Moral injury: A wound of conscience, not a clinical disorder
Moral injury, the inner turmoil arising from betraying one's own ethical code, is gaining traction in both military and civilian contexts, and research as well as clinical settings. However, unlike PTSD or depression, many argue that moral injury is not a medical disorder to be diagnosed or treated with medication or given the person a label. Instead, it is considered a natural human response to extreme moral conflict, a "wound of the soul" or "violation of one's beliefs”, that calls for understanding, meaning, and ethical growth, rather than clinical medicalisation.
Understanding Moral Injury: A wound to the conscience
Moral injury occurs when an individual does something (or fails to do something) that deeply violates their moral beliefs, or when they witness others (or leaders they "trusted") committing moral wrongs. It's the gut-wrenching guilt or shame experienced when one's inner self screams "I did wrong" or "I let this happen". For example, a soldier might experience moral injury after following a lawful order that resulted in civilian casualties, or a nurse might feel it after being forced to prioritise one patient’s life over another due to limited resources, such as during the Covid-19 pandemic.
It is important to note that moral injury is not currently classified as a mental disorder. It does not appear in the DSM, and one cannot be "diagnosed" with moral injury. PTSD, on the other hand, is an established mental disorder characterised by fear-based symptoms such as flashbacks and hyperarousal resulting from real and measurable life-threatening trauma. Moral injury has a different psychological framing; it is less about fear and more about guilt, shame, violation of one’s ethics or beliefs, and a crisis of trust in oneself or others. It has been described that PTSD is a racing heart, and moral injury is a broken soul.
For veterans, moral injury is considered a "dimensional problem"; a spectrum of inner conflict with no clear threshold. Moral injury is not pathological – rather, it is a human response to a moral breach. Unlike PTSD, the nervous system is not on high alert; instead, the hallmark is a collapse of trust and questioning, either in oneself, in others, or in the wider world.
In short, moral injury isn’t about a hardwired dysfunction; it’s about one’s conscience reacting to something that went against their individual values, standards, and moral code. Rather than medical symptoms, individuals experience moral emotions: remorse, shame, anger, and disgust at their own actions or those of others. These feelings can be intense and painful, but many argue they are also fundamentally normal. In essence, these feelings are a normal part of everyday life; indeed, experiencing them indicates that a person's moral compass is still functioning and that they have a conscience.
Impossible choices: Moral Injury in war and healthcare
War often places soldiers into impossible moral dilemmas. One scenario used during officer selection describes a person in charge of two outbound flights in a war zone, one carrying badly needed blood for transfusions, the other carrying reinforcements and ammunition for troops under fire. Only one plane can take off in time due to weather. Whichever is chosen, at least one life will be lost. How does one decide? How does one live with that decision? Many personnel carry the weight of such choices long after the decision has been made.
For some personnel, these experiences leave a “soul wound”; a deep sense of having violated “what’s right”, even if they followed orders. Shay in 2014 described a form of moral injury as “a betrayal of what’s right, by someone who holds authority, in a high-stakes situation”. In war, that betrayal might even be by oneself; individuals do what they have to do, but may still feel they betrayed their own values in the process.
Real-world examples are vast. But focusing on the war setting, the first accounts and reflections come from the US war in Vietnam. US soldiers participated in several massacres and atrocities during the war, some without any apparent remorse or guilt. However, others who attempted to intervene and stop these events reported feeling guilt for years, believing they couldn’t stop the killings sooner.
One example is that of Hugh Thompson, who intervened to stop a massacre and suffered for many years afterward, feeling that he bore a moral burden. This was despite the fact that he did the right thing by trying to stop the massacre. Witnessing, feeling of duty, and responsibility to prevent it from happening left him feeling morally injured. This illustrates that moral injury isn’t about legal guilt; it’s about ethical guilt. Individuals often hold themselves to high standards of right and wrong, sometimes unfairly.
Moving away from a military context, some of the clearest examples of moral injury have emerged in health, notably during and after the Covid-19 pandemic. Medics found themselves in difficult situations: too few ventilators or beds for too many patients, guidelines requiring them to delay or deny care to people who might have lived if resources were available, or watching patients die alone without friends or family due to quarantine rules. These aren’t just “stressful work conditions”, they are moral challenges.
Frontline health workers reported feelings similar to those of morally injured soldiers; guilt, shame, and a sense of betrayal. For example, an ICU nurse might think, “I let that patient die because we had to ration care; that goes against everything I believe as a nurse”. Or a doctor needing to make a triage decision might be haunted by thoughts such as, “did I do the right thing? Did my choice cost someone their life?” One survey of UK healthcare workers during the pandemic found a spike in experiences of betrayal: nurses feeling let down by their seniors, doctors feeling society abandoned them by ignoring public health advice.
