What is Moral Injury?

The British Medical Journal has stated that Moral Injury may become the most significant injury for healthcare staff dealing with the Covid-19 pandemic.

Moral Injury was a concept first developed by psychiatrist Jonathon Shay over 20 years ago whilst working with Vietnam veterans. It describes the ethical and moral suffering that arises from experiences which strongly clash with one’s moral code. Within the military, this might include such instances as witnessing brutality and not being able to stop it or killing in combat only to find out that the deceased was a loving father.

Shay contends that violence and suicide among army veterans stem more from moral injury than from Post-Traumatic Stress Disorder (PTSD). In fact, the cluster of symptoms that accompany moral injurious events is very similar to those associated with PTSD.

Moral injury is the social, psychological, and spiritual harm that arises from a betrayal of one’s core values.

Moral Injury in Healthcare Workers

Moral injury is likely to be particularly prevalent in those who are psychologically and practically ill-prepared, inexperienced, and poorly supported, and one could argue that frontline NHS workers have experienced a heavy combination of these throughout the coronavirus pandemic.

For example, many frontline healthcare workers:

• were provided with insufficient or non-functional personal protective equipment (PPE) during the early stages of the virus (leaving them practically ill-prepared and poorly supported)
• were unable to communicate effectively with colleagues and patients due to the level of PPE
• and were working in unfamiliar clinical environments.

Many healthcare workers were forced to make decisions regarding which patient, among many, would have access to the limited number of ventilators, and which wouldn’t. They were then faced with the task of informing the family members over the telephone as family members weren’t allowed inside the hospital.

For most healthcare workers, who entered the profession to save lives and help people, deciding who could and couldn’t receive treatment would have been a major blow to their core values.

Symptoms of Moral Injury

Moral injury is not a diagnosable mental health condition, as it doesn’t fit neatly into the medical diagnostic and treatment model. It is also a natural response to having one’s ethical compass thrown off track. However, it does have it’s own cluster of symptoms.

Morally injurious experiences can cause complex feelings of guilt, remorse, shame, and anger. It can lead to persistent self-criticism, feelings of unworthiness, thoughts of being unforgivable, and feeling like you are permanently damaged.

The symptoms of moral injury, described above, can manifest in changes in sleep patterns, significant or persistent changes in behaviour or habits, mistakes, isolation, compulsive behaviour, and a weakened sense of empathy or compassion.

Although it is not a mental health condition, if left to persist for too long, it can lead to depression, anxiety, aggression, and suicidal ideation (suicidal thinking) in some.

Long-term negative consequences of morally injurious events are not inevitable. Although exact data is not available, likely, most health care workers who experience morally injurious events will not have long term negative outcomes. In fact, after potentially morally injurious experiences, some even eventually develop a redefined meaning in life and, with time and support, begin to incorporate the experience into growth or helping others.

How can we protect ourselves from Moral Injury?

Typically, those working in healthcare, those at high risk for moral injury, strongly value caring for others and often prioritise the needs of others over their own needs. Therefore, self-care for those experiencing morally injurious situations in the health care field can be challenging. In these circumstances, frontline healthcare staff should look for signs of moral injury in each other and promote self-care in each other.

Another important factor in protecting against moral injury is to be aware of your self-talk. The way that we talk to ourselves can either promote a healthy outlook or self-criticism and lower self-worth. After a negative event, we can either tell ourselves “you should have done it better/this way” or we can tell ourselves “you did the best you could under the circumstances you were in.”

We also must look for the lessons. When we experience a situation in which we go against our better judgement and our moral code, we are undoubtedly going to feel negative about it. The best thing that we can do is to accept what has happened, try not to judge ourselves, and think “how could I do this differently next time?” or “what has this taught me about my values?” As Ray Dalio says, “pain plus reflection equals progress.” If we can take something positive from a painful situation, then the pain has the potential to turn into something positive. We can use the experience to teach others, to help more people, to develop a deeper sense of understanding and compassion.   

It is often only in conversations with others that we can hear a different, more helpful way to think about or make meaning from morally distressing situations. It can be helpful to get support about feelings that come up when dealing with these complex moral situations. Health care workers, particularly at the moment, may not feel that they have the time or energy to immediately engage in getting support, but it may be an important protection against the social withdrawal or negative coping that sometimes happen as a result of moral injury.

If you’d like professional therapeutic support to help you process your experiences of the pandemic then get in touch with us by calling 020 8673 4545 or emailing [email protected] We have face-to-face appointments available at our centres in Clapham and Tooting, seven days a week, as well sessions via phone or online video.