‘Moral Injury’ Will Linger Long After the Pandemic Ends

Throughout the pandemic, people have had to make impossibly tough decisions. Kathleen Turner, a 52-year-old intensive-care nurse in San Francisco, has been haunted by hers. Since COVID-19 patients started overwhelming her hospital last spring, she has had to give patients sedatives knowing they would likely have lasting negative health consequences, and systematically deny relatives a chance to say goodbye to dying loved ones. Last year, Turner was following guidelines when she told a woman that she could not visit her dying mother—on Mother’s Day. “I upheld the rule on the piece of paper,” she told me. “But in terms of what would a good person do? It’s not that.” Collectively, these experiences have fundamentally shaken her sense of morality. “Am I really a good person? There’s that seed of doubt,” she said.

Health-care workers have had it especially hard during the pandemic, triaging who gets access to life-saving medication and reusing personal-protective equipment with the risk of contaminating patients, colleagues, and themselves. But other people have also been forced into unenviable scenarios. Undertakers have had to empty out old graves to make space for more dead bodies. Many of us have wrestled with whether to visit a parent or grandparent given the possibility of exposing them to the virus. In some cases, these situations have left people with what psychologists call “moral injury”—residual feelings of shame, guilt, and disorientation after having violated their own ethical code. Often, moral injury manifests as feelings of betrayal at the leaders and institutions that forced them into making these decisions in the first place, which may lead to behaviors such as substance abuse and social isolation.

We’re only beginning to understand pandemic trauma. Every COVID-19 death has unleashed a river of grief still flooding over the bereaved. Millions of coronavirus survivors are still ravaged by what the disease did to them. Even those who haven’t personally been touched by the virus have had to contend with lost jobs, anxiety, and missed opportunities. But for some people, the past year has also fundamentally broken their moral compass.

Moral injury is not a new idea. In 1994, Jonathan Shay, a clinical psychiatrist, coined the term after noticing that some American soldiers who had experienced traumatic events in Vietnam returned with profound changes to their character. These shifts, he wrote, were markedly different from what would ordinarily be recognized as PTSD: They were predominantly triggered by events that violated a soldier’s moral code rather than, say, narrowly escaping death and then dealing with lingering fear and helplessness. Moral injury is not considered a mental illness, and researchers are still working to clarify the boundaries of what exactly fits into the concept and what behavioral changes it leads to. But what they do know is that exposure to morally injurious events is associated with mental-health conditions such as depression.

Since Shay introduced the idea, psychologists and psychiatrists have expanded the scope of moral injury to include all sorts of scenarios: police officers who must make split-second decisions about whether to shoot someone, firefighters who have to choose whom to save before a burning building collapses, even journalists covering tough stories such as Europe’s 2015 migrant crisis. During the pandemic, the notion has gained new traction with all the tough positions people have been put in. Grieving relatives who can’t say goodbye to their dying loved ones, mourning families who can’t attend funerals, and patients themselves who have been inadequately treated—all might be contending with moral injury. “I think the whole population has got potential to develop those difficulties,” says Neil Greenberg, a psychiatry professor at King’s College London. He told me that people may be asking themselves, “Did I do the right thing? Did others do the right thing?”

The core features of moral injury are feelings of betrayal by colleagues, leaders, and institutions who forced people into moral quandaries, says Suzanne Shale, a medical ethicist. As a way to minimize exposure for the entire team, Kathleen Turner and other ICU nurses have had to take on multiple roles: cleaning rooms, conducting blood tests, running neurological exams, and standing in for families who can’t keep patients company. Juggling all those tasks has left Turner feeling abandoned and expendable. “It definitely exposes and highlights the power dynamics within health care of who gets to say ‘No, I’m too high risk; I can’t go in that patient’s room,’” she said. Kate Dupuis, a clinical neuropsychiatrist and researcher at Canada’s Sheridan College, also felt her moral foundations shaken after Ontario’s decision to shut down schools for in-person learning at the start of the pandemic. The closures have left her worrying about the potential mental-health consequences this will have on her children.

For some people dealing with moral injury right now, the future might hold what is known as “post-traumatic growth,” whereby people’s sense of purpose is reinforced during adverse events, says Victoria Williamson, a researcher who studies moral injury at Oxford University and King’s College London. Last spring, Ahmed Ali, an imam in Brooklyn, New York, felt his moral code violated when dead bodies that were sent to him to perform religious rituals were improperly handled and had blood spilling from detached IV tubes. The experience has invigorated his dedication to helping others in the name of God. “That was a spiritual feeling,” he said.

But moral injury may leave other people feeling befuddled and searching for some way to make sense of a very bad year. If moral injury is left unaddressed, Greenberg said, there’s a real risk that people will develop depression, alcohol misuse, and suicidality. People suffering from moral injury risk retreating into isolation, engaging in self-destructive behaviors, and disconnecting from their friends and family. In the U.K., moral injury among military veterans has been linked to a loss of faith in organized religion. The psychological cost of a traumatic event is largely determined by what happens afterward, meaning that a lack of support from family, friends, and experts who can help people process these events—now that some of us are clawing our way out of the pandemic—could have serious mental-health repercussions. “This phase that we’re in now is actually the phase that’s the most important,” Greenberg said.

The cost of letting moral injury fester is high: Feelings of betrayal and a loss of trust may even further erode our sense of unity, says Cynda Rushton, a professor of clinical ethics and nursing at Johns Hopkins University. “Those wounds have to be named, acknowledged, and healed—otherwise they remain in our bodies, hearts, and minds in ways that degrade our well-being and integrity and our democracy,” Rushton told me. These societal effects may already be surfacing among health-care workers in the U.S.:  A recent survey shows that a quarter of them are seeking early retirement as a result of the pandemic, and about 12 percent are considering a career change away from medicine.

One of the most powerful ways to start the healing process, Greenberg said, is to try to help people create a meaningful narrative about what happened. Doing so involves helping people realize that, in most cases, they are not to blame for what happened. “It’s a story that doesn’t end up with it all being my fault, or being the boss’s fault,” Greenberg said. “It ends up with: No one asked to be in this situation.”

Turner’s circumstances at work have gotten better over the past few months: Her hospital has fewer COVID-19 patients and the staff is now better equipped. But when she leaves the hospital at the end of her shift and walks home, she’s overwhelmed by a sense of alienation. She passes people who are back to sitting inside coffee shops and chatting in the park, but she can’t just let go of what she’s been through.