Traumatic Events Can Create Moral Dilemmas
Many people struggle with feelings of guilt and regret after traumatic events, wondering what, if anything, they could have done differently, or how they could have prevented events, or how they will live with what happened. Part of this struggle may involve wrestling with moral questions, especially if they were asked to perform duties that conflict with their values or moral compass. Moral injury can occur after someone takes part in, fails to prevent, or witnesses an event that conflicts with their morals or values. These kinds of events are called potentially morally injurious events. If the distress after such an event persists and leads them to question their beliefs, they may have experienced a moral injury.
Who Might Be at Risk for Moral Injury?
Military personnel and the National Guard are called to defend posts or take part in operations they may personally oppose, or if asked to commit actions that conflict with their values in civilian life, may experience serious moral conflict.
Examples of national or state defense events that may lead to moral injury include:
- Killing or harming others
- Making decisions that affect the survival of others
- Being unable to care for all who were harmed
- Freezing or failing to perform a duty during a dangerous or traumatic event (for example, falling asleep on patrol)
- Failing to report an event that violates rules
- Engaging in or witnessing acts of over-the-top violence
- Feeling nothing or excitement while causing harm or killing others
Moral Injury in Non-Military Settings
Moral injury may also happen in non-military settings. For example, health care workers may experience moral injury if they need to make difficult decisions related to life and death—such as deciding who gets care first, or how limited resources are distributed—or when they believe they should have been able to save a patient’s life but were not able to do so. During disasters, deciding who receives assistance and of what type can be especially difficult, as choices may have life-altering consequences. Many first responders, such as Police, Firefighters, Emergency Medical Personnel, SWAT, Dispatchers, Air-Traffic Controllers, and others, must make life-and-death decisions instantaneously and cannot always save the life they try to help.
Not only do first responders and the military face moral injury, but civilian victims of trauma and their significant others do as well. Many, touched by violence, extreme fear, and unexplained loss of significant magnitude, ask why. Most manage to work through it, but those who can’t have a moral injury.
How Does Moral Injury Affect Someone?
Moral injury involves upsetting emotions, changes in behavior, difficulties relating to others, and/or a spiritual crisis. Many people may experience distress after a potentially morally injurious event, but most feel better over time. Those who continue to struggle emotionally and possibly spiritually long after the event, such that it affects their day-to-day functioning in relationships or work, school, or other activities, may have moral injury.
People with moral injury often feel guilt, shame, disgust, and/or anger. Another common reaction to moral injury is being unable to forgive oneself or feeling the need to punish oneself. Someone with moral injury may end a relationship because they do not believe they are worthy of love, or they may not show up for therapy appointments because they do not believe they deserve to feel better or are too ashamed.
Moral injury can affect a person’s faith and spirituality. For example, someone may have difficulty understanding how their beliefs and relationship with God can be true, given the horrific event. This can lead to questioning prior faith and personal beliefs.
Moral Injury and PTSD
Moral injury can occur together with mental health conditions like post-traumatic stress disorder (PTSD) and depression, but it is not a diagnosis itself. Moral injury and PTSD have a great deal in common:
- Often begins with a traumatic event (in the case of moral injury, the event also violates moral values).
- Cause people to feel distress that lasts long past the initial event.
- Share common features such as feelings of guilt, shame, and a loss of trust in others.
There are also differences between moral injury and PTSD. For example, people with PTSD may feel like they need to be on high alert, which is not usually a feature of moral injury.
Research studies have shown that when someone has moral injury in addition to PTSD, the PTSD symptoms may be more severe. They may also have more severe depression symptoms, be more likely to think about suicide, and have more trouble functioning in their everyday lives.
How Is Moral Injury Treated?
It can be difficult to talk about the events that led to moral injury or PTSD. Especially because of guilt and shame, some people fear talking to anyone about what happened due to their feelings of guilt or shame. While they might want to speak to a member of their faith organization, they fear a lack of understanding for the depth of their distress or, at worst, rejection and judgment.
Seeking the counsel of a therapist trained in PTSD is a good starting place because therapists are trained to be accepting and non-judgmental. They counsel clients who have experienced horrible life events, whether self-inflicted or inflicted by others. Furthermore, their training can help create an effective plan directed toward not only their moral injury but also the associated PTSD and other factors affecting it.
Sources
PTSD: National Centers for PTSD U.S. Department of Veterans Affairs
