A moral injury is a traumatic experience emerging from the witnessing of or participation in an act of perceived moral transgression on the part of themselves or others. It produces profound feelings of guilt or shame, moral disorientation, and societal alienation. In some cases it may cause a sense of betrayal and anger toward colleagues, commanders, the organization, politics, or society at large.
Moral injury is most often studied in the context of military personnel, and is studied in occupational groups that frequently encounter "high-stakes" situations. It has been studied in healthcare workers (especially during the COVID-19 pandemic), prison officers, humanitarian aid workers, human trafficking survivors, people involved in accidents, and people who have been raped or abused.
Definition Psychiatrist Jonathan Shay and colleagues coined the term moral injury to describe experiences where someone who holds legitimate authority has betrayed what is morally right in a high-stakes situation. The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma.
According to the International Centre for Moral Injury, it "involves a profound sense of broken trust in ourselves, our leaders, governments and institutions to act in just and morally 'good' ways" and the experience of "sustained and enduring negative moral emotions – guilt, shame, contempt and anger – that results from the betrayal, violation or suppression of deeply held or shared moral values."
The US Department of Veterans Affairs uses the term moral injury to describe the experiences of military veterans who have witnessed or perpetrated actions in combat that transgressed their deeply held moral beliefs and expectations.
History In 1984, the term moral distress was first conceptualized by philosopher Andrew Jameton in his book on nursing issues, Nursing Practice: The Ethical Issues to describe the psychological conflict nurses experienced during "ethical dilemmas". He wrote that "moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action."Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984
In the 1990s, the term moral injury was coined by psychiatrist Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay's definition of moral injury had three components: "Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation." As of 2002, Shay defined moral injury as stemming from the "betrayal of 'what's right' in a high-stakes situation by someone who holds power."
In 2009, the term moral injury was modified by Brett Litz and colleagues as "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (2009, p. 695). According to Litz et al., the term moral injury had been developed in response to the inadequacy of mental health diagnoses, such as post-traumatic stress disorder (PTSD), to encapsulate the moral anguish service members were experiencing after returning home from war. Unlike PTSD's focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust. The shame that many individuals face as a result of moral injury may predict symptoms of posttraumatic stress disorder.
As of 2017, no systematic reviews or meta-analyses exist on the construct of moral injury, although a literature review of the various definitions since the inception of moral injury has been undertaken, as well as psychological and interdisciplinary literature reviews of how moral injury develops and the factors involved.
In 2019, researchers surveyed previous literature and expertise to compile a list of events that could distress civilians at a level consistent with moral injury. Examples include causing a car accident or experiencing sexual assault, but researchers emphasize that not everyone will respond to an event in the same way.
In the early 2020s, moral injury emerged as one of the explanations for the wave of employee resignations across industries. In particular, Ludmila Praslova proposed that moral injury might be a better explanation for a segment of resignations and employee distress than burnout, and provided suggestions for organizational-level interventions.Praslova, Ludmila N. (2022). Feeling distressed at work? It might be more than burnout. Fast Company, January 14, 2022Ron Carucci and Ludmila N. Praslova (2022). Employees Are Sick of Being Asked to Make Moral Compromises. Harvard Business Review, February 21, 2022.
In 2022, researchers identified associations between moral injury and complex post-traumatic stress disorder (CPTSD). CPTSD's disturbances in self-organisation constitute the three additional clusters of symptoms distinguishing it from PTSD (i.e. emotional dysregulations, interpersonal difficulties, negative self-concepts around beliefs of worthlessness or failure and related guilt or shame). Veterans with possible CPTSD reported greater moral injury related to perpetration- and betrayal-based events compared to those with and without possible PTSD and findings suggesting the special relevance of moral injury among veterans with CPTSD.
Military To understand the development of the construct of moral injury, it is necessary to examine the history of violence and the psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so. Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors. Ethical and moral challenges are inherent to warfare. Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken.
Service members who are deployed into war zones are usually exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing post-traumatic stress disorder. PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences.
As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events. PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity. Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms.
Moral injury can also be experienced by warriors who have been transgressed against. The injury may in those cases, which are often about transgressions by the soldier and others (e.g. the commander) at the same time, include a sense of betrayal and anger. For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, or when the soldier is sent to war with an impossible mandate rendering him powerless in the face of human suffering, the soldier can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, etc. – can also suffer moral injury.
The exposure to violence during war times puts the military and veteran population at a higher risk of developing moral injury. According to statistics collected in 2003, 32 percent of American service members deployed to Iraq and to Afghanistan were responsible for the death of an enemy, 60 percent had witnessed both women and children who were either ill or wounded to whom they were unable to provide aid, and 20 percent reported being responsible for the death of a non-combatant.
Similar work has been conducted in a Canadian military context – out of Canadian Armed Forces personnel deployed to the mission to Afghanistan, more than half endorsed a traumatic event that was conceptually linked to moral injury. Specifically, 43 percent saw ill or injured women or children who they were unable to help; 7 percent felt responsible for the death of Canadian or allied personnel, and 38 percent had difficulty distinguishing between combatants and non-combatants. Controlling for other fear-based deployment-related stressors, exposure to such potentially morally injurious events has been related to increased prevalence of PTSD and depression in military personnel.
During times of war a service member's personal ethical code may clash with the decisions they are expected to make or the behavior they are expected to display. Approximately 27 percent of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond. Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield.Mental Health Advisory Team (MHAT-IV). (2006, November 17). Operation Iraqi Freedom 05-07. Retrieved December 18, 2008 This is problematic considering deployment lengths increased for the war in Iraq and Afghanistan.
During times of war, the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members. While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home, the socio-cultural expectations are largely different from when they were deployed. The ethical code back home has not changed, making the transition from deployment to home difficult for some service members. This clash between personal ethics and the ethics and expectations of the military can further increase a service member's deep-seated feelings of shame and guilt for their actions abroad.
Healthcare professionals Moral distress among healthcare professionals was first conceptualized in 1984 by Andrew Jameton. The concept was gradually explored over the subsequent 30 years in both nursing and veteran literature, though, as above, the definitions were slightly different. In the healthcare literature, moral injury is the accumulation of negative effects by continued exposure to morally distressing situations.Rushton, C. H. (2018). Moral Resilience: Transforming moral suffering in healthcare. New York: Oxford City Press. In 2000 the concept of moral distress being generated by systemic issues was called "the ethical canary"Sommerville, M. (2000). The ethical canary: Science, society and the human spirit. New York, NY: Viking. to draw attention to the sensation of moral distress signaling a need for systemic change.
Situations in which moral distress is experienced may be caused by:
Hierarchical imbalances, such as a nurse being unable to challenge a decision made by a senior physician Legal requirements, such as a necessary treatment being banned