The Hidden Wound Emerging from Crisis
As the COVID-19 pandemic continues to challenge healthcare systems across Australia and globally, a particular form of psychological wound has emerged from the shadows of clinical awareness. In overwhelmed hospitals, exhausted emergency departments, and isolated aged care facilities, healthcare workers are experiencing something beyond traditional burnout or stress. This is moral injury—a concept once confined to military psychology that has gained urgent relevance as healthcare workers face impossible decisions daily.
Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code.¹ When healthcare workers must decide who receives ventilators with limited resources, when they cannot allow families to say goodbye to dying loved ones, or when they lack adequate protective equipment to safely care for patients, the resulting psychological impact extends far beyond conventional occupational stress.
Defining Moral Injury: A Framework for Understanding
The Core Components
Moral injury represents a unique form of psychological distress that occurs when individuals perpetrate, fail to prevent, witness, or learn about acts that transgress deeply held moral beliefs and expectations.² Originally conceptualised by psychiatrist Jonathan Shay in his work with Vietnam veterans, moral injury has evolved to encompass experiences across multiple high-stakes professions.³
The concept encompasses three primary types of potentially morally injurious events (PMIEs):
- Acts of commission: Doing something that violates one’s moral code
- Acts of omission: Failing to act in accordance with one’s values
- Betrayal: Being let down by trusted leaders or institutions in high-stakes situations
Distinguishing Moral Injury from Related Conditions
Understanding moral injury requires distinguishing it from related but distinct psychological conditions:
Moral Injury vs PTSD: Unlike post-traumatic stress disorder, which typically involves fear-based responses to life-threatening events, potentially morally injurious events do not necessarily involve a threat to life. Rather, morally injurious events threaten one’s deeply held beliefs and trust.⁴ Where PTSD involves the fear circuitry of the brain, moral injury engages systems related to self-concept and social emotions.
Moral Injury vs Burnout: Whilst burnout reflects exhaustion and depersonalisation from chronic workplace stress, moral injury specifically results from discrete events or ongoing situations that violate core values. Recent conceptualisations suggest a continuum exists between moral distress, moral injury, and burnout.⁵
Moral Injury vs Moral Distress: Moral distress, a term coined by Andrew Jameton in 1984, represents the immediate psychological discomfort experienced when one knows the right action to take but is constrained from taking it.⁶ When this distress persists and fundamentally alters one’s worldview, it becomes moral injury.
The COVID-19 Crucible: Moral Injury in Real Time
The Pandemic’s Moral Challenges
The COVID-19 pandemic has created unprecedented conditions for moral injury among healthcare workers globally. A 2020 study from China found that healthcare workers in direct contact with COVID-19 patients reported elevated symptoms of depression (50.4%), anxiety (44.6%), insomnia (34%) and distress (71.5%).⁷
In Australia, healthcare workers face unique moral challenges:
- Resource allocation dilemmas: Deciding who receives ICU beds or ventilators
- Isolation protocols: Preventing families from being with dying loved ones
- Personal protective equipment shortages: Choosing between self-protection and patient care
- Workforce limitations: Being unable to provide usual standards of care due to staffing shortages
Voices from the Frontline
“I’ve been a nurse for 20 years, and nothing prepared me for having to tell a daughter she couldn’t hold her mother’s hand as she died,” shares one Melbourne ICU nurse. These experiences reflect what researchers at Phoenix Australia—Centre for Posttraumatic Mental Health describe as the moral challenges faced by workers who know what care their patients need but are unable to deliver that care due to obstructions beyond their control.⁸
The Psychology and Neuroscience of Moral Injury
Psychological Mechanisms
The psychological impact of moral injury operates through several interconnected mechanisms:
- Cognitive Dissonance: The conflict between one’s actions (or inactions) and core beliefs creates intense psychological tension⁹
- Shattered Assumptions: Fundamental beliefs about self, others, and the world become fractured¹⁰
- Identity Disruption: The sense of who one is as a moral agent becomes compromised
The Symptom Profile
Moral injury manifests through a constellation of symptoms that may overlap with, but extend beyond, traditional trauma responses:¹¹
Emotional symptoms:
- Guilt and shame
- Anger and disgust
- Spiritual/existential distress
- Emotional numbing
Cognitive symptoms:
- Rumination and intrusive thoughts
- Self-condemnation
- Loss of trust in authority
- Questioning of fundamental values
Behavioural symptoms:
- Social withdrawal
- Self-destructive behaviours
- Substance use
- Difficulty in relationships
Spiritual symptoms:
- Loss of faith
- Existential crisis
- Questioning life’s meaning
- Feeling unforgivable
Assessment and Recognition
Current Assessment Tools
Several instruments have been developed to assess moral injury, though the field continues to evolve:
The Moral Injury Events Scale (MIES): A 9-item scale assessing exposure to potentially morally injurious events, including subscales for transgressions and betrayal¹²
The Moral Injury Symptoms Scale-Military Version (MISS-M): A 45-item measure assessing psychological, social, and spiritual symptoms following exposure to PMIEs¹³
The Expressions of Moral Injury Scale (EMIS): A 17-item scale measuring self- and other-directed moral emotions¹⁴
Clinical Considerations
When assessing for moral injury, clinicians should consider:
- The specific nature of the potentially morally injurious event
- The individual’s role (perpetrator, witness, or victim of betrayal)
- Pre-existing values and belief systems
- Cultural and contextual factors
- Co-occurring mental health conditions
Treatment Approaches: Current Evidence and Emerging Interventions
Adapted Evidence-Based Treatments
Researchers have hypothesised that trauma-focused PTSD treatments may be effective for patients with moral injury:¹⁵
Cognitive Processing Therapy (CPT): CPT helps patients work through beliefs that underlie guilt, shame, and betrayal. The structured approach addresses self-blame and helps contextualise moral violations.
