Moral injury
Lasting psychological harm from doing, failing to prevent, or witnessing acts that violate one's deep moral beliefs, or from being betrayed by those in authority.
What drives it
Injures a person's sense of being good or of the world being trustworthy; the dominant feelings are guilt, shame, anger and disgust rather than fear.
How it shows
Work
A nurse after a period of rationed care, a manager forced to run layoffs they thought unjust, an employee who covered up a safety issue: cynicism, withdrawal, contempt for leadership, 'I'm not who I thought I was', loss of meaning in the work. Often leaves the profession.
Relationships
Withdraws from people who did not share the experience; feels unworthy of love; anger at institutions; difficulty forgiving self or others.
Self
A persistent feeling of being stained or complicit, anger at those who put you there, a loss of faith in yourself or in institutions.
What tells it apart
Post-traumatic stress disorder (PTSD): PTSD centres on fear, startle and threat reminders; moral injury centres on guilt, shame and betrayal, often without hyperarousal.
Guilt: Ordinary guilt resolves with apology and repair; moral injury persists because the violation was severe, could not be undone, or was imposed by the system.
Burnout: Burnout comes from chronic overload; moral injury comes from a specific violation of values, and rest does not fix it.
A test
Ask what the person did, saw or was made to do that went against what they believe is right; a moral injury produces a clear answer and strong shame or betrayal when they tell it.
Questions to carry
- When they tell what they did, saw, or were made to do, what shows in their voice?
- Which act, mine or someone above me, went against what I believe, and where do I carry it?
How strong the research is
moderate. A growing literature, mainly in military and healthcare samples, with validated measures; there is no agreed definition and it is not a diagnosis.
Where it comes from
Jonathan Shay, 1994; Brett Litz and colleagues, 2009