The term ‘moral injury’ is a new one for me, as it probably is for most. It’s more commonly applied in a military context and only recently in health and social care, since 2020 to be precise. Indeed, the literature gently, knowingly or unknowingly, nudges us into believing that moral injury, reframed as occupational moral injury, isn’t a new concept but an inevitable consequence of working in an ethically challenging health and social care system.
Moral injury is understood as the damage done to an individual’s conscience or moral compass when one perpetrates, witnesses or fails to prevent acts that transgress one’s own moral beliefs, values or code of ethics. The term is thought to have originated after the Vietnam war when returning veterans and their carers struggled to make sense of high levels of anguish, anger and alienation that couldn’t be explained in terms of a mental health diagnosis such a post-traumatic stress disorder. It doesn’t take much stretch of the imagination to understand why veterans were morally injured but the Moral Injury Project at Syracuse University in New York cites examples such as using deadly force in combat and inadvertently causing harm or death to civilians and colleagues, giving orders which result in the injury or death of colleagues, failing to provide medical aid to civilians or colleagues and failing to report incidents such as sexual assaults.
When lockdowns were implemented in 2020, the health and social care workforce faced insurmountable and intolerable challenges when it was deemed unsafe in many situations to have close contact with fellow human beings who were in need of assistance. In essence, a workforce which functions on the need for human contact could endanger life by workers simply doing their job. Subsequently, care and support was withdrawn or compromised through almost non-existent face-to-face interactions or time limited, with minimal physical contact if they took place at all.
Moral injury therefore makes sense in the context of health and social care. Staff were forced to deny medical and compassionate care to the injured and dying, leave adults and children in risky situations which in some cases led to death and injury, isolate frail older people from the life-giving company of family and friends and ignore or dismiss situations that previously justified urgent attention; all done while hiding smiles and humanity behind useless and potentially dangerous masks.
Moral injury during the pandemic can be applied across most professions and indeed the population: the police officer investigating a peaceful family gathering, the funeral director separating distressed relatives, the religious leader closing the door of a place of worship or the teacher who forced children to wear masks for hours on end. There were also the children who isolated their parents and parents who isolated their children, neighbours and community groups who withdrew essential help and support, and friends and family who got angry or fell out with those they disagreed with. Emotions and tensions ran high, leading me to think that many of us are morally injured to some degree or another. Is it any wonder that so many are struggling with poor mental health?
The growing number of articles drawing attention to moral injury, the most significant in the BMJ in July 2020 and a reference point for further articles, all focus on reassuring staff that a conflict of morals and the potential for injury is a normal consequence of doing what was necessary to prevent illness and death from COVID-19. At no point are the logic and morality of the rules called into question, which is surprising because the Moral Injury Project makes reference to two other potential causes of moral injury that are not referred to in recent literature:
- “Following orders that were illegal, immoral, and/or against the Rules of Engagement or Geneva Convention;”
- “A change in belief about the necessity or justification for war, during or after one’s service.”
As the realisation slowly dawns on the world that the inhumane actions which staff were forced to take were in fact unnecessary and based on flawed concepts with no robust evidence base, are we facing a rising tide of the morally injured? All measures were applied in the absence of risk-benefit analysis, despite common knowledge that blanket approaches to managing risk are likely to cause more damage than the presenting problem. Yet the whole population was terrified into believing we were all at equal risk of severe illness or death from a lethal virus, to which we had no natural immunity and was quietly spread from those with no symptoms, especially children. Lockdowns, school closures, testing, mask wearing, social distancing, mass vaccination programmes and subsequent passports were said to be necessary but in reality were unjustified and immoral. Dismissing the question of the necessity and morality of these measures and normalising moral injury as a natural consequence of a warlike situation wrongly places the burden of accountability solely on those who enforced the polices while purporting to vindicate those who created them.
A morally injured workforce is evidence that the response to COVID-19 was morally wrong. None of us know how we would have behaved in the shoes of the workers who enforced immoral policies that contravened their conscience and moral compass. However, we can be sure of one thing: many of the injured will need support to come to terms with the realisation they have inadvertently played a part in injuring some of the very people they intended to protect.