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.

War zone veterans who experience posttraumatic stress disorder (PTSD) symptoms might struggle with co‐occurring cognitive, emotional, and behavioral expressions of suffering that align with conceptual definitions of moral injury (MI). However, given that PTSD is a multidimensional condition, disentangling the apparent interplay with MI may inform clinical practice and research. This study incorporated a cross‐lagged design to explore temporal associations between self‐ and other‐directed outcomes related to MI and severity of DSM‐5 PTSD symptom clusters while accounting for depressive symptoms. Drawing on the Expressions of Moral Injury Scale–Military Version in a community sample of 182 previously deployed veterans, MI‐related outcomes were linked with severity of PTSD symptom clusters at two assessments spaced apart by 6 months, rs = .58–.62. Of possible models for conceptualizing the temporal nature of these associations, structural equation modeling analyses revealed a cross‐lagged primary MI model best fit veterans’ responses. Within this model, veterans’ self‐directed MI at Time 1 predicted greater PTSD symptoms at the 6‐month follow‐up. However, an equivalent cross‐lagged path also emerged between Time 1 PTSD Cluster D symptoms and self‐directed MI at Time 2, suggesting the value of a reciprocal MI model for this symptom domain. In contrast, other‐directed outcomes of MI were not linked with PTSD in the presence of other variables. Overall, these findings support the prognostic value of assessing for MI‐related outcomes among veterans who might be struggling with PTSD symptomatology, particularly with respect to self‐directed problems associated with enduring moral distress.

Medical leaders have warned of the potential public health burden of a “parallel pandemic” faced by healthcare workers during the COVID-19 pandemic. These individuals may have experienced scenarios in which their moral code was violated resulting in potentially morally injurious events (PMIEs). In the present study, hierarchical linear modeling was utilized to examine the role of PMIEs on COVID-19 pandemic-related difficulties in psychosocial functioning among 211 healthcare providers (83% female, 89% White, and an average of 11.30 years in their healthcare profession [9.31]) over a 10-month span (May 2020 –March 2021). Reported exposure to PMIEs was associated with statistically significant poorer self-reported psychosocial functioning at baseline and over the course of 10-months of data collection. Within exploratory examinations of PMIE type, perceptions of transgressions by self or others (e.g., “I acted in ways that violated my own moral code or values”), but not perceived betrayal (e.g., “I feel betrayed by leaders who I once trusted”), was associated with poorer COVID-19 related psychosocial functioning (e.g., feeling connected to others, relationship with spouse or partner). Findings from this study speak to the importance of investing in intervention and prevention efforts to mitigate the consequences of exposure to PMIEs among healthcare providers. Interventions for healthcare providers targeting psychosocial functioning in the context of moral injury is an important area for future research.

Rates of suicide and posttraumatic stress disorder remain high among United States military personnel and veterans. Building upon prior work, we conducted a systematic review of research published from 2010 to 2018 regarding: (1) the prevalence of suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans diagnosed with posttraumatic stress disorder; (2) whether posttraumatic stress disorder was associated with suicidal ideation, suicide attempt, and suicide among United States military personnel and veterans. 2,106 titles and abstracts were screened, with 48 articles included. Overall risk of bias was generally high for studies on suicidal ideation or suicide attempt and low for studies on suicide. Across studies, rates of suicidal ideation, suicide attempt, and suicide widely varied based on study methodology and assessment approaches. Findings regarding the association between posttraumatic stress disorder diagnosis with suicidal ideation and suicide were generally mixed, and some studies reported that posttraumatic stress disorder was associated with lower risk for suicide. In contrast, most studies reported significant associations between posttraumatic stress disorder and suicide attempt. These findings suggest complex associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, which are likely influenced by other factors (e.g., psychiatric comorbidity). In addition, most samples were comprised of veterans, rather than military personnel. Further research is warranted to elucidate associations between posttraumatic stress disorder and suicidal ideation, suicide attempt, and suicide, including identification of moderators and mediators of this relationship. Addressing this among United States military personnel, by gender, and in relation to different trauma types is also necessary.