Introduction

Amidst the narrative of today’s serving personnel (whether military or civilian), an invisible and ancient ‘wound’ seems to be re-emerging and becoming more widely understood. Known as ‘moral injury’ (MI) and often accompanied by, or possibly masked by, a diagnosis of post-traumatic stress disorder, it has in recent years been empirically studied and attempted to be pathologized by psychiatrists and psychologists alike, predominantly relegating its previous names such as ‘moral sin’, ‘moral pain’ or ‘spiritual injury’, into the annals of history.

It has been argued that a ‘moral injury’ (however it is defined) may not be a ‘wound’ exacerbated by psychological fear, but rather an injury to the soul, affected by ‘loss or shame, guilt or regret’ (Dokoupil 2012). Indeed, moral injury may be more closely related to an existential wound of lament where one’s morality is dissected by the destructive impact of war or other traumatic events to such an extent that a person’s integrity, morality and/or spiritual well-being may no longer be what it once was. There is, however, a degree of uncertainty as to what exactly causes and constitutes a ‘moral injury’. Since the inception of the term ‘moral injury’ over a decade ago, there have been a multiplicity of definitions and (perhaps understandably) there is still no precise delineation agreed upon (Phelps et al. 2015; Beard 2015, p. 125).

Unfortunately it is not possible to simply delineate that all the differing approaches to defining moral injury are purely based on specific professional backgrounds or clinical experiences. While it is not the purpose of this paper to trace the intellectual history of moral injury (as other texts have presented; refer Shay 2002; Sherman 2015; Frame 2015), it does appear that some professionals (e.g. psychiatrists, social workers, historians, theologians, chaplains, military and veteran organizations), for reasons which they have not always explained, prefer to use and define the term moral injury without acknowledging the dynamics of ‘betrayal’ or ‘spirituality’ or both, while other researchers (irrespective of professional background) have been inclusive of such factors.

Building on the previous literature regarding Moral Injury, Spiritual Care and the role of Chaplains (Carey et al. 2016a, b)—which are recommended pre-reading for JORH readers newly entering the field—the intent of this paper is to undertake an overview of (i) a number of key definitions that have developed in an attempt to explain moral injury, (ii) consider the place of ‘betrayal’ and ‘spirituality’ (if any) with regard to moral injury and (iii) briefly consider the potential role of chaplains to assist those who may be suffering moral injury.

Moral Injury

The first contemporary usage of the term ‘moral injury’ was provided by the psychiatrist Jonathan Shay (2002) in his book, ‘Odysseus in America: Combat trauma and the trials of homecoming’. Shay defined ‘moral injury’ as when, ‘there has been a betrayal of what’s right, by someone who holds legitimate authority, in a high-stakes situation’ (Shay 2002 p. 240). It is important to note that Shay’s definition emphasizes the failure of ‘legitimate authority’ (i.e. those in leadership or command), not the failure of the individual who may or may not have acted in any particular moral or immoral way.

Shay’s earlier work ‘Achilles in Vietnam: Combat trauma and the undoing of character’ (Shay 1994) in conjunction with his later work ‘Odysseus in America’ (Shay 2002) articulates the experience of trauma caused by war through his exploration of the ancient Grecian narratives of Achilles and Odysseus—noting how the existential wounds of war (moral injury) can cause the negative transformation of one’s being and sense of virtue. Achilles and Odysseus for Shay epitomize the potential destruction that moral injury can do to a person’s inner being by being betrayed by comrades and/or commanders (Shay 2002, p. 141, 243). Within these Grecian narratives, a number of moral injury factors can be discerned—namely the receiving and carrying out of authorized yet immoral orders, and the subsequent witnessing of the horrors of war and suffering, and finally the ‘broken self’ caused by the betrayal of one’s morals by others and/or one’s self (Wilson 2014 p. 59).

