Mapping the Terrain of Moral

Suffering

Joanne M. Braxton,* Eric M. Busse,† and

Cynda Hylton Rushton‡

ABSTRACT  This essay explores what to make of the various kinds of moral dis-
tress and moral injury increasingly discussed in multiple disciplines and fields of work.
It argues for transdisciplinary cooperation and inquiry and proposes a common name
“moral suffering” to embrace the diversity of morally fracturing experiences that neg-
atively impact those in health care and other helping professions. The authors offer
important insights into the phenomenological relationship between moral conscience
and traumatic experience, presenting questions and offering a possible hypothesis for
those who want to pursue this discussion further. The essay reviews the diversity of

*Eastern Virginia Medical School, Norfolk, VA; and the Braxton Institute for Sustainability, Resil-
iency and Joy, Williamsburg,VA.
†Fielding Graduate University, Santa Barbara, CA.
‡Johns Hopkins University, Baltimore, MD.
Correspondence: Joanne M. Braxton, The Braxton Institute, 2202 18th Street NW #312, Wash-
ington, DC 20009.
Email: jmbrax@wm.edu.
JB is grateful to William & Mary and The John W. Kluge Center at the Library of Congress for a
David B. Larson Fellowship in Spirituality and Health, which helped make this essay possible. Support
for EB’s related MDiv fieldwork came from Harvard Divinity School and the Harvard Medical School
MBE Program, both with supervision from the Braxton Institute for Sustainability, Resiliency and Joy.
An earlier draft of this work was presented at the American Society of Bioethics and Humanities
Annual meeting in Anaheim, CA, on October 21, 2018. JB presented a subsequent draft as a work
in progress as Thomas G. and Nancy B. Davis Visiting Professor of Judeo-Christian Values, Ursinus
College, Collegeville, Pennsylvania, on February 14, 2019. JB and CR field-tested some of these
concepts in a CME training sponsored by the Los Angeles County Department of Mental Health,
May 29–31, 2019.

Perspectives in Biology and Medicine, volume 64, number 2 (spring 2021): 235–245.
© 2021 by Johns Hopkins University Press

235
Joanne M. Braxton, Eric M. Busse, and Cynda Hylton Rushton

theories regarding moral distress and moral injury advanced by health-care researchers,
military clinicians, and educators. It names questions that transdisciplinary engagement
can help address, such as what do the disciplines of health humanities, psychology, and
education have to teach each other about prevention of moral harm and the healing
of invisible wounds?

The Landscape of Moral Suffering

T he study of “moral distress,” “moral adversity,” “moral injury,” and as-

sociated terms is rapidly gaining attention across realms of clinical care, mil-
itary psychology, criminal justice, humanitarianism, education, and other fields.
However, there is little dialogue or agreement about the meaning of related terms
across disciplines. To address this dilemma, we invite a robust examination of the
concept of “moral suffering” as a basis for collaboration and dialogue toward de-
velopment of strategies for preventing, responding to, and healing moral suffering
across the professions.
“Moral suffering,” defined as “the anguish in response to moral adversity,
harms, wrongs, or failures, or unrelieved moral stress” (Rushton 2018), can take
the form of moral distress, moral outrage, moral injury, and, unfortunately, a
more recalcitrant and enduring moral decline. Whether these categories are dis-
tinct, overlapping, or relate to other forms of suffering requires further concep-
tual and empirical work. We overview terms presently in use in clinical, military,
and educational contexts to illuminate the state of current scholarship and to
open up questions that transdisciplinary dialogue might fruitfully explore.
What do the disciplines of health humanities, psychology, and education have
to teach each other about prevention of harm and the healing of invisible wounds?
How, for example, do chronic situations of moral distress experienced by clini-
cians differ from acute situations of moral injury experienced by war-fighters?
What factors, for each, contribute to moral suffering being silenced, denied or
minimized as “just part of the job”? When, if ever, should moral suffering be
borne and when should it be alleviated? How can one’s observation of one’s
own moral suffering be a useful tool for self-stewardship? What ethical guidelines
might be important to consider for improved situational outcomes, diminished
burnout, and greater sustainability for long-haul front-line service?
The implications of our work apply specifically to clinicians and those serv-
ing or preparing to serve in health care, education, law enforcement, and other
domains of public service, including ministry and the military. While this essay
draws on current scholarly research and our experiences as scholars of health
humanities, clinical ethics, spirituality, and the arts, it also draws on our expe-
riences as facilitators of restorative practices for scientists, clinicians, war-fight-
ers, educators, and chaplains. The increasingly urgent need for interprofessional
community-building, knowledge-sharing, and social action at the intersections
of ethical theory, moral suffering, and professional practice motivates our call to
attentive action.

