Borges LM, Barnes SM, et al.
Psychol Trauma. 2020 Aug;12(S1):S138-S140.
doi: 10.1037/tra0000698. Epub 2020 Jun 4. PMID: 32496101.
Here is an excerpt:
Moral injury in COVID-19 may be related to, but is distinct from: 1) burnout, 2) adjustment disorders, 3)
depression, 4) traumatic stress/PTSD, 5) moral injury in the military, and 6) moral distress. Moral injury
may be a contributing factor to burnout, adjustment disorders, or depression, but they are not equivalent. The diagnosis of PTSD requires a qualifying exposure to a traumatic stressor, whereas experiencing a moral injury does not. Moral injury in the military has been addressed in a different population and particularly after deployment, and its lessons may not be generalizable to moral injury during COVID-19, which we are seeing acutely among healthcare workers. Finally, moral distress may be a precursor to moral injury, but the terms are not interchangeable. Previous literature has noted that moral distress signals a need for systemic change because it is generated by systemic issues. Thus, moral distress can serve as a guide for healthcare improvement, and rapid systemic interventions to address moral distress may help to prevent and mitigate the impact of moral injury.
While not a mental disorder itself, moral injury undermines core capacities for well-being, including a
sense of ongoing value-laden actions, competence to face and meet challenges, and feelings of belonging and meaning. Moral injury is associated with strong feelings of shame and guilt and with intense self-condemnation and a shattered core sense of self. Clinical observations suggest that uncertainty in decision-making may increase the likelihood or intensity of moral injury.
In the context of a public health disaster such as the COVID-19 pandemic, acknowledgement of the need
to transition from ordinary standards of care to crisis standards of care can be both necessary and helpful to 1) provide a framework upon which to make difficult and ethically fraught decisions and 2) alleviate some of moral distress and indeed moral injury that may otherwise be experienced in the absence of such guidance. The pandemic forces us to confront challenging questions for which there are no clear answers, and to make “lose-lose” choices in which no one involved ends up feeling satisfied or even comfortable.