Alternative Definitions

Numerous attempts to define and redefine the term ‘moral injury’ have occurred over recent years. For example, Nash et al. (2010), while noting moral injury can be caused by ‘betrayals of trust in leadership’, broadened Shay’s definition to include ‘stress resulting from witnessing or perpetrating acts or failures to act that transgress deeply held, communally shared moral belies and expectations’ (refer Table 1). Other researchers in developing their own definition of moral injury have tended to placate leadership malpractice and/or the role of the chain of command in causing moral injury to veterans. These researchers have commandeered Shay’s term ‘moral injury’ and refocused its scope away from those of ‘legitimate authority’ to focusing specifically upon the behaviour of the individual—who may or may not be impacted by leadership or organizational decisions. Whether deliberate or unintentional, diminishing the responsibility of organizational leadership, can subsequently minimalize and undervalue the sense of betrayal perceived by current and former serving personnel and effectively exonerated corporate culpability and the liability of organizations with respect to moral injury.

Table 1 Examples of moral injury definitions in chronological ordera,b
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This is evident, for example, by Litz et al. (2009) who developed and utilized a neo-definition of moral injury (refer Table 1) to argue that the symptoms of guilt and shame, which are indicative of moral injury, occur when individuals have been ‘…perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’. Though Litz acknowledged that ‘betrayal has emerged as an important theme’, both within moral injury research and in clinical practice, nevertheless Litz et al.’s (2009) definition altered the original definition of moral injury to emphasize individual or personal transgression (of one kind or another), rather than explicitly acknowledging ‘betrayal’ by organizations or corporate culpability as a real or potential cause of an individual’s cognitive dissonance and stress. The subsequent literature indicates that a number of researcher’s definitions regarding moral injury have seemingly followed Litz et al.’s pattern—avoiding the use of the term ‘betrayal’ and emphasizing individual responsibility but with little explanation as to why (e.g. Nash et al. 2010; Boudreau 2010; Vargas 2012; McCarthy 2016).

Interestingly some researchers and organizations have rejected the term moral injury outright. For example, while the US Department of Veteran Affairs (USDVA 2009; refer Table 1) endorsed their definition based on Litz et al. (2009), in contrast the US Navy and Marine Corps (USMC 2010) totally rejected the term ‘moral injury’ and endorsed the term ‘inner conflict’ or ‘inner conflict stress injury’, defining it as ‘stress arising due to moral damage from carrying out or bearing witness to acts, or failure to act, that violate deeply held belief systems’. According to Nash et al. (2013), the Navy’s preferred use of the term ‘inner conflict’ was because some within the US Navy Department perceived ‘moral injury’ to be a ‘pejorative’ termFootnote 1 (Nash et al. 2013, p. 647). Nevertheless, in essence, the definition of ‘inner conflict’ (while also avoiding terms relating to authoritative or corporate responsibility and culpability), still emphasized the ‘moral damage’ done to the individual, plus it can be argued that the term ‘inner conflict’ is primarily a modification ‘in name only’, as the definition of ‘inner conflict’ is still very similar to Litz et al.’s (2009) definition of moral injury (refer Table 1).

Holistic Definition

What should be noted, however, about Litz et al.’s (2009) definition (and particularly relevant for this article), is the definitional prelude ‘…the lasting psychological, biological, spiritual, behavioral and social impact’ of moral injury (refer Table 1). Whereas many researchers and authors utilize a twentieth century ‘biomedical-psycho-social’ model as their frame of reference, it is Litz et al. (2009) who defines moral injury in a more contemporary holistic ‘bio-psycho-social-spiritual’ paradigm (Sulmasy 2002). Other authors and researchers have also taken this approach, noting issues of existential and/or spiritual well-being (e.g. Drescher et al. 2011; Nash et al. 2010).

