic governance.\u003c/p\u003e \u003cp\u003eAlthough emphasizing moral injury is important, it can be a limiting diagnostic approach. This label risks pathologizing and individualizing psychological issues, potentially undermining an individual\u0026rsquo;s sense of agency. It may not fully capture the fluid psychological states or the varied meanings of negative feelings when an individual encounters difficulties. Experiences should not be framed solely as moral injuries because exploring the specific context and diversity of an individual\u0026rsquo;s moral world is crucial.\u003c/p\u003e \u003cp\u003eThis study adopts a different approach, while examining the negative feelings experienced by Taiwanese healthcare workers during the pandemic. Using a narrative perspective and focusing on the meaning of emotions, this article analyzes the social, cultural, and political significance of emotions. Moral injury may be conceptualized as a conflict between individual conscience and institutional demands. In contrast, putting \u0026ldquo;affect\u0026rdquo; as the main concern enables us to address how geopolitics, national identity, and collective memory are jointly woven into clinicians\u0026rsquo; embodied experiences.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eShifting to Affective Narratives\u003c/h2\u003e \u003cp\u003eAiming to provide a nuanced, contextualized perspective that complements existing epidemiological data, this study adopted a qualitative approach, utilizing one-on-one interviews to capture the affective experiences of healthcare workers, supplemented by a literature review. Interviews were conducted with 26 healthcare workers. The participants were aged between 23 and 75 years. Some participants possessed extensive work experience, including work during the 2003 severe acute respiratory syndrome (SARS) outbreak. Most participants aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years had worked in medical institutions during the SARS 2003 outbreak, with some having frontline care experience. Participants were asked open-ended questions regarding the influence of SARS on their COVID-19 caregiving experiences.\u003c/p\u003e \u003cp\u003eThis study employs narrative-oriented in-depth interviews to capture information that cannot be obtained through closed-ended interviews, utilizing narrative medicine rooted in Freud\u0026rsquo;s descriptive symptom approach. The narrative adopts a storytelling format and emphasizes plot development to identify the positions of events within the story. Narrative research, a form of qualitative research, is based on hermeneutic interpretations. By situating events based on relationships with other events in time and space, narrative research identifies the meaning of events, reflecting not only simple realities, but also choices, organizations, and simplifications of reality (Hinchman and Hinchman, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1997\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious research employing the narrative medicine approach have predominantly concentrated on patients' life stories and narratives, garnering attention within the fields of medical sociology (Williams, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Frank, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) and anthropology (Kleinman, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Garro, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). In contrast, the narratives of healthcare professionals have been relatively underexplored. Atkinson (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1995\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) introduced healthcare workers' narratives, examining how they judge, discuss, and approach decision-making when faced with challenges. Pollack (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) suggested that physicians' autobiographical narratives could capture the social history of medical development and the culture of medical practices, even highlighting gender perspectives within medical settings. Good and Good (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) propose a fictional understanding of medical stories, constructing a recognition of medical reality and historicity.\u003c/p\u003e \u003cp\u003eSince Durkheim, anthropologists and sociologists have considered the role of emotions in the body, sensation, emotion, and social change. Philosopher Deleuze (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1988\u003c/span\u003e) defined it as the dynamic relationship between bodies, enhancing or diminishing their capacity to affect and be affected by other bodies. The \"affective turn\" in humanities and social sciences has recently renewed interest in these dynamics. From a certain perspective, affect contrasts with emotion, possessing potential agency rather than a fixed cultural meaning. Affect is perceptible, dynamic, vibrant, and variable, enabling a holistic understanding of the lifeworld.\u003c/p\u003e \u003cp\u003eMazzarella (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2009\u003c/span\u003e:291) highlighted that contemporary public culture has become more overtly affective; thinking affect offers \"a way of apprehending social life that does not begin with the bounded intentional subject while foregrounding embodiment and sensuous life. \"In essence, affect points to social and embodied practices rather than individual emotional expressions. This concept aids in rethinking overly individualized psychiatric terminology. Anthropologist Lester (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) proposed that trauma narratives create ambivalent agency victimhood, necessitating a re-evaluation of the timeline of trauma. Interpersonal and social relationships are more critical than internal cognitive and emotional issues. She emphasized affect as an embodied cultural model for understanding mental illness, highlighting the importance of considering affect as an embodied practice.\u003c/p\u003e \u003cp\u003eIn the tradition of political philosophy, fear has long been recognized as a foundational element in collective formation and governance. This perspective traces back to classic thinkers like Niccol\u0026ograve; Machiavelli, who famously posited that fear is a more effective tool for maintaining social order than love, and Thomas Hobbes, who argued that the fear of anarchy serves as the very basis for individuals granting legitimacy to a governing body. Sara Ahmed (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2014\u003c/span\u003e:74) noted that the experience of fear is activated in patriotic declarations against terrorist attacks and serves as a tool for national identity cohesion. Taiwanese psychologist Liu Wen (2021) examined paranoid affect during the pandemic, emphasizing its role in understanding social experiences, contextual situations, and interpersonal relationships. She adapted the concept of \"affective practice,\" advocating for close observation of affect's concrete realization in daily practice, addressing issues of subjectivity and agency. Given Taiwan's geopolitical context, it is imperative to investigate this effect. Geographer Steve Pile (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2010\u003c/span\u003e:16) states, \"Emotional geography ensures there is no split between thought and affect.