Moral Injury and the Fabric of Civil Society
Cindy Little was an ICU nurse manager at the height of the COVID pandemic. Given her hospital’s strict isolation requirements, she was torn by her inability to live her professional and personal values when family were not allowed in-person visits with critically ill patients. “We knew we couldn’t provide that same level of comfort to patients without their family,” she said. “When one gentleman was dying, we had 20 of his family members on Zoom. A nurse and a nurse in training were there, holding his hands, as his family sang him to heaven.”
Little’s distress illustrates “moral injury.” First studied in the military, where soldiers reported doing or observing things that deeply troubled their sense of who they were, moral injury is defined by Dr. Brett Litz, a clinical psychologist with Boston University and the Veterans Affairs Boston Health Care System, as the lasting impact of “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”
Moral injury often goes unacknowledged and unaddressed. As other examples, it may happen to social workers, first responders, police officers, journalists and lawyers who witness or engage in acts that disturb their sense of self or whose superiors demand behavior that violates their moral principles. It can happen to veterinarians who put animals to sleep. It can affect minorities who witness police abuse against those they are sworn to protect and police who observe other officers doing what they should not. In one study, teachers in Midwestern predominantly minority and low income schools were ordered to improve student performance. They reported moral injury because, as Erin Sugrue, the study’s author reported, “they hadn’t received any training or support” and “also believed administrators focused more on giving higher grades than improving education.”
Moral injury can happen to people in their personal lives. Driving along a winding road in 1994, David Peters misjudged a curve, was blinded by the setting sun and hit a motorcyclist. The cyclist’s female passenger was killed. Twenty-eight years later, it still haunts him.
The impact and extent of moral injury may differ depending on the person and the experience. Moral injury, as captured in the Moral Injury Outcome Scale, can produce feelings of guilt, shame, disgust and anger. It can lead people to blame themselves, lose trust in others who abet or deny the morally repugnant behavior and worsen relationships with family, friends and work colleagues. It can lead to physical and mental health problems and drive people out of professions. In a Kings College, London meta-analysis of 13 studies, moral injury was associated with higher rates of depression and suicidal impulses.
Moral injury is not identical to Post-Traumatic Stress Syndrome (PTSD). The latter may result from events such as physical injury, death or even a natural disaster when one’s moral values are not violated. Moral injury requires experiencing something that calls into question one’s sense of moral right, of being a good person or whether one deserves a good life. Thus, the treatment for moral injury requires helping people cope with the feeling they have witnessed or themselves violated deeply held values. This requires moral reckoning, sometimes a plan to apologize, make amends or to otherwise find closure.
Society, not just individuals, bears the costs. At work moral injury can lead people to question their professional judgment and expertise and destroy trust in leaders and organizations. It can lead to quitting and make recruiting replacements harder. It can lessen one’s sense of efficacy in and of outside work, leading to poor productivity, destroyed relationships, high physical and mental health care costs and the potential for serious physical harm.
Treating moral injury faces obstacles. It’s not yet included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the “bible” for mental health care professionals, as its definition and characteristics are still being clarified. Treatment protocols are in the early stages. Even getting treatment can be difficult when it is confused with PTSD, dismissed with appeals to just “relax” or use stress reduction practices. It can be driven underground when individuals don’t recognize it, fear admitting it to superiors or the organizational culture ignores or refuses to deal with it.
Prevention, of course, is better than relying on treatment alone. Moral injury can be fostered when fake news, conspiracy theories and social media raise moral anger about manufactured and real events. In our hyperpolarized societal climate, the likelihood of experiencing moral injury and fostering it for political gain represent dangers not just to individuals but to the social fabric. Moral injury can lead to loss of trust in institutions and people, anger and feelings of disgust. Moral injury will flourish when organizations and society lack incentives to promote moral action and sanctions to punish immoral behavior. Much of what is now reported as moral injury cannot be prevented by passing laws. Prevention requires moral actors in a climate that values ethical behavior.
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