236 Perspectives in Biology and Medicine

 Mapping the Terrain of Moral Suffering

Moral Distress in Nursing and Health Care

“Moral distress,” a term that has been heavily researched in nursing and more re-
cently other health-care disciplines, is a common form of moral suffering (Ulrich
and Grady 2018). Despite robust scholarly attention, however, the concept of
moral distress “has been understood in diverse, and sometimes conflicting, ways”
(Carse and Rushton 2017, 6). This plurality of meaning has not prevented mor-
al distress from being recognized as a clinical reality informing “escalating rates
of burnout and turnover, challenging recruitment and quality of patient care”
(15). Like moral injury, a term more frequently applied to war and military set-
tings, moral distress can be accompanied by various levels of post-traumatic stress
(Epstein et al. 2019; Nash et al. 2013). Just as COVID-19 has shone a light on
structural and systemic inequality and disparities among the social determinants
of health, it has also made visible the moral distress of those working in health-
care settings where everyone is at risk, though not in equal ways. On the 27-
item Moral Distress Scale for Health Care Professionals (MMD-HP), MMD-HP
scores are “higher for nurses than physicians,” and higher for those “considering
leaving the position” than those who were not (Epstein et al. 2019). Within the
COVID-19 pandemic, clinicians have expressed moral distress in response to the
scarcity of personal protective equipment that significantly increased their risk of
being infected with and/or spreading the disease.
“Moral distress” is broadly defined as “anguish or anxiety tied to a sense of
imperiled integrity” and entails a “[personal] judgment that one has violated a
core value commitment, failed to fulfill a fundamental moral obligation, or in
some other significant way fallen morally short under conditions of constraint or
duress” (Carse and Rushton 2017, 16). Others have proposed a broader defini-
tion that encompasses “one or more self-directed emotions or attitudes that arise
in response to one’s perceived involvement in a situation that one perceives to
be morally undesirable” (Campbell, Ulrich, and Grady 2016, 6). Morley and
colleagues (2019) further specify the definition to include “(1) the experience of
a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal
relation between (1) and (2) together” as “necessary and sufficient conditions for
moral distress” (646–62). Distinctions between constraint-focused and uncertain-
ty-focused moral distress suggest that there may be different types of moral dis-
tress. Morley, Ives, and Bradbury-Jones (2020) went further to propose four types
of moral distress arising from moral tension, moral uncertainty, moral constraint,
moral conflict, and moral dilemmas.
Carse and Rushton (2017) argue that the recognition of a moral problem
and one’s responsibility to respond to it, coupled with a discernment process in
which one determines the “correct” response but is unable to act on it because
of external constraints, can result in a “‘residue’ of insufficiently resolved moral
distress” (16). In this scenario, conflicted moral emotions and unmet moral obli-
gations acquired in the past are often “carried into new situations in ways that can

spring 2021 • volume 64, number 2 237

Joanne M. Braxton, Eric M. Busse, and Cynda Hylton Rushton

diminish clinicians’ moral resilience and responsiveness, leading to escalations of

