Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium

Abstract

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.

The Correlates of Abusive Violence Among Post-9/11 U.S. Military Veterans

“…The observed profile similarity between participation and observation is notable and may be indicative of shared, non-fear-based etiological pathways. One pertinent area of literature to this effect is moral injury (MI), which describes a pattern of psychosocial symptoms that may emerge following perpetration, observation, learning about, or victimization by acts of commission or omission that transgress deeply held moral beliefs and expectations (Litz et al, 2022). However, we caution against conflating the nomological network described here with that of MI.…”

Exploring the health and well-being of a national sample of U.K. treatment-seeking veterans.

“…Moral injury was measured using the Moral Injury Outcome Scale (MIOS; Litz et al, 2022). The scale is split into two sections: (a) a question about the presence of a potential moral injurious event (PMIE), and (b) a 14-item measure of symptoms associated with moral injury.…”

Policy Changes as a Context for Moral Injury Development in the Wake of Dobbs v Jackson Women's Health Organization

“…Moral injury results when efforts to manage moral distress cause an individual's life to narrow and lead to social, psychological, and spiritual suffering. 5–8 This suffering can manifest through a number of psychological symptoms (eg, suicidal ideation and behavior, symptoms of posttraumatic stress disorder and depression, substance use) and psychosocial functional impairment (eg, difficulties engaging in relationships, work, spirituality, self-care). 9–12…”

“…Moral injury results when efforts to manage moral distress cause an individual's life to narrow and lead to social, psychological, and spiritual suffering. [5][6][7][8] This suffering can manifest through a number of psychological symptoms (eg, suicidal ideation and behavior, symptoms of posttraumatic stress disorder and depression, substance use) and psychosocial functional impairment (eg, difficulties engaging in relationships, work, spirituality, self-care). [9][10][11][12] Exposure to potentially morally injurious events and negative psychosocial outcomes associated with moral injury have been demonstrated in health care professionals across contexts, including the COVID-19 pandemic, deployments to combat zones, and cases involving child protective services.…”