Moral Injury Events Research Articles

Moral injury associated with increased odds of past-year mental health disorders: a Canadian Armed Forces examination

ABSTRACT Background: Potentially morally injurious experiences (PMIEs) are common during military service. However, it is unclear to what extent PMIEs are related to well-established adverse mental health outcomes. Objective: The objective of this study was to use a population-based survey to determine the associations between moral injury endorsement and the presence of past-year mental health disorders in Canadian Armed Forces (CAF) personnel and Veterans. Methods: Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS). With a sample of 2,941 respondents, the weighted survey sample represented 18,120 active duty and 34,380 released CAF personnel. Multiple logistic regressions were used to assess the associations between sociodemographic characteristics (e.g. sex), military factors (e.g. rank), moral injury (using the Moral Injury Events Scale [MIES]) and the presence of specific mental health disorders (major depressive episode, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, and suicidality). Results: While adjusting for selected sociodemographic and military factors, the odds of experiencing any past-year mental health disorder were 1.97 times greater (95% CI = 1.94–2.01) for each one-unit increase in total MIES score. Specifically, PTSD had 1.91 times greater odds (95% CI = 1.87–1.96) of being endorsed for every unit increase in MIES total score, while odds of past-year panic disorder or social anxiety were each 1.86 times greater (95% CI = 1.82–1.90) for every unit increase in total MIES score. All findings reported were statistically significant (p < .001). Conclusion: These findings emphasize that PMIEs are robustly associated with the presence of adverse mental health outcomes among Canadian military personnel. The results of this project further underscore the necessity of addressing moral injury alongside other mental health concerns within the CAF.

Group early intervention eye movement desensitization and reprocessing therapy as a video-conference psychotherapy with frontline/emergency workers in response to the COVID-19 pandemic in the treatment of post-traumatic stress disorder and moral injury-An RCT study.

Frontline mental health, emergency, law enforcement, and social workers have faced unprecedented psychological distress in responding to the COVID-19 pandemic. The purpose of the RCT (Randomized Controls Trial) study was to investigate the effectiveness of a Group EMDR (Eye Movement Desensitization and Reprocessing) therapy (Group Traumatic Episode Protocol-GTEP) in the treatment of Post-Traumatic Stress Disorder (PTSD) and Moral Injury. The treatment focus is an early intervention, group trauma treatment, delivered remotely as video-conference psychotherapy (VCP). This early intervention used an intensive treatment delivery of 4x2h sessions over 1-week. Additionally, the group EMDR intervention utilized therapist rotation in treatment delivery. The study's design comprised a delayed (1-month) treatment intervention (control) versus an active group. Measurements included the International Trauma Questionnaire (ITQ), Generalized Anxiety Disorder Assessment (GAD-7), Patient Health Questionnaire (PHQ-9), Moral Injury Events Scale (MIES), and a Quality-of-Life psychometric (EQ-5D), tested at T0, T1: pre-treatment, T2: post-treatment, T3: 1-month follow-up (FU), T4: 3-month FU, and T5: 6-month FU. The Adverse Childhood Experiences - International version (ACEs), Benevolent Childhood Experience (BCEs) was ascertained at pre-treatment only. N = 85 completed the study. Results highlight a significant treatment effect within both active and control groups. Post Hoc comparisons of the ITQ demonstrated a significant difference between T1 pre (mean 36.8, SD 14.8) and T2 post (21.2, 15.1) (t11.58) = 15.68, p < 0.001). Further changes were also seen related to co-morbid factors. Post Hoc comparisons of the GAD-7 demonstrated significant difference between T1 pre (11.2, 4.91) and T2 post (6.49, 4.73) (t = 6.22) = 4.41, p < 0.001; with significant difference also with the PHQ-9 between T1 pre (11.7, 5.68) and T2 post (6.64, 5.79) (t = 6.30) = 3.95, p < 0.001, d = 0.71. The treatment effect occurred irrespective of either ACEs/BCEs during childhood. However, regarding Moral Injury, the MIES demonstrated no treatment effect between T1 pre and T5 6-month FU. The study's findings discuss the impact of Group EMDR therapy delivered remotely as video-conference psychotherapy (VCP) and the benefits of including a therapist/rotation model as a means of treatment delivery. However, despite promising results suggesting a large treatment effect in the treatment of trauma and adverse memories, including co-morbid symptoms, research results yielded no treatment effect in frontline/emergency workers in addressing moral injury related to the COVID-19 pandemic. The NICE (2018) guidance on PTSD highlighted the paucity of EMDR therapy research used as an early intervention. The primary rationale for this study was to address this critical issue. In summary, treatment results for group EMDR, delivered virtually, intensively, using therapist rotation are tentatively promising, however, the moral dimensions of trauma need consideration for future research, intervention development, and potential for further scalability. The data contributes to the emerging literature on early trauma interventions.Clinical Trial Registration:Clinicaltrials.gov, ISRCTN16933691.