\" Expressions of affect relate not only to personal beliefs and values, but also to temporal and spatial contexts. Based on these discussions, this article examines the affective experiences of health-care workers through in-depth interviews, employing \"affect\" as an analytical framework to comprehend Taiwan's distinctive social and political milieu during the pandemic and to critically reflect on trauma narratives.\u003c/p\u003e \u003c/div\u003e"},{"header":"Research Design and Case Collection","content":"\u003cp\u003eThis research project was conducted over a 10-month period from August 2021 to June 2022. Crucially, this timeframe witnessed a pivotal shift in Taiwan\u0026rsquo;s pandemic trajectory: transitioning from a strict 'Zero-COVID' policy toward a strategy of living with the virus and achieving collective community immunity. This period of transition provides a unique vantage point to examine the evolving affective experiences and moral dilemmas faced by healthcare workers as they navigated the systemic reorganization of care protocols amidst escalating community transmission.\u003c/p\u003e \u003cp\u003eGiven the absence of specific assessment tools for moral injury, and this article \u0026lsquo;s focus on capturing narrative information about the concept, the study utilized semi-open questions to explore clinical workers' awareness, definition, and understanding of moral injury. Additionally, it investigated whether work experiences of moral injury influenced attitudes and decisions in medical practice. Participants\u0026rsquo; narratives extended beyond the initially defined scope of moral injury; therefore, the researcher documented their experiences and feelings. This study received ethical approval from the relevant institutional review board (the institution and approval numbers are temporarily withheld).\u003c/p\u003e \u003cp\u003eThe initial research design involved the recruitment of 30 clinical workers including physicians, nurses, medical technologists, and clinical psychologists. The interviews addressed experiences of moral injury, employing semi-structured questions. The subjective experiences of clinical workers during the SARS and COVID-19 pandemics were analyzed. Ultimately, the study recruited 26 participants (3 supervisors, 15 physicians, and 11 nurses; Table. 1). The interviews focused on clinical experiences during the pandemic, personal psychological effects, ethical dilemmas, and value conflicts. All participants provided written informed consent. No adverse effects were reported and no participants withdrew from the study.\u003c/p\u003e \u003cp\u003eAll interviews were recorded and transcribed verbatim, with all transcripts anonymized and encrypted. The research team reviewed and analyzed the transcripts, extracting keywords related to moral injury or other affective experiences. The keywords were contextualized within the participants\u0026rsquo; environments, work ecology, and pandemic policies. In this study, the participants\u0026rsquo; personal information was anonymized to avoid the potential of institutional pressure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipant initial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLocation of Institution\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetired Internal Medicine Doctor (Supervisor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTaipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttending Emergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNew Taipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Resident Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNew Taipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Resident Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNew Taipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttending Physician, ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNew Taipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttending Emergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNew Taipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Isolation Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Isolation Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHead Nurse, Internal Medicine ICU (Supervisor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily Medicine Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTainan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospice Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTainan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Internal Medicine ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTaipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Internal Medicine ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eENT Physician, Private Clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTaipei\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHead Nurse, Professor (Supervisor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTainan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency Physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKaohsiung\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse, Negative Pressure Ward\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHsinchu\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Rèxiě, Professional Commitment, and National Identity","content":"\u003cp\u003eThis study included several emergency department physicians, who were pivotal during the pandemic as emergency departments served as the front line of epidemic prevention efforts. All patients, irrespective of their condition or hospitalization requirements, underwent COVID-19 antigen screening at emergency stations, rendering emergency personnel the most experienced in epidemic prevention. Participants frequently utilized the term \"r\u0026egrave;xiě\" (hot-bloodedness) to describe their passion and sense of responsibility toward epidemic prevention work.\u003c/p\u003e \u003cp\u003eR\u0026egrave;xiě is the literal Chinese translation of \"hot blood,\" which in English means \"passion.\" The keyword r\u0026egrave;xiě was repeatedly mentioned during the interviews, possessing a more embodied connotation. Although healthcare workers' dedication to patient care is self-evident, this professional passion is rarely discussed during routine work, but becomes a shared affective experience during major infectious disease outbreaks.\u003c/p\u003e \u003cp\u003eAn emergency physician at a New Taipei medical center, who was an intern during the SARS outbreak and now teaches emergency medicine, often emphasized to students: \"We think of ourselves as frontline soldiers. Patients with SARS, COVID, or any other infectious disease who visit the emergency room cannot be refused treatment. We must manage and save everyone. This concept is ingrained in the blood of emergency physicians as a matter of professional pride.\"\u003c/p\u003e \u003cp\u003eDr. C, a resident of the Department of Family Medicine at a medical center in Taipei during the SARS outbreak, shared his experiences:\u003c/p\u003e \u003cp\u003e\"At that time, I was young and did not have many family responsibilities or significant concerns, so I was not afraid. I did not contemplate much about the potential consequences if I became ill. This passion (r\u0026egrave;xiě) propelled me.\"\u003c/p\u003e \u003cp\u003eA second-year resident in the emergency department of a medical center in New Taipei City said:\u003c/p\u003e \u003cp\u003e\"Initially, I thought it appeared truly admirable, as it seemed exceptionally powerful and exciting. I was filled with passion (r\u0026egrave;xi\u0026egrave;). Intubation and CBCs were impressive to me, and I felt a strong compulsion to learn how to perform them.