Likewise Brock and Lettini’s (2011) definition from a theological perspective, in their work ‘How do we repair the souls of those returning from Iraq’, argues that ‘…moral injury is a wound in the soul,Footnote 2 an inner conflict based on a moral evaluation of having inflicted or witnessed harm…it can also involve feeling betrayed by persons in authority’ (refer Table 1). Another moral theologian, also a psychiatrist, Kinghorn (2012) in ‘Combat trauma and moral fragmentation’, defines moral injury as ‘the experience of having acted (or consented to others acting) incommensurably with one’s most deeply held moral conceptions’ (p. 57) (refer Table 1). It is important to note that while Kinghorn does not specify ‘legitimate authority’ as part of his definition, Kinghorn acknowledges Shay’s definition as being closely tied, not to the individual actions of a soldier, but to the failure of military leadership, and thus, his phrase ‘consenting to others acting’ is intended to be inclusive of those in legitimate authority who command the actions of others that can lead to a morally injurious event. Fundamentally, Kinghorn also takes a holistic approach recognizing the place of medical, psychological and social paradigms, but he emphasizes the moral significance of the veteran’s experience and the important part that faith communities can have to facilitate the healing of morally injured veterans.

Drescher et al.’s research (2011) with mental health workers and clergy considered the construct of ‘moral injury’. Drescher et al.’s (2011) moral injury definition (refer Table 1) used for their research found that the concept of ‘moral injury’ was strongly endorsed; however, Drescher et al. concluded that there was a need for a simple definition that veterans could understand that would incorporate examples. While one could spend time arguing that Drescher et al.’s definition was no more or less complicated than the alternatives, nevertheless Drescher et al.’s results identified several key moral injury events affecting veterans (including ‘betrayal’), plus various signs and symptoms of moral injury (i.e. social, mental, spiritual/existential, trust and self-deprecation) and suggested several direct interventions (which included spiritual interventions) (refer Table 2).

Table 2 Moral injury events, signs/symptoms and interventionsa
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Diplomacy

It can be argued that in recent years some researchers have deliberately used Litz et al.’s (2009) clinical description of moral injury to exclude Shay’s political and somewhat controversial consideration of ‘betrayal’ as being caused by legitimate authorities. This exclusion, however, has limited their research surveys or interview protocols, and subsequently their research findings (e.g. McCarthy 2016). Beard (2015) argues that in fact both Shay’s and Litz’s definitions have ‘much in common’. Beard developed his own working definition of moral injury which appears to be somewhat of a compromise between Shay and Litz et al.’s definition (refer Table 1).

Several supposed definitions have also sought to navigate the maze of understandings about moral injury by attempting to be neutral in emphasis focusing more on the effects of moral injury rather than actually providing a decisive definition (e.g. Sherman 2015; Zust 2015; Neilson 2015) (refer Table 1). One exception to this is Forbes et al. (2015) who (like others) paraphrased Litz et al.’s (2009) definition, but failed to note Litz’s prelude (i.e. moral injury having a ‘…lasting psychological, biological, spiritual, behavioral and social impact’) and (like others) failed to mention ‘betrayal’. Interestingly, however, while Forbes et al.’s definition argues that MI is a ‘psychological state’, nevertheless they assert that the treatment of moral injury requires a multidisciplinary approach that, along with social interventions, should include spiritual and religious interventions (Forbes et al. 2015, p. 14).

Carey et al. (2016b)—in recognition of the original and organizationally focused definition of moral injury by Shay (2002), plus Litz et al.’s more specific and clinical definition focusing on the individual (2009)—collated a compromise definition by proposing two types of ‘moral injury’, namely that which (i) ‘originates at the individual level’ and (ii) that which ‘originates at the organizational level’ (refer Table 1). The use of this collated definition which drew solely upon Shay’s and Litz et al.’s definition, suggests that individual and organizational factors can separately and/or jointly lead to moral injury. While Carey et al. sought to be inclusive of both types of moral injury, it is unfortunate that they did not explicitly acknowledge, as part of their definition, a ‘bio-psycho-social-spiritual’ paradigm as did Litz et al. (2009). Nevertheless, an overarching argument of Carey et al.’s paper was exactly that—the importance of a bio-psycho-social-spiritual model (Sulmasy 2002) for understanding moral injury and particularly for addressing the spiritual well-being of veterans—something which they argue can be facilitated by adopting a multidisciplinary approach whereby health professionals ‘work closely alongside chaplains’ to help those who may be experiencing MI (Carey et al. 2016b, p. 1236).