moral distress, [a dynamic] now widely known as the ‘crescendo effect’” (Carse
and Rushton 2017, 21). Moral residue and the crescendo effect can contribute
to the phenomenon popularly known as “burnout” (Epstein and Hamric 2009;
Moss et al. 2016). Alongside the familiar physiological consequences of chronic
stress, researchers have identified particular ways in which sustained experiences
of moral distress engender an ongoing sense of deficiency. This morally laden
sense of shame corresponds with appraisals of the self as an “inferior, defective,
or in some way diminished” moral agent, as well as an identity of “personal or
professional moral deficiency” (Carse and Rushton 2017, 21). The persistent
appraisal of responsibility for moral failures, even if they were unavoidable, can
intensify the distress even when others would not conclude it is justified. Re-
gardless of whether these appraisals of moral culpability are avoidable or morally
justified, such appraisals can lead to a cascade of physical, psychological, spiritual,
and existential consequences (Tessman 2020).
Moral distress in clinical settings, like moral injury in the military, remains a
contested concept. For those who define moral distress in terms of an individual
knowing the “right” action to take, concerns have been raised about the tenden-
cy for some to become so attached to their particular point of view that a kind
of self-righteousness can emerge, foreclosing robust and generative discernment
that includes alternative understandings of what is morally required or desirable.
Here unconscious bias needs to be considered. For example, Williams and col-
leagues (2017) argue for “the grandmother principle” as a form of evidence-based
patient-centered care that reduces the risk of unconscious bias in critical deci-
sion-making for older patients. Clinicians who come from cultures that place a
high value on the role of the elderly and geriatricians devoted to compassionate
care of the older patient may carry a heavier load of moral distress when they are
unable to fulfill their own standards for care or when their standards come into
conflict with what the system they are in tells them is possible. This is especially
difficult under surge conditions, like those resulting from the COVID-19 pan-
demic (Braxton 2020; Braithwaite and Reuben 2020).
Situations where moral distress can arise include those in which clinicians lack
knowledge of professional standards for limiting therapies such as CPR when
deemed medically ineffective. Lack of skills in effective communication with pa-
tients or their surrogates about treatment choices can be another source of moral
distress. These settings can be exacerbated when there are ambiguous or nonexis-
tent organizational policies, lack of administrative support or resources, or when
the organizational culture sanctions behaviors known to erode the integrity of at
least some segment of the workforce. From a different perspective, some have
suggested that moral distress can be “self-inflicted” when individuals or groups
fail to exercise their legitimate moral and professional authority (Berger, Hamric,
and Epstein 2019).

238 Perspectives in Biology and Medicine

 Mapping the Terrain of Moral Suffering

Controversy persists regarding whether the goal in clinical practice ought to be

to extinguish moral distress altogether. Probably not. Some argue that the inten-
sity and frequency of exposure to morally distressing events and the persistence of
shame, guilt, and self-blame are unjustified and therefore ought to be avoidable.
However, viewing moral distress as an avoidable reality in health care overlooks
the very real possibility that the experience of moral distress is a signal of moral
conscientiousness rather than a moral failing (Carse and Rushton 2017). Humans
are hard-wired to recognize when we have transgressed a moral value or our
conscience or acted contrary to our professional vows. Our nervous system is
constantly scanning for threats, including threats to our integrity. The distress we
experience can be viewed as a signal to alert us to such threats or violations and
to focus our attention to examine and inquire into its sources. It can also be the
fuel to examine our responsibility for our responses to it (Tessman 2020).
The resources and tools clinicians need to be able to heal the wounds of moral
distress in a way that does not intensify unfitting responsibility, blame, or shame
are still under investigation. Surely, we ought to be committed to removing the
causes of moral distress that arise from structural inequities, policies that favor one
group unfairly over another, and organizational practices that sustain bias in the
allocation of resources. These inequities impact personnel, access to health care,
and decision-making in clinical care. Health-care organizations and the broad-
er society have obligations to build systemic structures and processes that foster
rather than disable the integrity of clinicians who are entrusted with the health
and well-being of citizens (Rushton and Sharma 2018). Rising rates of suicide
among health-care providers, like those among veterans, might be considered as
an inability to resolve ethical and moral contradictions in life-or-death situations,
especially when one is unable, for whatever reason, to live up to one’s own
ethical and moral standard. Without systemic reforms, the burden of restoring
wholeness is relegated to individuals who work in toxic environments without
the necessary tools or skills to do so. Moral repair will require commitment, re-
sources, and new paradigms for designing systems that produce sustainable and
compassionate results.
Others have begun to explore the relevance of moral injury, rather than moral
distress, in health care to illuminate the systemic contributions to moral suffering.
For example, in hospice and end-of-life care settings, where the ethics of con-
tinued treatment must be weighed against quality of life, more clinicians have
begun to adopt the concept of moral injury to signify the intensity of violations
of their professional values and commitments that emanate from toxic and un-
healthy work environments. Others have proposed that the epidemic of burnout
among clinicians may be more accurately defined as moral injury (Talbot and
Dean 2018). In the context of medical errors, moral injury has been proposed as
a more accurate description of the aftermath of making mistakes in clinical care
(Stovall, Hansen, and van Ryn 2020). Early empirical data from the COVID-19

