Canadian Medical Association

What is moral injury? 

Moral injury is a term that originated in the military. It is defined as the psychological distress that results from events that go against one’s values and moral beliefs. In the context of health care, when physicians are unable to uphold the oath they took to deliver the best care and put the needs of their patients first, they can experience moral injury. Moral injury is not considered a mental illness; however, those who experience moral injuries often develop negative thoughts about themselves and others, and these symptoms can lead to the development of mental health conditions. Among health care workers, moral injury has become an urgent and prevalent issue during the COVID-19 pandemic, as some may be encountering situations where they cannot uphold their moral or ethical code. Similarly, moral distress occurs when one feels unable to take what they believe to be an ethically appropriate or right course of action, including avoiding wrongdoing or harm, because of institutionalized obstacles. With time, moral distress can lead to moral injury. Addressing moral injury among health care workers must continue to be a high priority after the pandemic is over. 

What are the symptoms and outcomes of moral injury? 

According to the Centre for Addiction and Mental Health, the emotional, cognitive and behavioural symptoms of moral injury can include: 

  • guilt; 
  • anger and betrayal; 
  • feelings of worthlessness, helplessness and powerlessness; 
  • loss of identity and role; 
  • loss of trust in oneself and in others; 
  • self-isolation; 
  • reduced empathy; and 
  • negative beliefs about oneself. 

Moral injury is associated with the development of mental health conditions such as post-traumatic stress disorder (PTSD), depression and anxiety. A study assessing the mental health and well-being of health care workers early in the COVID-19 pandemic found that health care workers with high exposure to moral injury had increased odds of developing common mental health disorders, depression, alcohol misuse and PTSD.  

How should we respond to morally injurious events? 

According to “A Guide to Moral Injury,” these events can be managed at the organizational, leadership and individual levels.  

At the organizational level, the moral stressors that health care workers are experiencing because of the COVID-19 pandemic should be addressed. Organizations should also ensure access to support services for all health care staff and consider rotating staff between roles that are considered high stress and low stress. 

Leaders should ensure they are prepared to discuss moral injury and the prevalence of ethical challenges with their team members. They should also schedule regular check-ins with their team members to discuss well-being and be prepared to facilitate referrals should further support or counselling be required. 

Individuals should access available material on moral stressors and moral injury, participate in peer support sessions and seek professional support.

Moral injury beyond the COVID-19 pandemic 

Following the COVID-19 crisis, it is important that physicians, health care leaders and their teams take time to reflect on and learn from the difficult experiences faced by many. According to the BMJ, reflecting as a team is an opportunity to create a meaningful narrative, rather than a traumatic one.  

Health care leaders play an important role in mitigating long-lasting impacts of the COVID-19 pandemic on health care staff. Leaders should acknowledge the adverse situations and the inherent psychological risks that many faced during the pandemic. 


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