\"\u003c/p\u003e \u003cp\u003eR\u0026egrave;xiě implies the embodiment of responsibility and ideals and carries martial connotations. This suggests that medical care is a calling that requires healthcare workers to be at the forefront during a pandemic. R\u0026egrave;xiě also reflects the moral values of frontline clinical workers during epidemic prevention efforts. However, this moral narrative not only highlights the sense of duty that health-care workers feel in fulfilling their \"calling\" to assist others, but also originates from a collective sense of honor. This collective sentiment not only arises from professionals' recognition of their individual responsibilities, but is also intertwined with emotions shaped by a form of collectivism.\u003c/p\u003e \u003cp\u003ePandemics have exposed the inadequacies of epidemic prevention infrastructure. Healthcare workers obtain less rest during a pandemic. R\u0026egrave;xiě enables clinical workers to temporarily set aside concerns about their working conditions. On one hand, it drives healthcare personnel to dedicate themselves selflessly and unhesitatingly, but consequently, it may also be the reason why they are placed in danger.\u003c/p\u003e \u003cp\u003eTherefore, the discourse of r\u0026egrave;xiě serves as more than a mere expression of individual professional dedication because it also operates as an \"affective regime\" that aligns clinical labor with national survival. By interpreting pandemic fatigue through the lens of sacrificial passion, the state and the public effectively mobilize healthcare workers to sustain a form of \"biological citizenship, which seeks collective recognition in a structurally unequal world. However, this affective mobilization becomes a dual-edged sword, providing clinicians with a sense of heroic purpose, while simultaneously obscuring systemic deficiencies. When r\u0026egrave;xiě is institutionalized as a normative expectation, any deviation is not perceived as a systemic failure, but as a personal moral lapse, marking the juncture at which affective labor can no longer bridge the gap between national representation and the precarious reality of care. These issues are addressed in detail in the subsequent sections.\u003c/p\u003e"},{"header":"Betrayed by the System: The Structural Drivers of Moral Injury","content":"\u003cp\u003e COVID-19 exacerbated tensions in hospitals and led healthcare workers to feel disconnected from the ethical and moral principles they typically adhere to. Some participants noted that the challenges during the pandemic impeded their ability to fulfill their professional responsibilities. These challenges sometimes arose from resource shortages and, at other times, from human factors such as differences in examination and treatment approaches among colleagues and the effects of policies.\u003c/p\u003e \u003cp\u003eA typical case of betrayal in a hospital setting occurred in the emergency department of a medical center in Kaohsiung. Physicians expressed anger when they were unable to effectively treat a patient due to stringent infection prevention requirements.\u003c/p\u003e \u003cp\u003e\"A radiologist noted that the patient's lungs were white, suggestive of COVID-19. Despite the clear symptoms of myocardial infarction and heart failure, a second negative test was required, leading to the patient's death. This is absurd and contradicts our medical oath.\"\u003c/p\u003e \u003cp\u003eMany institutions have strict infection prevention requirements, leading to numerous unreasonable demands during the process of transferring patients between departments. A nurse from a negative-pressure ward at another medical center in Kaohsiung stated:\u003c/p\u003e \u003cp\u003e\"I think some tests can still be done; it's just that other departments might find it really troublesome. Therefore, additional precautions must be taken. For example, if a patient needs to undergo a computed tomography scan, they must be escorted in protective gear, and security guards control the flow. Emergency procedures will still be carried out, but sometimes they simply ignore you.\"\u003c/p\u003e \u003cp\u003eThis process not only results in delays, but also hinders collaboration and communication among healthcare workers when treating patients.\u003c/p\u003e \u003cp\u003eInitially, most healthcare workers had a sense of duty and willingness to contribute to pandemic control and treatment. A second-year emergency resident at a New Taipei hospital shared his frustration with the epidemic prevention measures.\u003c/p\u003e \u003cp\u003e\"I felt I could attend to patients too. However, the hospital's system protected residents by keeping attending physicians outside. I am convinced that we could manage patients while employing appropriate protective measures. However, the hospital did not do so. I wanted to assist more and gain experience, but we had limited responsibilities inside the consultation room.\"\u003c/p\u003e \u003cp\u003eThese protective protocols prevented patients from receiving timely care and posed moral dilemmas for healthcare workers who wished to assist but were unable to participate, leading to a sense of guilt and anger toward institutional management. In fact, this perceived \"overprotection\" felt by young healthcare workers originated from the experience of the 2003 SARS outbreak. The SARS epidemic inflicted indelible trauma on Taiwan\u0026rsquo;s healthcare system. During that period, 151 healthcare workers were infected, and unfortunately, 11 succumbed to the disease in the line of duty. This tragedy revealed severe deficiencies in infection control training and protection mechanisms for young physicians within the medical system during that era. Consequently, the government immediately initiated a fundamental reform of medical education that same year, introducing a comprehensive Post-Graduate Year (PGY) training program. This system aimed to strengthen the foundational infection control capabilities and adaptive resilience of every clinician through general medical training before they entered specialized fields. Simultaneously, the medical community established stricter \"protection strategies,\" particularly for medical interns and residents.\u003c/p\u003e \u003cp\u003eThe sense of profound frustration and \"institutional betrayal\" experienced by healthcare workers during the pandemic was not merely an individual emotional response but a consequence of the fundamental conflict between professional ethics and the logic of medical governance. When physicians were compelled to witness patients succumb to conditions such as myocardial infarction due to administrative delays and stringent testing requirements, it highlighted a tragic reality where \"infection control administration\" overshadowed \"clinical rescue,\" directly contradicting the medical oath. This sense of betrayal is rooted in structural interventions driven by economic efficiency and risk aversion: departments engaged in patient-shuffling to minimize their own administrative \"trouble,\" while the \"overprotection\" of young doctors\u0026mdash;although historically grounded in the trauma of the 2003 SARS deaths and the subsequent PGY system\u0026mdash;evolved into a strategy to prevent the loss of \"expensive human capital.\u0026rdquo; For young clinicians, being restricted from high-risk areas not only impeded their professional development but also engendered profound guilt and anger, as they were unable to fulfill their professional values during a crisis. Ultimately, when the healthcare system treats its workers as \"sterile components\" to be preserved for operational capacity rather than as moral subjects, these efficiency-driven interventions become the structural drivers of moral injury.