spring 2021 • volume 64, number 2 239

Joanne M. Braxton, Eric M. Busse, and Cynda Hylton Rushton

pandemic suggest that clinicians are experiencing moral injury as they confront
the ethical challenges created by it (Mantri et al. 2020). Stovall and colleagues
(2020) reject the category of moral distress in favor of the more severe rhetorical
force conveyed by moral injury, though others find this expanded meaning prob-
lematic. When the term “moral injury” is used in reference to chronic moral dis-
tress, it usually implies an extreme placement on the spectrum of moral suffering.
But is this an appropriate implication, or do “moral distress” and “moral injury”
describe two distinct realms of moral suffering which should not be conflated?
Do they perhaps overlap? Further examination and interrogation is merited if the
clinical professions are to be sustainable for individuals of high moral character
who wish to remain faithful to their vocational callings.

Moral Injury and Moral Transgression in War

The term “moral injury” was first articulated in the language of combat psy-
chology by psychiatrist and scholar of posttraumatic stress, Jonathan Shay. His
combat-based theory of moral injury is described in numerous publications (see,
for example, Shay 1994, 2003). In his ground-breaking work Achilles in Vietnam
(1994), he notes: “I’ve come to strongly believe through my work with Vietnam
veterans that moral injury is an essential part of any combat trauma that leads
to lifelong psychological injury” (20). For Shay, moral injury has three com-
ponents—(1) a high-stakes situation and (2) a betrayal of “what’s right” by (3)
someone who has authority and power—and its consequences are serious: “The
moral dimension of trauma destroys virtue, undoes good character” (37). “Vet-
erans can usually recover from horror, fear, and grief once they return to civilian
life,” Shay observes, “so long as ‘what’s right’ has not also been violated.”
Litz and colleagues (2009) published a thorough review of moral injury re-
search and emerging interventions within the combat trauma and military psy-
chology literature. These authors defined moral injury as a traumatic wound of
moral conscience experienced by “perpetrating, failing to prevent, bearing wit-
ness to, or learning about acts that transgress deeply held moral beliefs and expec-
tations” (697). With this definition, distinctions between moral distress and moral
injury are still not so obvious. However, the Litz review identifies the parameters
of moral injury as a unique category by focusing on the specific nature of vet-
erans’ experience in combat. The authors clarify that “Moral injury requires an
act of transgression that severely and abruptly contradicts an individual’s personal
or shared expectation about the rules or the code of conduct, either during the
event or at some point afterwards” (700). This emphasis on the traumatic, severe,
and acute origins of “moral injury” differentiates this term from the seemingly
more chronic and cumulative category of moral distress.
Moral injury may also arise when one is unable to prevent harm to others, as
in the case of the 2019 conflict in Syria, where US soldiers were unable to pre-

240 Perspectives in Biology and Medicine

 Mapping the Terrain of Moral Suffering

vent harm to the Kurdish troops who have historically been US allies, or when
a soldier may be under orders to participate in or simply witness an action which
he or she regards as a form of betrayal. It is worth noting, that in a manner akin
to experiences of morally distressed clinicians, active-duty personnel and mor-
ally injured veterans may come to view themselves as “immoral, irredeemable,
and un-reparable or believe that he or she lives in an immoral world” (Litz et
al. 2009, 698). Such a pervasive, visceral sense of personal or global immorality
may lead to self-harming behavior, social isolation, substance abuse, suicidality,
and an abiding sense of personal shame. This can lead to spiraling rates of suicide,
especially among those who have the moral capacity to comprehend situational
ethical contours and the gap between what is espoused and what is practiced.
Others simply “numb out” or become cynical, angry, depressed or disengaged
(Bryan et al. 2018).
With the definition of moral injury posited by Litz and colleagues, theoret-
ical and therapeutic attention has focused on accounting “morally transgressive
events,” which may include, but are not limited to, betrayals of leadership and
trust, and which are characterized by Shay as being necessary components of
moral injury. So, like the category of moral distress, moral injury “began its
life with one definition and then evolved to fit a wider definition” (Mcaninch
2016, 30). Shay himself has further developed and refined his initial definition.
The understanding of moral injury continues to expand beyond its conceptual
and empirical roots in the experience of war, especially as the world’s popula-
tion of refugees and asylum seekers grows. Specifically, Nickerson and colleagues
(2015) remind us that “moral injury contributes significantly to mental health
outcomes in traumatized refugees, over and above the impact of trauma exposure
and postmigration stressors” (123). Is this expanded definition of moral injury
broad enough to also include the moral distress of clinicians? How should we
theorize moral suffering and chronic moral distress in relation to acute or trau-
matic wounds of moral conscience?

