Abstract
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.
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Notes
Some philosophical accounts have emphasized the objective effect on moral interactions with others, whether felt or not. (Wiinikka-Lydon 2019) Such moral injury also damages moral identity, as character is distorted by structures and systems. While such malformation is an important issue in which to attend, we find such a broad definition of moral injury to diminish the ability to give language to the experience of moral suffering felt by those forced to act against moral convictions. Our understanding of moral injuries is in line with Shay and Litz’s understanding of moral injury as a trauma arising from the violation of a moral norm.
References
Albott, Cristina, Jeffrey R. Sophia, P. Wozniak, Brian, Michael H. McGlinch, Barbara S. Wall, and Gold, and Sophia Vinogradov. 2020. Battle Buddies: Rapid Deployment of a psychological resilience intervention for Health Care Workers during the COVID-19 pandemic. Anesthesia and Analgesia 131: 43–54. https://doi.org/10.1213/ANE.0000000000004912.
Alford, C., and Fred. 2016. Depoliticizing Moral Injury. Journal of Psychosocial Studies 9: 7–19.
Antal, Chris J., D. Peter, Rotunda Yeomans, Douglas W. East, Solomon Hickey, Kimberly M. Kalkstein, Brown, and Dana S. Kaminstein. 2019. Transforming veteran identity through Community Engagement: a chaplain–psychologist collaboration to address Moral Injury. Journal of Humanistic psychology. SAGE Publications Inc. https://doi.org/10.1177/0022167819844071.
Atkins, Kim. 2008. Narrative identity and Moral Identity: a practical perspective. New York: Routledge.
Atuel, Hazel R., Nicholas Barr, Edgar Jones, Neil Greenberg, Victoria Williamson, Matthew R. Schumacher, Eric Vermetten, Rakesh Jetly, and Carl A. Castro. 2021. Understanding moral injury from a character domain perspective. Journal of Theoretical and Philosophical Psychology 41. US: Educational Publishing Foundation: 155–173. https://doi.org/10.1037/teo0000161.
Baylis, Francoise. 2012. The self in situ: a relational account of personal identity. In Being Relational: reflections on Relational Theory and Health Law, eds. Jocelyn Downie, and Jennifer J. Llewelyn, 109–131. Vancouver, BC: UBC Press.
Bernstein, J. M. 2005. Suffering Injustice: Misrecognition as Moral Injury in Critical Theory. International Journal of Philosophical Studies 13. Routledge: 303–324. https://doi.org/10.1080/09672550500169117.
Bodie, Graham D., and Andrew D. Wolvin. 2020. The Psychobiology of Listening: Why Listening Is More Than Meets the Ear. In The Oxford Handbook of the Physiology of Interpersonal Communication, ed. Lindsey S. Aloia, Amanda Denes, and John P. Crowley, 0. New York, NY: Oxford University Press. https://doi.org/10.1093/oxfordhb/9780190679446.013.16.
Braxton, Joanne M., Eric M. Busse, and Rushton Cynda Hylton. 2021. Mapping the terrain of Moral suffering. Perspectives in Biology and Medicine 64: 235–245. https://doi.org/10.1353/pbm.2021.0020.
Brémault-Phillips, Suzette, Terry Cherwick, Lorraine Alison Smith-MacDonald, and John Huh, and Eric Vermetten. 2022. Forgiveness: a key component of Healing from Moral Injury? Frontiers in Psychiatry 13: 906945. https://doi.org/10.3389/fpsyt.2022.906945.
Buber, Martin. 1958. I and Thou. Second Edition. New York: Charles Scribner’s Sons.
Cahill, Jonathan M., Warren Kinghorn, and Lydia Dugdale. 2022. Repairing moral injury takes a team: what clinicians can learn from combat veterans. Journal of Medical Ethics. Institute of Medical Ethics. https://doi.org/10.1136/medethics-2022-108163.
Dean, Wendy, and Simon Talbot, and Austin Dean. 2019. Reframing Clinician Distress: Moral Injury not Burnout. Federal Practitioner 36: 400–402.
Donati, Pierpaolo, and Margaret S. Archer. 2015. The relational subject. Cambridge, United Kingdom: Cambridge University Press.
Eisenstein, Leo. 2018. To fight burnout, organize. New England Journal of Medicine 379 Massachusetts Medical Society: 509–511. https://doi.org/10.1056/NEJMp1803771.
Gallagher, Shaun. 2006. How the body shapes the mind. New York: Oxford University Press.
Griffin, Brandon J., A. Marilyn, Shira Cornish, Maguen, and Everett L. Worthington Jr. 2021. Forgiveness as a mechanism of repair following military-related moral injury. Addressing moral injury in clinical practice, 71–86. Washington, DC, US: American Psychological Association. https://doi.org/10.1037/0000204-005.
Hauerwas, Stanley. 1986. Suffering Presence. Notre Dame, Ind: University of Notre Dame Press.
Hilfiker, David. 1984. Facing our mistakes. New England Journal of Medicine 310 Massachusetts Medical Society: 118–122. https://doi.org/10.1056/NEJM198401123100211.
Honneth, Axel. 1996. The Struggle for Recognition: The Moral Grammar of Social Conflicts. Translated by Joel Anderson. Cambridge, Mass: The MIT Press.