\u003c/p\u003e"},{"header":"SARS as an Affect Capital","content":"\u003cp\u003eAs previously mentioned, the SARS experience propelled reforms in Taiwan's medical training system. Moreover, for the healthcare professionals who experienced that epidemic, it facilitated the accumulation of a form of 'affective capital' used to confront the challenges posed by COVID-19. The 2003 SARS outbreak ranked among the most severe infectious diseases globally, with a high fatality rate, particularly affecting regions in Asia, including China, Hong Kong, Taiwan, and Singapore. In Taiwan, the SARS outbreak represented a pivotal turning point in the evolution of epidemic prevention policies. The Taiwan Central Epidemic Command, along with medical graduates, gleaned substantial insights from their experiences during the outbreak.\u003c/p\u003e \u003cp\u003eHealthcare workers with prior SARS experience were less apprehensive of the COVID-19 pandemic, leveraged their experience, and delivered timely responses. The organizational efforts undertaken over the past two decades have been imparted to younger personnel, who are now better equipped to comprehend the concerns and needs of frontline workers and to make empathetic decisions regarding work distribution.\u003c/p\u003e \u003cp\u003eAs an illustrative case, a study conducted at a major tertiary hospital in Taiwan during the 2003 SARS outbreak revealed that nearly 75% of healthcare workers experienced significant psychiatric morbidity (Chong et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). This immense psychological pressure stemmed from feelings of extreme vulnerability, the perceived threat to life, and the persistent uncertainty surrounding the highly contagious virus (Chong et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Hospital staff were forced to navigate heavy workloads and social isolation while facing the constant risk of infection without prior precedent. This profound collective trauma, however, eventually crystallized into a form of 'affective capital' within their professional careers, serving as a foundational reservoir of resilience when confronting the later challenges of COVID-19.\u003c/p\u003e \u003cp\u003eDr. C, a general practice resident working at a medical center in Taipei, recounted the frustration of being assigned to a fever screening station without adequate experience during the SARS outbreak:\u003c/p\u003e \u003cp\u003e\"It was absurd to place the critical responsibility of protecting the hospital from patients with SARS on family medicine residents instead of thoracic, internal, or infectious disease specialists.\u0026rdquo;\u003c/p\u003e \u003cp\u003eNearly two decades later, Dr C became the senior attending physician. In confronting the COVID-19 pandemic, he believed that excessive worry was unwarranted, and had confidence in the government's prevention policies.\u003c/p\u003e \u003cp\u003eTaiwan's initial experience with a large-scale, unfamiliar, infectious disease epidemic was with SARS. In response, the central government established new public health systems and medical education guidelines, and provided general medicine training through post-graduate training programs. Furthermore, the government implemented new institutional infection control procedures. Consequently, Taiwan\u0026rsquo;s response to COVID-19 was better than to SARS, with healthcare workers demonstrating greater preparedness and courage.\u003c/p\u003e \u003cp\u003e A head nurse at Hsinchu Regional Teaching Hospital, who was a new nurse during the SARS 2003, shared the following:\u003c/p\u003e \u003cp\u003e\"We retrieved paper regulations from the SARS period, read and adapted them to our unit, and prepared to go inside, reviewing cases with colleagues.\"\u003c/p\u003e \u003cp\u003eAn emergency physician at a New Taipei medical center highly endorsed the post-graduate year training program: \"SARS influenced this pandemic's response. The post-graduate program, often criticized, ensured that all physicians in Taiwan understood general medicine and were prepared to assist during emergencies.\"\u003c/p\u003e \u003cp\u003eThe narratives of the participants who experienced the SARS outbreak, suggest that when initially confronted with an unknown virus, healthcare workers may feel fear largely due to institutional inadequacies. However, after 20 years of improvements in the medical system and training protocols, novices have now become leaders. Fear and anger from the past evolved into affective capital in the context of the new pandemic.\u003c/p\u003e \u003cp\u003eThis transformation of past trauma into \"affective capital\" demonstrates how collective memory functions as a stabilizing force in pandemic governance. The legacy of SARS is not merely a technical repository of protocols, but a lived \"affective archive\" that anchors current actions in a historical narrative of survival. This capital enables clinicians to overcome the paralyzing effects of radical uncertainty by enacting a form of resilience that is predicated on beliefs about institutional progress. However, such affective capital is inherently conditional and demands reciprocal accountability from the state. When clinicians draw upon their memories of SARS to bolster their courage, they are not just performing duties, but reinforcing a social contract. Consequently, when policies appear politically motivated rather than scientifically grounded, the sense of betrayal intensifies, as it threatens the integrity of the affective capital invested in national defense.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFear of Becoming a \u0026ldquo;War Criminal\u0026rdquo;\u003c/h2\u003e \u003cp\u003eDespite the enhanced sense of security under more comprehensive prevention systems compared to during SARS, clinicians still experienced fear during the COVID-19 pandemic, often concerned they might become a \"breach in prevention\" or even a \"war criminal.\" This pressure was unique to Taiwan's initial zero-tolerance policy, which aimed to position Taiwan as a model for pandemic control, placing moral pressure on healthcare workers so as not to undermine national achievements. A dedicated ward nurse in Hsinchu said the following:\u003c/p\u003e \u003cp\u003e\"I tell others I work at a hospital but don't want to mention that I care for critically ill patients to avoid trouble.\"\u003c/p\u003e \u003cp\u003eA fourth-year emergency resident doctor in New Taipei City said:\u003c/p\u003e \u003cp\u003e\"Everyone was cautious, fearing becoming a breach in prevention. Taiwan is quick to assign blame, so we had to be very careful, fearing not just illness but also being seen as a war criminal.