Moral Injury: A Theme in Search of Definition

Changiz Mohiyeddini ^1,*, Elizabeth Carlson ¹, Deena Sukhon ¹, Wesam Almasri ¹, Marwa Saad ¹, Daniel Eshun ², Stephanie Baker ³

1. Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Oakland University, USA

2. Roehampton University, London, UK

3. Boston Symphony Orchestra, USA

* Correspondence: Changiz Mohiyeddini

Academic Editor: Marianna Mazza

Received: May 27, 2024 | Accepted: October 14, 2024 | Published: October 22, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 4, doi:10.21926/obm.icm.2404062

Recommended citation: Mohiyeddini C, Carlson E, Sukhon D, Almasri W, Saad M, Eshun D, Baker S. Moral Injury: A Theme in Search of Definition. OBM Integrative and Complementary Medicine 2024; 9(4): 062; doi:10.21926/obm.icm.2404062.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Moral injury refers to a complex psychological condition that emerges following exposure to distressing events that challenge the moral values or ethical beliefs of individuals through direct commission, omission, observation, or betrayal by a trusted leader [1,2,3]. For instance, healthcare personnel working during the COVID-19 pandemic could encounter moral injury as they feel forced to prioritize life-saving procedures based on the available resources due to a shortage of equipment [4].

Research on moral injury has proliferated in recent years and is been studied in a broad range of occupations and environments, such as the military [5,6,7,8,9,10,11], police and law enforcement [12], child protection services [13], healthcare [4], education [6], and humanitarian aid work [14]. Empirical evidence suggests that moral injury is associated with depression [15], anxiety [16], burnout [17], suicidal ideation [18], and maladaptive coping responses, such as substance misuse, social withdrawal, or self-destructive and self-handicapping behaviors [19]. These consequences can severely impact the daily functioning, mental health, well-being, identity, and social relationships of those suffering from moral injury [2,6,20]. Therefore, it is plausible to consider moral injury as a serious public health issue [21]. Thus, the aim of this paper is to provide a narrative overview of the scientific literature for clinicians to develop a better understanding of moral injury.

The concept of moral injury was proposed by Jonathan Shay [3], a physician seeking to elucidate the persistence of the characteristics of PTSD experienced by veterans. Shay observed that PTSD alone was an inadequate explanation of the veterans' condition, as the underlying cause was not merely exposure to typical traumatic events but stemmed from experiencing betrayal from a trusted leader. Litz and colleagues later added that moral injury also arose from committing, failing to prevent, observing, or being informed about acts that violate moral beliefs fundamental to that individual [1].

Although Shay is credited with coining the term 'moral injury,' the concept itself has been recognized for centuries. In fact, Shay references the work of Johannes Haubold, a Homer scholar, who, in his book's conclusion, identifies moral injury in Homer's Iliad due to the loss of trust in a leader. Haubold describes how the warriors' defining structure, embodied by their leader, fails them, resulting in the metaphorical destruction of the people [3]. Shay further elucidates that a leader holds the role of a 'shepherd of the people' [3], bearing the responsibility of caring for and demonstrating loyalty to their subordinates. When a leader neglects or violates this duty, their subordinates become susceptible to moral injury [3].

While moral injury was originally introduced in the context of war and leadership betrayal, modern research has expanded its application to various professions and has led to ongoing debates about its definition and the need for standardized assessment tools. However, as the extensive review by Houle et al. [22] points out, there is no consensus on the definition of moral injury, nor are there standardized diagnostic criteria or assessment tools for this evolving concept [14]. While there are several scales used to assess moral injury, including the Moral Injury Events Scale (MIES) [23] and the Moral Injury Outcome Scale (MIOS) [24], these tools have varying levels of validation across different contexts. Houle et al. [22] emphasize that while some of these tools have been validated in military populations, their use in other occupational contexts, such as healthcare, is less established. Importantly, many of the existing scales conflate the measurement of moral injury exposure with psychological outcomes, making it difficult to discern the precise role of the moral transgression in causing subsequent distress. As a result, there is an ongoing need for more rigorous psychometric evaluations of these tools in diverse populations.

Consequently, moral injury is not classified as a mental illness and is often described as a 'wound' [25], 'a wound to the soul' or a 'crisis of conscience' [26]. Nevertheless, Shay [3] describes moral injury as 'a betrayal of what's right by someone who holds legitimate authority in a high-stakes situation'. In contrast, Litz et al. [2] define moral injury as 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations'. Shay places emphasis on the profound sense of betrayal experienced by individuals who trust authority to act with moral and ethical standards, while Litz et al. [2] emphasize the violation of deeply held moral beliefs.

