The original understanding of moral injury was developed in the 1990s by a psychiatrist working with military veterans, Jonathan Shay. Moral injury is caused by a threat to one’s morality, such as harming an innocent bystander or destroying civilian livelihoods, as well as by a failure to prevent harm to others and by observing betrayal by leadership in high-stakes situations. While its causes and manifestations may sometimes overlap with PTSD, moral injury is different in its connection to morality and ethics rather than survival.
The study of moral injury was soon adopted in healthcare, teaching, law enforcement, and other workplace contexts where individuals might be charged with providing significant benefits to others but are not always able to deliver such benefits due to structural, resources, or workload limitations, and may in fact cause harm instead. In addition, leadership failures resulting in inferior services and harm to employees also play a role in developing a moral injury.
However, most jobs have the potential to inflict harm on individuals. For example, a customer service representative who uses scripts designed to manipulate and psychologically pressure vulnerable customers to pay for unnecessary, overpriced, or potentially harmful products and services can also experience moral distress. Due to the cumulative nature of stress, these moral distress experiences can add up to a moral injury that may cause an individual to be unable to continue their employment.
Recently, I proposed that moral injury across occupations can be defined as a “trauma response to witnessing or participating in workplace behaviors that contradict one’s moral beliefs in high-stakes situations with the potential of physical, psychological, social, or economic harm to others.” It is important to emphasize that while the experience of distress is subjective, focusing on high-stakes situations and significant harm helps preserve the gravity of the concept and the respect to its military, life-and-death roots.
Not all workplace negative emotion is moral injury.
When in doubt, it is helpful to apply the “significant harm to others” test. For example, while a new dental assistant may experience a negative emotion when working with distressed patients, if the assistant is following the standards of proper care and the ultimate aim of treatment is the long-term patient benefit rather than harm, there is no moral injury. However, if the assistant is pressured into using inferior tools and materials and into violating the standards of care, then the patients, upset or not, might indeed be subject to harm, and the worker to a moral injury.
Injurious events are typically seen as falling into three categories:
1) Transgressions by others, including managers, coworkers, or clients (e.g., the dental practice owner using inferior materials to save the cost).
2) Transgressions individuals committed themselves (e.g., the dental assistant participating in inferior care practices).
3) Betrayal—feeling that managers, colleagues, or policymakers had betrayed occupational values, employees, or clients/customers/students/patients. For example, the dental practice owner might betray professional standards, and possibly even attempt to put the blame on individual employees if there is a complaint.
The experience of witnessing and participating in a moral transgression may result in a range of intense feelings such as the generally internalized grief, anxiety, guilt, shame, and disgust, or more often externalized anger. The key differentiating aspect between moral injury and PTSD is the specific focus on damage to one’s sense of morality and trust. Individuals may also develop physical illness or a range of self-harming behaviors. Those who experience workplace moral injury are also likely to disengage at work, quit, or become too physically or emotionally ill to continue working.
Moral injury and neurodiversity.
Many adult-diagnosed neurodivergent individuals report workplace burnout as a catalyst event that made them search for a diagnosis. As one of these individuals, I wonder if for many of us moral injury is a better explanation of the experience we might have attributed to burnout or autistic burnout. It certainly was for me.
Is there research evidence that may suggest that autistic, and more generally neurodivergent individuals might be at higher risk for developing a workplace moral injury? At least two research-supported lines of reasoning suggest that this might be the case.
Autistic people and the sense of justice. Research indicates that autistic individuals are more likely than allistics to consistently follow moral rules, regardless of whether they are acting privately or publicly, even if “an immoral action can benefit themselves, and experience an increased concern about their ill-gotten gains and the moral cost.” Although initially misinterpreted from the perspective of the autistic deficit, this experimental study provides evidence that autistic people are highly concerned with doing the right thing and are distressed by violating their moral principles, as demonstrated by their refusal to monetarily benefit themselves by supporting a bad cause, whether in public or in private. Allistics, on the other hand, were more likely to benefit themselves by supporting a bad cause while acting privately.
It is logical to suggest that individuals with increased concern over the moral cost of their actions will be more susceptible to moral injury. Lived experience accounts from a Twitter thread on the topic suggest that the potential of doing harm to others as part of the job can prevent autistic individuals from taking certain types of jobs in the first place and increase their likelihood of developing a moral injury.
Cumulative trauma as a sensitization factor. Cumulative psychological trauma exposure is documented to be much higher in autistic individuals than in general population. Such exposure has the potential to sensitize or make individuals statistically more vulnerable to distress in subsequent potentially traumatic situations (although such vulnerability is a statistical probability rather than a certainty in each individual case). Repeated trauma exposure is also likely to be experienced by other neurodivergent populations. Moreover, neurodivergent populations with sensory sensitivities also experience regular sensory-trauma. Childhood and adult bullying, workplace discrimination, and the minority stress overall are likely to create complex mental wellness vulnerabilities.
Additionally, for many neurodivergent individuals, dealing with schools, workplaces, and even social support services adds up to the experience of constant betrayal. The sense of repeated betrayal by institutions (e.g., public education; employers who tout neurodiversity hiring programs yet, upon closer look, seek to exploit a narrow segment of talent at lower rates of pay) is often reported in accounts of neurodivergent lived experience. Cumulatively, these experiences may create a betrayal vigilance in addition to the general physiological vigilance, and further sensitize individuals to moral injury.
What should responsible organizations do?
Responsible organizations interested in neurodiversity hiring and providing an inclusive work environment must take preventative measures to minimize the risk of moral injury for all employees by guaranteeing ethical organizational operations. In addition, when working with neurodivergent populations, an extra care must be taken to ensure clear and unambiguous, multichannel communication, transparency, and psychological safety. Multiple channels for asking questions and providing input (in-person, via web forms, via third parties to ensure anonymity) and clear organizational responses to any issues are crucial for building and restoring trust.
Restorative organizational practices may also include an inventory by neurodivergent employees of all practices that may, intentionally or not, create the potential for moral injury. Examples of such practices are exclusion, infantilization, segregation, under-resourcing, silencing, or otherwise inconsistent treatment of different employee or client populations. Rectifying such practices is essential to rebuilding trust.
As an integrated solution, trauma-informed organizational practices and inclusion by design are likely to support the needs of employees regardless of neurotypes.
What can individuals do?
Dealing with moral injury depends on specifics of the situation, one’s overall health and mental health, and psychological and economic resources. Some individuals might be able to effectively cope by using self-care, others may need community or professional mental health support. In my case, multiple experiences of workplace moral injury contributed to significant distress over the years, yet also resulted in a post-traumatic growth. The latter was largely facilitated by interactions with the community, activism, and working to accelerate organizational change to reduce the incidents of moral injury. I will address coping, healing, and post-traumatic growth in the context of moral injury and neurodiversity in the next installment.
Individuals or organizations interested in participating in the next phase of my research project on workplace moral injury and disillusionment can sign up here. You may also use this form to submit confidential comments on this article.