\"\u003c/p\u003e \u003cp\u003eThe term \"war criminal\" is a strong phrase. War metaphors appear to have frequently been used and readily accepted in Taiwan's pandemic response. Some scholars have suggested avoiding the association of pandemic prevention with war metaphors to prevent nationalism, racial discrimination, resource injustice, authoritarianism, and conspiracy theories (Panzeri et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Musolff, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, war metaphors are unavoidable in specific geopolitical contexts, such as when mobilizing prevention efforts. Taiwanese healthcare workers feared being labeled \"war criminals,\" reflecting Taiwan's persistent war threat since World War II. During the early stages of the pandemic, due to its geographical proximity to China, where the first cases of the COVID-19 were identified, coupled with long-standing political tensions, Taiwan\u0026rsquo;s strict epidemic prevention measures assumed a nationalistic character. A resident doctor in the emergency department of a medical center in Kaohsiung was restricted from returning to work at the hospital after visiting relatives in China during the Lunar New Year. The hospital implemented stringent quarantine measures, heightened level of precaution regarding the initial site of the outbreak. The doctor expressed the following:\u003c/p\u003e \u003cp\u003e\"What I felt more keenly was that people would start saying that these viruses were brought over from there. For a long time, Taiwan has been in a delicate and somewhat tense relationship with China. Being caught in the middle of one\u0026rsquo;s identity, hearing these comments can sometimes be uncomfortable.\"\u003c/p\u003e \u003cp\u003eDuring the COVID-19 pandemic, the public was advised to avoid using war metaphors. However, the statements of the participants in this study indicated that war metaphors are difficult to avoid. Clinicians who apply war narratives to their own circumstances reflect on their fear of war. This fear was not solely directed at the virus, but also at the palpable threat of war under regional political tensions. War metaphors can deepen the effects of discrimination but can also serve as a driving force for stricter epidemic prevention measures.\u003c/p\u003e \u003cp\u003eThe dread of being labeled a \"war criminal\" reveals how pandemic governance in certain political contexts transcends clinical management to become a project of national security. This \"affective state of exception\" illustrates that a breach in prevention is perceived not merely as a medical error, but also as a geopolitical failure that jeopardizes national prestige. In this context, the \"war metaphor\" is not a mere linguistic choice but a reflection of tangible political stakes. When clinicians internalize the possibility of being deemed \"war criminals,\" they are navigating a space where they are mobilized as frontline buffers against perceived external threats. This fear indicates that the negative feelings experienced are fundamentally linked to the nation\u0026rsquo;s precarious standing, where affective labor becomes a mechanism of state security, further blurring the boundaries between medical ethics and national loyalty.\u003c/p\u003e \u003c/div\u003e"},{"header":"Resonance of Suffering: Doing More for Patients and Families","content":"\u003cp\u003eDuring the early stages of the pandemic, \"even as the 'Zero-COVID' policy compelled everyone to be hyper-vigilant to avoid becoming a breach in prevention, with few cases of COVID-19 in Taiwan, healthcare workers did not feel a heavy labor burden. Workers would often go beyond their normal caregiving duties and voluntarily offer additional services. This motivation sometimes arose from their experiences or from witnessing similar struggles, creating psychological resonance.\u003c/p\u003e \u003cp\u003eDr. M, an emergency critical care physician, made video calls instead of in-person meetings.\u003c/p\u003e \u003cp\u003e\"During my time caring for patients with COVID-19, there was a case where a patient was very breathless before intubation and managed to speak to their family through a video call. After intubation, the patient experienced cardiac arrest due to low blood oxygen levels. Although the heartbeat was revived, the patient remained in a vegetative state. I managed to arrange a video call, allowing the husband and brother to speak to her, encouraging her to keep fighting.\"\u003c/p\u003e \u003cp\u003eSuch practices indicate that regulatory frameworks often restrict medical actions. Healthcare workers typically do not use remote communication to explain conditions. However, isolation as a key measure against COVID-19 led to the establishment of remote consultation regulations. Healthcare workers\u0026rsquo; experimental actions sometimes embody resistance and breakthroughs against existing systems.\u003c/p\u003e \u003cp\u003eTwo nurses working in a negative-pressure ward at a medical center in Kaohsiung were interviewed. These nurses had experience dealing with infectious diseases and recalled encountering severe anxiety when they suspected contracting tuberculosis.\u003c/p\u003e \u003cp\u003eOne nurse stated, \"An X-ray showed abnormalities, and we suspected tuberculosis. I had to undergo a test and was extremely fearful. Despite my extensive experience with infectious diseases, the prospect of explaining this to my family kept me awake at night.\"\u003c/p\u003e \u003cp\u003eDuring the pandemic, the nurse cared for a Ukrainian patient with no family support and assisted in establishing a social media page to locate his family:\u003c/p\u003e \u003cp\u003e\"We even created a Facebook page for him to connect with his mother. He spoke limited English and was mentally ill. He had attacked the captain of a ship and was quarantined in accordance with COVID-19 protective measures. Hearing his mother's voice and connecting with her helped him to calm down.\"\u003c/p\u003e \u003cp\u003eAnother nurse from the same negative-pressure isolation ward recounted her experience caring for foreign caregivers. As the foreign workers were in isolation and had no family to care for them, the nurses voluntarily took turns purchasing Indonesian food.\u003c/p\u003e \u003cp\u003e\"We would buy some Indonesian food from nearby vendors who cooked and sold their dishes. This made them very happy, as they were reminded of home.\"\u003c/p\u003e \u003cp\u003eMany patients have experienced loneliness and homelessness during the COVID-19 pandemic. Healthcare workers can provide additional services beyond medical care to provide patients with a sense of home. This form of empathy, in which healthcare workers go beyond usual duties for their patients, is precisely the unique aspect revealed in this study., showing that the affective experiences and moral values of healthcare workers are closely intertwined. Although the pandemic imposed physical and mental stress on healthcare workers, their resilience may manifest through a pronounced display of empathy, serving as a compensatory strategy for their negative emotions.\u003c/p\u003e"},{"header":"Silenced Grievances","content":"\u003cp\u003eTaiwan’s pandemic trajectory shifted significantly in May 2021. The community infection rate had remained nearly zero for an extended period; however, airline crew members and quarantined hotel staff contracted COVID-19 in late April, leading to an increase in the number of community infection cases in May. The number of infected individuals surged, prompting Taiwan to elevate its alert level to level three. Frontline healthcare workers encountered immense physical and mental pressure under stringent isolation measures and hospital care protocols. They reported feeling compelled into silence, with the hospital's zero-infection policy primarily aimed at preserving healthcare workforce capacity. Workers were subjected to constant moral pressure, perceiving an unspoken prohibition against social behaviors, and any positive diagnosis implied disloyalty to hospital policy.