Moral Injury in Complex Adaptive Human Systems

 

Dinner parties can be fertile ground for conversation and connection.  Last night amidst the friendly banter of a lively dinner party I listened carefully to an emergency health care provider discuss the highs and lows of his career.  He talked about feelings of love, intimacy, honor, frustration, and betrayal that accompany the care of patients within health bureaucracies.  At one point in the conversation I mentioned to him that an event he was describing sounded like a moral injury had occurred. He was not familiar with the term ‘moral injury’ and so we discussed the meaning.

I first learned the term ‘moral injury’ when listening to an episode of Fresh Air broadcast on NPR in 2014.  During the broadcast Terry Gross interviewed military correspondent, David Wood, who said, “I think that almost everyone who returns from war has suffered some kind of moral injury…….and I do not mean by that that they have done something wrong, only that they have seen or experienced things, which violate their own sense of who they are, their own sense of right and wrong, their own sort of moral compass.”  

The United States Department of Veterans Affairs defines moral injuries as the psychological distress and symptomology that result from “acting or witnessing behaviors that go against an individual’s values or moral beliefs,” and most research on moral injury to date has been done in relation to military service.  However, increasingly researchers are examining the experience and consequents of moral injury in a broader set of occupations, and findings are consistent.  Moral injury is associated with mental health problems including higher rates of anxiety, depression, PTSD, and in some cases suicidality [1,2,3].  A recent article in The Lancet Psychiatry [4] indicates that moral injury could be a growing public health concern as it affects numerous professions including journalists, law enforcement agents, and health care providers and is exacerbated by crises such as pandemics, public unrest, and war.  

At this point in exploring moral injury, I wonder if it is fair to make a leap using complex systems thinking.  Is it possible that as individuals within a society experience moral injury, the individual incidence at some point aggregates upward toward a collective experience of moral injury?  For example does membership in communities comprised of individuals experiencing moral injuries, or even networks like social media sites comprised of individuals experiencing moral injuries, lead to a type of collective moral injury that is challenging to name and observe but pervasively destructive nontheless?  I offer as evidence for this possibility the research on secondary trauma that describes the psychological distress that results from witnessing another’s traumatic experience and the work of Dr. Sandy Bloom to address organizational level trauma in human services.

If we understood the potential for collective moral injury would we then better understand the interplay of individual and collective factors when protests break out on campuses, when health care workers and educators strike, when adolescents are harmed by social media, or when students disengage from school? Could we then design our responses to address not only individual experiences, but collective experiences and contexts as well to generate better outcomes for more people?

I’ll admit that Nicholas Kristof’s article about the war in Sudan published in today’s New York Times got me thinking about moral injury once again this morning. I cried while reading the article.  Humans cry when they are in pain, and our tears can teach us that it is truly injurious to witness the suffering of fellow humans.  No wall can block out the reality of our human connections.

[1] Coimbra, B. M., Zylberstajn, C., van Zuiden, M., Hoeboer, C. M., Mello, A. F., Mello, M. F., & Olff, M. (2024). Moral injury and mental health among health-care workers during the COVID-19 pandemic: Meta-analysis. European Journal of Psychotraumatology, 15(1), 2299659.

[2] McEwen, C., Alisic, E., & Jobson, L. (2021). Moral injury and mental health: A systematic review and meta-analysis. Traumatology, 27(3), 303.

[3] Williamson, V., Stevelink, S. A., & Greenberg, N. (2018). Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346.

[4].  Williamson, V., Murphy, D., Phelps, A., Forbes, D., & Greenberg, N. (2021). Moral injury: The effect on mental health and implications for treatment. The Lancet Psychiatry, 8(6), 453-455.