Moral injury can occur if someone does or witnesses something that violates their personal moral beliefs. They may feel guilty, ashamed, or angry or feel that they have experienced a betrayal.
The concept of moral injury has some overlap with post-traumatic stress disorder (PTSD) and can have some of the same effects.
However, people who have experienced moral injury do not always meet the criteria for PTSD. For this reason, some experts consider moral injury a separate, although sometimes related, phenomenon.
Read on to learn more about what moral injury is, potential examples, how it affects mental health, and more.
Moral injury is the harm that can occur when a person violates a deeply held moral belief or sees someone else doing so. It is not a distinct mental health condition but can contribute to one.
Moral injury can be the result of something a person does themselves or something they witness others doing. Additionally, it can be an act of either commission or omission — in other words, something a person did or did not do.
For moral injury to take place, a person must feel that there has been a serious transgression of some kind. A less severe form of this phenomenon, known as moral distress, involves more minor transgressions that can still affect a person’s mental health over time.
Moral injury can affect people in any situation, but it has
- military personnel
- law enforcement officials
- emergency responders
- healthcare workers
- veterinarians
- journalists
The situations that may cause a moral injury can vary depending on each person’s idea of right and wrong.
Below are some examples of situations that may cause moral injury in certain professions.
In healthcare
Scenarios that may cause moral injury in healthcare include:
- making tough decisions about who to treat because of a lack of resources or staff
- not having enough time, or being too fatigued, to support patients
- notifying superiors of a risk to a patient but being ignored
- following hospital policies that a person profoundly disagrees with
- carrying out decisions in accordance with patient wishes, even if doing so could result in harm
- treating patients who have a contagious condition and accidentally transmitting it to others
- taking shortcuts that compromise a patient’s care or seeing others do so
In veterans
Situations that may cause moral injury among military veterans include:
- making a mistake that puts others at risk, such as falling asleep while on patrol
- saving oneself from danger instead of someone else
- freezing or running away in response to traumatic events instead of following orders
- making tough decisions that affect others’ safety or survival
- giving or following orders that harm civilians
- hurting or killing someone
- feeling exhilarated, or feeling nothing, when causing harm
- not reporting when someone breaks rules or violates ethics
The potential signs of a moral injury include:
- feeling guilty or ashamed
- feeling angry
- feeling disgusted
- feeling betrayed by others or by an institution
- not being able to forgive oneself or others
- feeling as if oneself or others deserve punishment
- experiencing survivor’s guilt
These feelings may affect behavior. For example, a person who feels guilty or as if they deserve punishment may:
- keep what happened to themselves
- not seek help with what they are experiencing
- stop going to therapy because they feel they do not deserve to get better
- sabotage good things in their life, such as relationships
- withdraw socially
Some may also feel that the event has affected their spirituality, causing them to question their beliefs.
Moral injury and PTSD have some overlapping signs and effects. Like PTSD, moral injury can occur as a result of a traumatic event — but it is a separate phenomenon.
One reason for this is that, unlike PTSD, moral injury
PTSD also causes some symptoms that moral injury, on its own, does not. These include:
- hyperarousal, a feeling of being very alert and “on edge”
- flashbacks
- nightmares
Not everyone who experiences moral injury goes on to develop PTSD, or vice versa. A person may experience one, the other, or both.
According to the U.S. Department of Veterans Affairs (VA), many people who experience moral injury recover with time. However, some people experience longer-lasting distress.
If this distress affects a person’s daily life or occurs along with symptoms of PTSD or depression, the person may need help getting better.
Research into treatment for moral injury is ongoing. Below are some methods that may help.
Psychotherapy
Psychotherapy, often known simply as “therapy,” can help with many emotional or psychological problems. It may help whether someone has moral injury alone or along with other symptoms.
However, people with moral injury can sometimes find it difficult to talk about what happened to them, especially if they feel responsible.
If a person is worried about this, it is important for them to remember that therapy with a licensed psychotherapist is confidential and that therapists aim to create a judgment-free space in which to talk.
Researchers are still investigating which types of therapy may help with moral injury, but examples include:
- acceptance and commitment therapy, if adapted for moral injury
- adaptive disclosure, which involves discussions with an imaginary moral authority to process what happened
- trauma-informed guilt reduction therapy
Therapies for trauma may also help if the moral injury relates to traumatic memories.
Specialized programs and support groups
In some cases, programs and support groups may be available to specifically address the type of moral injury a person has experienced. The VA, for example, lists options such as:
- Moral Injury Group: a group that involves discussing moral injury with a psychologist and a chaplain
- Impact of Killing: a structured 10-week treatment that explores forgiveness, which people can participate in after PTSD treatment
- Building Spiritual Strength: a type of group therapy that addresses the impact of moral injury on spirituality
Self-care
People can also cope with moral injury by taking steps to care for themselves. This may look different from person to person, but a 2020 review focusing on moral injury among nurses recommends:
- Building moral resilience: This means making decisions based on one’s values and beliefs while maintaining perspective on the limitations. For example, a person might spend as much time with patients as they can but recognize that there are time constraints that are beyond their control.
- Sharing with others: If possible, people can discuss how they feel in a safe environment with others who may have had similar experiences. This may help people feel understood and less alone. Others may also have useful insights on how they handle ethical dilemmas.
- Practicing mindfulness: Mindfulness may help people manage stress, anxiety, or feelings of helplessness. It encourages people to focus on the present moment and may help them cope with challenging situations.
Moral injury is not always preventable. Sometimes, people experience situations that require quick decision making or tough calls that affect the well-being of others. A person cannot get things right or help everyone in every case.
But a 2021 report from the British Medical Association (BMA) highlights how systemic problems in an institution can make it harder for people to act in accordance with their morals.
The report found that many employees in the United Kingdom’s National Health Service had experienced moral distress or injury, particularly since the COVID-19 pandemic. The most prominent factor the respondents reported was a lack of staff and resources.
Certain groups were more likely to say that moral injury resonated with their experiences, including people from minority ethnic backgrounds and those with disabilities or health conditions. These results suggest that members of certain groups are more likely to feel moral distress or more likely to be in positions in which they experience it.
The report recommends empowering health workers with the staff, resources, autonomy, and support they need to do their jobs well.
On an individual level, the BMA suggests that a person:
- talk about moral distress and moral injury so that others become more familiar with these concepts
- develop a support network they can lean on when having trouble
- speak out when it is possible to do so
- have a plan for mental and physical self-care
In addition, the VA highlights the important role that leaders can play by:
- setting rules
- reinforcing values and standards
- clearly communicating decisions or policy changes
- checking in with people, especially during challenging times
- looking out for signs of moral injury and helping people get support
Moral injury can occur when a person experiences an event that violates their moral beliefs. This could be something the person did themselves, something they did not do, or something they saw someone else do. Moral injury may result in feelings of anger, betrayal, guilt, shame, or disgust.
This phenomenon is not a medical condition, but it may contribute to PTSD or depression and can have long-lasting effects for some people. It has associations with certain groups, such as people who work in healthcare or the military, but it can affect anyone.
Research into therapies for moral injury is ongoing, but there are several types of talk therapy that may help. Peer support, spiritual support, and self-care may also play a role in recovery.
