AMA Journal of Ethics^®

Abstract

ESP

Police officers and clinicians are exposed to a broad range of moral risks in the field. When they perceive that a moral transgression has been committed by an agent responding to those risks, they are susceptible to moral injury. This article canvasses situations that can generate moral injury and describes symptom profiles of moral injury in law enforcement personnel, which tend to be more diverse than those in military personnel. This article also offers recommendations to clinicians who work with and care for police officers experiencing moral injury regarding symptom identification, recovery, and possible prevention.

Moral Injury in Policing

According to Litz et al, “Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations might be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury).”¹ Although the risk of moral injury among police officers might not be significantly different from that of members of other helping professions, the present paper focuses specifically on the circumstances that police officers face, which make them susceptible to transgressions that result in moral injury. It is important for clinicians who treat police officers and for those who work in the field of tactical medicine to understand moral injury, how it affects police officers, and how it follows from other moral risks.

Somewhat surprisingly, moral injury in policing has not received much empirical attention. The term originates from work with military service members and veterans.¹ Combat situations, in which service members engage in and are exposed to violence and experience its aftermath, are commonly identified as potentially morally injurious events (PMIEs). There is some overlap between moral injury and posttraumatic stress disorder (PTSD). One criterion for the diagnosis of PTSD is exposure to actual or threatened death, actual or threatened serious injury, or actual or threatened sexual violence.² In law enforcement, reported incidence rates of PTSD have varied considerably—from 3.9% to between 7% and 19%^3,4—which are little higher than prepandemic rates reported in the general public. In one study of police officers, moral injury predicted PTSD as well as its symptom clusters.⁵ Therefore, whenever a police officer presents with symptoms of PTSD, it is vitally important also to assess for moral injury (see Currier et al on treating PTSD in the military⁶).

In policing, however, PMIEs can occur in the absence of actual or threatened violence, just as they can in health care.⁷ Accordingly, the symptom profile of someone suffering from moral injury can diverge from that of someone with PTSD (ie, moral injury can result from an event that does not meet the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for PTSD²). Furthermore, in the absence of violence or another potentially traumatizing event, it is more difficult to identify PMIEs. Lack of awareness of PMIEs and their impact on officers’ functioning extends from police leaders and supervisors to mental health professionals and the officers themselves. The result has been a lack of early intervention following PMIEs that occur without any violence. For example, although it is common for officers who are involved in a shooting to receive a post-incident debriefing at which questions about moral transgressions can be posed, other PMIEs that occur without violence typically receive no such debriefing. Instead, officers who develop moral injury from a PMIE in which there was no violence might experience symptoms that are not even temporally connected to the PMIE.

Types of PMIE

Before describing the symptom profiles of officers who suffer from moral injury, it is important to shed some light on PMIEs in law enforcement. Greater awareness of PMIEs would improve early intervention with officers who experience moral injury and help to prevent the significant decline in officers’ functioning that inevitably occurs when moral injury remains untreated. In addition to traditional PMIEs, which involve violence, police officers encounter a variety of other PMIEs. The following list has been adapted from Blumberg et al.⁸

1. Police officers can experience a moral injury when they are ordered to perform enforcement actions that run contrary to their moral values. For example, an officer might be ordered to relocate people who are experiencing homelessness.
2. Police officers can experience a moral injury when they observe the behavior of trusted colleagues or supervisors violating their moral beliefs.
   1. Such behavior includes a supervisor giving orders that officers view as morally wrong, which might result in officers losing respect for the supervisor, who is now seen as less morally upstanding.
   2. The behavior viewed as morally wrong can include policies and procedures of the organization as well as actions of command staff personnel who are not the officers’ direct supervisors, which might result in officers becoming disillusioned with their agency’s moral “compass.”
3. Police officers can experience a moral injury when they do something or fail to do something that violates their core values, which is independent of the orders of a supervisor.
   1. Such behavior can be committed intentionally, without thinking about the subsequent reactions that might be experienced. For example, due to a deliberately slow response to a radio call, the officer does not get to the scene in time to prevent a tragic outcome. Parenthetically, this behavior stems from other moral risks of policing, such as moral disengagement, which can lead to the behavior that results in moral injury.
   2. Such behavior also can be unavoidable due to circumstances beyond the officers’ control. For example, due to heavy traffic, the officer is not able to respond to a call in time to prevent a tragic outcome.
4. Police officers can experience a moral injury following a mistake. For example, due to choosing the wrong route, the officer is not able to respond to a call in time to prevent a tragic outcome.
5. Police officers can experience a moral injury due to a momentary lapse in judgment. For example, due to a traffic accident while speeding to the scene of a call, the officer is not able to get there in time to prevent a tragic outcome.

Whenever a police officer presents with symptoms of PTSD, it is vital to also assess for moral injury.

When a PMIE is experienced as a moral transgression, a moral injury has occurred. Such an injury causes officers to question the kind of person they are or the kind of person that a trusted colleague or supervisor is. Moral injury erodes confidence in one’s own or others’ character. A result can be an officer in crisis who begins to question their purpose and goals, allegiances, and personal relationships.

Symptom Profile

A moral injury manifests in 2 primary ways. Officers who perpetrate a moral transgression, whether through an act of commission or omission, might experience feelings of guilt, shame, remorse, and regret. Officers who experience a sense of betrayal from the moral transgression of a trusted colleague or supervisor might experience feelings of anger, disappointment, and disillusionment. Thus, treatment of moral injury must focus on these emotions and the concomitant cognitive, behavioral, social, and spiritual symptoms that such feelings engender. Unfortunately, early intervention poses a challenge, because signs of moral injury can be concealed, as some officers choose to suffer in silence. Therefore, rather than waiting for symptoms to become disruptive to officers’ functioning, it is imperative for officers as well as police leaders to learn about PMIEs and to implement a variety of preventative measures.

