Moral injury embodies the claim that war is so transgressive for soldiers that it can create situations that may undermine one’s trust in oneself, others, and the world. Central to leading conceptu...

Increasingly, scholarship on moral injury is expanding to include non‐military personnel, and considers a violation of bodily integrity—for example, of civilian women who are targeted for sexual violence in warfare—as a particularly egregious harm. Moral injury discourse also extends beyond the individual to the social context in which moral injury arises, its relational effects, and its utterly devastating impact on personhood, an impact frequently characterized as a “soul wound.” The intersection of genocidal rape—both as an individual and a group harm—with (...) religion, as facilitating moral injury and restorative “soul repair,” exemplifies these trends. Although moral injury research rarely addresses the detrimental influences of religion or references the “soul” with precision, the discourse of moral injury does provide an opportunity for exploring the relationship between personhood and agency from the perspectives of those who inflict and are subjected to harm. (shrink)

Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare (...) context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration. (shrink)

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians’ emotional state. We argue that this may relate (...) to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of ‘burnout’ and the phenomenology of ‘moral injury’. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care. (shrink)

In recent years, there has been significant interest in injustices that do not consist in inflicting physical or material harm on others, but operate in more subtle ways, e.g. by targeting our status as epistemic agents. In a similar fashion, this paper aims to bring to the forefront a currently overlooked kind of injustice that occurs in relation to our concepts: conceptual injustice, which is characterised by wrongful in- or exclusion from the application of a concept. The first part of (...) the paper is concerned with spelling out the notion, discussing its characteristic wrongs, and with tracing it in a number of examples. In the second part, I discuss conceptual injustice in relation to connected but different forms of injustice, such as epistemic injustice. This highlights the advantages of having the notion on hand: it enhances our understanding of other forms of injustice like hermeneutical injustice, and allows us to capture a ‘remainder of injustice’ for which we could not account otherwise. (shrink)

Michael Walzer’s foundational essay on dirty hands raises the very possibility of a good person in politics. Dilemmas in the context of high stakes situations sometimes require politicians to compromise their morality and character for the sake of the greater good by choosing the lesser evil. Much has been written about dirty hands, but little has been said about Walzer’s implicit virtue ethics. This essay sketches this implicit virtue ethics, which is central to Walzer’s argument. These are “dirty” virtues, however, (...) that allow one to choose the lesser evil in a dilemma while recognizing that, although evil was mitigated, and some degree of good achieved, wrong done is still wrong done. For this to work, Walzer argues the politician must be and feel guilty, making this an odd virtue ethics that requires a degree of suffering from the politician. The essay further develops this notion of dirty virtue through comparison with Lisa Tessman’s “burdened virtue,” arguing at the end that the guilt and instrumental suffering, which are so central to Walzer’s virtue ethic, may be more corrosive to practical reasoning and character than Walzer allows for. (shrink)

Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon (...) against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one’s sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one’s identity. The repair of moral injury requires the transformation of a moral identity in community. (shrink)

In this article, I undertake three main tasks. First, I argue that, contrary to the standard view, moral injury is not a species of PTSD (post-traumatic stress disorder) but rather, on the most coherent conception of moral injury, PTSD is (in effect) a species of moral injury. In doing so, I make use of the notion of caring deeply about something or someone worthy of being cared deeply about. Second, I consider so-called “dirty hands” actions in police work and in (...) war, and distinguish these from the morally legitimate, but harmful, actions of police officers and of war fighters, such as the morally legitimate use of coercive force and lethal force (respectively). While the morally legitimate use of harmful methods is constitutive of these occupational roles, “dirty hands” methods are not. Roughly speaking, a “dirty hands” action is one that is morally wrong and (typically) unlawful but done for the sake of a good outcome. Both categories of action are conducive to moral injury, but “dirty hands” actions much more so, especially given the slippery moral slope from “dirty hands” actions to egregious moral wrongdoing. Third, I offer some recommendations for reducing moral injury among police officers and war fighters. (shrink)

Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly (...) its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury. (shrink)

Moral injury is a term coined both to reflect the moral dimension of wartime experience and to critique overly clinical approaches to psychological harms originating in wartime. Originally defined not only with the tools of the behavioral sciences but also literature and philosophy, clinical approaches have come to dominate moral injury discourse over the past decade. This article argues for a return to interdisciplinarity by engaging metaphysics and ethics, and in particular Iris Murdoch’s post‐Christian notions of the Good and void, (...) to help better account for the experiences of veterans who claim that they hurt not only physically but also morally as a result of their wartime experience. (shrink)

Background Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses’ experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. Research aim To analyze frontline U.S. nurses’ experiences of ethics during the COVID-19 pandemic. Research design Qualitative analysis using a directed content (...) methodology. Participants and research context The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. Ethical considerations Participant privacy and data confidentiality were addressed. Findings Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. Discussion This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. Conclusions Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available. (shrink)

Value and responsibility are two central concepts in philosophy and bioethics. The articles that comprise this issue of The Journal of Medicine and Philosophy engage topics of moral injury, madness, transhumanism, cognitive enhancement, and the woman’s responsibility to assist her fetus. Clearly diverse in matter, these subject articles univocally present fruitful ground for engagement with contemporary questions that impact society today. The ability to cure or to enhance, to treat or to terminate through advances in medical technology are all actions (...) that come with personal and social responsibility for their consequences. By approaching each article through the dual lens of value and responsibility, the reader is challenged to think seriously about the values we hold as human persons and the responsibility we take to pursue and protect these values. (shrink)