Moral injury has been most commonly defined as psychological, behavioral, social and spiritual problems stemming from perpetrating, failing to prevent, witnessing, or learning about acts that transgress deeply held beliefs and expectations (Griffin et al., 2019, Litz et al., 2009; Norman & Maguen, 2023). Moral injury requires both exposure to a potentially morally injurious event (PMIE) as well as associated symptoms. A PMIE can include events where the individual did something, failed to do something or witnessed an act that transgressed their values (e.g., a veteran killed civilians in the context of war; a healthcare worker failed to save a patient; a first responder witnessed harm to another and did not intervene). Guilt, shame, and disgust are some of the hallmark symptoms of moral injury (Farnsworth et al., 2014; Norman et al., 2024).

Moral injury may also entail functionally impairing alterations in: (a) beliefs about personal or collective humanity; (b) moral thinking (i.e., moralistic judgments of oneself and others); (c) social behavior (i.e., social exclusion, social rejection; loss of valued, valuing, and kindred attachments); (d) moral emotions and moods (i.e., the self-conscious emotions of guilt and shame and the other-condemning emotions of anger and disgust); (e) self-harming or self-sabotaging (behaviors that negatively affect safety and quality of life/well-being); and (f) beliefs about meaning and purpose (e.g., emptiness, purposelessness, questioning faith; e.g., Litz & Walker, 2025; Norman et al., 2024).

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Moral injury can also be conceptualized as part of the moral stress continuum, with reactions and symptoms varying with time and intensity (Grimell & Nilsson, 2020). At one end of the continuum is moral stress, which can be a normative response when individuals are confronted with choices or events that go against their moral or values, with little impact on daily functioning. Moral stress can also result in impacted individuals coming together for discussion, consultation, and advocacy. Moral distress is next in the continuum and can result in a negative stress reaction due to PMIEs, as well as short-term feelings of frustration or helplessness that have some impact on functioning yet are not long lasting. Finally at the far end of the continuum is moral injury which has longer lasting symptoms and a more pervasive impact on functioning. This continuum is important because most individuals who are exposed to PMIEs do not develop moral injury. Epidemiological studies have shown that among groups at high-risk of moral injury, while exposure to PMIEs is high, a much smaller proportion of these individuals were experiencing clinically meaningful moral injury (Litz et al., 2025; Maguen et al., 2025). In one study 49% of combat veterans, 51% of healthcare workers, and 42% of first responders  endorsed exposure to a PMIE. However, clinically meaningful moral injury symptoms were endorsed by 6.5% of combat veterans, 7.3% of healthcare workers, and 4.1% of first responders (Maguen et al., 2025).

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Measurement

There are currently two moral injury measures that assess exposure to a PMIE as well as moral injury symptoms that are indexed to the worst PMIE. Both scales measure symptoms along the stress response continuum described above (e.g., moral distress and moral injury).

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The first is the Moral Injury and Distress Scale (MIDS; Norman et al., 2024; Maguen et al., 2024). The MIDS was developed and validated in a large national sample of veterans, healthcare workers and first responders. The MIDS includes questions about exposure to a PMIE followed by 18 questions that assess cognitive, emotional, behavioral, social, and religious/spiritual symptoms indexed to the PMIE. Participants respond to each item using a 5-point response format (0 =not at all, 4 = extremely). Because the MIDS is a unidimensional scale, responses to the 18 symptom items may be summed into a total score, where higher values indicate greater symptom severity. The MIDS is also the first measure to have a cut score of > 27 to identify clinically meaning levels of moral injury (Maguen et al., 2025). Because of these flexible scoring algorithms, the MIDS may be easily used as a tool to screen for moral injury and to track change in symptoms severity over time. The benefits of the MIDS as a clinical tool are that it is easy to use and score given its unidimensional scale, clear cut score, and ability to track symptoms over the course of treatment. The MIDS and scoring can be downloaded free or charge at the website below: https://www.ptsd.va.gov/professional/assessment/te-measures/mids.asp

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The second measure is the Moral Injury Outcomes Scale (MIOS). Although the content of the MIOS was developed with veterans, the scale has been validated with veterans in several countries and healthcare workers (Litz et al., 2022; Plouffe et al., 2025). The MIOS includes questions about exposure to a PMIE, followed by 14 symptom items score on a 5-point response format (0=strongly disagree to 4= strongly agree). The MIOS has two factors, a subscale that assesses trust-violation symptoms and a subscale that assesses shame-related symptoms. Total symptom burden can be scored by summing the 14-items. Cut-scores for moral distress (T-scores ≥60 and ≤64; raw scores =26–30) and moral injury (T-scores ≥65; raw scores ≥31) have been generated (Litz et al., 2025; there are also case threshold for the two subscales). For a more comprehensive evaluation of moral injury measurement issues please see Griffin et al., 2025 (https://link.springer.com/content/pdf/10.1007/s40501-024-00342-9.pdf) or Houle et al., 2024.

