Moral Injury Is an Invisible Epidemic That Affects Millions

Moral Injury Is an Invisible Epidemic That Affects Millions

In early 2021 emergency room physician Torree McGowan hoped the worst of the pandemic was behind her. Although she and her colleagues had adjusted to the COVID-causing virus by wearing layers of protection before treating each patient, they were able to keep everything running smoothly. McGowan’s home in central Oregon, a plateau of high desert surrounded by snow-capped mountains, had largely escaped the first COVID waves which ravaged New York City.

The virus’s Delta variant struck central Oregon with an explosive fury and brought down the delicate balance McGowan had been maintaining. Soon, COVID patients began to flood into the ERs of the hospitals where McGowan worked. She had to tell many patients that the few drugs she did have didn’t work in the late stages of the disease and that she was unable to help them. McGowan said, “That feels really horrible.” “That’s not what .”

meant for us.” McGowan says.

McGowan could not help COVID patients. It was everyone. People still approach a health-care emergency expecting to be taken care immediately. In the midst the surge, there weren’t any beds .. McGowan says that there were no beds in the hospital during the surge. McGowan had to send the patient home because there were no beds available.

McGowan found it hard enough to let go of her standards and watch others suffer and die. It was also disorienting to realize that McGowan’s patients were not caring about what happened to them or anyone else. She assumed that she and her patients followed the same basic rules: that she would do her best to help them get well and that they would support or at least treat their patient humanely.

But as the virus spread, these relationships fell apart. The hospital policy forbids COVID patients from coming into the exam room without masks. They cursed her for telling them they had the disease. McGowan said, “I have heard so much people say, I don’t care if someone makes someone sick and kills them,’” McGowan adds. Their ruthlessness terrified and enraged McGowan, not least because her husband was an immunocompromised man. McGowan states, “Every month, I do hours upon hours of continuing education.” McGowan says that every patient I have ever made a mistake with, I can tell you everything about it. It’s amazing to think that people are so insensitive about a person’s life. .”

Moral Injury is a type of trauma that occurs when people are confronted with situations that violate their core values or seriously violate their conscience. McGowan is one of those who struggle with it. They may feel guilt, anger, and a constant sense of inability to forgive others or themselves.

The condition affects millions of people in many different roles. Doctors must admit a few patients in order to provide rationed healthcare. Soldiers kill civilians in order to accomplish their assigned missions. When no one is willing to adopt the animal, veterinarians must kill it.

Trauma is far more widespread than most people realize. “It’s really clear to us that it is all over the place,” says psychiatrist Wendy Dean, president and co-founder of the nonprofit Moral Injury of Healthcare in Carlisle, Pa. “It’s social workers, educators, lawyers.” Survey studies in the U.S. report that more than half of K-12 professionals, including teachers, moderately or strongly agree that they have faced morally injurious situations involving others. Similar European studies show that half () of physicians were exposed to potentially morally harmful events at high levels.

These figures may seem artificially low given the lack of public awareness about moral injury. Many people don’t have the vocabulary to explain what is happening. The mental health effects are extensive, regardless of the exact numbers. In a King’s College London meta-analysis that surveyed 13 studies, moral injury predicted higher rates of depression and suicidal impulses.

When COVID struck the world, the moral injury crisis became even more urgent. Ethically tangled dilemmas became the new norm–not only for health-care workers, but also for those in frontline positions. To make a living, store employees had to put their safety and the safety of their families at risk. It was often difficult for lawyers to meet clients in person, making them unable to properly represent these clients. Jenny Andrews, a California public defender, says that in such situations, “no no matter how hard you try, you’re always going be falling short.”

Although moral injury is not yet listed in the diagnostic manuals, there’s a growing consensus that it is a distinct condition from depression and post-traumatic stress disorder (PTSD). This consensus has led to the development of treatments that help people to overcome long-standing ethical traumas. These therapies, which are vital additions to a wide range of trauma therapies, encourage people to confront moral conflicts head-on and not just explain them or blot them out. They also emphasize the importance community support for long-term recovery. Therapy clients may even make plans to correct any harms they have done.