As a result, the experience of moral injury involves the convergence of three key elements: 1) a betrayal of deeply held moral principles, 2) perpetrated by direct commission, omission, or by an individual holding a position of legitimate authority (such as a military leader), and 3) unfolding within a context of high-stakes circumstances that may cause severe harm to the lives or livelihoods of other people [2,6,27]. This can be illustrated in a military context. Moral injury may be associated with actions such as killing or injuring noncombatants. It could also be associated with witnessing atrocities committed by one's own or allied forces or being ordered to carry out actions perceived as morally questionable [3]. Similarly, this can also be illustrated in a healthcare context. Moral injury may arise from situations such as providing care that is not aligned with a patient's values or wishes. It could also arise from being unable to provide necessary care due to institutional constraints (e.g. when patients do not have comprehensive health insurance coverage) or resource limitations (e.g. limited number of ventilators during the COVID-19 pandemic) or experiencing conflicts between personal and professional values [28,29].

2. Symptoms and Consequences

Symptoms of moral injury can include guilt, shame, anger, and a sense of moral disorientation or loss of meaning [2]. Individuals who experience moral injury may also struggle with spiritual or existential questions, such as doubting their own beliefs or questioning the meaning of life [6]. In a military context, symptoms of moral injury have been linked to negative mental health outcomes such as depression, anxiety, and suicidal ideation [30]. In healthcare, moral injury has been linked to burnout, decreased job satisfaction, and the intention to leave the profession [29].

3. Moral Injury and PTSD

A central controversy in the literature on moral injury pertains to whether moral injury that arises in the context of trauma should be categorized as a subtype of PTSD [31]. In the event of such classification, a question arises concerning whether the designation of "moral injury" should be restricted to cases wherein individuals undergo feelings of shame and guilt, excluding exposure to the revised criterion A of the DSM-5 [32], which encompasses 'death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.' However, empirical evidence suggests that mental health outcomes associated with moral injury differ from but are associated with PTSD [1,33]. In contrast to PTSD, which arises from traumatic events (such as threats to life, exposure to physical or sexual violence, accidents, or natural disasters), potentially morally injurious events may not involve exposure to life-threatening events. Instead, morally injurious events challenge an individual's core ethical beliefs, sense of right and wrong, and erode their trust in legitimate authorities. However, the symptoms of moral injury can be similar to and overlap with those of posttraumatic stress disorder (PTSD), including intrusive thoughts, nightmares, avoidance behaviors, and hyperarousal [2,34]. Shay states that "pure PTSD, as officially defined, with no complications, such as substance abuse or danger seeking, is rarely what wrecks veterans’ lives, crushes them to suicide, or promotes domestic and/or criminal violence" [3]. Therefore, it has been proposed that unidentified and untreated moral injury may contribute to the unsuccessful treatment of PTSD in veterans and even stimulate an abnormal stress response [14,27].

Three different categories can classify the symptoms of moral injury. Psychologically, individuals may experience guilt or shame. The experiences of self-blame, anger, irritability, anxiety, or depression can also be grouped into this category. Behaviorally, individuals may exhibit social withdrawal or distrust of self or others. Engaging in substance abuse or displaying risk-taking behaviors, such as suicidality, can also be grouped into this category. Physically, individuals may present with fatigue, insomnia, chronic pain, chronic illness, or an increased risk of cardiovascular disease [27].

Moral injury shares many similarities with PTSD, particularly regarding symptoms like guilt, shame, and emotional distress. While both conditions often involve exposure to traumatic events, the key difference lies in the nature of the traumatic experience. PTSD typically results from direct exposure to life-threatening events, while moral injury arises from experiences that violate an individual's moral or ethical code. Houle et al. (2024) explain that PTSD symptoms tend to focus more on fear-based reactions (e.g., hypervigilance, flashbacks), whereas moral injury is often characterized by deep-seated guilt, shame, and moral disorientation, which may not always be present in PTSD. Another important difference between PTSD and moral injury is that the presence of physiological arousal is not a necessary diagnostic criterion for moral injury, whereas guilt and shame are not inherent in PTSD and are not required for the diagnosis of PTSD [27]. This difference underscores the need for distinct therapeutic approaches, although the boundary between the two conditions is often blurred.

4. Interventions for Moral Injury

The lack of clear diagnostic criteria and assessment tools presents significant challenges in treating patients who suffer from moral injury and related mental health issues [22]. Several studies have highlighted this problem, emphasizing that without standardized definitions and measurements, clinicians may struggle to accurately diagnose and effectively treat moral injury [1,2]. For instance, Griffin et al. [1] discussed the lack of consensus on the definition and assessment of moral injury, highlighting how this ambiguity hinders effective clinical interventions and research efforts. In a related vein, Jinkerson [27] argued that without clear diagnostic criteria, it is challenging for clinicians to differentiate moral injury from other trauma-related disorders, impacting treatment strategies.

However, some therapeutic interventions, such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE), which are adapted from PTSD treatments, show promising outcomes. For instance, CPT is a type of cognitive-behavioral therapy and involves identifying and challenging maladaptive beliefs related to the traumatic event. In the case of moral injury, it may involve working through feelings of guilt, shame, and self-blame related to the violation of one's moral beliefs and values and has been shown to be effective in reducing symptoms of PTSD and depression in individuals who have experienced moral injury [34].

