AMA Journal of Ethics^®

Abstract

A career as a public servant carries risk of moral injury. Law enforcement and health care personnel must subordinate some personal values in service to the public. Transgression and betrayal are primary mechanisms of moral injury, which this article explains. Identifying which value system (eg, personal, professional, or social) is affected by moral injury can inform efforts to mitigate it, help support personnel who have experienced it, and preserve public servants’ connection to the broader missions of their professions.

Moral Injury Among First Responders

Health care and law enforcement are professions that work in service to society, which entrusts professions with privileges in return for technical and ethical expertise.¹ Transgressions against foundational values or unexpected erosion of professional standards integral to members’ professional identities can generate deep conflict, which is recognized in health and service fields (eg, public defense, social work, education) as moral injury. Sharing lessons learned across medicine and law enforcement can help both fields promote healing.

Individuals sustain moral injury by 1 of 2 mechanisms: transgressions of deeply held moral beliefs² or betrayal by a legitimate authority in a high-stakes situation.³ In addition, individuals work within several value systems: personal, professional, and social. One can sustain moral injury due to transgression or betrayal of values in any of these systems. Understanding both mechanisms of injury and which values system has been violated can inform appropriate solutions. Moral injury via encroachment on social values is a topic unto itself, beyond the scope of this article, though germane to issues that are politicized (eg, mask wearing) or influenced by racism and inequity (eg, in health care). What follows are descriptions of individual and professional value system moral injuries and strategies for responding to both.

Moral Injury

Professionals in medicine and law enforcement must subsume their personal values to the professional values that benefit the society they serve.⁴ Such situations increase risk for moral injury. Transgression of foundational professional values, such as the oaths physicians or law enforcement officers swear, and betrayal by authority arise from systems issues within one’s field or one’s organization. The COVID-19 pandemic offered ample illustrations of such betrayals of health workers—by health systems that decided who qualified for ventilators and rationed personal protective equipment and by society, which failed to enact basic public health measures.^5,6 The US Capitol riots of January 6, 2021, involved similar betrayals of law enforcement officers, as being unable to protect those in their charge transgressed officers’ general professional values.⁷ Specifically, leaders’ failure to authorize reinforcements was described by the union representing Capital Police officers as being “betrayed.”⁸

Healing

Helping individuals better understand how to manage a discrepancy between their personal beliefs and their professional obligations is appropriately addressed via individual solutions—mentoring and role modeling by more seasoned colleagues, for example. A physician might talk with senior colleagues about how best to choose a specialty or design a practice that minimizes conflict with their beliefs, and a law enforcement officer might learn to reframe his or her role as ensuring safety rather than opposing protestors’ messages. Experience of professional moral distress and injury, however, can only reasonably be managed through systemic changes. Recognizing moral injury and using accurate language to describe it are the first steps toward resolution and prevention. Health care is beginning to reckon with moral injury in the wake of the COVID-19 pandemic and offers approaches that are easily generalized.

Train for these incidents. Critical incident training typically consists of practicing technical skills. What is practiced less often, if at all, are the building blocks of an ethics skill set. Most ethics training consists of contemplating what is the right thing to do. Spending more time learning and practicing how to follow through on what one knows is right is an essential step in reducing the risk of moral injury in difficult situations. Such training only occurs over time, with repeated practice, and with seasoned guidance in the following:

• Developing awareness of situations or events that have potential to disrupt personal or professional moral values.
• Learning which factors are critical in responding to potential moral disruption.
• Developing and practicing response actions.⁹

Leaders must use their positions to advocate for better, more efficient systems that facilitate high performance. It is difficult for those at the coalface to both care for those they serve and to advocate for system change. When a leader asks, “What do you need to be successful today?,” and then follows through with delivering it, workforce distress drops because clinicians or officers are less constrained in pursuing their missions. They are better able to get patients the care they need or better able to protect the most vulnerable when they have the right tools and resources, facilitated by responsive leaders. It is important for the workforce to support leaders who are strong advocates.

Maintain health care workers’ connection to the bigger picture of the profession. Even as clinicians work within the constraints of process, procedure, performance metrics, regulations, and legislation, organizations can maintain clinicians’ connection to the bigger professional picture by deliberately refocusing organizational culture on the why of the work as opposed to the what. Organizations can help do the following:

• Reconnect workers with the reasons for choosing their particular profession.
• Focus on workers’ purpose rather than their tasks.
• Restore or reinforce a sense of community among colleagues.

Law enforcement, like health care, reflects social values and priorities. It is inevitable that, at times, social values and priorities might conflict with personal values of individuals working in these fields, putting them at risk for moral injury. But it is possible to mitigate moral injury risk through clarity about professional purpose and standards, understanding how to voice and elevate challenges, supporting good leaders, and strengthening professional integrity individually and collectively.