Scientists and clinicians agree that understanding the true nature and consequences of moral injury is key to healing. They are not “bad seeds”, hopeless or irredeemable. They might not meet the criteria for PTSD, or another mental illness. They may be suffering from a severe disconnect between their moral principles and the reality of what is or has happened. Dean states that moral injury is “a loss of self-respect and a sense of identity as a person.” “We have a lot of people saying, ‘This is the language I’ve been looking for for the past 20 years.'”

Ancient Origins

Although VA psychiatrist Jonathan Shay coined the term “moral injury” in the 1990s, the phenomenon predates its naming by millennia. In the ancient Greek epic The Iliad, the hero Achilles loses his best friend Patroclus in battle and then inwardly tortures himself because he failed to shield Patroclus from harm. When world wars broke out in the 20th century, people labeled as “battle fatigued” the returning soldiers who bore mental scars. Many of these soldiers were not suffering from shell shock, but suffered from wartime traumas that they were too embarrassed to share. In the 1980s University of Nebraska Medical Center ethicist Andrew Jameton observed that this kind of moral distress was not confined to the military realm. It often occurs when one knows what to do, he wrote. However, it is almost impossible to follow the right course of action because of constraints.

The first thorough study of moral injury was prompted by the number of U.S. soldiers who were struggling after the wars in Vietnam and Iraq. Brett Litz, a Psychologist at Veterans Affairs Boston Healthcare System, saw many veterans from these conflicts who were not responding well to counseling after their deployments. They seemed stuck in a rut over the acts they’d committed such as killing civilians in conflict zones. Litz was reminded of a past therapist who seemed strangely detached and never mentally present in the room. Litz discovered the reason. Litz says that he had killed a child while biking down the road months before I arrived to him. He was as broken as you can imagine. I saw .”


Litz became convinced that he was seeing a different condition than PTSD and depression after long conversations with veterans. PTSD usually takes root when someone’s safety or life is at risk. Litz found that many of the lingering trauma Litz observed in veterans had nothing to do directly with personal threat. He says it was due to growing guilt and hopelessness, “the whole of the inhumanity and the lack of meaning, and the participation in grotesque military things.” “They were pariahs, or felt that way, at minimum .”

Using Shay’s previous work, Litz decided to create a working concept for moral injury so researchers could investigate it in detail and determine the best treatment. He says, “This is going to impact our culture, and there will be broad impacts.” “We had to bring science to bear. We had to define .”

To that end, Litz and his colleagues published a comprehensive paper on moral injury in 2009, outlining common moral struggles veterans were facing and proposing a treatment approach that involved making personally meaningful reparations for harm done. He also noted that not all “potentiallymorally injurious” events can cause moral injury. Moral injury may not occur if you kill someone and feel completely justified. Moral injury is when you see the world as fundamentally fair, good, and something you’ve seen or done destroys that vision.

Litz soon attracted Rita Nakashima Brock’s attention, who was then a visiting scholar from Starr King School of the Ministry in California. A theologian and antiwar activist, Brock was preparing to convene the Truth Commission on Conscience in War, an event where returned soldiers would testify about the moral impact of engaging in battle.

Brock was deeply rooted in antiwar activism. After her father, a U.S. Army medical officer, returned from Vietnam, he withdrew his family. He reacted with a furious rage when he tried to speak to his family. She says, “My dad was so unique that I didn’t even want to go home anymore.” With the help of a cousin, she reconstructed Brock’s story after his father died. Brock had been deployed with a guide, a young Vietnamese woman. She was tortured and later killed. He was horrified by what had happened and likely felt guilt for knowing that his ties to the guide could have placed her in danger.

It clicked as soon as Brock saw Litz’s moral injury paper. She recalls that she and a colleague read Litz’s moral injury paper and said, “Oh, my god, this is what the whole thing’.” “We sent it out to everyone testifying and said, “Read this .'”


Torree McGowan, a Central Oregon emergency physician, had to cope with challenges of care that went against her core moral principles. Credit: Richard Darbonne

Chronicling the Unspeakable

After Brock’s 2010 Truth Commission, her committee set forth a key objective: creating programs to inform the public about moral injury. With a grant from the private Lilly Endowment, Brock established a moral injury research and education program at Texas’s Brite Divinity School. Later Tommy Potter–then a development officer at Brite–mentioned Brock’s work to his childhood friend Mike King, CEO of the national nonprofit Volunteers of America (VOA), and Brock and King arranged a time to meet.