Re-orienting narratives of moral injury towards positive development: The experiences of emerging adults with child welfare histories

This paper is the second in a series of papers from a mixed methods study examining moral injury in childhood and adolescence as described by emerging adults with histories of child welfare involvement. This paper focuses on the ways emerging adultsmay alleviate their moral injury, grow and develop.Twenty -eight emerging adults (18–26 years) who reported exposure to morally injurious events during childhood or adolescence on a modified version of the Moral Injury Events Scale(MIES; Nash et al., 2013)participated in life story interviews. Life story analyses of psychosocial contexts considered resiliency, especially any re-orientation of participants’ narratives of moral injury away from the anomie, guilt, shame, and rage characteristic of moral injury, and towards themes such as hope, forgiveness, and gratitude. In addition, psychosocial-spiritual contexts that may support these shifts in meaning were explored through thematic analyses. Findings indicate that supportive relationships, especially with caring adults, engagement with spirituality, and access to prosocial activities provide foster youth with opportunities to re-orient their moral injury narratives, and provide a foundation on which to build towards recovery. Implications for policy, practice and research are discussed.

Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress.

Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI. This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively. Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS. Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of moral injury and posttraumatic stress disorder on health care utilization and suicidality in rural and urban veterans.

This study explored the impact of moral injury (MI) and posttraumatic stress disorder (PTSD) on health care utilization, mental health complexity, and suicidality in rural and urban veterans. Analyses combined data from the Salt Lake City PTSD Clinic Intake Database and the Department of Veterans Affairs Corporate Data Warehouse. Participants (N = 1,545; Mage = 45.9 years) were predominately male (88.3%) and White (87.8%). Adjusted analyses indicated associations between a 1-unit increase in Moral Injury Events Scale (MIES) score and increased mental health complexity, RR = 1.01, 95% CI [1.01, 1.02], p < .001; psychotropic medication utilization, RR = 1.01, 95% CI [1.01, 1.03], p < .001; VA drug class count, RR = 1.01, 95% CI [1.00, 1.01], p = .030; outpatient utilization, RR = 1.01, 95% CI [1.01, 1.02], p < .001; and mental health outpatient utilization, RR = 1.01, 95% CI [1.00, 1.03], p < .001. For the MIES x PTSD interaction, all associations remained statistically significant with similar estimated effects. However, for rural veterans, this interaction did not significantly affect utilization. Among those with PTSD, a 1-unit MIES increase was associated with an increased risk of suicidality, OR = 1.02, 95% CI [1.01, 1.04], and psychiatric admission, OR = 1.02, 95% CI [1.00, 1.04]. Findings suggest that higher MIES scores predict increased health care utilization and mental health complexity. Further, PTSD combined with higher MIES scores may increase the risk of suicidality and psychiatric admission. Rural veterans with PTSD and higher MIES scores may require additional outreach and intervention.

‘It hurts your heart’: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic

ABSTRACT Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone’s moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646–652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients. HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance. Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

6 Validation and Application of a Survey of on-Farm Worker Attitudes Towards Euthanasia

Abstract On-farm euthanasia of pigs considers aspects of welfare and economics, but few comprehensive guidelines are available for swine producers and further, do not consider cultural barriers. The Hispanic workforce largely represents the bulk of agricultural workers. Euthanasia requires the ability to identify compromised pigs, technical skills, and willingness to euthanize pigs. In addition, timely euthanasia is part of the Common Swine Industry Audit (CSIA) and thus, can lead to failed audits. The U.S. swine industry employs a large percentage of Latin American workers through NAFTA visas. These workers vary in their degree of education and pig experience. Proper training of this workforce and identification of the barriers to performing timely euthanasia is critical. The objectives of this study were to: 1) develop and validate surveys (including demographic information, swine management, moral injury events scale, impact of event scale and the professional quality of life scale) in Spanish to determine Hispanic caretaker attitudes towards timely euthanasia and 2) to assess Hispanic caretakers using the validated surveys to determine the barriers associated to timely euthanasia. A total of 163 workers were surveyed and data were analyzed using Chi-Square. The results indicated that employees with less time working in the company presented less CSIA knowledge and a reduced capacity to identify pigs that needed to be euthanizing (P&amp;lt; 0.001). Spearman's rank-order correlations indicated that stress was the most frequently correlated scale, related with burnout, transgressions, betrayals, and worker satisfaction (P=0.022). A Mann-Whitney U test determined that there was a gender difference, presenting a high level of stress and a low level of satisfaction in females and the opposite results in males (P=0.026). It is important to identify the factors that decrease or negatively affect the ability of employees to perform euthanasia in order to provide efficient training that improves good practices in the swine industry.