More recently, Litz (2016) revised his definition of moral injury clearly delineating that there are two main types of moral injury—namely (i) ‘perpetration-based moral injury’ (resulting in shame and grief) and (ii) ‘betrayal-based moral injury’ (leading to anger). This revised definition reiterates Shay’s findings regarding the dynamic of ‘betrayal’ and reasserts those advocating for a more complex understanding of moral injury (e.g. Brock and Lettini 2011; Carey et al. 2016b; refer Table 1). For Litz (2016), both forms of moral injury (perpetration and betrayal) can lead to PTSD. It is not, however, the purpose of this paper to discuss the differences or possible development between PTSD and moral injury—this would require another paper.

Unfortunately there is not sufficient space within this paper to consider all the various definitions of moral injury. Perhaps, however, the most currently comprehensive and seemingly practical/useful definition of moral injury is that formulated by Jinkerson (2016) based on his thorough review of previous research regarding (a) ‘potentially moral injurious events’, (b) the ‘incidence of moral injury’ (or ‘prevalence’ of moral injury), (c) empirically described ‘moral injury symptoms’ (based on expert opinion derived from quantitative and qualitative evidence) and (d) the ‘distinction’ and/or similarity of moral injury to PTSD. Jinkerson summarizes and defines moral injury as:

Phenomenologically, moral injury represents a particular trauma syndrome including psychological, existential, behavioral, and interpersonal issues that emerge following perceived violations of deep moral beliefs by oneself or trusted individuals (i.e., morally injurious experiences). These experiences cause significant moral dissonance, which if unresolved, leads to the development of its core symptoms: (a) guilt, (b) shame, (c) spiritual/existential conflict including subjective loss of meaning in life (or questioning of meaning in life), and (d) a loss of trust in self, others, and/or transcendental/ultimate beings. Its secondary symptomatic features include (a) depression, (b) anxiety, (c) anger, (d) re-experiencing of the moral conflict, (e) self-harm (i.e., suicidal ideation/behavior, substance abuse, self-sabotage), and (f) social problems (e.g., social alienation, other interpersonal difficulty). It is likely that core symptomatic features influence the development of secondary symptomatic features (Jinkerson 2016, p. 126).

Jinkerson notes that it is still premature to suggest diagnostic criteria for moral injury; nevertheless, he clearly asserts that for moral injury to be identified and assessed, the following criteria must be present: (a) history of moral injurious event/exposure, (b) guilt and (c) at least two additional symptoms, which may be from either the core or secondary symptomatic lists. Jinkerson argues that such a syndrome definition ‘honours existing treatment models by emphasising the theoretical and empirical centrality of guilt ….and catalyze[s] efforts and empower[s] clinicians, clergy and communities to recognise moral injury for what it is: a terrible perversion of the naturel guilt process…’ (p. 128). While Jinkerson’s definition seems to be the most ample thus far and clearly acknowledges spirituality and ‘violations by trusted individuals’, nevertheless it fails to specifically note the term ‘betrayal’—which would, if specified, clearly associate authoritative responsibility and which was fundamentally foundational to the development of ‘moral injury’ (Shay 2002).

Summary

In essence, what has so far been noted is, firstly, an overview of the transitional development of the term ‘moral injury’ (particularly the flux with regard to specifically noting ‘betrayal’ as a primary component of moral injury) and that moral injury (while arguably an ancient phenomena) is a construct that is ‘relatively new and evolving’ (Nash et al. 2013, p. 647). Thus, an understanding of moral injury is considered to be still in its infancy (or perhaps more accurately ‘adolescence’) requiring a ‘validation process’ to finalize a definition (Kraus 2013, p. x).

Secondly, whether moral injury is caused by ‘betrayal’ (military leadership/chain of command) or ‘perpetration’ (individual/collective) or a combination of both, it can be argued that either element alone (‘omnino solus’) would be too narrow to define moral injury given its complexity. Thirdly, during the semantic transition of alternative definitions and compromise, the more holistic emphasis of the ‘lasting psychological, biological, spiritual, behavioral and social impact’ of moral injury noted by Litz et al.’s definition (2009) has become somewhat buried—particularly, we would argue, the spiritual and/or religious component.