\u003c/p\u003e \u003cp\u003e A dedicated ward nurse at a regional teaching hospital in Hsinchu described a pronounced sense of detachment from early pandemic enthusiasm:\u003c/p\u003e \u003cp\u003e\"I only know that I felt very sad. It is not exactly sadness but negative emotions, such as frustration and helplessness. It felt like an endless situation with no end in sight, which made me feel annoyed.\"\u003c/p\u003e \u003cp\u003eThis sense of interminability reflects disillusionment with the once seemingly effective zero-infection strategy. As the pandemic response evolved into a prolonged battle, the mindsets of clinical workers underwent significant transformations. Unlike the initial fear of becoming a breach in the pandemic prevention efforts, healthcare workers under extreme stress sometimes expressed a desire to test positive to obtain a break. One nurse shared:\u003c/p\u003e \u003cp\u003e\"I am not sure if it is similar for others, but persons around me are generally unhappy. Some, like me, just want to test positive to get a break, even though it burdens our colleagues.\"\u003c/p\u003e \u003cp\u003eAnother nurse who worked at the same hospital described the intense workload and restrictions:\u003c/p\u003e \u003cp\u003e\"The pressure was so intense that we spent seven out of eight working hours inside, only emerging to handle orders. We often had lunch as late as 5 PM or 6 PM and this was repeated daily. We encountered many restrictions and had no outlet to relieve stress, even as our supervisors kept reminding us not to eat out or gather, which made us feel even more constrained.\"\u003c/p\u003e \u003cp\u003eYoung nurses responsible for caring for patients with COVID-19 in negative-pressure wards were predominantly in their twenties. Many were unmarried and did not have the responsibility of caring for children, making them more likely to be assigned night shifts. However, as the pandemic progressed, they gradually began experiencing physical and mental exhaustion. Another nurse from the same unit as the two previously mentioned earlier was reprimanded by her supervisor after testing positive for COVID-19. During the interview, she displayed her phone showing how her illness was publicly disclosed in the team’s social media group, raising questions about her adherence to health management protocols.\u003c/p\u003e \u003cp\u003e\"One morning, I had breakfast outside, and my supervisor immediately assumed I contracted COVID-19 there. They announced my illness in a group chat, blaming me for not adhering to the rules. I felt targeted and angry.\"\u003c/p\u003e \u003cp\u003eUnder immense pressure, young nurses resorted to clandestine gatherings as a coping mechanism. However, dedicated ward supervisors also faced pressure to maintain operational capacity, reflecting the broader challenges in risk management under pandemic policies. These policies were influenced by Taiwan's unique geopolitical context, which necessitated strict measures. A key reason these feelings could not be openly expressed was that these clinicians believed they were powerless to alter the situation and therefore saw no necessity to do so. First, they felt unable to challenge the hospital's hierarchical organizational culture. Furthermore, they maintained the belief that the pandemic would eventually subside and that normality would be restored. If someone could not endure the circumstances, the only option was to leave.\u003c/p\u003e \u003cp\u003eThis shift from passionate dedication to desperate longing for infection marks the limit and eventual disintegration of national affective mobilization. When the \"Zero-COVID\" policy transformed from a public health goal into a mechanism of \"moral surveillance,\" the affective atmosphere of the clinic shifted from collective honor to the dread of punishment. The reprimands of supervisors and public shaming in social media groups reflect a governance logic that prioritizes biosecurity over individual subjectivity. Under this regime, the clinician’s body is instrumentalized as a \"sterile resource\" to maintain national capacity; any sign of illness is interpreted as both a professional and moral betrayal. This \"enforced silence\" not only masks systemic vulnerabilities but also inflicts a profound moral injury—clinicians realize they are not cared-for subjects in the eyes of the state, but rather biopolitical components required to function in a vacuum, devoid of personal needs or human limitations.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRighteous Anger: Imagining Justice and Public Interest\u003c/h2\u003e \u003cp\u003eClinicians’ positions and affective experiences during the pandemic varied hierarchically. Unlike frontline practitioners facing institutional oppression, senior healthcare workers with SARS experience often express anger over public issues, which this article terms \"righteous anger.\" This affective reaction arose from senior workers workers’ experiences and empathy for frontline workers' struggles, reflecting their sense of justice in public policies. This section highlights another type of response, empathy, which is more radical.\u003c/p\u003e \u003cp\u003eThe Taiwanese government established a command center for the pandemic, and daily press briefings served as a singular communication channel. While some criticized this centralization of power, the majority of healthcare workers interviewed supported national policies and expressed anger at key opinion leaders who opposed them. During the pandemic, many discussions were held regarding vaccines and many influencers claimed that the government's promotion of vaccinations was detrimental. Dr. L, who experienced quarantine at Hoping Hospital during SARS, dismissed the opinions of those influencers.\u003c/p\u003e \u003cp\u003e\"They do not hold the position, so they do not bear the responsibility. Some already have a specific stance, and as long as they are supported by certain media outlets, their voices are heard. But to put it bluntly, what do they really know? Do they believe infectious disease specialists are incompetent?\"\u003c/p\u003e \u003cp\u003eTaiwanese society is highly politically polarized, and many influencers express extreme views in the media, complicating the public’s ability to discern the accuracy of professional opinions. Dr. L continued,\u003c/p\u003e \u003cp\u003e\"I think the media thrives by creating chaos. Initially, they criticized the AstraZeneca vaccine, rendering it worthless. However, many individuals receiving the BioNTech vaccine do not realize that the second dose can be more potent. The media brainwashed them into thinking that getting the AstraZeneca vaccine would be deadly, but they would understand when they receive the second dose of BioNTech.\"\u003c/p\u003e \u003cp\u003eThe world has been presented with a completely different media landscape during the COVID-19 pandemic, with numerous studies and discussions on misinformation and post-truth-era epidemic prevention. During the 2003 SARS outbreak, the media was perceived to have considerably complicated Taiwan's epidemic prevention efforts. Retired pulmonologist Dr. K, who served as the executive director of a crisis management center at a medical facility during SARS, stated that his most vivid memory of the anti-epidemic experience was dealing with the media. At that time, a resident physician caring for SARS patients traveled to Japan and was diagnosed with the infection upon return. The Japanese media questioned the physician’s professionalism, stating that he had traveled despite exhibiting fever symptoms, potentially spreading the virus to the Japanese populace. Dr. K publicly defended the resident physicians against the Japanese media ‘s criticisms, stating:\u003c/p\u003e \u003cp\u003e\" These health news reporters had no substantial material to work with, so they simply resorted to sensationalism. The most alarming aspect was the media's reckless reporting.