Moral injury / Moral distress / Moral dilemma

• The terms moral injury, moral distress, and moral dilemma fall along a continuum. Moral injury is usually understood as the most severe and debilitating experience, moral dilemma as the least, and moral distress as somewhere between the two.

General public definition

• Moral injury, moral distress, and moral dilemma are currently not listed as diagnoses in the DSM-5-TR or ICD-11.
• The meanings of these terms are evolving and may change.
• During potentially psychologically traumatic events or other unusually stressful situations, people may carry out, witness, or fail to prevent events that go against their moral beliefs and expectations.⁴⁴
• A moral injury can occur in response to doing something or witnessing behaviours or acts that go against a person’s values and moral beliefs. Events that cause moral injury can be:
  • acts of commission (what someone has done)
  • acts of omission (what someone has failed to do), or
  • acts of betrayal.

Academic definition

• Moral injury, moral distress, and moral dilemma are currently not listed as diagnoses in either the DSM-5-TR or ICD-11. These are evolving concepts.
• Moral injury describes the psychological, social, and spiritual distress, harm, or impairment that results from experiencing a violation of deeply held morals, ethics, or values.
• When an event has the potential to cause moral injury, it is called a potentially morally injurious event (PMIE).
• The development of moral injury following a PMIE may parallel the development of posttraumatic stress disorder following a potentially psychologically traumatic event.
• Moral injury may impact the following domains:
  • emotional (increased feelings of guilt, shame, anger)
  • spiritual (loss of spiritual or religious beliefs, loss of sense of life’s purpose)
  • self (alterations in identity, self-perception)
  • moral (changes in moral appraisals of self and others), and
  • relational (difficulty maintaining existing relationships or fostering new ones).
• During potentially psychologically traumatic events or other unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict (their) deeply held moral beliefs and expectations.³⁸
• “When [individuals do] something that goes against their beliefs, this is … referred to as an act of commission, and when they fail to do something in line with their beliefs, that is … an act of omission. Individuals may experience betrayal from leadership, others in positions of power, or peers, [which] can result in adverse outcomes.”⁴⁵
• “Moral injury is the distressing psychological, behavioural, social, and sometimes spiritual aftermath of exposure” to acts of commission, omission, or betrayal.⁴⁶
• “A moral injury can occur in response to acting in a way or witnessing behaviours that go against an individual’s values and moral beliefs.”⁴⁷
• “In order for moral injury to occur, individual(s) must feel like a transgression occurred and that they or someone else crossed a line with respect to their moral beliefs.

Guilt, shame, disgust and anger are some of the hallmark reactions of moral injury.”⁴⁷

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