It Takes a Village to Repair Moral Injury

Moral injury represents a kind of trauma tied to circumstance and social context.

The term “moral injury” originated in the military veteran literature and is generally understood to refer to the traumatic violation of deeply held moral beliefs. These violations can occur through acts of omission or commission or through witnessing morally violative activities. A classic example is an artilleryman who feels duty-bound to shell an area or witnesses the shelling of an area where children are known to be present. More recently, the term moral injury has been applied to a range of professionals, including those in health care.

I highlight here our recent paper, “Repairing Moral Injury Takes a Team: What Clinicians Can Learn from Combat Veterans,” in which we argue that healthcare professionals would benefit from heeding the experiences of military veterans in identifying and addressing the social dimensions of moral injury. The phenomenon does not occur in a vacuum. It is not, as we note, “a disorder of the combatant alone; it is deeply tied to the circumstances of the veteran’s experience of war and trauma.” The same holds for health care practitioners. Unless we work to address the social factors that precipitate moral injury, neither the combatant nor the clinician can heal.

Social Dimensions of Moral Injury

We highlight in our paper two social dimensions that are particularly relevant to the development of moral injury: (1) the moral communities in which moral norms are formed and which influence interpretations of events; and (2) the social conditions, systems, institutions, and other actors that damage agency.

By “moral communities,” we mean groups “constituted by widely shared goals and norms … that promote pursuit of these goals and adherence to these norms among their members.” This could be the military or the medical profession. It could also be religious groups or political affiliations, or neighborhood associations. These communities have a shared understanding of the good and help members understand what it means to orient toward that good.

Moral injury occurs when one’s agency to act or orient toward this shared conception of the good is damaged, thwarted, or constrained. There is a betrayal of what is understood to be good and right in a high-stakes situation. In the context of health care, for example, doctors are constrained from acting as healers because metrics for billing and collection take precedence. Forced to see more patients in less time to meet the bottom line, they hardly feel like the caring practitioners they set out to become.

Or take the case of the COVID-19 pandemic. Physicians accustomed to treating all patients with the highest standard of care suddenly found themselves constrained to care for too many critically ill patients in suboptimal circumstances. Many felt betrayed by hospital leadership who had inadequately prepared or resourced solutions. The response, then, cannot be to offer wellness sessions. If social factors precipitate moral injury, then social factors must repair it.

Social Dimensions of Moral Repair

Our paper argues that communities can contribute to moral repair in two key ways: 1) they can work to relieve suffering, and 2) social groups can empower the morally injured to exercise their agency.

To the first point, moral communities can relieve suffering and facilitate moral repair by connecting the injured to co-sufferers, those who have healed, and those who can aid in healing. We highlight these examples:

1. Professional peer groups and community-based groups might provide advice and support for the repair of moral injury. They can increase relational cohesion and decrease feelings of alienation among the morally injured.
2. Writing opportunities have given voice to the morally injured. Writing and social media engagement for veterans and healthcare professionals provide opportunities to connect with sympathetic audiences, co-sufferers, and a broader community.
3. Religious groups offer unique support that combines standard community elements with rituals and practices and an existential framework for hope, joy, or other virtues. Religion also offers a familiar subculture within a community—shared language, heritage, and/or customs. Professional chaplains are typically embedded in the military or medical spaces, making them uniquely equipped to understand how contexts can be morally injurious and respond with compassion toward the injured.

It bears stating that no community is perfect, and some propagate their own injuries. While we acknowledge this fact, we clarify that beneficial communities are those that “listen in non-judgmental ways, are empathetic, help contextualize the injury in a way that is consistent with deeply held beliefs, empower the injured to find constructive ways to exercise agency and summon the morally injured to constructive forms of service, vocation, and leadership.”

Moral Injury Essential Reads

Identifying and Addressing the Hidden Cost of Moral Injury

A New Writing Therapy is Helping to Heal Moral Injury

Second, collective efforts can empower the morally injured to act in ways that mitigate the social dimensions of moral injury. We outline a number of such efforts in our paper, and they range from large-scale responses by governments and non-governmental organizations to community-level efforts such as feeding and/or providing childcare for frontline workers.

Collective action might take the form of protesting inhumane or unsustainable conditions, such as working without adequate personal protective equipment. Empowering the morally injured might require unionizing. Since moral injury isolates and alienates, the collective work of communities in action goes a long way toward moral injury repair.

Conclusion

The military has long understood that contextual features give rise to moral injury. Healthcare practitioners would do well to emulate their military colleagues in seeking morally reparative communities and opportunities for the exercise of agency and collective action.