As psychiatrists, we strive to do all we can for our patients, but what happens when circumstances force us to do less than our best?

Moral injury refers to the emotional toll of witnessing or participating in actions that violate our moral or ethical beliefs. It can arise when external constraints force us to compromise patient care, such as discharging someone too early because their insurance won’t pay for more days.

What distinguishes moral injury from everyday ethical dilemmas is the depth and persistence of the psychological impact. It’s not just feeling bad about a tough decision; it’s that decision continuing to haunt us and changing how we see ourselves as healers. While we all face ethical challenges, moral injury occurs when these conflicts cause lasting emotional wounds—persistent guilt, shame, or a fundamental loss of trust in ourselves or our profession.

The term “moral injury” was originally used to describe Vietnam War veterans who showed symptoms similar to PTSD but didn’t respond to traditional treatments (Dean W et al, Fed Pract 2019;36(9):400–402). It’s now recognized in other professions too, including health care workers, police officers, and child protective service workers. 

Clinical scenarios that can lead to moral injury
Most of us have had moments where we question whether we’ve done the right thing. Here are a few situations where moral injury can arise:

• Involuntary treatment: A psychotic patient becomes aggressive and is physically and chemically restrained. Later, he tells you that being restrained and involuntarily medicated was the most traumatizing experience of his life. In emergency department or inpatient settings, we often have to weigh patient autonomy against safety. When patients are restrained or medicated against their will, we may be left questioning whether we’ve done more harm than good.
• Confidentiality vs safety: You report a patient’s threat to harm someone, knowing that your action may shatter the patient’s trust in you. Sometimes we’re legally required to break confidentiality to prevent harm, such as in Tarasoff-related cases. Even when it’s necessary, it can feel like a betrayal and damage the therapeutic relationship.
• Systemic constraints: A patient needs ECT for catatonic depression, but the insurance refuses to pay. A lack of beds, staff, or insurance coverage can force premature discharges or prevent needed admissions. These decisions can leave us feeling helpless or complicit.
• Challenging clinical situations: A psychiatrist treating a violent offender feels unsafe and frustrated. The patient is stuck in the system and not improving; staff are frequently injured while caring for them. The psychiatrist begins to question whether continuing treatment under these conditions is ethical or simply enabling further harm. Working with patients who are severely ill, chronically violent, or unresponsive to treatment can evoke fear, frustration, and moral distress, especially when we’re legally required to continue care despite believing the current approach may be ineffective or even retraumatizing.
• Financial pressures: A psychiatric resident is told to prepare a discharge summary after learning that a patient’s insurance has stopped covering the hospitalization, even though the patient remains suicidal and lacks a safe discharge plan. We’re sometimes asked to justify decisions based on cost rather than clinical judgment. These moments can chip away at our professional integrity.

Recognizing moral injury
Moral injury can leave us feeling emotionally numb, guilty, ashamed, or even angry at our institutions, ourselves, or our peers. We might avoid ethically complex cases or feel disconnected from work that we used to enjoy. It can also affect our lives outside of work. In one study, nearly a quarter of health care workers with moral injury reported moderate impairment in family, social, or occupational functioning. Younger clinicians, or those without a strong support system or spiritual framework, were especially vulnerable (­Mantri S et al, J Nerv Ment Dis 2021;209:174–180). 

How to identify moral injury
If you’re concerned about your ­emotional well-being, consider whether you’re carrying unresolved ethical dilemmas, persistent guilt, or spiritual distress. The Moral Injury Symptom Scale–Health Professionals (MISS-HP) is one tool that can help clarify whether moral injury may be affecting your functioning (Mantri S et al, J Relig Health 2020;59:2323–2340). It includes 10 questions covering themes like betrayal, shame, difficulty forgiving, and spiritual distress. A score above 36 suggests that moral injury is interfering with functioning. Supervisors and support teams may also find the scale useful during debriefings or wellness check-ins.

Approaches to healing 
There’s no quick fix for moral injury, but several therapeutic approaches can help:

• Cognitive processing therapy (CPT) helps reframe ethical conflicts and replace distorted beliefs with more compassionate, realistic ones.  
• Acceptance and commitment therapy (ACT) promotes psychological flexibility and encourages “values-driven action”: taking steps that align with one’s core beliefs, even when it’s difficult. A 2017 study on the feasibility and acceptability of ACT, delivered over six group sessions, showed promising results in the treatment of moral injury (Griffin BJ et al, J Trauma Stress 2019;32:350–362). 
• Peer support groups and narrative therapy (which uses storytelling to process experiences and find meaning) offer opportunities to share experiences, reduce isolation, and rebuild a sense of community and trust. 
• Pastoral or chaplain support can be especially helpful for those struggling with spiritual distress.

Institutional and leadership responses
Because moral injury is often caused by systemic issues, addressing it depends on responsive and engaged leadership. When leaders openly talk about moral injury, share their own struggles, or create space for discussion (eg, through ethics rounds and support groups), it sends a powerful message: “You’re not alone, and this work is hard for all of us.”

Distinguishing moral injury from burnout or PTSD 
Moral injury often gets confused with PTSD, but the two are not the same. PTSD involves threats to bodily integrity and includes symptoms like hypervigilance, flashbacks, and nightmares. Moral injury involves threats to moral integrity and centers on guilt, shame, and demoralization.

Moral injury also differs from burnout. Burnout is typically driven by excessive workload, systemic inefficiencies, and emotional exhaustion. While burnout may respond to rest or self-care, moral injury is rooted in ethical conflict, and addressing it requires a different approach.

In some cases, moral injury may overlap with depression or with compassion fatigue—a form of emotional depletion from prolonged exposure to others’ suffering. But unlike those conditions, moral injury is specifically anchored in moral and ethical distress.

Prognosis and long-term considerations
If we don’t recognize and address moral injury, it can take a toll on our mental health, our relationships, and even our desire to remain in the profession. Studies show that moral injury is a major predictor of clinicians expressing a desire to leave the practice of medicine altogether (Mantri et al, 2021).

But with the right support, we can recover from moral injury and reconnect with our work in a way that is more grounded and meaningful. Cultures that acknowledge ethical dilemmas and validate clinicians’ emotional experiences help foster healing and long-term resilience.

A case of moral injury
Dr. C, an attending psychiatrist on an inpatient psychiatric unit, was treating Maria, a 28-year-old woman with bipolar disorder admitted during a severe manic episode. Maria was still significantly symptomatic, but her insurance had a strict 72-hour limit. Despite her clinical judgment that discharge was premature, Dr. C felt pressured by administration to discharge the patient.

Two days later, Maria was brought back to the emergency department after a car accident during another manic episode, this time with her young daughter in the car. “I couldn’t sleep for weeks,” Dr. C says. “I kept thinking about that little girl who could have been killed because I didn’t fight harder against the discharge. I started questioning every decision and even considered leaving psychiatry altogether.” Dr. C’s healing began when she joined a peer support group and learned through CPT to separate her professional integrity from systemic failures beyond her control.

Carlat Verdict: We are vulnerable to moral injury when we feel that our actions, or those of our colleagues, conflict with our core ethical beliefs. It can be painful, isolating, and disorienting—but it’s also something we can recover from, especially when leaders and colleagues acknowledge the reality of these struggles and support honest, compassionate dialogue.