Preventing and Minimizing Moral Injury

Although police officers regularly encounter PMIEs and might experience a moral transgression from time to time, there are strategies that officers can utilize to minimize the impact of moral injury. These strategies should be introduced in police training and regularly reinforced during officers’ mandatory continuing education classes. They should also be modeled by supervisors and peer support members. Although beyond the scope of the present article, training and leadership are factors that can mitigate the impact of PMIEs. (These factors are described in considerable depth in Blumberg et al.⁸) Given the current climate of policing, it is especially important to consider budgeting for resources that would enable officers to navigate moral risks more confidently and successfully. In addition to this strategy for improving relations between communities and police, the following prevention measures should be utilized specifically by mental health professionals who work with police officers.

1. Showing self-compassion equates with being more self-accepting.⁹ Officers able to forgive themselves for a transgression are less likely to suffer long-term consequences associated with feelings of guilt and shame.
2. Making amends can assuage feelings of guilt. In law enforcement, amends might not be able to be made directly, due to impending legal proceedings or department policy. However, officers can donate time or money to a related cause as a form of restitution for their transgression. For example, if a “tragic outcome” involved an act of child abuse, the officer might volunteer at or donate to an emergency shelter for children who have experienced abuse.
3. Forgiving others can reduce feelings of anger associated with a sense of betrayal. If the moral transgression was committed by a colleague, the officer might consider having a discussion, expressing their feelings, and coming to a mutually agreeable decision about how similar situations could be avoided or prevented in the future. If the transgression was committed by a supervisor or higher-ranking member of the organization, the officer must weigh the potential consequences of reporting the behavior or discussing it with the transgressor. Although the sense of betrayal might remain whatever the officer chooses to do, the officer must find a way to let go of the anger.
4. Accurately apportioning blame goes hand in hand with accepting responsibility for one’s moral transgressions. Police officers can learn to accurately apportion blame because many PMIEs involve numerous people (eg, other officers on scene, supervisors, perpetrators, and civilians). Rather than irrationally thinking, for example, I am responsible for what happened, after recognizing that others played a part in an incident, a police officer can more rationally think, we messed up there. Accordingly, as Blumberg et al note, the intensity of officers’ “anger or guilt or frustration will decrease to more tolerable emotions like shared sadness, group remorse, or collective frustration.”¹⁰

Additionally, to minimize the most harmful outcomes, it is imperative for law enforcement agencies to bring moral injury to light. Police officers, like everyone else, make mistakes, including moral transgressions. Organizations with strong wellness and ethics cultures will address and normalize moral injury in policing during recruiting and hiring; academy, field, and continuing professional education training; supervisory and disciplinary efforts; and promotional practices.⁸ It is essential for police leaders to destigmatize moral injury and provide resources to address it.

Moral Injury Causes

A discussion of moral injury in policing is not complete without some attention to why moral transgressions occur in the first place. Moral injury not directly related to human error is best understood in the broader context of other moral risks of policing. These moral risks are prevalent in routine policing and take 2 converging paths: risks that increase the likelihood that officers will experience emotional and spiritual distress (eg, moral distress,¹¹ compassion fatigue,¹² and emotional exhaustion¹³) and risks that increase the likelihood that officers will engage in misconduct (eg, moral disengagement,¹⁴ moral compromise,¹⁵ moral licensing,¹⁶ and the slippery slope¹⁷). (For detailed descriptions of moral risks, see Blumberg et al.¹⁸) One result of police officers’ moral disengagement and emotional exhaustion is that they become vulnerable to ethical erosion. With their ethical values compromised, officers are more likely to commit moral transgressions and suffer moral injury.

Clinicians’ Roles

It is especially important for physicians and other health care professionals who work in the field with police officers to understand the complexities and subtleties of moral injury in policing. Knowledge of PMIEs provides an understanding of the context in which moral injuries occur. When working with police officers during a PMIE, clinicians can defuse an officer’s psychological reaction to what the officer perceives as a moral transgression (and, in some cases, the clinician can prevent the transgression from occurring). In such cases, it would be helpful to provide a supportive statement of awareness that the incident might have caused the officer to question himself or herself and to suggest how beneficial it might be for the officer to reach out to a member of the department’s peer support team or chaplaincy program. Clinicians should pay close attention when an officer experiences or expresses the following symptoms:

1. Excessive or inappropriate anger, which might be an indication of a prior betrayal by a trusted colleague or supervisor
2. Guilt, shame, regret, or other emotional experiences of moral injury
3. Dehumanizing behavior toward others, which conveys moral disengagement and increases the likelihood of a future moral transgression
4. Anxiety, depression, hopelessness, or powerlessness, which could lead to a future moral transgression¹⁹

No instrument is currently available to assess moral injury in police officers, although one is currently being validated (D. M. Blumberg, K. Papazoglou, M. D. Schlosser, unpublished data, 2021). When clinicians observe these symptoms, they should consider initiating a one-on-one conversation with a member of the command staff to discuss some intervention strategies.⁸

Finally, during a PMIE, all members of a tactical team are susceptible to moral injury. During a critical incident, everyone is capable of falling short of personal expectations, which could be experienced as a moral transgression; awareness of moral injury can mitigate its most harmful outcomes. However, it would be a mistake to assume that time alone can heal moral injuries. Tactical clinicians should seek support for their moral injury experiences.