Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Wednesday, October 26, 2022

Moral Injury Is an Invisible Epidemic That Affects Millions

Elizabeth Svoboda
Scientific American
Originally published 26 SEPT 22

Here are two excerpts:

A 2019 study by researchers at the Salisbury VA Healthcare System in North Carolina reports that moral injury has different brain signatures than PTSD alone: People with moral injury have more activity in the brain’s precuneus area, which helps govern moral judgments, than those who only have PTSD. And after people suffer moral traumas, they display different brain glucose metabolism patterns than those who suffer direct physical threats, according to a 2016 study by researchers at the University of Texas Health Science Center at San Antonio and their colleagues. The results support developing theories that moral injury is a unique biological entity.

As Brock’s Shay Moral Injury Center found its footing, she forged connections with powerful people who could get the word out about moral injury—including Margaret Kibben, the current chaplain at the U.S. House of Representatives. Kibben holds regular events for House members, and one of her recent talks was about moral injury. The event drew about three times more members than usual, Brock reports, “and they all wanted to talk about their experience.” Brock and Kibben’s partnership reflects a growing trend in the study of moral injury: collaboration between scholars and clergy members who aim to chronicle the unspeakable and to help people through it. Moral injury “does really bring together a lot of disciplines,” says psychologist Anna Harwood-Gross of Metiv, the Israel Psychotrauma Center in Jerusalem. “It’s rare to see articles written by chaplains and psychologists together.”

As COVID ravaged the planet from 2020 onward, moral injury research and inquiry took a distinct new turn. Health care workers spoke out about how rationing care was affecting them psychologically, and Dean and her colleagues Breanne Jacobs and Rita Manfredi, both at the George Washington University School of Medicine and Health Sciences, published a journal article that urged employers to monitor moral injury’s effects. “We need time, energy and intellectual capacity to make peace with those specters,” they wrote.

The moral injury Dean sees in health care often doesn’t stem from one-time, cataclysmic events. Many providers are suffering what she calls “death by a thousand cuts”—the constant, stultifying knowledge that they have to give people subpar care or none at all. “They think they suck. They think they’re inadequate,” says trauma surgeon Gregory Peck of New Jersey’s Rutgers Robert Wood Johnson Medical School. “No one’s putting their finger on ‘You don’t suck. This is moral injury you’re suffering.’” 


But one sticking point with CBT is that it focuses on correcting clients’ distorted thought patterns. For people with moral injury who’ve experienced wrenching events that upend their entire value system, ethical distress is genuine, not the product of distorted thinking, Harwood-Gross says . If people with moral injury simply try to retrain their thoughts, they may be left unsatisfied and unhealed.

Therapies for PTSD can likewise fall short for morally injured patients, in Harwood-Gross’s experience. PTSD-focused approaches teach clients to adapt to traumatic triggers, such as fireworks that sound like gunshots, but this exposure approach doesn’t really help them resolve deep ethical conflicts. Effective moral injury counseling is “more about the processing,” Harwood-Gross says. “There has to be that movement: ‘How do I see it for what it is and, from there, develop something more meaningful?’ It’s a more spiritual approach.”

Recognizing moral injury’s unique challenges, psychologists such as Litz have been creating therapies that more directly address clients’ needs. Litz and other providers have pioneered a moral injury treatment called adaptive disclosure. Researchers at Australia’s La Trobe University and University of Queensland have developed a similar approach called pastoral narrative disclosure. The latter involves discussing moral issues with a chaplain or other spiritual adviser rather than a doctor.

These therapies stress the importance of moral reckoning. They encourage clients to accept uncomfortable truths: “I led that attack on Iraqi civilians”; “I sent that suffering patient home without treatment.” Then, with clients’ input, counselors can help them develop strategies for making amends or pursuing closure—say, apologizing to a family whose child they injured.

Early evidence suggests these approaches make headway where others can’t. In Litz’s initial trial of adaptive disclosure on 44 Marines, participants’ negative beliefs about both themselves and the world diminished. Most also said the therapy helped resolve their moral struggles.