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Addressing moral injury in the military
  1. Andrea J Phelps1,
  2. A B Adler2,
  3. S A H Belanger3,4,
  4. C Bennett5,
  5. H Cramm6,
  6. L Dell1,
  7. D Fikretoglu7,
  8. D Forbes1,
  9. A Heber8,9,
  10. F Hosseiny10,
  11. J C Morganstein11,
  12. D Murphy12,13,
  13. A Nazarov9,14,15,
  14. D Pedlar4,6,
  15. J D Richardson14,15,
  16. N Sadler1,
  17. V Williamson16,17,
  18. N Greenberg13 and
  19. R Jetly18
  20. Members of the Five Eyes Mental Health Research and Innovation Collaborative
  1. 1Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
  2. 2Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
  3. 3Royal Military College of Canada, Kingston, Ontario, Canada
  4. 4Canadian Institute for Military and Veteran Health Research, Kingston, Ontario, Canada
  5. 5New Zealand Defence Force, Wellington, New Zealand
  6. 6School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
  7. 7Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
  8. 8Veterans Affairs Canada, Charottetown, Prince Edward Island, Canada
  9. 9Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
  10. 10Canadian Centre of Excellence on PTSD and Related Mental Health Conditions, Ottawa, Ontario, Canada
  11. 11Center for the Study of Traumatic Stress, Department of Psychiatry, School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
  12. 12Combat Stress, Leatherhead, UK
  13. 13King's Centre for Military Health Research, King's College London, London, UK
  14. 14MacDonald Franklin Operational Stress Injury Research Centre, Lawson Health Research Institute, London, Ontario, Canada
  15. 15Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
  16. 16Institute of Psychiatry Psychology, and Neuroscience, King's College London, London, UK
  17. 17Department of Experimental Psychology, University of Oxford, Oxford, UK
  18. 18Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Dr Andrea J Phelps, Psychiatry, University of Melbourne, Phoenix Australia Centre for Posttraumatic Mental Health, Carlton, Victoria, Australia; ajphelps{at}


Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one’s moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face.

  • Adult psychiatry

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  • NG and RJ are joint senior authors.

  • Twitter @HeidiCramm, @vwilliamson_psy

  • Contributors All authors contributed to the planning, conduct and reporting of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting true views of the US Department of the Army or the US Department of Defense or respective governments.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.