Moral injury

Produced by Dr Nathan Smith, University of Manchester

Expert reviewed by Dr Victoria Williamson, Kings College London

Download the printable 1-page PDF version of this brief here.

Why is moral injury relevant?

Covid-19 is placing significant demand on an already stretched healthcare system. Prioritisation of resources (e.g., staff, beds and ventilators) due to increased demand means that some patients may not receive the care that they would ordinarily get. When preventable loss of life occurs due to these reasons, healthcare workers may be at risk of moral injury. 

Core constructs/concepts

Moral injury is defined as the psychological distress which results from actions, or the lack of them, which violate your moral or ethical code.

Potentially morally injurious experiences (PMIEs), include ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply help moral beliefs and expectations’. Due to the current covid-19 outbreak, frontline workers may be at increased risk of exposure to such PMIEs. 

Exposure to PMIE can cause strong moral emotions, termed ‘moral distress’. Moral distress can include guilt, anger and disgust. These emotions can lead to distress and further psychological difficulties. MI is not a mental illness but can contribute to other mental health problems, such as Post-traumatic Stress Disorder (PTSD).

Those who experience MI may have extreme negative self-appraisals which seem to contribute towards and maintain distress in a recursive cycle.

MI can impact upon work and social life. It has been linked to increased difficulties coping with occupational stressors and difficulties with authority figures. Socially, individuals who have experienced MI have been found to withdraw from others, which can lead to relationship breakdown with spouses, children and others. This can exacerbate the impact of MI. 

Evidence from a recent systematic review of occupational moral injury (Williamson et al., 2018) (mostly relying on cross-sectional studies) suggests there is a moderate-to-strong relationship between moral injury and PTSD symptoms (mean effect size based on Pearson correlation = 0.30; CI 0.20–0.39), weak-to-moderate relationships with stress and hostility, and negative associations with social adjustment, positive affect and resilience.

A number of risk and protective factors for MI have been proposed. These include:

  • Increased risk if loss of life is a vulnerable person (e.g. woman, child, elderly)

  • Increased risk if perceived lack of support from leader or family and friends post event

  • Increased risk if unaware or unprepared for emotional/psychological consequences of decisions

  • Increased risk if low education attainment

  • Increased risk if the PMIE occurs alongside other trauma

  • Decreased risk if receiving empathetic support after the event, particularly from fellow personnel who have experienced similar

  • Decreased risk if leaders and decision makers take responsibility

Systematic research on MI and interventions designed to resolve feelings associated with morally injurious events are still emerging. Initial intervention research suggests that Cognitive-Behavioural Therapy (CBT) and adaptive disclosure (having imagined conversations with a moral authority) might be beneficial.

Given the nature of morally injurious experiences, some individuals may be reluctant to talk about MI due to potential social and legal repercussions.    

Practical recommendations

  • People who are likely to be exposed to PMIEs should be frankly prepared for the nature of the tasks they face and the emotional, cognitive and behavioural responses they may experience. Challenges should not be ‘sugar coated’ and discussions about PMIEs should be leader led and shared amongst all the team.

  • Empathetic leader, peer and family support to workers who may have experienced a PMIE themselves is important. Having an opportunity to develop a narrative which does not lead to psychological ill-health will be beneficial.

  • Those in a position of authority should appropriately take responsibility for decisions and outcomes. These leaders will also need to be supported and organisations should recognise such leaders may be reluctant to seek help.

  • If a PMIE does occur, similar processes to those described in the PTSD brief may be followed. If distress related to a PMIE persists over time, professional psychological support may be required.

Relevant literature

Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., ... & Neylan, T. C. (2017). Impact of killing in war: A randomized, controlled pilot trial. Journal of clinical psychology, 73(9), 997-1012.

Williamson, V., Stevelink, S. A., & Greenberg, N. (2018). Occupational moral injury and mental health: systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346.

Williamson, V., Greenberg, N., & Murphy, D. (2019). Impact of moral injury on the lives of UK military veterans: a pilot study. Journal of the Royal Army Medical Corps, jramc-2019.

Williamson, V., Murphy, D., Stevelink, S. A., Allen, S., Jones, E., & Greenberg, N. (2020). The impact of trauma exposure and moral injury on UK military veterans: a qualitative study. European Journal of Psychotraumatology, 11(1), 1704554