Moral injury in secure mental healthcare: part I: exploratory and confirmatory factor analysis of the Moral Injury Events Scale

ABSTRACT In recognition that existing theoretical paradigms may not offer a comprehensive account of the range of occupational stressors and responses experienced by healthcare professionals, interest in moral injury has grown. The Moral Injury Events Scale (MIES) remains the dominant assessment tool used to measure potentially morally injurious experiences (PMIEs) across different occupational groups, including healthcare professionals. Given the proliferation of research using the MIES in healthcare, in the context of ongoing debates about its structure and utility, an exploration of the psychometric properties of the MIES with this population is timely. Using the data (N = 235) from a study exploring the prevalence of exposure to PMIEs, the current study reports on the factor structure of the MIES in healthcare professionals working within a secure mental health setting. The results yielded a two-factor model representing transgressions and betrayals by ‘others’, and transgressions committed by the ‘self’. Exploration of the internal consistency of the scale yielded a McDonald’s ω of .93. Multi-group confirmatory factor analysis highlighted the model was an adequate fit for White females, tentatively suggesting that experiences of moral injury may vary by gender, intersected by ethnicity. Accordingly, future frameworks, measures and interventions to remediate the impact of moral injury may require an intersectional approach.

Moral injury events and behavioral health outcomes among American veterans

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health.

The impact of “moral injury” (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be associated with other psychopathologies, including chronic pain, sleep disorders, fear of death, anomie, and use of alcohol/drugs to cope post deployment. Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere. Altogether, 95.1% of the veterans were male and their mean age was 61.6 years (SD = 11.8). Among the veterans, 24.4% had high combat exposure, 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts. Based on the Moral Injury Events Scale (MIES), 25.8% had high MI post deployment, defined as a score above the 75th percentile. Results show that high MI among veterans was associated with current global mental health severity and recent mental health service use, but not suicidal thoughts. In addition, as hypothesized, MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment. Deployed veterans with MI are more likely to have current mental health disorders and other psychological problems years after deployment. Further research is advised related to the screening, assessment, treatment, and prevention of MI among veterans and others after trauma exposures.

Moral injury experienced by emerging adults with child welfare histories in developmental and sociocultural contexts: “I knew the system was broken.”

This mixed methods research examines moral injury in childhood and adolescence as described by emerging adults with histories of child welfare involvement. Twenty-eight emerging adults (18–25 years) with foster care histories participated in life story interviews, and assessments of exposure to potentially morally injurious events (Moral Injury Events Scale, MIES; Nash et al., 2013). Participants reported on the MIES exposure to potentially morally injurious events during their involvement in the child welfare system as children and adolescents. The most common events described by participants were child maltreatment (82%), adults’ failure to protect them (75%), and injury to their identities as individuals worthy of respect, and as members of particular groups (families, ethnic communities) (39%). In addition, most participants reported multiple moral injuries, and moral injuries that were sustained across months or years. Participants’ reported responses to these events included: rage, shame, guilt, and feelings of betrayal, vulnerability, confusion and worthlessness. Longer term responses included relationship problems, mental health and substance abuse disorders. Perpetrators of moral injury included parents, substitute caregivers, and child welfare professionals. Events occurred in birth homes, but also in out-of-home placements and social service settings. This study contributes to child welfare by highlighting the voices of young people, and identifying moral as an issue for practice and policy intervention. In so doing, this research also contributes to the literature on moral injury by examining the lived experiences of individuals reporting moral injury, by extending the concept to emerging adults with child welfare histories, and by considering moral injury in developmental and sociocultural contexts.

Morally injurious events and post-traumatic embitterment disorder in UK health and social care professionals during COVID-19: a cross-sectional web survey

ObjectiveTo estimate the prevalence and predictors of morally injurious events (MIEs) and post-traumatic embitterment disorder (PTED) in UK health and social care professionals during the COVID-19 pandemic.DesignCross-sectional study.SettingSeptember–October 2020 in...

