Friday, March 1, 2024

Moral Injury Among First Responders


In the 1990s, the term Moral Injury was coined by psychiatrist Jonathan Shay and colleagues and defined it as “A betrayal of what is right by someone who holds legitimate authority in a high stakes situation.”

In 2009, the term “Moral Injury” was modified by Brett Litz and colleagues, adding,

“Perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

In simple terms, it means acting in a way (witnessing, participating, or failing to prevent something) that goes against a person’s moral beliefs. These “transgressive acts” violate an individual’s acceptable boundaries of behavior.

Journalist Diane Silver describes Moral Injury as “A deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The pain of Moral Injury is a sign of a working conscience and the loss of deeply held beliefs and/or trust. It challenges our fundamental core values and eats away at us, undermining the trust we had in ourselves, in others, and the world we live in.

While Moral Injury research has mainly focused on military service members and veterans, it is gradually gaining recognition as a significant and widespread issue among first responders.

This isn’t surprising considering the constant exposure to traumatic events that come with their job. First responders have a multitude of responsibilities, including advocating for patients, providing social services, enforcing laws, and protecting the community. As professionals in bureaucratic systems, first responders must follow strict codes of conduct, adhere to standards of practice, and follow the law when making decisions.

The unpredictable and potentially traumatic nature of their work often requires first responders to make split-second decisions. These decisions are often made in high-stress situations where their own safety and that of others are on the line and may go against their personal morals. Even if a first responder's actions don’t violate their morals at the time, an unfavorable outcome such as the death of a victim or serious injury to a team member can reveal the injury in later feelings of deep remorse, guilt, and shame. As lifesavers and problem-solvers by nature, any deviation from this perception can have a damaging effect on a first responders' mental well-being.


Scenarios that could lead to moral injury:

  • A firefighter being unable to save a victim or having to choose between victims to save.
  • A law enforcement officer having to use physical or lethal force to resolve a criminal incident.
  • A paramedic having a patient die in route to the hospital or finding out that their patient died after arriving at the hospital.
  • Being forced to make difficult decisions about how to allocate resources during a crisis
  • making a mistake that led to the death of a colleague
  • A fellow first responder dying by suicide

 With Moral Injury, the trauma and its meaning need to be processed. We need to stare into the belly of the beast and process betrayal, anger, self-loathing, and the desire to self-harm. A 2018 meta-analysis found that exposure to potentially morally injurious events were significantly associated with Post-Traumatic Stress Disorder, depression, and suicidality.

Signs of Moral Injury

  • Feeling demoralized
  • Feeling guilt/shame
  • Feeling “haunted” by decisions, actions or inactions that have been made
  • Anger in particular following betrayal
  • Feelings of worthlessness, helplessness and powerlessness
  • Sense of loss of identify and role
  • Questioning our sense of self and a loss of trust in oneself and in others
  • Persistent self-blame or blaming others
  • Negative beliefs and self- condemnation
  • Self-isolation, avoidance and withdrawal from others
  • Reduced empathy or wanting to interact with others
  • Increase in substance use
  • Loss of spirituality or religious beliefs (if previously held).
  • Suicidal ideation

 It's important for first responders to recognize when their work has begun to take a toll and seek support and professional help. It’s time to drop the stigma. If you feel you are suffering from moral injury and from some of the symptoms above, please seek social support and professional help. Seeking help is not a sign of weakness, it's a necessary step towards healing and maintaining overall well-being.


If you believe change is possible, you want to change, and you are willing to do the work, you absolutely CAN get your life back.”

Get your copy of The Soldier's Guide to PTSDThe Soldier's Workbook

or Acknowledge & Heal, A Women's-Focused Guide to PTSD

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