Moral injury

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. 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." 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 The shame that many individuals face as a result of moral injury may predict symptoms of posttraumatic stress disorder. 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. 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. 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. 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. Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield. 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. In 2000 the concept of moral distress being generated by systemic issues was called "the ethical canary" 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 Physicians in the United States were caught in situations that prevented them from doing what they perceive is the right course of action, i.e. taking care of the patient well. Instead, they were caught in double and triple and quadruple binds between their obligations of electronic health records, their own student loans, the requirements for patient load through the hospital and number of procedures performed. The injury stems from the proximity to secondary trauma and the inability provide the optimal level of care. Moral injury has been studied in medical students working within the National Health Service (NHS). NHS doctors come to psychological harm as a result of not being able to give patients the care that they need in an under-resourced NHS. Since the beginning of the COVID-19 pandemic in 2020, healthcare workers in the United States in particular have been faced with decisions like rationing care while hospital policy and insurance constraints remain, without support or training on how to psychologically process the toll these decisions can take. Driven by changes in health care reimbursement structures, systems were "optimized" to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic. As such, COVID-19 has only exacerbated an already deeply challenged system. The United Nations Special Rapporteur stated that mental interventions should be geared towards removing barriers to well-being. Support for realization of civil, political, economic, social, and cultural rights may be the results of mental health interventions. ==First responders==

The concept of moral injury has more recently also been discovered among police, and likely exists among firefighters as well and other forms as first responders work and should include such Emergency Medical Services, legal defenders/lawyers, and Child/Adult Protective Services. Professions with non-human subjects such as veterinarians are also beginning to be studied. == Prisons ==

An ex-prison official "has used the term 'moral injury' to describe the experience of staff working in unsafe, dangerous prisons: alienated from their own morality or professional standards, they try to get to the end of each day without losing a life, but suffer the consequences in elevated rates of suicide, alcohol addiction, breakdown, or domestic violence." Moral injury in prisons could include causing or witnessing injury to detainees with undue force, feeling powerless to prevent assaults or detainee suicides, and "may include having to follow specific correctional procedures which the individual believes are unethical within the specific scenario". A study found that some Canadian correctional officers "felt they had no means to "discipline"" prisoners who harmed others in prison, leading to forced acts of omission and potential moral injury. Detainees Detainees "may be especially vulnerable to moral injury-related mental health difficulties". ==Psychology==

Brett Litz and colleagues define moral injury as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations." Litz and colleagues focus on the cognitive, behavioral, and emotional aspects of moral injury, positing that cognitive dissonance occurs after a perceived moral transgression resulting in stable internal global attributions of blame, followed by the experience of shame, guilt, or anxiety, causing the individual to withdraw from others. The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors. Psychological risk factors which make an individual more prone to moral injury include neuroticism and shame-proneness. Protective factors include self-esteem, forgiving supports, and belief in the just-world fallacy. ==Sociology==

Anthropologist Tine Molendijk's transdisciplinary research has shown that as unresolved conflicts at the political level create potentially morally injurious situations for soldiers on the ground, "experiences of institutional betrayal" and "a resultant search for reparations" by veterans can also be part of moral injury. She further demonstrates that not only public condemnation of veterans, but public heroification, too, may contribute to moral injury, given that both are generally experienced by veterans as alienating distortions of their war experience, meaning that both may entail an "injustice" being done to the experience. As the causes of moral injury lie not only in the individual but also at the organizational, political and societal levels, Molendijk further argues, solutions should be sought at these levels as well. The practical implications of a holistic approach to moral injury, for instance, include that we need 'a more elaborate moral vocabulary, the decision-making framework of the Just War Tradition, and purification and reintegration practices'. ==Theology==

Rita Nakashima Brock and Gabriella Lettini emphasize moral injury as "...souls in anguish, not a psychological disorder." This occurs when veterans struggle with a lost sense of humanity after transgressing deeply held moral beliefs. Moral injuries can cause religious struggles, such as feeling punished by God or alienated. == Treatment==

While moral injury can be experienced by people other than military service members, research has paid special attention to moral injury in military populations. According to Shay, the process of recovery should consist of "purification" through the "communalization of trauma". Shay places special importance on communication through artistic means of expression. Moral injury could only be absolved when "the trauma survivor... [is] permitted and empowered to voice their experience....". Fully coming "home" would mean integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support. == Moral injury vs. PTSD ==

Post-traumatic stress disorder (PTSD) and moral injury are related but distinct constructs, each associated with significant psychological distress arising from exposure to adverse events. PTSD is a well-defined psychiatric disorder that develops following exposure to actual or threatened death, serious injury, or sexual violence, and is primarily characterized by fear-based symptoms, including intrusive recollections, hyperarousal, avoidance, and negative alterations in cognition and mood. The underlying mechanism is typically linked to experiences of intense fear, helplessness, or horror in life-threatening situations. Moral injury, by contrast, refers to the psychological, emotional, and spiritual distress that results from actions, or the failure to act, which violate an individual’s deeply held moral or ethical beliefs. Rather than fear, moral injury is principally associated with guilt, shame, remorse, and a sense of moral disorientation or loss of integrity. Although PTSD and moral injury can co-occur, particularly in high-risk contexts such as military combat, they differ in both etiology and therapeutic approach. Evidence-based treatments for PTSD, such as cognitive behavioral therapy (CBT) and prolonged exposure therapy, focus on processing traumatic memories and reducing conditioned fear responses. In contrast, interventions targeting moral injury emphasize moral repair, including processes such as acknowledgment of wrongdoing, self-forgiveness, making amends, and the restoration of a coherent moral identity. While standard PTSD treatments may alleviate some overlapping symptoms, they do not directly address the moral and existential dimensions central to moral injury. Consequently, specialized therapeutic approaches have been developed to address these aspects, often incorporating elements of narrative reconstruction, ethical reflection, and reconciliation. ==References==

Long-term moral injury can harm mental health and cause psychological issues. People with moral injuries often feel guilty, ashamed, and use self-blame, feelings which can make daily life difficult. These emotions can lead to depression, recreational drug use, and thoughts of suicide. Moral injuries also relate to emotional numbness and relationship issues. People with moral injuries often trust others less and feel alone. It is suggested that early spotting and treatment can stop moral injury from developing conditions like complex PTSD or personality disorders (Litz et al., 2009). As moral injury is being researched, mental health experts are starting to focus on treatments made just for it, to heal and rebuild how they see themselves and the world. Their experiences can often break this view. ==References==