MORAL INJURY

Moral injury is a type of traumatic stress injury; a psychological, social and spiritual wounding that can occur in high-stakes situations that deeply challenge the integrity of personal values, expectations and social norms.

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Potentially morally injurious events (PMIEs) can include:

• Acts that transgress one's sense of what is morally right

• Feeling let down or betrayed by superiors, colleagues, or the public

• Gross injustice or systemic failure

• Exposure to human vulnerability, suffering and indignity

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Exposure to morally injurious events is very often associated with Post Traumatic Stress (PTSD), but one can also experience moral distress or moral wounding without PTSD. Although caused by threat to one's core moral beliefs rather than physical safety, moral injury may be encoded by the body as an 'assault' equivalent to a direct physical attack. Indeed, one possible explanation for the strong link between moral injury and PTSD is that morally injurious events can erode one's sense of safety in the world in just as powerful a way as threats to physical safety, but with moral injury this occurs through erosion or damage to fundamental pillars that create order and safety in society.

 

However, where life threatening events involve intense feelings of fear, terror and helplessness, morally injurious events provoke deep feelings of horror, anger, injustice, betrayal, embitterment, shame, guilt and loss. Most descriptions of moral injury tend to highlight guilt and shame, but the other feelings noted above are often just as present and important to address for healing. Sometimes feelings like anger or guilt cover other feelings that indicate the deeper injury.

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While much attention and research has focused on moral distress in veterans returning from war, there are a number of other populations exposed to PMIEs. Those who work in emergency response, law enforcement and child protection experience high rates of exposure to morally challenging events and the global COVID-19 pandemic has drawn increasing attention to the potential for moral distress faced by frontline medical staff. Moral injury has also been studied in refugee populations affected by large scale injustice, persecution and torture and, although not researched specifically, there is valid speculation about the potential for moral injury in other professional groups such as educators or in marginalised groups such as indigenous populations.

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Current mental health diagnoses and associated treatments do not adequately account for the depth of suffering and alienation experienced by those grappling with moral injury. Over the last decade, a broad distinction has emerged between self-focused (perpetration-based) and other-focused (betrayal-based) moral injury. In this site, we look beyond these broader constructs to step inside the lived experience of moral injury in order to promote understanding of the mechanisms of injury and pathways to recovery.

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