Moral Injury –
a brief introduction
Moral injury is a research-based concept that describes the profound psychological, moral, existential, relational, and often spiritual suffering that may arise when individuals perpetrate, fail to prevent, witness, or are subjected to acts or omissions that violate their deeply held moral values and convictions. The consequences may include guilt, shame, loss of trust, identity disruption, and a diminished sense of meaning and purpose.
The spiritual dimension forms an integral part of the understanding of moral injury because, for some individuals, it encompasses questions of meaning, hope, forgiveness, and reconciliation. This dimension is not necessarily religious in nature; it may also relate to a person's broader worldview, core values, and existential orientation.
Research on moral injury is developing rapidly. The concept emerged in the 1990s, drawing on experiences from the Vietnam War, when the American psychiatrist Jonathan Shay described the distinctive form of suffering he observed among military veterans. Since then, the concept has been refined and expanded through extensive international research.
Today, moral injury is understood as a phenomenon that can arise across a wide range of contexts, not only in military settings. Increasingly, it is applied in research concerning healthcare professionals, law enforcement personnel, emergency responders, humanitarian workers, clergy, social workers, educators, and others whose work involves significant ethical responsibility or exposure to serious moral dilemmas.
The COVID-19 pandemic contributed substantially to the expansion of research on moral injury, as many healthcare professionals found themselves forced by resource limitations, organisational constraints, or extraordinary circumstances to make decisions that conflicted with their professional and moral convictions.
Overall, moral injury is not a psychiatric diagnosis but a research-based construct that describes the consequences of severe moral adversity and ethically injurious experiences.
My work is grounded in this body of research and seeks to contribute to its application within a Danish context. I engage in knowledge dissemination, teaching, and the development of practice relevant to the Danish Armed Forces, the healthcare sector, law enforcement, emergency services, humanitarian organisations, the Church, and the fields of social work and education. In addition, I facilitate healing groups for individuals affected by moral injury, drawing on the approach of the THI Method.
Moral burden → Moral distress → Moral injury → Moral Injury Disorder (proposed)
Definitions
There is no single authoritative definition of moral injury. The concept has evolved considerably since it was first introduced into the research literature. Although definitions vary, they all describe moral injury as a persistent condition arising from severe moral burdens or violations that affect a person's identity, trust, and sense of meaning.
Jonathan Shay (1994/2014)
Jonathan Shay developed the first modern research-based understanding of moral injury through his work with Vietnam veterans. He described moral injury as the profound injury that can occur when a person experiences a serious moral betrayal committed by someone in legitimate authority.
In 2014, Shay summarised his definition in three criteria. Moral injury is present when there has been:
- a betrayal of what is right,
- by someone who holds legitimate authority,
- in a high-stakes situation.
The following three key definitions illustrate how the understanding of moral injury has evolved since the 1990s.
Brett T. Litz and colleagues (2009)
Litz and colleagues (2009) expanded the understanding of moral injury by describing it as the enduring emotional, psychological, behavioural, spiritual, and social consequences of experiences in which a person perpetrates, fails to prevent, witnesses, or learns about acts that violate deeply held moral beliefs and expectations.
Litz & Walker (2025)
Litz and colleagues (2025) further expand the definition:
Moral injury (MI) is a potential clinical problem characterised by moral emotions, beliefs, and behavioural patterns that impair functioning, along with negative perceptions of one's own or humanity's goodness, as well as life's meaning and purpose.
Litz et al., 2025
VanderWeele, Koenig et al. (2025)
More recent international research has proposed defining moral injury as:
Persistent suffering resulting from a personal experience that disrupts or threatens: (a) one's perception of one's own goodness, the goodness of others, institutions, or what is perceived as higher powers; or (b) one's beliefs or intuitions concerning right and wrong or good and evil.
Tyler J. VanderWeele, Harold G. Koenig and colleagues, 2025
What is the difference between Moral Distress and Moral Injury?
Moral distress refers to the moral burden that most people may experience in ethically difficult situations. If that burden becomes persistent and has profound consequences for identity, conscience, and trust, it may develop into moral injury.
The figure below presents a simplified, research-based continuum of moral burden and Moral Injury, inspired by a model proposed by Tyler J. VanderWeele and colleagues.
Figure. Simplified illustration of a research-based continuum of moral burden, inspired by a model proposed by Tyler J. VanderWeele et al.
How does Moral Injury differ from PTSD?
Post-Traumatic Stress Disorder (PTSD) is typically associated with experiences involving life-threatening events, violence, or serious threats to physical safety. The central threat is generally directed towards life or physical integrity.