Moral Injury and Spirituality

As noted earlier, previous attention has been given with JORH to moral injury, spirituality and the role of chaplains (Carey et al. 2016a). While ‘religion’ can be fundamentally defined as an institutionalized expression of a theologically systematic and formalized ‘spirituality’, the meaning of ‘spirituality’ itself is not so dogmatized. The first consensus definition of spirituality indicated something of its all-encompassing gambit namely, ‘…spirituality is that aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to self, to others, to nature, and to the significant or sacred’ (Puchalski et al. 2009).Footnote 3 The link between spirituality and moral injury has in some cases been ignored or undervalued while a number of other researchers have identified its relevance. For example, Kopacz et al. summarized that while moral injury is not inherently a spiritual construct, nevertheless:

An amassing base of empirical findings suggest that spirituality can factor prominently in service members experiences of MI. Most notably, research has documented that problems with forgiveness—of self and others—as well as apprehension of being forgiven by God or the divine—are frequently associated with worse mental health symptoms’ (Kopacz et al. 2016, p. 30).

Likewise Maguen and Litz (2012) stated that while ‘religious and spiritual causes and consequences of moral injury are complex and need to be [further] explored’, they acknowledged that ‘…religion and spirituality are critical components of moral injury’ because of the influence [these] have on pre-existing moral understandings held by individuals (Maguen and Litz 2012, p. 2). As noted by several researchers, these pre-existing moral understandings are fundamentally affected when service members ‘violate’ their own core beliefs and subsequently engage in self-condemning behaviours as they no longer consider themselves to be morally upstanding humans, and their place in the world seems no longer to be stable or meaningful (Brock and Lettini 2012, p. xv; Neilson 2015, p. 138).

Drescher et al.’s (2011) research (noted earlier) categorized a number of morally injurious events, their signs and symptoms arising from direct and indirect combat experiences leading to moral injury—namely betrayal, disproportionate violence, incidents involving civilians and within rank violence (refer Table 2). Kopacz noted that such experiences can lead to ‘an inner struggle or challenges for reconciling certain experiences with personal interpretations of right and wrong: self-condemnation, despair, shame, difficulty forgiving, reduced trust, aggression, poor self-care, self-harm, discord, guilt, lack of meaning in life and internal conflict’ (Kopacz et al. 2016, p. 30). For Drescher, the appropriate interventions are multifaceted and holistic (i.e. individually directed, socially directed and spiritually directed).

Theological Perspectives

It is important to note, as does Fritts (2013), that there is a bioethical dilemma for the military and its members. Military forces want combatants who are ready and able to kill the adversary, while at the same time to be moral. According to Fritts, this creates the conditions for a service member to experience moral injury, which occurs when they start to question the mandatory action of killing, or having killed, another person. Fritts contends, from a moral theological perspective, that ‘moral’ injury is basically a ‘psychologically descriptive label for the normative problem of sin’ (p. 1) which is ‘an offense against religious or moral law’ (Fritts 2013, p. 4). Thus, for example, those who break God’s commandment ‘thou shall not kill/murder’ (Exodus 20:13) (which is also a natural law and accepted social norm) will result in them questioning and self-challenging their moral belief that life is sacred. According to Kruger, an individual’s core beliefs are sometimes unable to re-adjust in the aftermath of a traumatic moral event simply because at times they cannot accommodate or contextualize the morally injurious experience within their pre-existing understanding of morality. Kruger argues that this incongruence between the individual’s internal and external worlds given a morally injurious event can create considerable psychological distress (Kruger 2014, p. 136).

Winright’s (2015) work notes, however, that moral injury is too often couched in purely psychological and/or cognitive terms, rather than within a philosophical or theological paradigm, and subsequently, moral injury has been boxed within the therapeutic or clinical realm, instead of the spiritual or pastoral. A further key writer along this argument is Kinghorn (2012; noted earlier), who argues that the treatment of moral injury should move beyond the constraining structures of psychology to that of moral theology. Further, Kinghorn believes that responding to moral injury should be through ‘specific communal practices’ rather than a ‘medical model’, so as to allow for an honest and real narration and recovery from moral injury experiences. Fundamentally, the problem that Kinghorn alludes to is that the ‘medical model’ is restricted from stepping outside ‘psychological and cognitive terms’ which ultimately fails to do justice for anyone, as morality is deeper than these constructs (p. 57), whereas it can be argued that clergy/chaplains utilizing a bio-psycho-social-spiritual model can understand and implement a more holistic approach as required.