\"\u003c/p\u003e \u003cp\u003eAlthough some criticized Taiwan's government for establishing a command center during the COVID-19 pandemic, citing concerns over centralized power and a lack of diverse perspectives, Dr. K commended this approach.\u003c/p\u003e \u003cp\u003eTherefore, the health department is completely transparent. They allow questions until there are none remaining. They provide answers daily, irrespective of the questions, and regardless of the media outlet you represent.\"\u003c/p\u003e \u003cp\u003eDr. K's narratives reflect his full support for the government[s initiatives and are based on the concepts of fairness and justice. However, each individual’s concept of justice varies and is influenced by their personal histories and social roles.\u003c/p\u003e \u003cp\u003eProfessor N, a nursing professor at a medical school in southern Taiwan, offered a contrasting perspective of command centers. Professor N was interviewed in 2021, when the Omicron variant began to spread. She disagreed with the command center's overly centralized approach, stating:\u003c/p\u003e \u003cp\u003eIncreasing evidence has shown that Omicron is not severe; however, every day, 40 or 50 people are sent to medical centers. I do not understand; we have always said that it was not necessary.\"\u003c/p\u003e \u003cp\u003eHaving experienced previous infectious disease outbreaks, Professor N understood the pressures encountered by frontline healthcare workers in hospitals and advocated for a more flexible response to the evolving pandemic. Her responsibilities included ensuring continuous communication, sufficient supplies, and an adequate workforce. She recounted that in January 2020, she had not anticipated taking certain actions. When COVID-19 was first reported in Taiwan, some N95 masks ordered from foreign suppliers did not arrive. She later discovered that other units intercepted the masks. After reading a story about a resident physician in New York who resorted to using a gun to seize supplies, she decided to personally retrieve the supplies from customs. \"It was really outrageous. Sometimes we realize that we are not so different from New York,’ she said.\u003c/p\u003e \u003cp\u003eThe righteous anger described in this section was also experienced by Dr. L, who was dissatisfied with certain influencers deliberately opposing government policies; Dr. K, who clashed with journalists during the SARS outbreak; and Professor N, who was frustrated with pandemic prevention policies during the COVID-19 outbreak. This anger pulsed among healthcare workers during the pandemic, prompting them to go beyond the call of duty. Their actions reflect a philosophy of action that transcends traditional moral standards, and the pandemic provided individuals with space to reimagine justice.\u003c/p\u003e \u003cp\u003eThis \"righteous anger\" functions as an affective mechanism for defending professional boundaries and expert authority in an era of polarized misinformation. Unlike moral injury which arises from a sense of powerlessness, this anger originates from a position of institutional seniority and \"affective capital\" accumulated through previous crises, such as SARS. It reflects a transition from passive compliance to an active \"scientific citizenship,\" wherein clinicians feel compelled to safeguard the public interest against what they perceive as the \"epistemic chaos\" engendered by media and political influencers. By dismissing critics as irresponsible \"outsiders,\" these senior professionals are not merely endorsing the state; they are asserting that true justice in public health must be rooted in clinical responsibility and specialized knowledge rather than populist rhetoric. However, Professor N’s experience with intercepted supplies demonstrates that this anger challenges the state’s bureaucratic inefficiencies. Ultimately, righteous anger serves as a catalyst that prompts clinicians to \"reimagine justice\" by reclaiming the agency to define what constitutes a rational and ethical response, thereby transforming their emotional frustration into a proactive philosophy of action that transcends conventional moral frameworks.\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion: Beyond Trauma – The Geopolitics of Affect","content":"\u003cp\u003eThis article contends that the experiences of Taiwanese healthcare workers during the COVID-19 pandemic have transcended the individualized diagnostic framework of \"moral injury\" or \"trauma.\" Instead, these experiences should be understood through what this study terms the “geopolitical affective regime.\" As Anderson (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) suggests, affective life is not merely a personal interior state but an \"object-target\" for biopolitics and security environmentality. In Taiwan, this biopolitical target was specifically shaped by a \"double bind\" of existence: the need to perform as a global model of health excellence, while navigating structural isolation from the international community.\u003c/p\u003e\u003cp\u003e1. The Temporality of Affect: From Capital to Betrayal\u003c/p\u003e\u003cp\u003eTaiwanese clinicians’ affective journeys revealed how temporality shapes moral experiences. In the early stages (2020– 2021), the pandemic response was fueled by the \"affective capital\" inherited from the 2003 SARS trauma. This capital transformed past fear into a \"heroic narrative\" explicitly linked to national survival. However, unlike the romanticized resistance often criticized by Scheper-Hughes (1993), the \"Team Taiwan\" sentiment represented an \"affective mobilization\" where clinicians voluntarily ceded individual rights for the sake of national \"biological citizenship.”\u003c/p\u003e\u003cp\u003eHowever, as the pandemic transitioned from the \"Zero-COVID\" ideal to the large-scale community outbreaks of May 2021, this capital began to deplete. The analytical shift here is critical: the exhaustion felt by clinicians was not merely a result of physical workload, but a \"rupture of the affective contract.\" When policies shifted and resources became strained, senior clinicians’ “righteous anger” functioned as an emotional critique of institutional management. This anger indicates that emotions are not just markers of victimhood but also tools for social critique, reflecting a demand for professional accountability that transcends psychological support.\u003c/p\u003e\u003cp\u003e2. The Spatiality of Affect: Geopolitical Dreads\u003c/p\u003e\u003cp\u003eThe anxiety associated with becoming a 'breach in prevention' or a 'war criminal' highlights the spatial dimension of affect. This spatiality is also reflected in the various levels of spatial deployment: for example, healthcare workers must serve as defensive sentinels for their medical institutions to achieve 'zero-infection,' while regional designated hospitals must bear the responsibility of maintaining zero infections across their entire administrative jurisdictions. Ultimately, these efforts are directed toward consolidating Taiwan's image as a “world model” for pandemic control. In Taiwan’s unique geopolitical situation, the 'war metaphor' is not a rhetorical choice but a reflection of tangible existential threats. The clinician’s body became a literal national border. This study finds that the 'moral injury' often reported in Western literature—typically centered on the inability to provide care—is, in Taiwan, reconfigured as a 'geopolitical moral burden.' Clinicians were pressured to maintain an image of national perfection in order to secure Taiwan’s global standing.