The "Moral Injury and Reconciliation Therapy" (MIRT) developed by Litz and colleagues [2] is another intervention with promise in treating moral injury. MIRT is a group-based intervention that provides a safe space for individuals to share their experiences and feelings of moral injury, aiming to promote post-traumatic growth and reconciliation. Emphasis is placed on empathy and forgiveness. The program also highlights connection with others as an important part of the process of healing from moral injury.

There are also several promising approaches that have yet to be fully tested in clinical trials in addition to these evidence-based interventions. For instance, mindfulness-based interventions have shown potential in reducing symptoms of moral injury in military veterans [35]. Similarly, acceptance and commitment therapy (ACT) is a promising proposal to address the existential distress associated with moral injury [36]. These interventions may be particularly useful for individuals who are hesitant to engage in traditional talk therapy approaches.

In addition, research has shown that spirituality may be an important resource for individuals struggling with the experience of moral injury and may play a role in promoting post-traumatic growth and resilience [37,38]. In this line of interventions, spiritual interventions, including forgiveness therapy and rituals of atonement, have also been explored, particularly in military contexts [2], with the limited available data suggesting promising outcomes.

Furthermore, group interventions, such as peer support groups or spiritual retreats, have also been used to address moral injury in military and healthcare contexts [6,29]. However, as highlighted by Houle et al. [22], these interventions are often applied on an ad hoc basis and have not been consistently validated for treating moral injury across diverse populations and contexts.

5. Future Directions

The veracity of moral injury among healthcare professionals has encountered skepticism, wherein it is postulated that this phenomenon bears a closer resemblance to pseudoscientific conjecture rather than a substantiated human condition amenable to treatment and systematic study [39]. In contrast to this skepticism, there is a considerable amount of literature on moral injury that addresses clinical concerns and effective treatment approaches [40]. Featured prominently among these studies are psychological outcomes. Further interdisciplinary research is still needed, though and could explore how moral injury may contribute to cognitive, biological, or spiritual imbalances. Additionally, there is a call for improved psychometric development to assess moral injury in various contexts, as it is often concealed or misdiagnosed, such as being diagnosed as post-traumatic stress in combat veterans or portrayed as burnout among physicians [41].

Not only military personnel and first responders are at risk for moral injury; this is important to recognize. There are many other high stress and high-risk professions that could put individuals at risk, for example healthcare workers, journalists, and aid workers. Moral injury is not limited to specific professions. Anyone who experiences events that challenge their moral beliefs can be affected. Hence, it is important for research to continue to address moral injury in both the workplace and in society. The existence of moral injury in workplace settings, such as healthcare, has been the subject of ongoing questioning and mischaracterization. A crucial step in addressing and preventing moral injury is acknowledging it as a genuine condition rather than dismissing it as pseudoscience, a perspective held by many individuals [40]. Therefore clinicians, policymakers, and researchers should continue to collaborate on the development of effective prevention and treatment strategies for moral injury. These important collaborations should include diagnostic criteria. They could also include assessing the efficacy of interventions and addressing the social and cultural factors that contribute to moral injury.

6. Conclusion

An individual's mental health and well-being can be significantly impacted by moral injury; it is a complex and severe psychological condition. Unlike post-traumatic stress disorder (PTSD), often associated with exposure to traumatic events, moral injury is more closely linked to moral values and beliefs, and the perception of having violated those values.

While the concept was first described in the context of war, it has since been extended to other settings where individuals may be exposed to events that violate their moral or ethical beliefs, such as healthcare and law enforcement. Causes of moral injury include witnessing or perpetrating acts of violence, participating in or bearing witness to unethical or unjust practices, and experiencing betrayal or neglect by leaders or institutions. Symptoms of moral injury can include guilt, shame, and anger, as well as a sense of moral disorientation and loss of meaning. Treatment options for moral injury include various types of therapy, group interventions, and mindfulness-based interventions. Given the significant impact of moral injury on mental health and well-being, there is a pressing need for future research, to develop clearer definition(s) and diagnostic criteria that are vital to enhance the clinical and research utility of moral injury. Furthermore, more rigorous psychometric validation of moral injury scales is essential to ensure that these tools are applicable across various occupational and cultural contexts. Additionally, there is a need to better understand the relationship between moral injury and other psychological conditions, such as PTSD, moral distress, and depression, to improve differential diagnosis between them. Lastly, research should focus on the development and validation of targeted therapeutic interventions that address the unique psychological, emotional, and spiritual aspects of moral injury.

Author Contributions

Changiz Mohiyeddini, Elizabeth Carlson, and Deena Sukhon were responsible for drafting the manuscript and conducting the initial database searches. Wesam Almasri, Marwa Saad, Daniel Eshun, and Stephanie Baker contributed by conducting additional data searches, performing the literature review, and providing critical input for the paper. Changiz Mohiyeddini supervised the overall project, ensuring its academic rigor and coherence.

Competing Interests

The authors have declared that no competing interests exist.