Kinghorn, Warren. 2020. Challenging the Hegemony of the Symptom: reclaiming Context in PTSD and Moral Injury. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 45: 644–662. https://doi.org/10.1093/jmp/jhaa023.
Lear, Jonathan. 2011. A case for irony. Cambridge, Mass: Harvard University Press.
Liaschenko, Joan, and Elizabeth Peter. 2016. Fostering nurses’ Moral Agency and Moral Identity: the importance of Moral Community. The Hastings Center Report 46 (Suppl 1): S18–S21. https://doi.org/10.1002/hast.626.
Lindemann, Hilde. 2014. Holding and letting go: the Social Practice of Personal Identities. Oxford New York Auckland: Oxford University Press.
Lindemann Nelson, Hilde. 2001. Damaged Identities, Narrative Repair. Ithaca: Cornell University Press.
Lipari, Lisbeth. 2010. Listening, thinking, being. Communication Theory 20: 348–362. https://doi.org/10.1111/j.1468-2885.2010.01366.x.
Litz, Brett T., and Patricia K. Kerig. 2019. Introduction to the Special Issue on Moral Injury: conceptual Challenges, Methodological Issues, and clinical applications. Journal of Traumatic Stress 32: 341–349. https://doi.org/10.1002/jts.22405.
Litz, Brett T., Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, and Shira Maguen. 2009. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review 29: 695–706. https://doi.org/10.1016/j.cpr.2009.07.003.
MacIntyre, Alasdair. 1984. After Virtue: A Study in Moral Theory, Second Edition. 2nd edition. Notre Dame, Ind: University of Notre Dame Press.
Marcel, Gabriel. 1951. The Mystery of Being, Volume I: Reflection and Mystery. Translated by G. S. Fraser. London: The Harvill Press.
Marcel, Gabriel. 2018. The Philosophy of Existence. Translated by Manya Harari. Providence, RI: Cluny.
Molendijk, Tine. 2018. Moral injury in relation to public debates: the role of societal misrecognition in moral conflict-colored trauma among soldiers. Social Science & Medicine 211: 314–320. https://doi.org/10.1016/j.socscimed.2018.06.042.
Purcell, Natalie, Brandon J. Griffin, Kristine Burkman, and Shira Maguen. 2018. “Opening a door to a New Life”: the role of forgiveness in Healing from Moral Injury. Frontiers in Psychiatry 9: 498. https://doi.org/10.3389/fpsyt.2018.00498.
Resnick, Kimberly S., and Joseph J. Fins. 2021. Professionalism and Resilience after COVID-19. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry 45: 552–556. https://doi.org/10.1007/s40596-021-01416-z.
Rosen, Amanda, Jonathan M. Cahill, and Lydia S. Dugdale. 2022. Moral Injury in Health Care: identification and repair in the COVID-19 era. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-022-07761-5.
Schechtman, Marya. 1996. The Constitution of Selves. Ithaca: Cornell University Press.
Shay, Jonathan. 1994. Achilles in Vietnam: Combat Trauma and the undoing of Character. New York: Simon & Schuster.
Smith, Eliot R., and Diane M. Mackie. 2009. Surprising Emotions Science 323: 215–216. https://doi.org/10.1126/science.1168650.
Soelle, Dorothee. 1975. Suffering. Translated by Everett R. Kalin. Philadelphia: Fortress Press.
Song, Ye, Sneha Kyung, Jennifer M. Mantri, Elizabeth J. Lawson, Berger, and Harold G. Koenig. 2021. Morally injurious Experiences and Emotions of Health Care Professionals during the COVID-19 pandemic before vaccine availability. JAMA network open 4: e2136150. https://doi.org/10.1001/jamanetworkopen.2021.36150.
Sumner, Rachel C., and Elaine L. Kinsella. 2021. “It’s like a kick in the Teeth”: the emergence of Novel Predictors of Burnout in Frontline Workers during Covid-19. Frontiers in Psychology 12: 645504. https://doi.org/10.3389/fpsyg.2021.645504.
Taylor, Charles. 1989. Sources of the self: the making of the modern identity. Cambridge, Mass: Cambridge University Press.
Taylor, Charles. 1992. The Ethics of authenticity. Cambridge, Mass: Harvard University Press.
Taylor, Charles. 1994. The politics of Recognition. In Multiculturalism: examining the politics of Recognition, ed. Amy Gutmann, 25–73. Princeton, N.J: Princeton University Press.
Wiinikka-Lydon, Joseph. 2017. Moral Injury as Inherent Political Critique: The Prophetic Possibilities of a New Term. Political Theology 18. Routledge: 219–232. https://doi.org/10.1080/1462317X.2015.1104205.
Wiinikka-Lydon, Joseph. 2019. Mapping Moral Injury: comparing Discourses of Moral Harm. Journal of Medicine and Philosophy 44: 175–191. https://doi.org/10.1093/jmp/jhy042.
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Cahill, J.M., Moyse, A.J. & Dugdale, L.S. “Ruptured selves: moral injury and wounded identity”. Med Health Care and Philos 26, 225–231 (2023). https://doi.org/10.1007/s11019-023-10138-y
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DOI: https://doi.org/10.1007/s11019-023-10138-y