Moral Injury: Definition, History, & Symptoms

[Editor’s Note: The monthly blog post from Dr. Weingarten is here! Kaethe Weingarten, PhD, founder and advisor of MCN’s Witness to Witness, shares stories, resources, and helpful tips to support health care workers and others through the many stressors of their daily lives. This is the first installment of a two-part series on moral injury.] 

How often does it happen that people have a salient experience without realizing there's a specific concept or term that captures it? I first encountered this myself in the 1990s, when I began conceptualizing the witnessing model. It was during that work that I came to understand that, when someone witnesses another’s suffering, there isn’t just one witness position—but four distinct ones. I applied this idea to people in two contexts: witnessing in the context of illness, dying, and death, and witnessing in the context of conflict. The term and the elaboration of different witnessing positions put language to those moments I had had but couldn’t yet quite capture to share with others.

I had the experience again at the start of the Witness to Witness (W2W) Program in 2018. A concept that I had learned about more than two decades before – moral injury -- emerged as applicable in a new context. The Witness to Witness Program started as a program that served first responders, lawyers, shelter workers, journalists, and clinicians working with people at various stages of the immigration process at the Southern Border. The program began by offering one-to-one deep listening conversations -- witnessing conversations – to the providers who were themselves witnessing people having challenging experiences trying to achieve safety in the United States. Thus, the name, the Witness to Witness program. As I listened during my conversations and read the notes taken by volunteers who were speaking to other providers, a common theme emerged that reminded me of the work of Jonathan Shay, MD, PhD, the psychiatrist, who coined the term moral injury in his 1994 book, Achilles in Vietnam: Combat Trauma and the Undoing of Character. 

The book creates a connection between the story of the warrior Achilles during the Trojan War that took place around 1200 BCE and veterans returning from Vietnam, with whom Shay was working at the Boston VA Hospital. Shay’s contribution was to name an experience he heard veterans describe when they talked about “freaking out” when they had followed an order or witnessed someone follow an order that resulted in an outcome that violated their sense of what was right, that is, of their morality and values. Shay realized that the symptoms these veterans were reporting could not be best captured by the diagnosis of PTSD, post-traumatic stress disorder. Rather, these veterans felt that they had been betrayed. Using the story of the Greek warrior Achilles in the Illiad as his case study, Shay coined the term “moral injury” to describe the berserk behavior Achilles exhibits after his best friend Patroclus is killed while carrying out an unjust order from his commander. Shay wrote that Achilles’ moral universe was shattered, and that this violation was as wounding to his psyche as a bullet wound to the body. 

The people I was talking to in 2018 were not in a war. They were people drawn to the work they were doing with immigrants because of strong values of care, compassion, and justice. Day in and day out, they felt they were making compromises in what would be best for the people they served. They were clear about what they wanted to offer, but in many instances, the systems within which they were operating were making it nearly impossible to deliver the best care possible. People did use the term “burnout” to describe what they were feeling, but they also often said, “There is something else that bothers me. I can’t quite put my finger on it.” The closest anyone came to naming the experience so many colleagues described was when an immigration lawyer spoke about the feeling of coming to work on Monday mornings to find a new directive—one that made their jobs harder and their clients' chances of gaining safety in the US even slimmer. She called the experience: “Monday morning inbox trauma.” That phrase was powerful! Then another young lawyer said something else. “It hurts our souls. It shakes us to the core. It violates what we believe in and why we do this work.” Putting those two together, it occurred to me that the term moral injury might be a good fit.

It turns out that in 2018 other people were hearing echoes of moral injury in those with whom they worked. At roughly the same time, I read an article in STAT by Wendy Dean, MD and Simon G. Talbot, MD. Their opening paragraphs resonated: “Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

“Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.” They make it clear that moral injury among health care workers arises when they know what timely, appropriate, and compassionate care looks like but are unable to provide it due to constraints beyond their control. The experience produces a variety of feelings, including guilt, shame, helplessness, and hopelessness among others.

This description must have hit home, because they were asked to write a Guest Editorial in the journal The Federal Practitioner in 2019. It would take the pandemic, though, before the term gained traction and became much more commonplace. Interviews with health care workers during the early days before vaccines when family members were only able to communicate with loved ones over iPads, took a toll on many health care workers. One nurse was quoted as saying, “I upheld the rule on the piece of paper…But in terms of what would a good person do? It’s not that…. Am I really a good person? There’s that seed of doubt.” 

This comment captures the heart of the matter: when people violate their moral code—either by doing something wrong or failing to do what they believe is right—they damage their sense of themselves as a good person. It turns out that decades ago, in 1984, a similar and related term was developed by Andrew Jameton, PhD and developed in his book, Nursing Practice: The Ethical Issues. He used the term, moral distress, to describe “the experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it.” In a follow up article he published in 2017, he noted that there were more articles using the term moral distress from 2013 to 2016 than in the previous three decades! He rightly asks why this might be so. One answer he provides is that hospitals are doing more care “at higher levels of acuity than in the 1980s,” and therefore health care professionals, not just nurses, are encountering more situations that are morally complex. In reviewing the literature, he finds that the proposed solutions span a continuum—from supporting individual providers after distressing experiences to reforming the systems they work within to reduce the occurrence of situations that lead to moral distress.

Coinciding with the increasing research into experiences of moral distress, has been increasing attention to the concept of moral injury. This statement is backed by research conducted by the team of Brett Litz, PhD, at the Boston VA, the same hospital where Jonathan Shay worked. In a stunning article published in the Journal of Traumatic Stress in 2025, Dr. Litz, whose seminal research published in 2009 set off an entire field of inquiry into moral injury, reports that as of October 2024, there were 2,569 nonduplicated PubMed and Google Scholar citations with “moral injury” in the title compared to two PubMed citations and 40 Google Scholar citations prior to 2009. In the 2009 paper and subsequently, Dr. Litz and his team define moral injury as the “lasting emotional, cognitive, behavioral, social, and/ or spiritual impact of exposure to a potentially morally injurious event (PMIE) such as ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs or expectations.’” 

There are primary, core symptoms that follow, including guilt, disgust, inability to self-forgive, spiritual/existential crisis, loss of trust, and betrayal, as well as secondary symptoms like depression, anger, anxiety, and social and functional impairments (e.g., self-sabotaging behaviors, self-punishment) that can follow exposure to a PMIE. In one article, a paramedic in New York City who was told to handcuff an unhoused woman at a subway station, was quoted as saying, “I hate that I have to do this to you. I’m sorry. It’s not my decision.” It’s easy to imagine that complying with a directive one fundamentally disagrees with could lead to moral injury.

Moral injury may be exactly the term that applies in those circumstances in which people leave a job or a career in order not to risk moral injury. Not everyone is able to make the decision to leave a job to avoid circumstances in which they may experience a PMIE leading to moral injury. In the July blog, I will discuss further elaborations of the concept of moral injury, note how most use the term are in a colloquial rather than a rigorous, scientific way, and provide ways that individuals, teams, and institutions can take steps to mitigate moral injury.