Prolonged Exposure (PE): Through imaginal and in-vivo exposure, patients have opportunities for emotional processing and reconnection with important values.
Specialised Moral Injury Interventions
Adaptive Disclosure: A 12-session treatment developed for military personnel that helps process moral injury through imaginary conversations with a compassionate moral authority¹⁶
Impact of Killing (IOK): A 10-session therapy specifically addressing moral injury related to killing in military service¹⁷
Acceptance and Commitment Therapy for Moral Injury (ACT-MI): An emerging approach focusing on psychological flexibility and values-based living despite moral pain¹⁸
Building Spiritual Strength: An 8-session group intervention addressing spiritual and existential aspects of moral injury¹⁹
The Australian Response to Healthcare Worker Moral Injury
Institutional Initiatives
Phoenix Australia has developed specific resources for healthcare organisations, including the “Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury.”²⁰ This guide provides practical strategies for both individual and organisational responses.
Key recommendations include:
- Establishing peer support programmes
- Creating ethical consultation services
- Ensuring transparent communication from leadership
- Providing adequate resources and staffing
- Offering mental health support specifically tailored to moral injury
Professional Support Networks
Australian healthcare organisations are beginning to recognise moral injury as distinct from burnout, implementing targeted interventions:
- Ethics rounds and debriefing sessions
- Chaplaincy and spiritual care services
- Peer support groups
- Leadership training on moral injury prevention
Beyond Healthcare: Other Affected Populations
Veterans and Military Personnel
The concept of moral injury originated in military contexts. Australian veterans from Afghanistan and other deployments may experience moral injury from:²¹
- Civilian casualties
- Inability to help local populations
- Perceived betrayal by leadership or government
- Actions taken under orders that conflict with personal values
First Responders
Police, paramedics, and firefighters face moral injury risks from:
- Inability to save lives despite best efforts
- Witnessing preventable tragedies
- Resource constraints limiting response capabilities
- Public criticism of necessary decisions
Organisational and Systemic Interventions
Creating Morally Sustainable Work Environments
Individual treatment alone cannot address systemic factors contributing to moral injury. Essential organisational interventions include:
- Leadership accountability: Transparent, ethical decision-making
- Resource allocation: Ensuring adequate staffing and equipment
- Ethical support structures: Active ethics committees
- Communication channels: Regular forums for moral concerns
- Policy reform: Addressing systemic moral stressors
The Role of Professional Bodies
Medical colleges, nursing organisations, and allied health bodies must advocate for:
- Recognition of moral injury as an occupational hazard
- Integration of moral injury education in training programmes
- Development of profession-specific support resources
- Systemic reforms to reduce moral stressors
Looking Forward: Recovery and Resilience
Post-Traumatic Growth
Not all individuals exposed to potentially morally injurious events develop lasting distress. Some may experience post-traumatic growth, including:²²
- Clarified values and priorities
- Deepened compassion
- Strengthened sense of purpose
- Enhanced spiritual development
Building Moral Resilience
Preventive strategies being explored include:
- Pre-deployment/pre-crisis ethics training
- Values clarification exercises
- Moral decision-making frameworks
- Peer support networks
- Spiritual and philosophical preparation
Implications for Mental Health Practice
Clinical Recommendations
For mental health professionals working with moral injury:
- Create safety: Establish non-judgemental therapeutic space
- Validate moral emotions: Acknowledge the legitimacy of moral distress
- Address shame directly: Distinguish appropriate guilt from toxic shame
- Explore values: Help clients reconnect with core values
- Consider spiritual dimensions: Integrate spiritual care when appropriate
- Collaborate: Work with chaplains, ethicists, and peer supporters
Training Needs
Mental health professionals require specific training in:
- Distinguishing moral injury from PTSD and other conditions
- Cultural competence in moral frameworks
- Integration of spiritual and existential approaches
- Collaborative care models
Conclusion: Healing Moral Wounds in Extraordinary Times
The COVID-19 pandemic has thrust moral injury into the spotlight, revealing the profound psychological toll of impossible decisions and constrained care. As healthcare workers continue to navigate unprecedented challenges, understanding and addressing moral injury becomes not just clinically important, but morally imperative.
Recovery from moral injury is possible. Through individual treatment, organisational support, and systemic reform, the wounds to moral integrity can heal. The path requires acknowledgment that moral injury reflects not weakness, but the depth of commitment to one’s values—a testament to the humanity of those who serve others in impossible circumstances.
As we continue through this pandemic and prepare for future challenges, integrating moral injury awareness into healthcare, emergency services, and military support systems will be crucial. The lessons learned during COVID-19 must inform lasting changes to protect the moral wellbeing of those we depend upon in crises.
Resources and Support
Australian Resources:
- Phoenix Australia – Centre for Posttraumatic Mental Health: www.phoenixaustralia.org
- Beyond Blue: 1300 22 4636
- Lifeline Australia: 13 11 14
- Open Arms (Veterans & Families Counselling): 1800 011 046
- Black Dog Institute: www.blackdoginstitute.org.au
Professional Resources:
- Phoenix Australia Moral Injury Resources
- Australian Guidelines for PTSD
- APS COVID-19 Mental Health Resources
International Resources:
References
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This article was written by the editorial team at Mind Health , drawing on emerging research and clinical guidelines in moral injury and trauma psychology during the COVID-19 pandemic.
Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. If you are experiencing symptoms of moral injury or other mental health concerns, please consult with a qualified mental health professional.
Acknowledgements: We thank the healthcare workers on the frontlines of the COVID-19 pandemic for their service and sacrifice.
