Psychological Trauma:

Theory, Research, Practice, and Policy

In the public domain 2020, Vol. 12, No. S1, S138 –S140
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000698

A Commentary on Moral Injury Among Health Care Providers During the

COVID-19 Pandemic

Lauren M. Borges and Sean M. Barnes Jacob K. Farnsworth

Rocky Mountain Mental Illness Research, Education, and Rocky Mountain Regional VA Medical Center,
Clinical Center, Aurora, Colorado, and University of Colorado Aurora, Colorado
School of Medicine

Nazanin H. Bahraini and Lisa A. Brenner

Rocky Mountain Mental Illness Research, Education, and Clinical Center, Aurora, Colorado, and
University of Colorado School of Medicine

Although little is known about moral injury in nonmilitary populations, the COVID-19 pandemic has
made it clear that moral injury’s relevance extends beyond the battlefield. Health care providers are
experiencing potentially morally injurious events that may violate their moral code or values, yet almost
no research has been conducted on moral injury among health care providers to date. The purpose of this
commentary is to describe the relevance of moral injury to health care providers and to spark a dialogue
that motivates future research, prevention, and intervention.

Keywords: moral injury, COVID-19, health care providers, treatment

Imagine being a health care provider required to triage
COVID-19 patients. You are inside a crowded emergency room
deciding which of two patients will get your emergency room’s
only remaining ventilator. Although you understand the situation
requires you to give the ventilator to the person with the highest
odds of survival, you were not trained to make these kinds of
decisions. You have always had the resources to equally treat all
patients. In this scenario both patients die, despite one’s having
been put on the ventilator. You wonder whether you made the
wrong decision. Could the other patient have survived with a
Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the Journal Editor.—
KKT
This article was published Online First June 4, 2020.
X Lauren M. Borges and Sean M. Barnes, Rocky Mountain Mental
Illness Research, Education, and Clinical Center, Aurora, Colorado, and
Department of Psychiatry, University of Colorado School of Medicine;
Jacob K. Farnsworth, Rocky Mountain Regional VA Medical Center,
Aurora, Colorado; Nazanin H. Bahraini and Lisa A. Brenner, Rocky
Mountain Mental Illness Research, Education, and Clinical Center, and
Department of Psychiatry and Department of Physical Medicine and Re-
habilitation, University of Colorado School of Medicine.
The contents of this article are not necessarily endorsed by the Depart-
ment of Veterans Affairs, Department of Defense, or the U.S. government.
This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
Correspondence concerning this article should be addressed to Lauren
M. Borges, Rocky Mountain Mental Illness Research, Education, and
Clinical Center, 1700 North Wheeling Street, Aurora, CO 80045. E-mail:
lauren.borges2@va.gov
ventilator? You are wracked with guilt, replaying the scenario over
and over, analyzing how different choices might have created
different outcomes. Your distress becomes overwhelming, so you
bury yourself in work, but the pain just follows you home. You
avoid genuine conversations with your family and peers and dis-
tract yourself at the expense of routines that were once meaningful.
You tell yourself that you followed protocol, did the best you
could, and yet still feel like you violated your moral values.
This scenario is precisely the context in which moral injury may
develop. Although little is known about moral injury in nonmili-
tary populations, the COVID-19 pandemic has made it clear that
moral injury’s relevance extends beyond the battlefield. The pur-
pose of this commentary is to describe the relevance of moral
injury to health care providers and to spark a dialogue that moti-
vates future research, prevention, and intervention.
Moral injury is characterized by difficulties in functioning that
sometimes emerge following exposure to potentially morally in-
jurious events (PMIEs). PMIEs occur in high-stakes environments
and violate one’s moral code or values. They may include one’s
own actions (e.g., doing something you felt you should not have
done), inactions (e.g., failing to do something you felt you should
have done), or other people’s actions or inactions (e.g., feeling
betrayed by other people’s actions or inactions). In the context of
COVID-19, a PMIE from one’s own actions might include taking
a patient off potentially life-saving treatment to make it available
for other patients. A PMIE from inaction could be failing to
properly screen a patient, resulting in other vulnerable patients’
being exposed to COVID-19. A PMIE from bearing witness to
another’s actions could include a health care system’s rationing of
resources that may have helped save lives. It is natural that in
response to these PMIEs, people experience moral emotions like
guilt, shame, disgust, anger, and contempt, as well as cognitions

