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Co-written by Tyler VanderWeele and Jennifer Wortham.
Our moral understanding of right and wrong, and good and evil, is fundamental to who we are. Such understanding guides our actions and evaluations and shapes our sense of integrity and wholeness. When our moral understanding is severely disrupted by something we have done, witnessed, or been subject to, we can feel torn apart by the resulting feelings of guilt, shame, and confusion.
Notions of “moral injury” or “moral pollution” arising from committing, experiencing, or witnessing wrongdoing are common in many societies, and are given vivid expression in the world’s great literature, from Oedipus to Lady Macbeth and beyond. Only in recent decades, however, have psychologists begun to use the term “moral injury” to speak of a distinct condition, caused by the disruption of one’s moral understanding. Early descriptions were given by Jonathan Shay in documenting the experience among veterans. The idea was developed further in the scientific literature by Brett Litz and colleagues who conceptualized moral injury as involving an act of transgression (either perpetrated, witnessed, or experienced as an act of betrayal) that violated deeply held assumptions and beliefs about right and wrong or personal goodness. The symptoms that some veterans were experiencing seemed distinct from post-traumatic stress disorder (PTSD), and treatment for PTSD was sometimes insufficient to address the difficulties. The distinctively moral aspects of betrayal, or of having committed a wrong act, needed to be dealt with.
Somewhat related phenomena, described as “moral distress,” were also described in the nursing literature. Nurses may sometimes feel that they know the right thing to do to care for patients, but institutional constraints may prevent them from acting accordingly. Not being able to act rightly can likewise give rise to severe distress of a moral nature.
While a lot has been written in the past decades on moral injury and moral distress, and numerous definitions and assessments have been put forward, often the work in these two areas have developed separately. Additionally, much of the work on moral injury has focused on the context of perpetrating a wrong act, or being witness to such an act and feeling betrayed. Less has been written on the experience of moral injury that may sometimes arise from being a victim of such an act. However, in some cases, such experiences can fundamentally shake one’s sense of right and wrong or of goodness.
Over the past several years, some of us at the Human Flourishing Program at Harvard have been wrestling with these issues, and have been trying to develop a more unified approach to moral injury and to moral distress that would be applicable to perpetrators, witnesses, and victims. We have brought together a number of experts on this topic to work with us, and earlier this year together published a paper on moral trauma laying out this vision, and one we hope will ultimately lead to better clinical attention to these matters as well.
Moral Trauma Spectrum, Definitions, and Assessments
In trying to bring these concepts together, we conceived of such moral distress as lying on a “moral trauma spectrum” that included matters of both the severity and the persistence of distress. After months of synthesis of prior work, we defined “moral distress” as “distress that arises because personal experience disrupts or threatens: (a) one’s sense of the goodness of oneself, of others, of institutions, or of what are understood to be higher powers, or (b) one’s beliefs or intuitions about right and wrong, or good and evil.” When that distress became sufficiently persistent it would constitute “moral injury.” For such moral distress or moral injury, it was not only that some moral code was violated, but rather that whatever took place somehow challenged one’s whole understanding of right and wrong, or of good and evil, or of the goodness of oneself, others, institutions, or even the divine. That disruption of one’s moral understanding would then give rise to, sometimes severe, distress. When that distress was persistent and would not go away it would be appropriate to speak of “moral injury.” When the distress was sufficiently severe so as to seriously impair functioning over extended periods of time, it might sometimes even be appropriate to speak of moral injury disorder.
These definitions, drawing on and synthesizing the work of others, were sufficiently general so as to be applicable to perpetrators, witnesses, and victims; and also so as to capture a diverse range of phenomena from the institutional moral distress of nurses, to the experiences of veterans, to that of the victims of other immoral acts, such as in cases of sexual abuse.
The generality of the definitions also allowed for a common assessment of such moral trauma including definitional assessments concerning confusions, doubts, and concerns about the very notions of right and wrong, and good and evil, or the goodness of oneself or others, but also moral symptoms that may arise from such moral trauma including guilt, shame, betrayal, anger, powerlessness, hopelessness, loss of meaning, struggles with faith, struggles with forgiveness, and loss of trust. Our paper provides more detail on the conceptual background, the assessment itself, and distinctions from PTSD. While further work is needed on psychometric validation and assessing the scale’s clinical utility, our hope for this unified assessment is that it would help advance our understanding of moral distress and moral injury. Our hope for this work was also that it would influence the provision of clinical care.
Recognition in the DSM-5
In parallel with the conceptual and assessment work, members of our collaborative team also worked with the American Psychiatric Association (APA) to provide recognition of these phenomena of moral distress and moral injury in the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). In December 2024, the APA took an historic step by approving the addition of “Moral” to the existing “Religious or Spiritual Problem” category in the “Section of Other Conditions That May Be a Focus of Clinical Attention” in the DSM-5-TR. The revised Z-code was just published in the September 2025 DSM-5-TR Update Supplement and incorporates aspects of our moral distress definition above, stating “Moral problems include experiences that disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions.” A paper is forthcoming that describes the process and documentation for this addition to the DSM. Our hope is that this new DSM Z-code opens important opportunities for awareness and treatment of moral trauma, moral distress, and moral injury.
Moral Injury Essential Reads
Acknowledging the Whole Person
As human persons, we are not only physical and mental creatures, but social, moral, and spiritual as well. Our capacity to treat physical and mental ailments has expanded dramatically over the past decades. However, more attention needs to be given to the social, moral, and spiritual aspects of our lives. While addressing our social, moral and spiritual challenges requires efforts that extend far beyond the clinical sphere, these issues should not be ignored in patient care. If we are to truly provide person-centered care, the very real possibility of moral distress and moral injury needs to be acknowledged. The present recognition within psychiatry is a step forward in this regard, and greater moral reflection and awareness throughout society, and perhaps especially when dealing with trauma, will better enable us to foster flourishing amidst the suffering that confronts us individually and as a society.
Jennifer Wortham is a Research Associate in the Human Flourishing Program at Harvard University.
The Human Flourishing Program grants reporters and journalists permission to re-use and quote any of the above material, provided proper attribution is given.
