Moral Injury: A New Description of What Ails You?

Photograph Source: aaayyymm eeelectriik – CC BY 2.0

Naomi Osaka withdraws from the French Open with mental health issues. Simone Biles withdraws from the Olympic all-around gymnastics competition because of mental health struggles. The pressure on top athletes is enormous. We are becoming familiar with their issues as more and more athletes come forward to articulate their problems. But what about you? What about someone who gets up in the morning and reads the daily newspaper and/or watches the news in the evening? How are you feeling?

Feeling in the dumps? What could be the reasons? Winter blues? Add COVID and lack of social interaction. Worried about climate change? Arctic melting? For Americans: Are the Republicans set to sweep mid-terms in 2022? No accountability for higher-ups in the January 6 assault on the Capitol? Supreme Court catastrophic? Bye-bye Roe vs. Wade? Potential U.S. civil war? Global politics? Russian troops ready to cross Ukraine border? Chinese pressure Hong Kong and Taiwan? Illiberal democracies flourishing? For the French: “Pissed off” with the man, Emmanuel Macron, who is pissed off with you? Aren’t the Brits incensed with partying BoJo? The list could go on and on. I have no magic cure for all that ails you (or me). But I do have a description of a new phenomenon which may explain some of your symptoms.

We learned what post-traumatic stress disorder (PTSD) is for returning Vietnam War vets. It is now considered a familiar disease for soldiers after combat. While it was certainly prevalent throughout history – shell shock and combat fatigue in W.W.II – it became officially recognized in 1980 when it was included in the American Psychological Association’s statistical manual for mental health practitioners.

Similar to but different from PTSD are potentially morally injurious events (PMIEs). They are described as “the psychic fallout of ‘morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress [one’s own] deeply held moral beliefs and expectations.’” Whereas PTSDs sufferers are overwhelmed with fear, PMIE sufferers are overwhelmed with shame or guilt.

PSTD and PMIE are usually connected to combat veterans. But they are different. While the military has recognized PTSD, only recently has the United States military established a program for treating veterans with PMIE. The San Diego Naval Medical Center has an eight-week moral injury/moral repair program.

But the diagnosis of PMIE has not been solely limited to soldiers. Moral distress among health care workers was described by the bioethicist Andrew Jameton in 1984. It has also been described in terms such as burnout or compassion fatigue.

But what about you (and me) who are not athletes, soldiers or health care workers? A center dealing with moral injury asks potential patients the following question: “Have you ever had people get hurt or die because of something you did (or failed to do)?” Failed to do? What have you done or failed to do on the list of the above?

For example: While there are limitations about what one individual can do to effect climate change, there are numerous small things that could make a difference. Worried about growing illiberalism in the U.S.? What have you done to make sure Trump and the Republicans don’t take over the country and establish an autocracy? Moral injury does not have to be limited to an event. It can also deal with a larger series of events.

PMIE focuses on the sufferer’s “perpetrating, failing to prevent, or bearing witness to acts that transgress [one’s own] deeply held moral beliefs and expectations.” It assumes that the patient has “deeply held moral beliefs and expectations.” A soldier can say that failing to prevent a massacre of civilians is against her moral beliefs. And a vegan could say that eating meat or watching a cow being slaughtered is against her moral beliefs.

How to certify that an individual or a collective has been injured morally? The answer is subjective. While I might consider myself a moral refugee from a country or a global citizen pilgrim against all forms of nationalism, someone else may not consider an event or series of events to be morally harmful.

But the fact that there is a label such as potentially morally injurious events opens up a new category of mental health issues. If mental health is as important as physical health, then moral injury should be considered similar to other injuries.

Naomi Osaka and Simone Biles’ revelations have been universally accepted. Among athletes, mental health issues are being recognized like physical injuries. Moral injury is a mental health issue; I’m sure there are plenty of sufferers out there. I am also sure that an eight-week moral injury repair program would not be long enough to cure what ails me.



Daniel Warner is the author of An Ethic of Responsibility in International Relations. (Lynne Rienner). He lives in Geneva.