Defining and Finding Moral Injuries

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

There seem to be 3 types of injuries for us humans. One is physical, which we can often see and feel, usually with associated pain. Another is psychological, really the basis of all our healing endeavors and described in our DSM classifications. Then the third is moral injury, value and spiritually based. However, as an evolving concept and concern, it still may be unclear what moral injuries refer to, and how they relate to our professional ethical principles. Moral injuries in health care professionals became an increasing focus during the COVID-19 pandemic, with all the obstacles, uncertainty, and risks of patient care.

For one thing, moral injuries are personal. They can—and often do—vary in each individual. They are the harm we perceive when something involving our actions or those of authority negatively impact our moral beliefs as they pertain to health care. Since they are so personal, at times they can be at odds with most others in society, which would seem to be the case with the extreme action taken by the assassin of Charlie Kirk. In the case of this assassination, whoever was responsible for security is liable to receive moral injuries for apparently not adequately preventing an action that was similar to the prior attempt on the life of President Trump.

Ethical principles are those professional values that pertain to all mental health care disciplines.

The primary one for psychiatrists is that the needs of patients must come first.

Therefore, there are uncountable personal moral values, but only 1 set of professional ethical principles. At times, personal moral values can come into conflict with professional ethical principles, though hopefully that would be unusual.

How to define moral injuries has also been a challenge. Perhaps the most common and relevant definition is that provided by the modern developer of the concept.¹ It describes the impact on individuals when they witness or are involved with something that violates their moral code. Common internal symptoms are ongoing and pervasive shame and guilt when one feels responsible for the violation: “I did something bad” or “I am bad.” Anger is common with the breaking of trust by others, especially those in trusted authority. Moral distress is a more acute and limited feeling of moral unease.² Neither degree is benign, though to the extent of an injury is much more concerning. Moral injury may also be the hidden cause of some episodes of burnout.

Regardless of definition, how to recognize moral injury is not often obvious or easy, in large part because it is often difficult to recognize and accept personal moral failures. Feedback from loved ones or colleagues can help. In addition, there are by now many scales that have been developed that can be used to measure it.³ The most useful ones track change over time and reference a particular workplace. Researchers at Duke have adapted the 10-item MISS-M-SF for physicians and nurses.⁴

Once such moral injuries are identified, there are emerging interventions that can help. These will be discussed in more depth in our next column.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Shay J. Moral injury. Psychoanalytic Psychology. 2014;31(2):182-191.

2. Litam SDA, Balkin RS. Moral injury of health-care workers during COVID-19 pandemic. Traumatology. 2021;27(1):14-19.

3. Koenig H, Al Zaben F. Moral injury: an increasingly recognized and widespread syndrome. J Relig Health. 2021;60(5):2989-3011.

4. Mantri S, Lawson JM, Wang Z, Koenig HKG. Identifying moral injury in healthcare professionals: The Moral Injury Symptom Scale-HP. J Relig Health. 2020;59(5):2323-2340.