Antal and Winings (2015) argue that moral injury needs to move beyond the clinical construct to a holistic paradigm. Consideration of the ideas of ‘sin, evil and redemption’ extend beyond a limited medical construct, into a holistic dimension that can also draw upon the richness of theological and pastoral traditions (Antal and Winings 2015, p. 386). Kinghorn acknowledges that the current clinical construct of moral injury is important and useful, but moral injury is a ‘phenomenon’ that ‘beckons beyond the structural constraints of contemporary psychology towards something like moral theology’ or ‘penitential theology’ (2012, p. 57, 62). Interestingly Antal and Winings (2015) discuss the need to explore the locution of ‘sin’ and to be quite honest about what the theologian Verkamp describes as ‘recovering a sense of sin’ (Verkamp 1983, p. 305). In this vain, it is Fritts when critiquing the psychological approach of adaptive disclosure for treating moral injury best summarizes a holistic interconnection of paradigms:

Moral injury results from the transgression of core moral beliefs; it is also the result of sin. A morally injured soldier is a patient; he or she is also a penitent. Successive narrative exposures of the morally injured soldier’s transgression are a modified cognitive behavioural therapy (CBT) process of extinction; they are also confession. Dialogue between the morally injured soldier and an imaginary, benevolent moral authority produces forgiveness-related content; it is also absolution. But a therapist is usually not also a priest, and a chaplain is usually not also a behavioural scientist. For the sake of healing morally injured soldiers, science and faith need each other (Fritts 2013, p. 30).

Chaplains and Community Clergy

Antal and Winings (2015) argue that health professionals alone ‘cannot adequately address’ the issue of moral injury and thus need to recognize the importance of connecting with clergy and religious communities for insights and support (Antal and Winings 2015, p. 383). Indeed, Shay went one step further by suggesting that ‘religious and cultural therapies are not only possible, but may well be superior to what mental health professionals can eventually offer’ (Shay 2002, p. 152). Likewise, Koenig et al. (2017) noted that ‘a number of studies utilizing patients spiritual beliefs/behaviours in psychotherapy have reported results superior to secular treatments or usual care … especially in religious patients’ (p. 149).

The previous literature and research have indicated the extensive involvement of clergy, and more particularly chaplains, with regard to addressing moral injury (or similar nomenclature) long before the term moral injury became popularized. Since the twenty-first century, the current literature and research available have been quite detailed with regard to the role (or the potential role) of chaplains in relation to both mental health issues and/or moral injury (Carey 2012; Carey and Del Medico 2013; Carey et al. 2016b). This is largely because the idea of ‘moral pain’ has been explored by religious scholars since the first millennium and clergy have traditionally responded, for example, with pastoral counselling, confession and other rituals. Antal and Winings (2015) argue that there is an acute need to renew these traditions in responding to moral injury, its causes and stepping ‘beyond the constraints of the medical model’ to meet the true needs of those suffering on the margins (Antal and Winings 2015, p. 383).

Kopacz (2014) recognized that military chaplains in particular, who regularly engage with service personnel, can help to explore the existential beliefs of personnel and their sense of purpose and meaning in life. This places chaplains in a pivotal position to help those affected by moral injury (Kopacz 2014, p. 722). The previous research literature has indicated that the interventions provided by chaplains/clergy can be undertaken at multiple levels, namely in terms of (i) spiritual/pastoral assessments, (ii) support, (iii) counselling and/or education and/or (iv) ritual and worship activities. Ritual and worship activities in particular are numerous and noted by many authors and researchers (refer Table 3). Koenig et al. (2017), for example, in their ‘spiritually orientated cognitive processing therapy’ (SCOPT) note the importance of utilizing both spiritual concepts and practice:

