Moral injury

The lasting psychological, moral, and spiritual damage caused by perpetrating, failing to prevent, witnessing, or being betrayed in the doing of acts that violate one's deepest sense of what is right. Two definitions sit on either side of the field's internal disagreement: the narrower Shay formulation (betrayal of what's right by someone who holds legitimate authority in a high-stakes situation) and the broader Litz formulation (perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations). The two are sometimes treated as variants of the same construct and sometimes treated as importantly different things.

Etymology§

The phrase moral injury in its modern clinical sense is from the mid-1990s, used roughly contemporaneously by clinical psychiatrist Jonathan Shay in Achilles in Vietnam (1994) and Vietnam-veteran philosopher Camillo Mac Bica in his 1999 International Journal of Applied Philosophy essay. Shay's vocabulary draws on the Homeric thémis (what's right, the ordering of things) and the betrayal of it; Bica's draws on Aristotelian and Stoic moral psychology. The construct went through a major reformulation in 2009 with Brett Litz and colleagues' Clinical Psychology Review paper, which is the citation point for almost all subsequent clinical and healthcare research.

Moral injury is the construct that names the gap between what combat veterans, healthcare workers under impossible conditions, and other agents in morally fraught roles report experiencing, and what the diagnostic category PTSD captures. The argument of the field — across all its internal disagreements — is that PTSD is well-suited to fear-based, life-threat trauma but poorly-suited to the guilt, shame, betrayal, and loss-of-meaning that participants in morally compromising actions describe.

The field is structured by a series of distinctions. The first is between Shay's narrower definition, which centres on betrayal by legitimate authority (the soldier ordered into actions that violate what is right), and Litz's broader definition, which counts perpetration and witnessing as much as betrayal. The second is between the clinical discourse, which treats moral injury as something close to a syndrome to be measured and treated, and the theological/philosophical discourse, which treats it as a moral condition that calls for communal and ritual repair. The third is between the original military application and the healthcare extension, which dates to the 2018 Dean–Talbot STAT News article and now constitutes a substantial sub-literature in its own right.

The field has its own internal critique — most articulately in Wiinikka-Lydon's philosophical work — about the risks of concept creep: the worry that a construct originally developed to name a particular kind of combat-leadership betrayal has been stretched to cover any work-context moral discomfort, with the cost that it loses the analytic edge that made it useful. The most useful entry to the literature reads Shay and Litz against each other before reading either alongside the secondary literature that tries to harmonise them.

Discussed in§

• A Therapeutic Application of Philosophy — The Moral Casualties of War
• The Morally Injured
• Soul Repair — Recovering from Moral Injury After War
• Initial Psychometric Evaluation of the Moral Injury Questionnaire — Military Version
• Physicians Aren't 'Burning Out.' They're Suffering Moral Injury.
• War and Redemption — Treatment and Recovery in Combat-Related Post-Traumatic Stress Disorder
• Combat Trauma and Moral Fragmentation — A Theological Account of Moral Injury
• After War, A Failure of the Imagination
• Redeployment
• The Moral Injury Symptom Scale — Military Version
• Home from the War — Vietnam Veterans, Neither Victims Nor Executioners
• Moral Injury and Moral Repair in War Veterans — A Preliminary Model and Intervention Strategy
• Perpetration-Induced Traumatic Stress — The Psychological Consequences of Killing
• What It Is Like to Go to War
• Killing from the Inside Out — Moral Injury and Just War
• The Road from Ar Ramadi — The Private Rebellion of Staff Sergeant Mejía
• Achilles in Vietnam — Combat Trauma and the Undoing of Character
• Casualties
• Odysseus in America — Combat Trauma and the Trials of Homecoming
• Afterwar — Healing the Moral Wounds of Our Soldiers
• War and the Soul — Healing Our Nation's Veterans from Post-Traumatic Stress Disorder
• Moral Repair — Reconstructing Moral Relations after Wrongdoing
• Moral Injury and the Promise of Virtue
• Shame and Necessity
• COVID-19 and Experiences of Moral Injury in Front-Line Key Workers
• Occupational Moral Injury and Mental Health — Systematic Review and Meta-Analysis
• What Have We Done — The Moral Injury of Our Longest Wars