What is Moral Injury?

Psychiatrist Jonathan Shay, who worked with U.S. veterans of the war in Vietnam, first coined the term moral injury in 1994 and defined it as the violation of what is right by someone in legitimate authority in a high stakes situation, which is accompanied by a physiological response of feeling attacked or completely swallowed up and by emotions such as mistrust and fierce outrage (Shay, 2014). Among such betrayals, sexual assault can be experienced by men and women alike as akin to incest, as a violation of trust and profound betrayal of unit cohesion.

In 2009, Veterans Affairs clinicians expanded moral injury beyond “someone in legitimate authority” to include anyone, including the self. They described it as:

Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code. … bearing witness to the aftermath of violence and human carnage [can] be potentially morally injurious. Moral injury requires an act of transgression that severely and abruptly contradicts an individual’s personal or shared expectation about the rules or the code of conduct, either during the event or at some point afterwards … The event can be an act of wrongdoing, failing to prevent serious unethical behavior, or witnessing or learning about such an event. The individual also must be (or become) aware of the discrepancy between his or her morals and the experience (i.e., moral violation), causing dissonance and inner conflict (Litz, 2009,700)

This definition widens moral injury to those in noncombat roles, such as mortuary affairs, chaplaincy, engineering, intelligence, psychiatry, journalism, and medical work, who can also be haunted by a sense of betrayal, things they failed to do, acts they supported, taboos they violated, harm they witnessed or heard about, or, in the aftermath of violence, handing human carnage (Snyder, 2014). In addition, while sometimes referred to as “secondary” trauma, experiences of another’s trauma can invade the inner states and inhabit the imaginations of others such as caregivers and families as something like emotional contagion…

Moral injury is the trauma of moral conscience, when harm cannot be amended and empathy yields only pain and self-condemnation. Moral emotions, such as guilt, shame, remorse, and outrage at others, result in broken trust, poor health, social isolation, and, in extreme cases, suicide or violence. Moral injury means the existing core moral foundations or faith of a person or group are unable to justify, make sense of, and integrate traumatic experiences into a reliable personal identity that enables relationships and human flourishing. Like a missing limb, it is not a reversible injury, so survival is a process of learning to live with an experience that cannot be forgotten. But how the experience is remembered is crucial.

While it has no diagnostic threshold or formal diagnosis and treatment protocol, moral injury identifies the power of moral conscience to inflict great suffering. [It]… is a human experience that can occur in many professions and contexts of extremity. Oppressive or coercive contexts, especially, often pose no-win choices and deny the possibility of making a “good” choice. Under such conditions, the desire to do the right thing can sour into hate, anger, or shame, and distort self-perception in terms of the trauma without remainder. Moral conscience, thus, can become isolating, punishing, and lethal.

Excerpted from Brock, R. N. Moral Conscience, Moral Injury, and Rituals for Recovery. Moral Injury and Beyond. Papadopolous, R. ed. New York. Routledge. Forthcoming 2017.

 

References:

Litz, B.T., Stein, N., Delaney E., Lebowitz, L, Nash, W. P., Silva, C., and Maguen, S. (2009). Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy. Clinical Psychology Review, 29, 695-706.

Shay, J. (2014). Moral Injury. Psychoanalytic Psychology. American Psychological Association Vol. 31, No. 2, 182–191.

Snyder, J. (2014). ’Blood, Guts, and Gore Galore’: Bodies, Moral Pollution, and Combat Trauma. Symbolic Interaction. September. DOI: 10.1002/SYMB.116.