These examples highlight the universality of moral injury across professions involving high-stakes and often quick decision-making. Whether in war or healthcare, individuals who hold frontline public roles face ethical dilemmas that can leave lasting emotional and hidden wounds. However, moral injury is not necessarily a sign of moral failure; it can also indicate deeply held values and ethical integrity.
Moral Injury: A human struggle, not a disorder
Moral injury is real, but it is not a disorder. It is not a medical condition requiring diagnosis and treatment, but rather a moral and ethical struggle best addressed through community, reflection, and meaning-making. A psychiatrist who worked with Vietnam veterans saw how some wounds went beyond PTSD. He described moral injury as a “violation of what’s right”, separate from psychiatric diagnoses. PTSD is about fear; moral injury is about losing trust and meaning. Recovery, he argued, comes from storytelling, communal reflection, and ethical reckoning; not medication.
Further research has cautioned against medicalising moral injury. Standard PTSD treatments such as exposure therapy or medication do not address guilt and shame. Instead, approaches like “adaptive disclosure” focus on ethical reflection and making amends. This position appears to be endorsed by the U.S. Department of VA, which acknowledges moral injury but states explicitly that it is “not a mental disorder”. Many veterans reject medicalisation, fearing it suggests that guilt is pathological rather than a natural response. The VA has explored alternative support, including peer groups, chaplain services, and ethical discussions.
One philosopher views moral injury as “part of the human condition”. Unlike PTSD, which is often viewed as a private struggle, moral injury is relational; about navigating guilt, responsibility, and justice. Healing is not about erasing guilt but learning to live with it and use it as a moral guide. Moral injury is painful, but it is not an illness; it is a sign of a working conscience. Those affected do not need a diagnosis but recognition, space for reflection, and pathways to make amends. By understanding moral injury as a human experience rather than a disorder, society affirms our collective ability to wrestle with right and wrong and grow from it.
Addressing moral injury requires more than just individual resilience; it demands systemic support, open dialogue, and acknowledgment from institutions and society. By fostering environments where these struggles can be discussed and validated, those affected are able to process their experiences in ways that promote healing and personal growth, rather than isolation or guilt.
Finding relief: Recovering from Moral Injury
If moral injury isn’t a disorder, how do people recover or find relief? Research has highlighted key elements that help soldiers, doctors, and others struggling with a damaged conscience. Acknowledgment and open discussion is important. Many suffer in silence, believing they are alone in their guilt and shame. Simply naming the pain can be a relief. Some military units now incorporate reflections into after-action debriefs, while peer support groups in health create spaces to share moral dilemmas, reducing isolation and self-blame.
Self-compassion and forgiveness help ease moral distress. Those with moral injury often hold themselves to impossible standards, focusing on perceived failures; “I should have done more”. Research shows self-forgiveness can foster growth. Therapists often ask veterans to consider what they would tell a fellow soldier in the same situation; usually, they offer understanding, not judgment. Also, making amends and finding meaning can be transformative. This may involve direct restitution, such as an apology, or symbolic action, like advocacy or humanitarian work. Philosophical and faith-based perspectives can help reframe guilt as a commitment to do better, shifting the focus from self-blame to responsibility.
Community support is an important aspect. Moral injuries often fester in secrecy, but healing happens in connection with others. Support groups for veterans, health workers, and first responders provide non-judgmental spaces for sharing experiences, reinforcing that moral distress reflects integrity, not failure. This also includes finding solace in religion. Research has linked unaddressed moral injury to increased suicide risk, making peer support vital. Systemic and leadership actions also play a role. Moral injury is often created by institutions, not just individuals. When leaders acknowledge that personnel were placed in impossible ethical situations, whether in combat or understaffed hospitals, it validates their suffering and helps prevent future crises.
Conclusion
In conclusion, moral injury is a hard truth of life and is inevitable, especially in professions such as the military or health, where life-and-death decisions occur and must occur. It’s real, it’s painful, but it’s not a mental illness in the typical sense. It’s the by-product of having a moral conscience in an imperfect world. While suffering shouldn’t be romanticised, it also doesn’t need to be pathologised away. As long as there is war, as long as there are emergencies, as long as tough choices must be made, there will be moral injuries; moments when people feel crushed by the weight of doing (or not doing) something under difficult conditions.
The silver lining is that where there is moral injury, there is also moral courage and integrity. The very existence of moral injury demonstrates the goodness in people, the aspiration to be just, loyal, and compassionate with clear values and standards. Supporting moral injury taps into that same goodness: through empathy, honesty, and striving to make things right.
It reminds us that being human is a moral endeavour, and even when we falter, we can find our way back to what’s right with the help of others. In the end, moral injury is not a sentence to lifelong guilt; it can be a journey to deeper wisdom and strength. By sharing and listening to these stories, whether from the battlefield or hospital ward, we all become a bit more human, and a bit more equipped to do what’s right when it matters most.
Repost from UK Military Research Group.