Table 3 Examples of publications noting spirituality and/or the role of chaplains in relation to moral injury categorized according to the WHO pastoral/spiritual intervention codingsa
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Spiritual concepts such as mercy, repentance, forgiveness, spiritual surrender, prayer/contemplation, divine justice, hope, and divine affirmations are discussed as means to engage shame, guilt, anger, humiliation, spiritual struggles, and loss of faith. These techniques are supplemented by powerful rituals involving confession, penance, and faith community involvement, depending on what is most appropriate given the participant’s spiritual beliefs and tradition (Koenig et al. 2017, p. 150).

Concluding Discussion

There have been a number of novels and films which have attempted to highlight trauma-related moral issues. Perhaps, the most relevant novel and subsequent film was that by Baker (1991)—‘Regeneration’—which, in a rehabilitative setting for WWI veterans, recounts ‘the damage inflicted by exposure to a succession of horrific events, witnessed, internalized, repressed’, but eventually expressed in negative ways—‘mutism, memory loss, recurring nightmares, paralysis, and a variety of psychosomatic symptoms’. One of the key meanings of the book and film is ‘not built on the frame of plot and the actions of its characters, but instead arises from the juxtaposition of irreconcilable forms of knowing’ (Hart 1998, p. 379). This indeed may help to explain something of the definitional quandary with regard to ‘moral injury’—it is still an explorative field being ‘discovered’ with differing professional knowledge, opinions and practice that currently seem far from alignment.

Overall, given the increasing literature identifying moral injury from multiple perspectives and a lack of definitional consensus, it can be argued that moral injury still remains explorative—simply because it is a complex phenomenon that requires a holistic approach beyond any one discipline. Nevertheless, three issues are identified from this review concerning a number of publications that have attempted to address the issue of moral injury. Firstly, it seems clear that some researchers, either deliberately or unintentionally, have chosen to ignore or failed to specifically recognize ‘betrayal’ as a key component to moral injury. Secondly, a number of research definitions seem to minimize the concept of moral injury—either naively or deliberately—by utilizing a predominantly psychiatric and/or psychological paradigm which subsequently can obscure any spiritual factors associated with moral injury. Any exploration, definition or research regarding moral injury should align with a more holistic bio-psycho-social-spiritual paradigm; otherwise, there is the devaluing of spirituality by its exclusion and the possibility of failing to recognize the utility of spiritual care as a means to assist people with restoring their faith and their sense of worth, re-establishing relationships and/or their reintegration with the community.

Finally, based on the historical development of moral injury (or similar nomenclature) and the more contemporary literature presenting theological insights, it is important to acknowledge the contribution of religious, spiritual and pastoral care practitioners who can potentially assist with addressing moral injury. Thus far, some proponents of moral injury have not understood the necessity for a holistic approach by failing to consider a spiritual perspective or have limited its relevance. While this article does not present a neo-definition, nevertheless (in line with a bio-psycho-social-spiritual model), the authors believe it is important to acknowledge that moral injury is essentially an existential-ontological wound that can have lasting psychological, biological, spiritual, behavioural and social consequences and that chaplaincy/pastoral care practitioners are well placed to assist alongside other health care providers to provide rehabilitation that is holistic.

Clearly there is a lack of research with regard to the operational environment, morality and spirituality (Drescher et al. 2011). Further it is clear that some researchers in relation to moral injury have not adequately addressed ‘spiritual/existential problems and loss of faith’ (Frankfurt and Frazier 2016, p. 9), and thus, existential issues associated with moral injury are very much underexplored within the literature (Phelps et al. 2015, p. 165). Further research, both quantitative and qualitative, is clearly warranted to more extensively explore the prevalence and condition of moral injury, as is the need for an international conference or other medium to reach definitional consensus (Carey et al. 2016b). Any attempt, however, to reduce the treatment of moral injury to one particular paradigm, would be like (to use an old adage), trying to squeeze ‘a camel through the eye of a needle’—and yes, some might argue it is possible, but only with a great deal of dissection and deception!Footnote 4