Moral injury and suicide

Moral injury refers to the biological, psychological, social, spiritual and emotional distress an individual experiences when they perpetrate, fail to prevent, or witness actions that conflict with their deeply held moral beliefs or values. This concept is particularly relevant in military contexts, where personnel often face high-stakes situations involving harm to others, moral compromise, or can experience feelings of betrayal by trusted leaders or institutions.^1,2 Unlike post-traumatic stress disorder (PTSD), moral injury centres on feelings of guilt, shame, and a disruption in one’s moral framework rather than a fear-based response and activates different regions of the brain (amygdala vs prefrontal cortex).

Moral injury can exacerbate suicide risk by fostering a profound sense of guilt, shame, self-condemnation and/or worthlessness, which undermines self-worth and social connection which are key protective factors against suicidality. Serving and ex-serving personnel may struggle with unresolved inner conflict, isolation, and stigma, making them less likely to seek help. Jamieson et al. (2020) highlight that moral injury contributes uniquely to suicidality, separate from PTSD, by intensifying existential despair and disconnection from meaning or purpose.²

We know suicide is complex and multifaceted and requires a multifaceted response.

Reducing suicide risk requires:

• Targeted interventions: Developing programs that specifically address moral injury, such as Acceptance and Commitment Therapy (ACT), Adaptive Disclosure and or spiritually integrated therapies for instance Pastoral Narrative Disclosure, which foster meaning-making and moral repair.²
• Peer support: Leveraging lived experience networks to provide a safe space for shared understanding and validation.
• Organisational transparency and accountability: Promoting ethical leadership and transparent decision-making to prevent institutional betrayal for instance.
• Early screening and support: Incorporating evidence based moral injury screening tools and assessments into routine mental health evaluations for Defence personnel. It would also be useful to see a moral injury framework developed that considers how we understand individual moral frameworks for recruitment so we can match the right people to right roles and reduce the risk of moral injury occurring.

Further research should explore:

• Cultural and contextual factors: Examining how moral injury manifests across different military and cultural settings, particularly underrepresented and or more vulnerable groups.²
• Intervention efficacy: Longitudinal studies evaluating the effectiveness of therapies specifically designed for moral injury to inform clinical best practices.
• Intersection with organisational betrayal: Investigating how institutions contribute to moral injury and subsequent suicidality, to drive systemic reforms.
• Intersection with workplace psychosocial risks and hazards: Exploring how psychosocial risk or hazard intersects with moral injury and approaches for risk or hazard minimisation.
• Neurobiological mechanisms: Understanding the biological underpinnings of moral injury to identify novel biomarkers and treatment targets.

This research is essential to advance tailored, evidence-based interventions and ensure comprehensive care for serving and ex-serving personnel.