Moral injury refers to the psychological, social, and spiritual impact of events or acts that a person performs, witnesses, or fails to prevent, which conflict with one’s own deeply held moral beliefs and values.

Moral injury is a specific type of psychological injury that reflects an enduring impact on an individual’s self-image and worldview.

When a moral injury occurs, the range of outcomes is broad and can include:

• Feelings of guilt, shame, anger, sadness, anxiety, and disgust
• Intrapersonal outcomes include lowered self-esteem, high self-criticism, self-destructive behaviours, and feelings of being bad, damaged, unworthy, or weak
• Interpersonal outcomes include loss of faith in people, avoidance of intimacy and lack of trust in authority figures
• Existential and spiritual outcomes include loss of faith in previous religious beliefs and no longer believing in a just world

While moral injuries are strongly linked to military service members due to the conditions of deployments or traumatic events, moral injuries are not limited to serving personnel and Veterans.

Moral injury can also impact non-military professions such as:

• Social workers
• Journalists
• Lawyers, judges, jurors and others in the legal field
• Aid workers
• Veterinarians
• Healthcare workers

The King’s Centre for Military Health Research released a video about moral injury – view it below:

Causes

There are three identified primary causes of moral injury.

• An act of commission: when someone does something they should not have done, or that strongly goes against their own moral code.
• An act of omission: when someone should have done something but did not.
• Betrayal: when someone feels betrayed by others, particularly by a higher authority who either acted, failed to act, or compelled an individual to act in a way that goes against their moral code.

Moral injuries typically result from events that fall into one of those three categories. These could be traumatic or morally challenging circumstances with vulnerable people or populations, events where a person is unprepared for the emotional consequences of their role, or a lack of social support.

Impact and treatment

The effects and impacts of moral injury vary for everyone.

Some people feel no lasting effect. Others will recover in the short term. Others will find that the lingering effects of their actions – or inaction – only become more intense over time and develop into a mental health crisis.

Research shows that people suffering from a moral injury are vulnerable to other disorders, including Post-Traumatic Stress Disorder (PTSD), depression and suicidal thoughts.

Moral injuries also act as barriers that stand in the way of recovery. Those suffering a moral injury often avoid seeking treatment, and refuse to discuss their injury with their support team or medical providers because they feel shame, anger or guilt, or even because they fear legal consequences from their actions.

While there is no single, defined treatment for moral injury, it is vital that anyone suffering from it discuss their feelings with a mental health professional. Treatment and therapy can begin to help make sense of a person’s feelings and actions, which is an important first step towards healing.

Research status

The research and clinical communities are in the early stages of understanding what moral injury really is, how best to treat it and potentially how to prevent it.

Evidence suggests that moral injuries are common among military personnel and Veterans. Research, including research from the Atlas Institute, has shown that military members who are exposed to potentially morally injurious events are at an elevated risk of developing adverse mental health outcomes such as PTSD and depression.

Researchers also recognize that moral injury may resonate with those who work in high-pressure environments such as health care. During the COVID-19 pandemic in particular, front-line health-care workers have faced moral stress from making critical decisions, often with limited resources.

By exploring this important new area of study, we can help to understand and treat this complex facet of Veterans’ mental health.

Resources