Moral Suffering Across Multiple Disciplines

The concept of moral suffering applies not only to the military and health care, it
is arguably an ever-present aspect of many daily lives. Within the theoretical dis-
course of education, for example, Meira Levinson (2015) argues that “educators
are obligated to take action that fulfills the demands of justice but under condi-
tions in which no just action is possible because of contextual and school-based
injustices” (203). Amidst such conflict, Levinson claims that “educators suffer
moral injury, the trauma of perpetrating significant moral wrong against others
despite one’s wholehearted desire and responsibility to do otherwise” (203). This
is a considerable turn from the defining characteristic of abrupt, severe moral
trauma described by combat veterans and espoused by Litz. And yet, as Margaret

spring 2021 • volume 64, number 2 241

Joanne M. Braxton, Eric M. Busse, and Cynda Hylton Rushton

Urban Walker (2006) points out, harm is sometimes caused by complicity or by-
stander negligence. Educators, like other practitioners, might not intend to cause
harm but are sometimes powerless to prevent it. Additionally, Koritha Mitchell
(2019) argues that “know your place aggression” can impact educational profes-
sionals from marginalized communities, compounding moral distress for profes-
sionals from minoritized populations. What does this expanded conceptualization
mean for locating the suffering of educators along a continuum of harmful moral
experience?
Several questions arise: is Levinson’s use of moral injury to describe the expe-
rience of teachers appropriate? Would it be more appropriate to say that teachers
experience moral distress? There are ways in which teachers are not unlike first
responders. Should a teacher’s experience of morally traumatic events be regard-
ed in a similar diagnostic manner to those experienced by war fighters? Could
teachers experiencing chronic moral distress not also develop moral injury or,
at the very least, “moral residue” as morally degrading experiences accrue over
time? Does moral suffering from being on the receiving end of repeated “know
your place aggression” contribute to stress-accelerated aging and related physical
morbidities like hypertension and diabetes? Preliminary research suggests that this
might certainly be the case (Geronimus et al. 2006). We theorize that moral inju-
ry and stress-accelerated aging might well play a role in health disparities faced by
individuals from historically marginalized populations who are continually being
silenced and told through either words or actions to “know your place.”
Levinson (2019) draws upon common themes of imperiled conscience to make
her argument while also centering conceptions of justice—a primary bioethical
principle only passively (though increasingly) engaged in the military psychology,
nursing, or clinical ethics literature. Acknowledging the veteran-centric origins
of the moral injury category, she respects this history and conceptual framework.
She sees no conflict in her use of the term “moral injury” in educational contexts
and offers evidence for her argument by pointing out that educators are perhaps
“particularly prone to [moral injury] because of their responsibilities for children,
who are innately vulnerable” (219).
This centering of justice is one of the primary contributions of the disciplines
of education and bioethics to the ongoing conversations about moral injury,
drawing the principle of justice from the margins to the center. This centering
consciousness requires exquisite care and attention to inner and outer possibilities
for harm. It can enhance transformation through the cultivation of tools for ad-
dressing moral suffering. In fact, embodied social justice can often mitigate moral
suffering and improve outcomes in both the classroom and the clinic.

