Moral injury

Moral injury refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional guilt and shame, and in some cases also a sense of betrayal, anger and profound 'moral disorientation'. The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma. Distinct from pathology, moral injury is a normal human response to an abnormal traumatic event. The concept is currently used in literature with regard to the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs and expectations. Moral injury can also be experienced by warriors who have been transgressed against, and thus also in circumstances other than combat. The injury may in those cases include a sense of betrayal and anger. For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, the soldier can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, et cetera – can also suffer moral injury. This injury can also occur in the medical space – among physicians and other emergency or first responder care providers who engage in traumatic high impact work environments which can affect their mental health and well-being.“Moral injury is a trauma related syndrome caused by the physical, psychological, social and spiritual impact of grievous moral transgressions, or violations, of an individual's deeply-held moral beliefs and/or ethical standards due to: (i) an individual perpetrating, failing to prevent, bearing witness to, or learning about inhumane acts which result in the pain, suffering or death of others, and which fundamentally challenges the moral integrity of an individual, organization or community, and/or (ii) the subsequent experience and feelings of utter betrayal of what is right caused by trusted individuals who hold legitimate authority. Moral injury refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional guilt and shame, and in some cases also a sense of betrayal, anger and profound 'moral disorientation'. The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma. Distinct from pathology, moral injury is a normal human response to an abnormal traumatic event. The concept is currently used in literature with regard to the mental health of military veterans who have witnessed or perpetrated an act in combat that transgressed their deeply held moral beliefs and expectations. Moral injury can also be experienced by warriors who have been transgressed against, and thus also in circumstances other than combat. The injury may in those cases include a sense of betrayal and anger. For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, the soldier can experience moral injury. Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, et cetera – can also suffer moral injury. This injury can also occur in the medical space – among physicians and other emergency or first responder care providers who engage in traumatic high impact work environments which can affect their mental health and well-being. The term 'moral injury' (also abbreviated 'MI') was first coined by psychiatrist professor Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay's definition of moral injury had three components: 'Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation. Since this original definition, other definitions have subsequently developed. To understand the development of the construct of moral injury, it is necessary to examine the history of violence and the psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so. Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors. Ethical and moral challenges are expected from warfare. Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken. Research has begun to look at the concept of moral injury to understand the impact that combat may have on soldiers, and their mental health afterwards. Currently, no systematic reviews or meta-analyses exist on the construct of moral injury – although a literature review of the various definitions since the inception of moral injury has been undertaken. Some of the literature reflects that moral injury was developed as a response to the inadequacy of mental health diagnoses (e.g., PTSD), to encapsulate the moral anguish service members were experiencing after returning home from war. Service members who are deployed into war zones are usually exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing posttraumatic stress disorder (PTSD). PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences. As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events. PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity. Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms. While PTSD symptoms can have devastating effects, in the first review of moral injury, Litz and co-authors argued that service members may experience long-term pain and suffering stemming from their time in combat that is not encapsulated or represented by a diagnosis of PTSD. Unlike PTSD's focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust. A diagnosis of PTSD in the DSM-III listed an individual experiencing guilt for behaviors that required for their survival as a symptom. However, conceptualizations of PTSD in each subsequent DSM has dropped guilt as a symptom. With the inability of current diagnoses to account for moral anguish, research has begun to encapsulate moral conflict in warriors. The phrase 'moral injury' (originally defined by Jonathan Shay) was modified by Brett Litz and colleagues (2009) as 'perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially' (p. 695). Treating moral injury is often thought of as 'soul repair' due to the nature of moral anguish. As someone wrestles with the impact of what they did, failed to do, or witnessed, it can seem like their entire guiding principles for life have been altered or removed. The consequences of moral injury can be disastrous. An individual with a moral injury can experience severe distress, including major depression, and suicidality. While moral injury can be experienced by people other than military service members, current research has paid special attention to moral injury in military populations. Although moral injury does not only exist among military populations, the exposure to violence that occurs during war times make military and veteran population at a higher risk of developing moral injury. It has been reported that 32% of service members deployed to Iraq and Afghanistan were responsible for the death of an enemy and 60% stated that they had witnessed both women and children who were either ill or wounded that they were unable to provide aid to. Additionally, 20% reported being responsible for the death of a non-combatant. These statistics were taken in 2003 and an updated survey of the number of service members who have been directly responsible for the death of an enemy, a non-combatant, or having to leave sick and wounded women and children behind can shed light onto the magnitude of the issue of moral injury among service members. During times of war a service member's personal ethical code may clash with what is expected of them during war. Approximately 27% of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond. Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield. This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan. During times of war the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members. While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home the sociocultural expectations are largely different from when they were deployed. The ethical code back home has not changed, making the transition from deployment to home difficult for some service members. This clash in a personal ethical code and the ethical code and expectations of the military can further increase a service member's deep-seated feelings of shame and guilt for their actions abroad.