VOA has long been focused on marginalized populations. King says that Brock’s description of the moral injury concept to King “instantly resonated with every aspect of our work.” It is deeply present with veterans. But I could see it in our work with folks coming out of incarceration and certainly with health care.” So in 2017 VOA put up about $1.3 million in funding to create the Shay Moral Injury Center in Alexandria, Va., named for Jonathan Shay. Brock was the first director of the center, leading research and training programs that aim to understand and treat moral injury.

Meanwhile, moral injury research at Litz’s lab and elsewhere was taking flight. In 2013, along with his health-care colleagues, Litz debuted and road tested what he called the Moral Injury Events Scale, a measure of exposure to events that can cause moral injury. The scale measured how much people felt they had violated their morals, how many they felt others had betrayed valuable values, and how much distress they felt as a consequence. Other investigators have confirmed moral injury can come with significant mental health burdens: in a 2019 study of five VA clinics across the U.S., people who’d experienced moral injury consistently had a higher risk of suicide than control participants.

Other research supports Litz’s initial hypothesis that moral injury is distinct than PTSD. However, the two conditions can sometimes overlap. A 2019 study by researchers at the Salisbury VA Healthcare System in North Carolina reports that moral injury has different brain signatures than for PTSD alone: People with moral injury have more activity in the brain’s precuneus area, which helps to govern moral judgments, than those who only have PTSD. And after people suffer moral traumas, they display different brain glucose metabolism patterns than those who suffer direct physical threats, according to a 2016 study by researchers at the University of Texas Health Science Center at San Antonio and their colleagues. These results support the idea that moral injury is an individual biological entity.

As Brock’s Shay Moral Injury Center was in process of being established, she made connections with powerful people who could spread the word about moral injury, including Margaret Kibben (current chaplain at U.S. House of Representatives). Kibben hosts regular events for House members and one of her recent talks was on moral injury. Brock reports that the event attracted three times as many people than usual and that they all wanted to share their experiences. Brock and Kibben’s partnership is a reflection of a growing trend in the study and treatment of moral injury: collaboration between clergy and scholars who seek to document the unspeakable and help people through it. According to psychologist Anna Harwood Gross of Metiv, the Israel Psychotrauma Center (Jerusalem), moral injury “does really combine a lot of disciplines.” “It is rare to see articles written together .”

As COVID ravaged the planet from 2020 onward, moral injury research and inquiry took a distinct new turn. Health-care workers spoke out about how rationing care was affecting them psychologically, and Dean and her colleagues Breanne Jacobs and Rita Manfredi, both at the George Washington University School of Medicine and Health Sciences, published a journal article that urged employers to monitor moral injury’s effects. They wrote that they needed time, energy, and intellectual capacity to make peace against those specters.

The moral injury Dean sees in healthcare is often not caused by one-time, catastrophic events. Many providers are suffering what she calls “death by a thousand cuts“–the constant, stultifying knowledge that they have to give people subpar care or none at all. They think they are suck. They think they are inept,” Gregory Peck, a trauma surgeon at Rutgers Robert Wood Johnson Medical School in New Jersey, said. “No one is putting their finger on “You don’t suck.” This is moral injury you’re suffering.'” Psychiatrist Mona Masood, who founded the Physician Support Line in 2020, has heard countless doctors agonize over daily moral compromises. “We’ll hear: ‘Am I really failing? Am I failing my calling? Am I not human anymore


These words would certainly resonate with McGowan. As we approach the hospital where McGowan works regular shifts, we see an ambulance pulling out of the parking lot. It flashes lights and is hidden by looming clouds as we approach. McGowan states, “That’s probably another transfusion.” In other words, someone has claimed one of the COVID beds in the area, which means that someone else, who is likely to be just as sick, may have to go without. The ER is a bare-bones space with hallways and rooms, and black cords hang from the walls. As we walk around, warning signs of moral compromises are visible. On a hallway whiteboard, a note was scrawled that reads “Critical shortage in green top tubes.” McGowan says that there is a 0-day supply for blue tops. If these tubes run out, McGowan may not be able order the blood tests patients require. This could lead to McGowan having a difficult time diagnosing what’s wrong.