 

Existing Gaps in the Field

Although the introduction of these two self-report moral injury measures into the field has helped move the field forward, there are still major measurement gaps that need to be considered. First, there is no gold-standard clinical interview to determine moral injury, which is a gap and important future direction. Second, there are many groups that may experience moral injury, and validation studies are needed to ensure that these measures can be utilized in groups other than the ones in which they were developed and validated. Third, cross-cultural adaptations may be needed when using these measures in countries in which these measures were not validated. Efforts are underway to translate the MIDS and the MIOS, ensuring that culturally sensitive and culturally appropriate language can be used while maintaining the integrity of the original questions.

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Author(s) and Reviewer(s): Prepared by Shira Maguen, PhD., Sonya Norman PhD., and Brandon Griffin, PhD. Reviewed by Brittany C. Davis, PhD. Please direct suggestions and feedback to Dr. Maguen (shira.maguen@va.gov).

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Version March 2026. 

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References

Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262, https://doi.org/10.1037/gpr0000018

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Griffin, B. J., Price, L. R., Jenkins, Z., Childs, A., Tong, L., Raciborski, R. A., Weber, M. C., Pyne, J. M., Maguen, S., Norman, S. B., & Vogt, D. (2024). A Systematic Review and Meta‑Analysis of Moral Injury Outcome  Measures. Current Treatment Options in Psychiatry, 12(7). https://doi.org/10.1007/s40501-024-00342-9

 

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350-362. https://doi.org/10.1002/jts.22362

 

Grimell, J., & Nilsson, S. (2020). An advanced perspective on moral challenges and their health-related outcomes through an integration of the moral distress and moral injury theories. Military psychology : the official journal of the Division of Military Psychology, American Psychological Association, 32(6), 380–388. https://doi.org/10.1080/08995605.2020.1794478

 

Houle, S. A., Ein, N., Gervasio, J., Plouffe, R. A., Litz, B. T., Carleton, R. N., Hansen, K. T., Liu, J. J. W., Ashbaugh, A. R., Callaghan, W., Thompson, M. M., Easterbrook, B., Smith-MacDonald, L., Rodrigues, S., Bélanger, S. A. H., Bright, K., Lanius, R. A., Baker, C., Younger, W., Bremault-Phillips, S., … Atlas Institute Moral Injury Research Community of Practice (2024). Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clinical psychology review, 108, 102377. https://doi.org/10.1016/j.cpr.2023.102377

 

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Litz, B. T., Walker, H. E., Pietrzak, R. H., & Rusowicz-Orazem, L. (2025). The prevalence of moral distress and moral injury among U.S. veterans. Journal of Psychiatric Research, 189, 435–444.

 

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war Veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. http://doi.org/10.1016/j.cpr.2009.07.003

 

Maguen, S., Griffin, B. J., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., & Norman, S. B. (2024). Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury. Journal of traumatic stress, 37(4), 685–696. https://doi.org/10.1002/jts.23050

 

Maguen, S., Griffin, B. J., Pietrzak, R. H., McLean, C. P., Hamblen, J. L., & Norman, S. B. (2025). Prevalence of Moral Injury in Nationally Representative Samples of Combat Veterans, Healthcare Workers, and First Responders. Journal of general internal medicine, 10.1007/s11606-024-09337-x. Advance online publication. https://doi.org/10.1007/s11606-024-09337-x

 

Norman, S. B., Griffin, B. J., Pietrzak, R. H., McLean, C., Hamblen, J. L., & Maguen, S. (2024). The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations. Psychological trauma : theory, research, practice and policy, 16(2), 280–291. https://doi.org/10.1037/tra0001533

Norman, S. B., & Maguen, S. (2024). Moral Injury. National Center for PTSD. Accessed on 9/23/25 at https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp

 

Plouffe, R. A., Houle, S. A., Birch, M., Ein, N., Nazarov, A., & Richardson, J. D. (2025). Validation of the Moral Injury Outcome Scale in Canadian health care workers. Psychological Assessment.