Moral injury: what it is, who it affects and where support can be found

Moral injury refers to the lasting emotional and psychological effects of events that violate a person's moral or ethical code. A UK study of military veterans describes potentially morally injurious events as acts of commission, omission or betrayal by trusted others, and more recent evidence suggesting they can also be mixed events that combine ethically challenging experiences with more routine traumatic events.

The BMA draws a distinction between moral distress and moral injury. Moral distress is the psychological unease that arises when professionals identify an ethically correct action to take but are constrained in their ability to take that action, for example by insufficient staff, resources, training or time. Moral injury, it says, can arise where sustained moral distress leads to impaired function or longer-term psychological harm, producing profound guilt and shame, and in some cases a sense of betrayal, anger and moral disorientation.

It is therefore different from burnout, which centres on exhaustion and overload, although the two can occur together and share some features.

The concept first came from military contexts, and the veterans study notes that most evidence comes from US studies, which is why it set out to examine UK Armed Forces veterans. In its sample of 204 UK veterans, those who reported potentially morally injurious experiences had worse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared with those who reported no event.

In health and social care, the BMA's 2021 survey of doctors found that 43.8% of respondents had not heard of moral distress and 48.4% had not heard of moral injury. After reading definitions, 78.4% said moral distress resonated with their experience at work and 51.1% said moral injury did. The BMA states there is an increasing belief across the UK that the problem is getting worse, and that it began before the pandemic.

The BMA lists causes of moral distress in medical staff, which can build up to moral injury if they are repeated. These include lack of agency to make the best decisions for patients, insufficient or non-existent resources to provide care to suitable professional standards, practical experience of care clashing with the ethical standards taught at medical school, being involved in wrongdoing, and end-of-life care decisions.

Its survey asked respondents to choose the five most important causes. The top answers were not enough staff to treat all patients suitably (52.5%), individual mental fatigue (40.8%), lack of time to give enough emotional support (37.2%), not being able to give timely treatment (37.2%) and deprioritising certain patients (36.3%).

The veterans study says experiences of this kind can lead to negative attributions about the self, such as "I am an awful person", and to profound feelings of guilt, anger, worthlessness and shame, which in turn can lead to formal psychological difficulties. Moral injury has been associated with PTSD, depression and suicidal ideation.

The BMA quotes a doctor who said that learning about moral distress and injury explained how they had felt since starting work, and that they had become depressed when they struggled to live up to the ideals they were taught. This reflects a common pattern: people often think the problem is a personal failing rather than a response to circumstances.

• Persistent guilt or shame about what you did, failed to do or witnessed.

• Anger or a sense of betrayal towards colleagues, leaders or institutions.

• Loss of trust in yourself or others, and feeling morally disoriented.

• Withdrawal, low mood, anxiety, sleep problems or thoughts of self-harm.

There is no single UK treatment guideline for moral injury. The veterans study notes that more work is needed to design effective pathways for prevention and intervention, and that people who seek treatment for PTSD often report morally injurious events as the most distressing event for them. In practice, support usually comes through talking therapies and PTSD or trauma-focused care, occupational health, peer support and, for veterans, specialist NHS and charity services.

A GP is the usual first step for anyone whose distress, sleep, mood or use of alcohol is affecting daily life. Anyone having thoughts of harming themselves should contact NHS 111, Samaritans, their GP or, in an emergency, 999. NHS staff can also usually access occupational health and employee assistance services through their employer.

The BMA argues that moral distress is a structural problem, as it arises from institutional and resource constraints, and cautions against framing it as a question of individual resilience. It reports that some doctors say the system implies the failing is with the doctor and that they lack resilience.

Practical steps that follow from this include creating a culture in which staff can speak up, addressing staffing and resources, supporting teams after difficult events and giving people agency in decisions. The sources used here describe the causes and the problem but not a tested set of interventions, so these are general principles.

NHS support runs through GPs, NHS Talking Therapies, mental health services and, for veterans, NHS veterans' mental health services. Employers may fund occupational health and counselling.

Some people choose private psychological therapy, particularly trauma-focused therapies, to access care sooner or to find a therapist with experience of moral injury. Because there is no single recognised treatment, it is reasonable to ask a therapist about their experience and how they would approach guilt and shame.