McGowan struggled for many days with the dislocation of moving between the ER and the outside world. This was a personal hell for COVID deniers, angry family members, and dying patients. She wonders how people can chat and drink coffee while they are rushing to get someone home who is unable to breathe minutes before. How is it possible that her moral world is so off-axis, while the larger world spins with barely a wobble?

McGowan visits a therapist to help with her dealing with the difficult situations she has faced. She says it has been very helpful. She continues to struggle with moral dilemmas. This is a reflection of a growing consensus that traditional therapy may sometimes not be enough to help morally wounded people overcome lingering demons. Basic cognitive-behavioral treatment (CBT) is the most popular option for those who seek help. Some researchers believe that CBT is sufficient to treat moral injuries.

CBT has one problem. It focuses on correcting clients distorted thinking patterns. Harwood-Gross states that ethical distress is real for people who have suffered from moral injury. These individuals have experienced life-altering events that upend their entire system of values. People with moral injury should not try to retrain themselves. They may feel unsatisfied or unhealed.

Therapies to treat PTSD can also fail morally-injured patients, according to Harwood-Gross. Although PTSD-focused methods teach clients how to adjust to trauma triggers such as gunshots or fireworks, this exposure approach doesn’t help them resolve deep ethical conflicts. Harwood-Gross states that moral injury counseling is more about the “processing”. “It has to be that movement: How do I see it as it is and develop something more meaningful from it?’ This is a more spiritual approach .”

Psychologists such as Litz recognize the unique challenges of moral injury and have created therapies that better address their clients’ needs. Litz and other providers have pioneered a moral injury treatment called adaptive disclosure. Researchers at Australia’s La Trobe University and University of Queensland have developed a similar approach called pastoral narrative disclosure. This involves talking with a chaplain, or other spiritual adviser, about moral issues rather than with a doctor.

These therapies emphasize the importance of moral reckoning. These therapies encourage clients to accept difficult truths such as “I led that attack against Iraqi civilians” or “I sent that patient home without treatment.” Counselors can then help clients develop strategies to make amends or pursue closure. For example, they can apologize to the family whose child was hurt.

Early evidence suggests that these approaches can make a difference where others cannot. In Litz’s initial trial of adaptive disclosure on 44 marines, participants’ negative beliefs about both themselves and the world diminished. Many also stated that the therapy helped them resolve moral dilemmas.

Earlier this year Litz wrapped up a 173-person clinical trial of adaptive disclosure at VA sites in Boston, Minneapolis, San Diego, San Francisco and central Texas. Although the trial’s results are not yet published, Litz found that adaptive disclosure generally increased participants’ functioning over time. Litz states that his goal is to help people thrive, not wipe their moral slates. Litz says, “You won’t ever feel bad when you think about the events.” “That’s the new normal. The question is: “How can you rehabilitate and live a decent life ?

For Brock’s VOA team and moral injury rehabilitation, a suite of peer support programs is also offered. The Shay Moral Injury Center’s core group offering, Resilience Strength Training (RST), is a 60-hour, in-person program where people with moral injury share stories about events that caused it, engage in talks about forgiveness (for themselves or others), and do exercises to help them define their value system and purpose going forward. In a survey study at two VOA program sites, participants scored an average of 46 percent higher on a scale of post-traumatic growth and 19 percent higher on a scale of perceived meaning in life than they had before starting the program. The in-person program was halted due to the pandemic. However, plans are underway to resume it.

In 2020 VOA created an online version of RST for health workers and others called Resilience Strength Time (ReST). ReST sessions are offered free of charge, and participants can sign up for as many as you like.

Several people attended a recent ReST video conference to discuss their moral dilemmas on the frontlines of health-care. One woman described feeling helpless watching a patient verbally abuse the nurse who was giving her vaccines. Jim Wong and Bruce Gonseth, both war veterans, were the peer-session leaders. They listened carefully to each attendee’s situation and shared their experiences, often recalling similar situations. Wong explained to the group that what he and his team experienced in war was similar to what frontline workers experience: the invisible enemy. You may feel like you are letting others down. You might see others engaging in dangerous behaviors. You are not alone. We are here to help .”