Moral injury, by contrast, concerns violations of a person's ethical values, conscience, and trust. The central threat is directed towards trust, relationships, and one's moral orientation.
Trauma is often complex. Moral injury and PTSD may coexist. Some people experience moral injury without PTSD, while others experience PTSD without moral injury.
Who can be affected?
Moral injury can affect anyone, but certain professions face a particularly high risk because of their responsibilities, ethical dilemmas, or repeated exposure to suffering.
- Soldiers and military veterans
- Police officers and emergency responders
- Healthcare professionals
- Clergy
- Social workers
- Teachers
- NGO and humanitarian aid workers
- Leaders in high-risk positions
- People facing severe life crises
How does Moral Injury manifest?
Moral injury may involve a range of emotional, psychological, social, and spiritual responses, including:
- guilt
- shame
- loss of trust
- anger
- hopelessness
- helplessness
- feelings of betrayal
- loss of meaning
- difficulty giving or receiving forgiveness
- spiritual and existential struggles
Why is Moral Injury not a diagnosis?
Moral injury is not a formal psychiatric diagnosis but a research-based construct that describes the psychological, social, existential, and spiritual consequences of severe moral adversity. Many individuals experiencing moral injury do not meet the diagnostic criteria for post-traumatic stress disorder (PTSD), while others experience both conditions concurrently.
An international group of researchers has proposed that severe moral injury should be understood as part of a broader moral trauma spectrum and has discussed whether, in the future, it should be recognised as a distinct clinical diagnosis under the designation Moral Injury Disorder.
Can Moral Injury heal?
There is no single treatment that is effective for everyone. Research suggests that recovery often involves a combination of evidence-based psychiatric and psychological interventions, supportive relationships, social connectedness, opportunities for meaning-making, and the ability to tell one's story in a safe and accepting environment.
Because moral injury also encompasses ethical and existential dimensions, some individuals may benefit from forms of support that extend beyond conventional psychological treatment.
Why Is the Spiritual Dimension Important in Moral Injury?
Moral injury extends beyond the psychological consequences of potentially morally injurious events (PMIEs) and also encompasses ethical and existential concerns. For many people, it involves a fundamental challenge to their values, sense of self, and experience of meaning, giving rise to guilt, shame, and a loss of trust in oneself, others, or the world.
Within this context, the spiritual dimension may play an important role, as it provides, for some individuals, a framework for engaging with questions of meaning, forgiveness, reconciliation, and hope.
The significance of spirituality, however, varies considerably between individuals. While some find support through religious or spiritual beliefs and practices, others derive meaning from secular values, relationships, or personal philosophies of life. A holistic understanding of moral injury should therefore attend to each individual's existential and spiritual needs without assuming that these are necessarily rooted in religion.
The THI Method includes a dedicated chapter on moral injury and offers a holistic framework in which biblical texts, existential reflection, and psychological knowledge are integrated to help individuals process guilt, shame, loss of meaning, and diminished hope.
___
Moral injury is a relatively new field of research, and our understanding continues to evolve. This page is updated regularly in line with international research with the aim of communicating current, research-based knowledge about moral injury to professionals and others with an interest in the subject.
Foundational works
Shay, J. (2014). Moral injury.Psychoanalytic Psychology, 31(2), 182–191.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706.
Litz, B. T., & Walker, H. E. (2025). Moral injury: An overview of conceptual, definitional, assessment, and treatment issues. Annual Review of Clinical Psychology, 21, 251–277.
VanderWeele, T. J., Wortham, J. S., Carey, L. B., Case, B. W., Cowden, R. G., Duffee, C., Jackson-Meyer, K., Lu, F. G., Potts, G. W., &
Koenig, H. G. (2025). Moral trauma, moral distress, moral injury, and moral injury disorder: Definitions and assessments.Frontiers in Psychology, 16, Article 1422441.
Danish contributions
Garff, S. (2024). The Inner War: Moral Injury in Working Life.Kristeligt Dagblads Forlag. (Danish edition.)
Garff, S. (2024). Moral Injury – The Overlooked Trauma.Bibliotek for Læger. (Danish edition.)
Resources and media
- Bibliotek for Læger (Journal of the Danish Medical Association)
- Kristeligt Dagblad
- Center for Faith, Loss and Trauma
Training and Speaking
I offer keynote lectures, workshops, facilitator training, and professional education in Danish and English for churches, higher education institutions, healthcare organisations, NGOs, and professional groups.
If you would like to discuss a lecture, workshop, facilitator training, or other collaboration, I would be delighted to hear from you.