The Silent Cry of Healthcare Workers: A Cross-Sectional Study on Levels and Determinants of Burnout among Healthcare Workers after First Year of the Pandemic in Turkey.

Although the acute phase of the pandemic is over, healthcare workers continue to face challenges. The aim of this study was to determine burnout levels and possible related psychological processes such as psychological flexibility, moral injury, and values among healthcare workers after the first year of coronavirus disease 2019 (COVID-19) pandemic. A cross-sectional study was performed using an online survey distributed through social networks. A sample of 124 front line healthcare workers working during the pandemic, between January and April 2021, were included in the study. Multiple linear regression was used to identify predictors of all 3 burnout dimensions (emotional exhaustion, depersonalization, and lack of personal accomplishment). While 51.6% of healthcare workers experienced high levels of emotional exhaustion, 75.8% of them were found to have experienced high levels of lack of personal accomplishment. On the contrary, 81.5% of the participants reported low levels of depersonalization. Emotional exhaustion was predicted by total Depression Anxiety Stress Scale score (P = .004) and total Moral Injury Events Scale score was the only predictor of depersonalization (P = .051). Predictors of lack of personal accomplishment were the number of days worked in COVID-19 (P = .001), total Moral Injury Events Scale (P=0.004), Valuing Questionnaire (VQ)-Obstruction (P = .009), and total Depression Anxiety Stress Scale score (P = .002). On the other hand, psychological flexibility did not predict any sub-dimension of burnout. Healthcare workers had high levels of burnout after 1 year with the pandemic. Our findings highlight the importance of factors such as moral injury, values, and emotional distress which need to be taken into consideration to develop future interventions to treat and prevent burnout in healthcare workers.

Psychiatric symptoms and moral injury among US healthcare workers in the COVID-19 era

BackgroundEmerging cross-sectional data indicate that healthcare workers (HCWs) in the COVID-19 era face particular mental health risks. Moral injury – a betrayal of one’s values and beliefs, is a potential concern for HCWs who witness the devastating impact of acute COVID-19 illness while too often feeling helpless to respond. This study longitudinally examined rates of depression, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and moral injury among United States HCWs in the COVID-19 era. We anticipated finding high levels of clinical symptoms and moral injury that would remain stable over time. We also expected to find positive correlations between clinical symptoms and moral injury.MethodsThis three-wave study assessed clinical symptoms and moral injury among 350 HCWs at baseline, 30, and 90 days between September and December 2020. Anxiety, depression, PTSD, and moral injury were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Primary Care PTSD Screen (PC-PTSD), and Moral Injury Events Scale (MIES).ResultsOf the 350 HCWs, 72% reported probable anxiety, depression, and/or PTSD disorders at baseline, 62% at day 30, and 64% at day 90. High level of moral injury was associated with a range of psychopathology including suicidal ideation, especially among healthcare workers self-reporting COVID-19 exposure.ConclusionsFindings demonstrate broad, persisting, and diverse mental health consequences of the COVID-19 pandemic among United States HCWs. This study is the first to longitudinally examine the relationships between moral injury and psychopathology among HCWs, emphasizing the need to increase HCWs’ access to mental healthcare.

Moral injury as a unique predictor of suicidal ideation in a veteran sample with a substance use disorder.

Suicide among military veterans accounts for 22.2% of all suicide deaths in the United States per year, and veterans with a substance use disorder (SUD) are at an even higher risk for death by suicide. This prevalence has led to increased efforts to identify and investigate both potential risks and protective factors for veterans. This study examines relationships between depression symptomology, exposure to potentially morally injurious events, posttraumatic stress disorder (PTSD) diagnosis, and suicidal ideation, with the primary aim of examining exposure to moral injurious events as a risk factor for suicide in veterans with SUD. An inpatient sample of 40 veterans with an active SUD admitted for suicidal ideation was evaluated to examine differences in suicidal ideation, depression symptomology, and exposure to morally injurious events in participants with and without a PTSD diagnosis. Further, exposure to morally injurious events and depression symptomology were examined as predictors of suicidal ideation. Analyses revealed that exposure to morally injurious events (d = 1.72) and depression symptomology (d = 0.72) were higher in participants with a PTSD diagnosis compared to those without a diagnosis, though no significant differences emerged between the two groups on suicidality. A hierarchical regression analysis indicated that only exposure to morally injurious events significantly accounted for variance in suicidality (β = .31, p = .04, 95% confidence interval [.01, .37]). These results suggest that although PTSD may be associated with exposure to morally injurious events and depression symptoms, exposure to morally injurious events may potentially lead to higher suicide risk among veterans above and beyond PTSD and depressive symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychometric Evaluation of the Moral Injury Events Scale in Two Canadian Armed Forces Samples.