S138
 MORAL INJURY AMONG HEALTHCARE PROVIDERS
related to blaming themselves and/or others. Moral injury occurs
when these painful moral emotions and cognitions are avoided
or suppressed, resulting in greater suffering that negatively
impacts the person’s ability to function effectively (Farnsworth,
Drescher, Evans, & Walser, 2017). Social, psychological, and
spiritual suffering often present in moral injury as difficulties in
meaningfully engaging in valued areas of life (e.g., spirituality,
relationships, employment, and self-care). Among war zone
veterans and service members, additional consequences of
PMIE exposure have included posttraumatic stress disorder
(PTSD), depression, suicidal ideation and behavior, and in-
creased substance use (Bryan, Bryan, Roberge, Leifker, &
Rozek, 2018; Wisco et al., 2017).
To date, limited research has been conducted on moral injury
among health care providers. The one exception is an archival
study in which investigators explored themes of moral injury
among nurses following unintended events that could or did cause
a patient harm. Consistent with moral injury, Stovall, Hansen, and
van Ryn (2020) found nurses experienced guilt, shame, spiritual–
existential crisis, and loss of trust. Additionally, several studies
have been published on moral distress in health care providers, a
concept that emerged in the nursing literature independently from
moral injury. Moral distress is defined as feeling constrained from
doing what you know to be right in a particular situation (Jameton,
1993). Although this definition does not require functional impair-
ment, its similarities to PMIE’s suggest parallels with moral injury
in COVID-19 health care providers. Furthermore, another related
construct, PTSD, is relevant given that both moral distress and
PTSD tend to be elevated among health care providers exposed to
high-acuity patients (DeLucia et al., 2019; Dyo, Kalowes, &
Devries, 2016; Sendler, Rutkowska, & Makara-Studzinska, 2016;
Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). Moral
injury and PTSD are empirically unique constructs (Bryan et al.,
2018), because moral injury has been shown to predict the later
development of PTSD, a relationship that is not bidirectional
(Currier, McDermott, Farnsworth, & Borges, 2019). This evidence
suggests that providers offering critical medical care in overtaxed
health care systems may be at elevated risk for developing moral
injury and PTSD during and following the COVID-19 pandemic.
This literature highlights the importance of investigating moral
injury among health care providers facing the COVID-19 pan-
demic. Just as moral injury has been investigated epidemiologi-
cally (Wisco et al., 2017) and qualitatively (Borges et al., 2020) in
war zone veterans, these research methods also need to be applied
to health care providers. Understanding and characterizing moral
injury in providers is critical to developing tailored evidence-based
prevention, assessment, and treatment methods.
An example of a prevention intervention may include creating a
triage committee to determine which patients are assigned venti-
lators, which could have prevented moral injury in the case exam-
ple described at the beginning of this commentary (Truog, Mitch-
ell, & Daley, 2020). Like the example of a triage committee,
prevention efforts that focus on team decision-making may de-
crease perceptions of personal culpability for patients’ deaths.
Health care organizations may also increase medical staff’s access
to mental health providers and chaplains to increase resiliency and
crisis management skills. Because providers reporting PTSD
and/or moral distress are more likely to engage in negative coping
and experience workplace burnout (Einav et al., 2008; Whitehead
S139
et al., 2015), treatment programs should promote early interven-
tion. Providers’ treatment preferences should therefore be investi-
gated to develop tailored interventions for these populations. Ex-
isting treatments for moral injury, such as Acceptance and
Commitment Therapy for Moral Injury (Borges, 2019; Farnsworth
et al., 2017) and Adaptive Disclosure (Gray et al., 2012), provide
promising foundations for such tailored approaches. More research
is needed to investigate moral injury among health care providers
to develop efficient and effective methods of prevention, assess-
ment, and intervention.
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Received April 24, 2020
Revision received April 27, 2020
Accepted April 28, 2020 䡲