In most therapeutic relationships, there is a power difference between the client and the therapist. VOA’s groups are a way for members and facilitators to be vulnerable together, which puts participants on a more equal footing. This transparency builds bonds that support recovery and ensures that people are not isolated from their moral struggles. Brock states, “These people know them intimately and well. It matters.” “Moral injury” is a relationship breakdown that can lead to identity crisis. You must establish new relationships that will sustain you .”

Therapies that address moral injury and bolster clients’ senses of purpose share a common goal. These treatments were developed by Viktor Frankl, an Austrian psychologist who believed that trauma recovery could be fueled by a personal search to find meaning. Frankl was able to survive his imprisonment in Nazi camps including Auschwitz by focusing on his motivations: his love for his wife and his determination to rewrite a Nazi-era research manuscript. “Everything can be taken from a man but one thing,” Frankl wrote, “the last of the human freedoms–to choose one’s attitude in any given set of circumstances, to choose one’s own way.” After his liberation in 1945, Frankl refined a treatment approach called logotherapy, which emphasized that a sense of purpose could help people endure the gravest suffering.

Therapists like Harwood-Gross and Litz encourage clients to recognize the humanity in the world, rather than trying to erase it. Frankl faced the same question: “In the midstof what has happened and is still happening, how do I find meaning in my life ?

Partnerships among clinicians and religious leaders have helped facilitate this search for meaning, Brock states. She says that mental health treatment can feel like a formalized system in which the “role of the professional isn’t to be personal.” The clergy are often able to connect on a more casual, human level with people who are morally wounded and have lost their humanity. Brock states that chaplains don’t charge by the hour. They spend the time they need with people .”

No Easy Method Out

Moral injuries treatments are a safety valve for those who struggle with guilt and ethical vertigo. However, the old guards on the front lines point out that nudging morally injured people towards self-repair is only a partial solution. Although therapy can help you make better choices in the future, unless your employer provides more staff and resources, you will likely continue to make decisions that are contrary to your ethics. This will only compound your trauma. Andrews, the California public defense attorney, says that many moral injury-related problems require systemic solutions at a much larger level.

But many organizations are choosing to take the easy route, Dean states. Instead of launching systemic reforms to prevent moral injury, many organizations are offering “wellness solutions” like massages and meditation tips. This can be as simple as putting a band-aid on a broken bone. Jane Kim, a New York City ER doctor, says, “If I have the to listen to another “eat well, sleep well and do yoga” conversation, I’m going throw up.” She believes that system-wide, in-depth conversations about what frontline workers need to do their jobs ethically would be more effective than what outside wellness providers think they need. She believes that reforms based upon these honest internal assessments would be beneficial for both workers and those they serve. She says, “We care about other people.” “But if you are broken, how can you possibly help others ?”


Similar thoughts are occupying McGowan’s head as the pandemic drags along. Despite COVID hospital admissions having decreased in her area, McGowan’s thoughts are similar to those of other people. This is because there aren’t enough providers to provide adequate treatment for patients. “I liken it to the Bataan Death March. McGowan states that there is no end in sight. A plaque adorning a bookshelf in McGowan’s light-filled farmhouse reads: “You don’t know how strong you are until you make the right choice .”

The windows overlook a barren field. McGowan’s husband, a farmer, grew only a small amount of his usual hay crop because of the drought. They face the same existential dilemma in a way: What do they do when circumstances beyond their control shrivel their highest intentions?

McGowan tries not to let down her feelings of despair and failure in her medical calling. Instead, she focuses on the positive acts that she has been able do. When she’s not in the ER, she serves as a lieutenant colonel in the Oregon Air National Guard, and her unit has vaccinated more than 100,000 people against COVID.

She has found that mentoring other doctors, offering advice and support as they make the same difficult decisions and regrets, has been a great source of encouragement. McGowan said, “That’s helped to me be a bit more kind to myself.” “The same words I tell them, I try and repeat to myself: You did what you could.” She exhales, hesitating. “And you are still an excellent doctor. I would still let you take care of my family.”

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