Moral injury (MI) is defined as the profound psychological distress experienced in response to perpetrating, failing to prevent, or witnessing acts that transgress personal moral standards or values. Given the elevated risk of adverse mental health outcomes in response to exposure to morally injurious experiences in military members, it is critical to implement valid and reliable measures of MI in military populations. We evaluated the reliability, convergent, and discriminant validity, as well as the factor structure of the commonly used Moral Injury Events Scale (MIES) across two separate active duty and released Canadian Armed Forces samples. In Study 1, convergent and discriminant validity were demonstrated through correlations between MIES scores and depression, anxiety, posttraumatic stress disorder, anger, adverse childhood experiences, and combat experiences. Across studies, internal consistency reliability was high. However, dimensionality of the MIES remained unclear, and model fit was poor across active and released Canadian Armed Forces samples. Practical and theoretical implications are discussed.

COVID-19 related moral injury: Associations with pandemic-related perceived threat and risky and protective behaviors

BackgroundThe coronavirus-2019 (COVID-19) pandemic is associated with increased potential for morally injurious events, during which individuals may experience, witness, or learn about situations that violate deeply held moral beliefs. However, it is unknown how pandemic risk and resilience factors are associated with COVID-related moral injury. MethodsIndividuals residing in the U.S. (N = 839; Mage = 37.09, SD = 11.06; 78% women; 63% White; 33% PTSD) participating in an online survey reported on COVID-19 related moral injury (modified Moral Injury Events Scale), perceived current and future threat of pandemic on life domains (social, financial, health), and COVID-19 risky and protective behaviors. Multivariate linear regressions examined associations of perceived threat and risky and protective behaviors on type of COVID-19 related moral injury (betrayal, transgression by others, self). ResultsParticipants endorsed MI betrayal (57%, N = 482), transgression by other (59%, N = 497), and by self 17% (N = 145). Adjusting for sociodemographics, only future threat of COVID-19 to health was significantly associated with betrayal (B = 0.21, p = .001) and transgression by other (B = 0.16, p = .01), but not by self. In contrast, high frequency of risky behaviors was associated with transgressions by self (B = 0.23, p < .001). Sensitivity analyses showed PTSD did not moderate the observed effects. ConclusionsBetrayal and transgression by others was associated with greater perceived future threat of COVID-19 to health, but not financial or social domains. Stronger endorsement of transgression by self was associated with more frequently engaging in risky behaviors for contracting COVID-19. These findings may suggest the need for individual, community, and system level interventions to address COVID-19 related moral injury.

Moral injury and the COVID-19 pandemic: A philosophical viewpoint

IntroductionMuch has changed in healthcare during the coronavirus disease (COVID)-19 pandemic. Medicine, a profession of traditional principles and virtues, has faced unprecedented challenges in the light of scarce and unequal distribution of ventilators, testing, and personal protective equipment. Healthcare workers have been- and are increasingly likely to be- forced into situations that require difficult decision making under life-and-death conditions. Concepts of “medical necessity” and “maximum benefit” challenge healthcare systems that already struggle to manage unequal treatment and access to services, giving rise to moral distress and moral injury on the front lines.MethodsThis article focuses on moral injury in the context of coronavirus disease (COVID)-19 pandemic. I review recent literature to highlight the psychological impact of many morally-injurious events that have been reported during the COVID-19 pandemic. With the help of a clinical vignette, I point out how healthcare systems adopt many utilitarian policies in times of excessive healthcare burden. A viewpoint is offered that many morally injurious events happen when healthcare workers, traditionally practicing Kantian and virtue ethics, are forced to follow utilitarian policies of healthcare system.ConclusionOne form of moral injury may arise from inherent conflicts between individual deontological moral judgments and organizational utilitarian moral judgments. More research is needed to validate the philosophical viewpoint as well as to explore whether increased awareness and education of key principles within moral philosophy can better equip healthcare workers in situations when public health takes precedence over individual health.

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Moral injury and suicidal behavior among US combat veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study.

Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans. Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior. Thirty-six point three percent of veterans reported at least one PMIE. Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%). Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.