Conclusion
In summary, what can our intellectual disciplines offer each other in furthering
our understanding of moral suffering and our conversations about a praxis of

242 Perspectives in Biology and Medicine

 Mapping the Terrain of Moral Suffering

care that will both be grounded in the realities of our disciplines and also able to
transcend them? The disciplines have much to teach each other. How is this to
be accomplished?
Working cooperatively and collaboratively primes the possibility of contem-
plating the many valuable and nuanced contributions each field makes to our
shared understanding of moral experience. The critical leverage gained from a
greater intimacy with the range of complex biopsychosocial and spiritual phe-
nomena contributing to individual and collective experiences of moral suffering
would signal a turn from individual pathology to collective reciprocity. Truly,
there can be no pretense of quick or easy solutions to these very human prob-
lems. Cooperation across medical and social sciences, as well as critical resources
from the arts and humanities, will be essential.
We must take up the root causes of moral suffering. We must attend to, rather
than avoid, consideration of the evolving organizational, societal, and political
forces that create environments wherein moral suffering arises—notably, but not
exclusively, in clinical settings, on the battlefield, at sites of incarceration, and in
educational contexts. In any of these settings, the reward for making unpopular
but courageous decisions can be career-ending, or sometimes even a matter of
life and death. Yet those who do so, such as Lt. Colonel Alexander Vindman in
his testimony before Congress in 2019, strengthen the moral fabric of society.
Deploying the bioethical principle of justice through an understanding of
moral suffering demands the will to look honestly and, indeed, painfully, at indi-
vidual complicity and collective moral failure (Brock n.d.). Failure is the gateway
to learning, growth, and imagination. It is also necessary to celebrate occasions of
personal and collective moral integrity and learn from those moments of ethical
resolve. Therefore, we must engage in this difficult and life-giving effort with-
out leaping to the more immediate, comfortable, and ultimately disingenuous
assumption that the moral work at hand is finished. Each day the work is born
anew, as the status quo resists its transformation. If we summon the transdisci-
plinary commitment required of us as individuals, professionals, parents, commu-
nities, and pathfinders, we will contribute greatly to empowering moral agency,
understanding the ethical terrain of undue human suffering, and enacting its ame-
lioration.
The highly specialized, diverse, and conflicting definitions of moral distress and
moral injury proliferate as opportunities for transformative interchange across dis-
ciplines and professions. We have traced some of the terrain and propose “moral
suffering” as an inclusive basis for transdisciplinary collaboration and dialogue. By
navigating this diverse literature, and by proposing a broad agenda for mapping
the spectra of moral suffering in pursuit of more humane and ethically responsive
systems, this article identifies an increasingly urgent need for community-build-
ing, knowledge-sharing, and social action at the intersections of ethical theory,
moral suffering, and professional practice.

