The concept of moral injury has recently emerged in the research literature as a separate aspect of trauma exposure, distinct from posttraumatic stress disorder (PTSD) (15). Moral injury is not classified as a mental disorder. It is a dimensional problem that can have profound effects on critical domains of emotional, psychological, behavioral, social, and spiritual functioning (15–18).
The definitions of moral injury have evolved considerably since its introduction in the 1990s, although a consensus definition has not yet emerged (11, 16, 18–22). The original definition, which was based on work with Vietnam era veterans, focused on failures by leaders. This type of moral injury required that three circumstances be present: “a betrayal of what’s right, by someone who holds legitimate authority, in a high-stakes situation” (20). A later definition of moral injury, which was based on work with Iraq and Afghanistan era veterans, focused on moral failures by the individual (16). This type of moral injury requires that the individual has experienced a potentially injurious event by “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” and the moral/ethical violation resulted in “lasting psychological, biological, spiritual, behavioral, and social impact” (16). As this definition makes clear, it is important to separate experiencing a potentially morally injurious event from developing moral injury. This is similar to PTSD. Experiencing a trauma (criterion A) does not inevitably lead to developing PTSD. Whether a moral injury develops is determined by how the individual interprets the potentially injurious event. The appraisal process determines whether the event generates significant dissonance with the individual’s belief system and worldview (11, 16, 22–25).