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Moral Injury
Moral injury is the social, psychological, and spiritual harm that arises from a betrayal of one’s core values, such as justice, fairness, and loyalty. Harming others, whether in military or civilian life; failing to protect others, through error or inaction; and failure to be protected by leaders, especially in combat—can all wound a person’s conscience, leading to lasting anger, guilt, and shame, and can fundamentally alter one’s world view and impair the ability to trust others.
A soldier in the line of duty may accept the necessity of shooting an enemy combatant. But when, in attempting to identify the assailant, he finds a picture of the dead man’s children, a sense of the value of service may itself be shattered.
A person who grossly violates what they believe is right may experience persistent self-criticism—feeling unworthy, unforgivable, or permanently damaged. Reflecting on the perceived transgression can fill a person with sorrow and bitterness.
Anyone forced to make intense ethical choices risks moral injury; circumstance—not character—produces this struggle.
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Anyone caught in a life-or-death or otherwise high-stakes situation with no good choices can suffer moral injury. Therapists, human rights workers, first responders, survivors of abuse and political violence can all face dilemmas that pitch moral and professional or self-preservation values into conflict.
Doctors, too, can feel the strain of moral injury. What is often labeled “physician burnout” may in fact come from deep frustration with ethical quandaries presented by the modern healthcare system. For example, electronic record-keeping isolates doctors from patients. Doctors may struggle with caregivers’ decisions to continue life support for loved ones who may be in great pain.
When the doctors’ oath to do no harm conflicts with the ability to prevent suffering, physicians can agonize personally. More than twice as many doctors die by suicide every year compared to the general population.
Research suggests that moral injury is widespread among members of the military, and it is linked to anxiety, depression, PTSD severity, and risk of suicide. One study reported that over 90 percent of veterans with PTSD had at least one severe symptom of moral injury and 59 percent had at least five such symptoms.
The way doctors are asked to practice medicine today is often in direct conflict with their deepest values. Over the past decade or so, doctors have gone from being independent practitioners to employees of healthcare systems, some owned by hospitals, some by insurance companies. One result, studies show, is that profits often come before patients, with the business of medicine divorced from—and controlling—clinical care. Doctors are squeezed, typically placed on tightly controlled schedules, with patient quotas to fill that drastically curb their time with each patient.
Intensive medical care for COVID-19 patients has required special technical equipment and skills regarding respiratory methods. Even when performing all measures correctly, there has still been a high rate of death among patients. In regions and countries where hospitals faced surges of ill patients, some doctors had to make life-or-death decisions when pressed for time and resources. These difficult conditions have led to moral injury among some healthcare professionals throughout the COVID-19 pandemic.
Collective moral injury involves the effect of ongoing moral injury on the body politic—how a community grapples with events that violate their values, for example if an unarmed civilian is killed by the police. The world today faces constant moral strain, visible in protests rife with moral outrage as well as injustice, discrimination, divisiveness, and the distortion of fact and fiction.
Treatments for moral injury are still in development. At the Department of Veterans Affairs in the United States, trials of cognitive behavioral therapy emphasizing forgiveness and self-compassion have been reported to bring about significant improvement in anxiety and depressive symptoms for veterans with moral injury.
The same treatment also fostered post-traumatic growth. Group therapy has also helped veterans restore a sense of trust through connection with others who have had similar experiences.
The military has learned—and other organizations can heed these lessons—that positive institutional values can diminish vulnerability to moral injury. Clearly articulating how organizational values link to the mission statement, inculcating positive organizational standards, and reinforcing values-based decision-making can help military personnel deal with the difficult choices they must make.
Practices like meditation, mindfulness, resilience skills, exercise, and healthy eating are helpful, but they often do not address the root cause of moral injury. In medicine, for example, physicians can learn these skills, but they do not address the incentive structure of a for-profit healthcare system. “There is a place for mindfulness. There is a place for yoga and resilience. But they are not reasonable ways to fix a structural problem,” says trauma surgeon and moral injury researcher Simon Talbot.
Moving away from avoidance and speaking openly about one’s experience is often the first step of moving beyond moral injury. Those with a moral injury should reach out to a trusted individual who will not judge their experience. This could be a family member, close friend, support group of those with similar experiences, a religious or spiritual leader, or a therapist. This outside perspective can help validate the person’s feelings and provide a more forgiving outlook.
In the military context, for example, one soldier struggled with feelings of blame and responsibility after his fellow officers were killed in a mission while he was on leave. He had to reframe the situation to achieve moral clarity: Did he see himself like a homeowner who never put a fence around his pool and discovers a child has wandered in and drowned? Or did he see himself as a police officer who might have had helpful information but was off-duty at a moment that would have saved lives? Practicing self-empathy and accepting that he was similar to the police officer helped him heal from moral injury.
Forgiving oneself and others can be a critical step toward releasing the burden of moral injury. This does not mean condoning or excusing a transgression. Forgiveness involves making a decision to acknowledge one’s own or others’ responsibility for what happened coupled with an emotional release of the burden of condemnation. Forgiveness also doesn’t require people to repair or reconcile with others who were involved in the transgression.
Moral beliefs and values are almost always imbued with social or religious significance; people may fear rejection or betrayal when disclosing a choice that feels wrong or unethical. Therefore it’s important to be empathetic and non-judgmental. When a friend or loved one struggling with a moral injury chooses to share their experience, acknowledge that it may have been difficult to disclose the experience, listen with compassion, and ask how to aid their process of recovery and repair.
Exposure to stress, in some cases, can lead to growth following adversity, called post-traumatic growth. Moral strain can also provoke positive responses, for example greater motivation to seek change, and moral, spiritual, and emotional development. (This may be more likely if one experiences guilt rather than shame.) Attitudes such as belief in a just world are also thought to be associated with better outcomes during stressful circumstances.
The self-loathing and distrust of others that often follow moral injury can lead to depression and anxiety, occasionally aggression, and, at worst, suicidal thinking. Psychiatrist Jonathan Shay, who developed the concept of moral injury in working with Vietnam veterans for over 20 years, contends that violence and suicide among veterans stem more from a moral injury than from PTSD.
Post-traumatic stress disorder and moral injury often go hand in hand, but there are important differences: PTSD is the result of a life-threatening experience that leads to chronic hypervigilance and fear; it is difficult to ever feel safe. Moral injury involves loss of trust; it is not a disorder but a reasonable response to having one’s ethical compass thrown off track.
Moral injury is not currently included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Scientific consensus has yet to be reached on the parameters of moral injury.
