People in so-called ‘high impact professions' can find themselves in stressful circumstances, sometimes involving the need to make life-or-death decisions. “As a doctor or soldier, you can face tragic dilemmas in which you have to choose between two evils,” explains anthropologist Tine Molendijk. “You may make mistakes which result in innocent victims or temporarily lose sight of your moral values due to workload and frustrations. Such situations can have an enormous impact.”
Post-traumatic stress disorder (PTSD) is a well-known condition. “Moral injury is less well known but equally traumatic,” says Molendijk. “Trauma research often focuses strongly on anxiety and the medical aspect of trauma, yet there is always a moral dimension as well.” After experiencing moral dilemmas, people may suffer from guilt and shame about what someone has or hasn’t done, or feel anger towards the organisation, politicians and society. As an example, she cites the story of a police officer who experienced many violent incidents during the course of a long career. When he got ill and was forced to take time off work, everything came back to him. He felt abandoned by his colleagues and by his organisation.
Covid pandemic
Another example from the book talks about a care home worker during the Covid pandemic. “We had to practise social distancing wherever possible, and if we had any symptoms at all, we were officially not allowed to come to work. But residents in a care home like this need contact. And too much social distancing and using protective equipment sometimes made people who were already confused quite aggressive. My colleagues and I were already working overtime, so it didn’t seem right to call in sick just because of a slight cough.” So she went to work with a cough anyway, and, like her colleagues, did not keep to the social distancing rules. “Then Covid broke out there because of me, and many of the residents died. And it was my fault.”
This example shows how difficult it can be to make choices in situations where people are weighing up different factors. Molendijk: “Most of us have a moral compass. But you may find yourself in situations where you don't act according to those values, for whatever reason. Moral injury really shows your human side.”
From individual to society
The researchers conducted extensive fieldwork in military units and the police, among others. They interviewed people who had experienced moral injury and explored ways to prevent or treat moral injury. They combine insights from psychology, philosophy, organisational studies and social sciences in a guide with stories of experience and explanations of causes, manifestations and treatments of moral injury.
Can moral injury be prevented? And how do people who have suffered moral injury get over their trauma? Molendijk: “We need to look for the answers at multiple levels, not just in debriefing after incidents and treatment of moral injury, but also in prevention. This must not just focus on the individual through training and therapy, but also at the level of an organisation, politicians and society through ethically sensitive decision-making, honest, nuanced narratives and adequate aftercare.”