\u003c/p\u003e\u003cp\u003e3. Reimagining Justice\u003c/p\u003e\u003cp\u003eUltimately, overemphasizing \"trauma\" or \"PTSD\" risks depoliticizing the clinician's experience, reducing structural and geopolitical tensions to a psychopathological condition. By shifting the focus to affect politics, we can observe how the moral worlds of individuals are inextricably intertwined with collective nationalistic mobilization. The \"righteous anger\" and \"tactical fear\" described by participants are not symptoms to be treated, but a philosophy of action that reimagines justice within a \"post-truth\" and polarized landscape. For Taiwan's democratic sovereignty, the lesson is clear: Fostering a resilient medical profession requires more than individualized psychological services; it demands recognition of the geopolitical stakes that shape the affective worlds of those on the front line.\u003c/p\u003e"},{"header":"Conclusion: Toward a Temporal-geopolitical and Contextual Approach to Affect","content":"\u003cp\u003eThe primary objective of this study was to move beyond the limiting narratives of individualized trauma to a more nuanced and context-sensitive interpretation of the affective challenges faced by healthcare workers. These findings suggest that clinicians’ experiences during the COVID-19 pandemic cannot be encapsulated in purely psychological or psychiatric terms. Rather, they are deeply embedded in the specific temporal and spatial logic behind Taiwan’s pandemic governance. As this research illustrates, the affective states of clinicians—ranging from the sacrificial fervor of rèxiě to the strategic dread of being labeled a \"war criminal\"—are not merely internal reactions to stress but are responses to a state striving for global legitimacy in a structurally unequal world.\u003c/p\u003e\u003cp\u003eThis study demonstrates that \"moral injury\" often discussed in academic literature must be contextualized within the highly politicized nature of epidemic prevention. While slogans of \"global solidarity\" prevail in health governance, the pandemic has reified borders and exacerbated geopolitical tensions. In Taiwan, when bureaucratic or political performance eclipses professional integrity, the resulting sense of erosion is not just clinical burnout but structural tension. However, these affect-laden experiences are not exclusively negative; they also embody a form of resilience. By viewing negative affect as a potential site of resistance or \"righteous anger,\" we can recognize the agency of clinicians who seek to reimagine justice amid institutional inadequacies.\u003c/p\u003e\u003cp\u003eConsequently, this article advocates for a narrative-oriented, de-victimizing approach to clinician well-being. By avoiding the tendency to equate suffering with a passive victim identity, this approach restores healthcare professionals’ subjectivity and dignity. To be effective, support interventions must transcend individualized psychological treatment and address the institutional and geopolitical factors that underlie clinician distress. Establishing healing spaces through independent third-party entities can provide a sanctuary in which the complexity of these affective worlds is acknowledged without being pathologized. Ultimately, understanding the affective politics of frontline care is not only a matter of mental health but also a necessary step toward fostering a more robust and ethical foundation for healthcare systems in an era of globalized epidemics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003eThe author has no conflict of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e(The institution and approval numbers are temporarily withheld.)\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was supported by a grant from [Anonymized for Peer Review].\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYi-Cheng Wu is the sole author of this article. He was responsible for all aspects of the study, including the conceptualization and research design, conducting qualitative interviews and data collection, performing the literature review, and drafting and revising the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnderson, B. (2009). Affective atmospheres. Emotion, Space and Society, 2(2), 77\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.emospa.2009.08.005\u003c/span\u003e\u003cspan address=\"10.1016/j.emospa.2009.08.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed, Sara. 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Psychiatry research, 153(2), 171\u0026ndash;177. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.psychres.2006.04.021\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2006.04.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, affective experiences, moral injury, geopolitics, Taiwan","lastPublishedDoi":"10.21203/rs.3.rs-8675330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8675330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis article provides a critical examination of the affective experiences of clinicians in Taiwan during the COVID-19 pandemic, challenging the individualized diagnostic framework of \"moral injury.\" While global scholarship has extensively documented the psychological distress of healthcare workers, this study posits that their moral experiences are inextricably intertwined with specific geopolitical anxieties and \"affective regimes\" of care. Combining ten months of qualitative research and in-depth interviews, the author analyzes how the temporality and spatiality of the pandemic influenced clinicians' emotional lives.\u003c/p\u003e \u003cp\u003eThe findings indicate that the experiences of Taiwanese clinicians\u0026mdash;ranging from the sacrificial fervor of r\u0026egrave;xiě (hot-bloodedness) to the strategic dread of being labeled \"national sinners\"\u0026mdash;are not merely psychological reactions to trauma. Instead, they function as a form of \"affective labor\" mobilized to sustain national \"biological citizenship\" amidst Taiwan\u0026rsquo;s structural isolation from the global health community. By exploring the transition from the \"affective capital\" inherited from the 2003 SARS crisis to the \"righteous anger\" sparked by pandemic-era misinformation, this article underscores the political significance of emotions. Ultimately, the study advocates for a narrative-oriented, de-victimizing approach that acknowledges clinician subjectivity and addresses the macro-structural tensions underpinning their moral worlds, thereby offering a contextualized alternative to de-politicized trauma narratives.\u003c/p\u003e","manuscriptTitle":"Beyond Moral Injury: Temporal-Geopolitical Anxiety and the Affective Regime of Care in Taiwan during COVID-19","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 11:07:44","doi":"10.21203/rs.3.rs-8675330/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7afd0a3-f939-4635-b094-8d1bee3ac78e","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T01:48:12+00:00","index":8,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-24T11:07:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 11:07:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8675330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8675330","identity":"rs-8675330","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}