spring 2021 • volume 64, number 2 243

Joanne M. Braxton, Eric M. Busse, and Cynda Hylton Rushton

References
Berger, J. T., A. B. Hamric, and E. Epstein. 2019. “Self-Inflicted Moral Distress: Oppor-
tunity for a Fuller Exercise of Professionalism.” J Clin Ethics 30 (4): 314–17.
Braithwaite, R., and W. Reuben. 2020. “The African American Petri Dish.” J Health
Care Poor Underserved (31) 2: 491–502.
Braxton, J. 2020. “Covid 19 Unevenly ‘Culls’ Humanity.” Sojourners. https://sojo.net/
articles/covid-19-unevenly-culls-humanity.
Brock, R. N. n.d. “Moral Conscience, Moral Injury, and Rituals for Recovery.” Forth-
coming in Moral Injury and Beyond: Understanding Human Anguish and Healing Traumatic
Wounds, ed. R.K. Papadopoulos. Milton Park: Taylor & Francis.
Bryan, C. J., et al. 2018. “Moral Injury, Posttraumatic Stress Disorder, and Suicidal Be-
havior Among National Guard Personnel.” Psychol Trauma 10 (1): 36.
Campbell, S. M., C. M. Ulrich, and C. Grady. 2016. “A Broader Understanding of Moral
Distress.” Am J Bioethics 16 (12): 2–9.
Carse, A., and C. H. Rushton. 2017. “Harnessing the Promise of Moral Distress: A Call
for Re-Orientation.” J Clin Ethics 28 (1): 15–29.
Epstein, E. G., and A. B. Hamric. 2009. “Moral Distress, Moral Residue, and the Cre-
scendo Effect.” J Clin Ethics 20 (4): 330–42.
Epstein, E. G., et al. 2019. “Enhancing Understanding of Moral Distress: The Measure
of Moral Distress for Health Care Professionals.” AJOB Empir Bioethics 10 (2): 113–24.
Fourie, C. 2017. “Who Is Experiencing What Kind of Moral Distress? Distinctions for
Moving from a Narrow to a Broad Definition of Moral Distress.” AMA J Ethics 19
(6): 578–84.
Geronimus, A. T., et al. 2006. “‘Weathering’ and Age Patterns of Allostatic Load Scores
Among Blacks and Whites in the United States.” Am J Pub Health 96 (5): 826–33.
Jameton, A. 1984. Nursing Practice, the Ethical Issues. Prentice-Hall Series in the Philosophy
of Medicine. Englewood Cliffs: Prentice-Hall.
Levinson, M. 2015. “Moral Injury and the Ethics of Educational Injustice.” Harvard Educ
Rev 85 (2): 203–28.
Litz, B. T., et al. 2009. “Moral Injury and Moral Repair in War Veterans: A Preliminary
Model and Intervention Strategy.” Clin Psychol Rev 29 (8): 695–706.
Mantri S., et al. 2020. “Identifying Moral Injury in Healthcare: The Moral Injury Symp-
tom Scale-HP.” J Relig Health 59 (5): 2323–40.
Mcaninch, A. 2016. “Moral Distress, Moral Injury, and Moral Luck.” Am J Bioethics 16
(12): 29–31.
Mitchell, K. 2018. “Identifying White Mediocrity and Know-Your Place Aggression: A
Form of Self-Care.” African American Rev 51 (4): 253–62.
Morley G., J. Ives, and C. Bradbury-Jones. 2020. “What Is ‘Moral Distress’ In Nursing?
A Feminist Empirical Bioethics Study.” Nurs Ethics 27 (5): 1297–1314.
Morley G., et al. 2019. “What Is ‘Moral Distress’? A Narrative Synthesis of the Litera-
ture.” Nurs Ethics 26 (3): 646–62.
Moss, M., et al. 2016. “An Official Critical Care Societies Collaborative Statement:
Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action.”
Am J Critl Care 25 (4): 368–76.

244 Perspectives in Biology and Medicine

 Mapping the Terrain of Moral Suffering

Nash, W. P., et al. 2013. “Psychometric Evaluation of the Moral Injury Events Scale.”
Military Med 178 (6): 646–52.
Nickerson, A., et al. 2015. “Moral Injury in Traumatized Refugees.” Psychother Psychosom
84 (2): 122–23.
Rushton, C. H., 2018. “Mapping the Path of Moral Adversity.” In Moral Resilience:
Transforming Moral Suffering in Health Care, ed. C. H. Rushton, 52–76. New York:
Oxford University Press.
Rushton, C. H., and M. Sharma. 2018. “Designing Sustainable Systems for Ethical Prac-
tice.” In Moral Resilience: Transforming Moral Suffering in Health Care, ed. C. H. Rush-
ton, 206–42. New York: Oxford University Press.
Shay, J. 1994. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York:
Atheneum.
Shay, J. 2003. Odysseus in America: Combat Trauma and the Trials of Homecoming. New
York: Simon and Schuster.
Stovall, M., L. Hansen, and M. van Ryn. 2020. “A Critical Review: Moral Injury in
Nurses in the Aftermath of a Patient Safety Incident.” J Nurs Scholarsh 52 (3): 320–28.
Talbot, S. G., and W. Dean. 2018. “Physicians Aren’t ‘Burning Out’: They’re Suffer-
ing from Moral Injury.” Stat, July 26. https://omahamedical.com/wp-content/up-
loads/2019/05/MD-burnout-as-moral-injury.pdf.
Tessman, L. 2020. “Moral Distress in Health Care: When Is It Fitting?” Med Health Care
Philos 23: 165–77.
Ulrich, C. M., and C. Grady. 2018. Moral Distress in the Health Professions. New York:
Springer.
Walker, M. U. 2006. Moral Repair: Reconstructing Moral Relations After Wrongdoing. Cam-
bridge: Cambridge University Press.
Williams, S. K., et al. 2017. “Evidence-Based Care for the Elderly: Uses of ‘the Grand-
mother Principle.’” J Health Care Poor Underserved 28 (1): 7.

spring 2021 • volume 64, number 2 245