Exploring the invisible psychological injuries faced by military healthcare professionals and the path toward measurement, prevention, and care
Imagine for a moment that you're a military physician, trained to save lives, stationed in a combat zone. You've just stabilized a critically wounded soldier when two more arrive with equally grave injuries. You have only enough blood products for one. Protocol dictates you follow triage guidelines, but your oath compels you to save everyone. You make a choice—and live with the consequences.
While post-traumatic stress disorder (PTSD) has entered public consciousness, moral distress describes a different kind of psychological injury. It occurs not from fear for one's own safety, but from being unable to act according to one's core moral values due to external constraints. For military clinicians who swear both the Hippocratic Oath and a military oath, these ethical conflicts are particularly acute 1 . Recent research has begun to illuminate this hidden epidemic, developing new tools to measure it and novel approaches to help those affected heal.
Moral distress was first defined in nursing ethics in the 1980s as the psychological distress that arises when one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action . In military medicine, these constraints multiply exponentially: triage protocols, resource limitations, chain of command structures, and the inherent tension between military mission and medical ethics.
The concept has since evolved to include broader situations where healthcare professionals feel moral uncertainty or feel compelled to participate in acts that contradict their values 8 . What distinguishes moral distress from other forms of psychological distress is that it specifically threatens a person's core values and has ethical implications at its root 2 .
Though often mentioned together, moral distress and moral injury represent related but distinct concepts:
| Aspect | Moral Distress | Moral Injury |
|---|---|---|
| Definition | Knowing the right action but being constrained from taking it 5 | Psychological consequence of perceived moral violations 1 |
| Primary Context | Healthcare settings | Military combat (increasingly used in healthcare) |
| Temporal Nature | Often immediate reaction | Deeper, persistent wounds that interfere with daily life 1 |
| Core Experience | Frustration, powerlessness | Guilt, shame, betrayal, loss of meaning 1 |
| Common Symptoms | Anxiety, frustration, sleep disturbances | Persistent shame, social withdrawal, self-punishing behaviors 1 |
As Drs. Maguen and Norman explained in VA's PTSD Quarterly, both moral injury and PTSD start with a traumatic event, but they manifest differently. People with PTSD often startle easily or live in a state of constant vigilance—conditions less common among those with moral injury. Those with moral injury are more likely to experience persistent and profound feelings of guilt, shame, or betrayal 1 .
Military healthcare clinicians occupy a particularly challenging intersection—they are simultaneously caregivers and service members, which places them in situations where both moral distress and moral injury are applicable 5 . A military nurse might experience moral distress when required to return a stable patient to combat duty, knowing the psychological trauma this might cause, and then develop moral injury if that soldier subsequently dies by suicide.
For years, the subjective nature of moral distress made it difficult to study systematically. How does one quantify the weight of an impossible choice? The lack of validated tools hampered both research and clinical care, leaving many suffering in silence without appropriate support.
Early attempts to measure moral distress adapted general psychological instruments, but these failed to capture the unique ethical dimensions of the experience. Researchers recognized the need for a "gold-standard outcome measure" that would include both assessment of exposure to potentially morally injurious events and the moral emotions, cognitions, and behavioral consequences of these exposures 1 .
In 2023, a team of VA researchers led by Drs. Shira Maguen, Sonya Norman, and Brandon Griffin unveiled the Moral Injury and Distress Scale (MIDS), the first measure specifically designed to assess moral injury symptoms indexed to a specific event and validated across several high-risk populations, including Veterans, healthcare workers, and first responders 1 .
The power of MIDS lies in its two-stage design that mirrors the structure of moral injury itself. Part One consists of three items designed to determine whether a person was exposed to a potentially morally injurious event. If so, the person continues to Part Two, which consists of 18 questions that assess any cognitive, emotional, behavioral, social, or spiritual impacts experienced over the last month 1 .
3 items to determine exposure to potentially morally injurious events
18 questions assessing cognitive, emotional, behavioral, social, and spiritual impacts over the last month
Total score calculated with cutoff of 27 indicating clinically significant distress
The development of MIDS followed rigorous scientific protocols. The research team designed and validated the scale across multiple high-risk populations, including military Veterans, healthcare workers, and first responders 1 . This approach ensured the tool would be sensitive to the unique moral challenges faced by different professions.
The scale was rolled out in 2023 after extensive testing. Its simplicity allows for easy administration—it is self-administered and all items on Part Two can be summed into a single total score 1 . This practicality makes it suitable for both clinical settings and research studies.
The MIDS team established that a score of 27 or higher is associated with psychiatric and functional problems—and elevated risk for suicide—that can be addressed through further evaluation and treatment 1 . This critical cutoff provides clinicians with a clear indicator for when intervention is necessary.
