What is Moral Injury?
A quick answer would be: a type of psychological trauma. Moral injury is defined as “the lasting psychological, biological, spiritual, behavioural, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”. It is characterized by immense psychological distress caused by perceived violation of one’s strong moral beliefs either by themselves or close trusted individuals, and was first coined by Jonathan Shay in his book, Achilles in Vietnam: Combat Trauma and the Undoing of Character. In the book, Shay introduces Moral Injury as the psychological distress caused by the violations of ‘what’s right’ as observed in combat veterans.
Moral Injury can be described as an individual committing an act of perceived transgression, usually as an act of commission (actions against their beliefs) or as an act of omission (failing to carry out actions in line with their beliefs). The perceived transgression induces guilt, shame, betrayal, disgust, anger, unable to forgive oneself, engaging in self sabotage and uncertainty about spiritual or religious beliefs.
As we understand it, Moral Injury is due to the violation of one’s moral beliefs. Potentially morally injurious or distressful events (PMIDEs), as the name suggests, are such events that could lead to the said transgressions. Examples of PMIDEs are the risk of contracting or transmitting COVID-19, prioritizing critical patients, allocation of limited resources, perceived lack of support, discrimination, and abuse. In fact, the professionals who perceived a higher risk of the infection and a threat to their own well-being showed increased symptoms of Moral Injury and PTSD. It is important to consider that not only Moral Injury but also moral distress is associated with low job satisfaction, ineffective coping strategies, and physical symptoms such as sleep disturbances, especially in those with children. Ineffective coping strategies include use of the non-medical use of prescription drugs [NMUPD], illicit drugs, and harsh drinking in US healthcare workers of varying ethnicity/race or occupational level; the same was found for US combat veterans.
Moral Injury and COVID-19
A recent study highlights the growing rate of Moral Injury seen in Healthcare Professionals, wherein symptoms causing moderate functional impairment showed a prevalence of 29.3% in healthcare workers. COVID-19 brought a surge in Moral Injury symptoms observed in healthcare workers due to various ethical dilemmas. Another study indicates an association between MI and other mental health problems like anxiety, depression, burnout, and PTSD to a moderate effect size and even suicidal ideations to a small effect size in healthcare workers who actively provided medical services during the pandemic, regardless of their practice area or setting.
A study focusing on Chinese healthcare workers has suggested that healthcare professionals providing care to the virus-afflicted patients had a 28% greater chance of developing Moral Injury than those who worked with other patients. Moral Injury symptoms are strongly correlated with higher clinician burnout in healthcare workers, especially during the pandemic, but also stress the need for strategies to address Moral Injury with or without COVID-19, which is also observed in Japanese hospitals. Other possible factors affecting Moral Injury are low confidence and low resilience, whereas positive components like self-kindness, mindfulness, and common humanity show no significant effect on Moral Injury.
Moral Injury and PTSD
While a study conducted on Canadian healthcare workers proves strong correlations between Moral Injury and PTSD and when with Moral Distress when the sex, age, depression, anxiety, stress, and childhood adversity were controlled, a key to distinguish them is hyperarousal caused by PTSD and that Moral Injury is strongly related with inability to self forgive for the transgression. Biologically speaking, PTSD is more of a fear response, which causes damage to the amygdala and hippocampus, which can lead to difficulty in recognizing emotions or impaired memory. Moral Injury impacts the prefrontal cortex, as Moral Injury is rather related to moral thinking. Guilt, betrayal, loss of trust, and shame are core dimensions of Moral Injury, they are also notable symptoms of PTSD.
This blog entails what Moral Injury is, from its origins to a modified definition. It highlights the relationship between Moral Injury and PTSD, substance use, Moral Distress, and depressive symptoms, and the association with COVID-19 based on findings from recent research. The blog brings out the urgency for coping strategies not only for Moral Injury but also for clinician burnout that healthcare workers face. While the blog focuses on healthcare workers, it should be noted that Moral Injury also affects other professions like law enforcers, firefighters, and combat veterans. Owing to its hazardous impact on the mental well-being of individuals from various professions, organizations should introduce effective means to cope with PMIDEs or ethical dilemmas.
Heet Suthar