In the two years since its introduction, the MIDS has been downloaded more than 28,000 times, demonstrating the tremendous need for such a tool 1 . The scale has been featured in VA's Clinician Trauma Update, which has 77,800 online subscribers, and a PTSD Quarterly article on moral injury by Drs. Maguen and Norman has been viewed nearly 70,000 times since the MIDS was introduced 1 .
| MIDS Score Range | Clinical Significance | Recommended Action |
|---|---|---|
| 0-26 | Minimal to mild moral distress | Routine monitoring |
| 27+ | Clinically significant moral distress | Further evaluation and potential intervention |
| N/A | Elevated suicide risk | Immediate assessment and safety planning |
The validation of MIDS has enabled the first robust studies of moral distress prevalence. In January 2025, the MIDS team published a report that established prevalence rates of clinically meaningful moral injury across three high-risk groups: military Veterans, healthcare workers, and first responders 1 . This groundbreaking research provides the foundation for targeted interventions.
Established prevalence rates for moral injury
Identified unique moral challenges in medical settings
Documented moral distress in emergency situations
Research into moral distress has identified several key resources that are essential for both studying and addressing this challenging condition:
| Resource/Tool | Function | Application in Military Medicine |
|---|---|---|
| Moral Injury and Distress Scale (MIDS) | Assesses exposure to morally injurious events and their impacts 1 | Screening and monitoring at deployment phases |
| Ethical Debriefing Sessions | Structured discussions of morally challenging cases 8 | Processing difficult decisions after trauma cases |
| Peer Support Programs | Shared experiences among colleagues 8 | Normalizing reactions to moral challenges |
| Measure of Moral Distress for Healthcare Professionals (MMD-HP) | Assesses frequency and intensity of moral distress 3 | Identifying systemic sources of moral distress |
| AboutFace Website | Veteran stories about PTSD and moral injury 1 | Reducing stigma, encouraging help-seeking |
The MIDS instrument itself represents a crucial "research reagent" that enables standardized measurement across studies and populations. Its validation across multiple groups allows for comparison between military and civilian healthcare workers, helping identify both universal and unique aspects of moral distress in military settings 1 .
Qualitative research methods, including interviews and free-text survey responses, have proven equally vital for understanding the nuanced experience of moral distress. As one study noted, "Using a single quantitative measure cannot fully explain what might be underlying a participant's responses," suggesting the need for mixed-methods approaches 6 .
Standardized tools like MIDS enable consistent evaluation of moral distress across different military healthcare settings.
Structured peer support programs help normalize experiences and reduce isolation among affected clinicians.
Training materials and ethical frameworks prepare military clinicians for moral challenges they may face.
Research has identified several effective coping strategies that healthcare professionals use to manage moral distress. A 2025 qualitative study identified eight primary strategies: Reframing the situation, Trying to modify the situation, Limiting own involvement, Tolerating the situation, Meeting and sharing with colleagues, Rejecting and withdrawing from the situation, Searching for alternative actions, and Venting 8 .
Typically, healthcare professionals use more than one strategy (mean = 4.1) and recount learning and adapting strategies over time 8 . This suggests that building a diverse toolkit of coping mechanisms may be more effective than relying on a single approach.
Addressing moral distress requires more than individual resilience—it demands systemic change. The National Academies of Sciences, Engineering, and Medicine has emphasized that improving clinician well-being "will require multilevel and multifaceted approaches that address their physical, mental, moral, and social health and create safe, supportive, and ethically grounded environments" 6 .
Successful organizational approaches include:
The development of reliable measurement tools like MIDS opens the door to targeted interventions and preventive strategies. By identifying those at risk early, support can be provided before moral distress evolves into more entrenched moral injury 1 .
The research conducted during the COVID-19 pandemic provided unexpected insights into moral distress as a collective experience rather than solely an individual one. Studies found that moral distress was relationally experienced by healthcare workers 7 . This understanding suggests that interventions should harness collective solidarity rather than only focusing on individual psychological responses.
Using validated tools to detect moral distress before it becomes severe
Implementing organizational changes to reduce moral challenges
Establishing peer networks and professional support resources
Regular assessment of intervention effectiveness and adjustment
The recognition and systematic study of moral distress in military medicine represents a critical advancement in caring for those who care for others in impossible circumstances. As research continues to refine our understanding of this complex phenomenon, we move closer to a future where military healthcare clinicians receive as much support for their ethical wounds as they do for their physical ones.
What remains clear is that the courage to face impossible choices deserves equal courage in addressing their consequences—through rigorous science, compassionate care, and institutional responsibility. The path forward requires acknowledging that healing moral wounds is not just an individual responsibility but a collective one, demanding systemic changes that support ethical practice in even the most challenging circumstances.