On April 13, 1919, colonial soldiers from the 9th Gurkha and 54th Sikhs infantry regiments stood at the entrance of Jallianwala Bagh in Amritsar and, on Brigadier-General R. E. H. Dyer’s orders, opened fire on a peaceful crowd gathered for Baisakhi and to protest the Rowlatt Act. Over ten minutes, more than 1,650 bullets were fired by the soldiers (recruited from Nepal and Undivided Punjab) into the trapped gathering, killing hundreds, including women and children. While General Dyer was “forced into retirement”, the emotional aftermath for the soldiers who executed the firing remains undocumented.
What, then, did those who fired feel inside their minds and hearts as they shot at unarmed civilians? Was there guilt? Shame? Anxiety? Or was the act simply normalised within a chain of command, leaving no inner mark at all? No testimonies, letters, or psychiatric records exist to reveal their inner world. For decades, such questions remained unasked. Wars came and went—World War II, Korea, Vietnam—yet the psychological toll on those ordered to commit or witness violence stayed in the shadows.
In the 1980s, philosopher Andrew Jameton introduced the concept of ‘moral distress’, particularly in healthcare settings. In the 1990s, psychiatrist Jonathan Shay identified ‘moral injury’ in Vietnam veterans, suffering rooted not in fear, but in moral betrayal.
Moral – injury or trauma?
Unlike PTSD (post-traumatic stress disorder), symptoms of which are startling flashbacks, hyper‑arousal, and nightmares, stemming from fear in life-threatening situations, moral injury is rooted in shame, guilt, disgust, and spiritual conflict after actions that violate deeply-held beliefs. It is about what one has done, seen, failed to stop, or been required to participate in. Moral injury occurs through three elements: betrayal of what is morally right, by someone in legitimate authority, in a situation of extreme significance. Later, in 2009, Brett Litz and colleagues broadened it to include perpetrating, witnessing, failing to prevent, or learning about acts that transgress deep moral beliefs.
Modern definitions emphasise both cognitive and emotional components: feelings of intense guilt or shame, loss of trust (in self, others, institutions), spiritual or existential crises, self-condemnation, difficulty forgiving oneself, and a collapse of meaning or purpose. Scientists also note behavioural outcomes: self-sabotage, social withdrawal, substance use, demoralisation, and increased risk of suicide. Psychological risk factors include shame‑proneness and neuroticism; protective factors include self-esteem, supportive relationships, and belief in justice and forgiveness.
Studies of veterans show standardised tools (like the Moral Injury Symptom Scale–Military Version) measure exposure to morally injurious events and symptoms such as guilt, loss of faith, and shame‐driven alienation. Importantly, research confirms moral injury is distinct from PTSD—even when both occur, treatments that only address fear‐based trauma often fail to heal the wound created by moral conflict. Traditional PTSD therapies reframe frightening memories, but moral injury usually requires “forward‐looking” interventions that help individuals accept moral responsibility while rebuilding purpose and self-forgiveness.
The burden of moral codes
Colonel Paul Tibbets, who piloted the Enola Gay and bombed Hiroshima in August 1945, expressed no regret, believing his act ended the war and saved lives. In contrast, Emperor Ashoka in the 3rd century BCE felt remorse after the Kalinga War and undertook a deep moral reckoning, despite being the authority responsible. This highlights that moral injury is subjective, rooted not in the act itself but in personal moral beliefs.
The risk of moral injury varies from individual to individual and culture to culture, depending on how strongly actions clash with personal or institutional values. It is about how deeply that act clashes with one’s personal moral framework. During the COVID-19 pandemic, (many, though not all) healthcare workers experienced similar inner conflict. They were harmed by impossible choices regarding whom to save and whom to turn away. For some, the inability to meet their moral duties led to lasting guilt, helplessness, and a sense of betrayal by the very systems they served.
Why this matters locally
Although the term is little known in India, the same moral conflicts occur daily in police, medical and journalistic offices and bureaucratic settings. A junior police officer told to falsify records in an undisclosed custodial death, a doctor forced to ignore malpractice in an organ transplant scam, a journalist ordered to sensationalise grief for TRP, an officer coerced into turning a blind eye to sexual harassment charges or corruption—all are at risk of moral injury. These scenarios mirror the components defined in literature: transgressions of deeply held moral codes, authority-imposed betrayal, internal moral dissonance, and emotional turmoil. But the phenomenon rarely enters public discussion—research in India on moral injury is minimal.
Healing an ethical wound
Though moral injury isn’t an official psychiatric diagnosis, it is increasingly treated seriously within mental health fields. There is no universally accepted treatment for moral injury; responses vary widely. Even cognitive behavioural therapy has limitations. Recognition remains the first step toward developing effective, individualised interventions through research. Critically, institutional acknowledgement matters: moral injury only begins to heal when wrongdoing is named, responsibility is accepted, and support is offered; not judgment or ostracism.
Why recognition helps
Public attention often fixes on the victim, and rightly so. But without recognising the psychological injury borne by those within the system—especially those coerced into complicity—we lose part of the story. Moral injury creates professionals numbed to empathy, disengaged or cynical, and institutions that tolerate ethical compromise. If unaddressed, it erodes conscience, accountability, and institutional moral integrity. Moral injury rooted in guilt can disrupt sleep, impair focus, and increase mistakes at work. Over time, those suffering a moral injury may turn to addictive behaviour, reflecting a silent struggle that alters both daily function and emotional well-being.
India needs systemic reform for accountability and compassionate recognition of the moral costs borne by individuals. How do we understand the suffering of someone who is both complicit and wounded? How can we acknowledge that some of the brutality we see may emerge not just from cruelty but from repeated moral injury that’s never addressed?
If we hope to build humane institutions, we must learn to see—not just the visible harm done to victims—but also the invisible harm done to those within the system who lose parts of themselves while protecting it. What may seem externally as carelessness or burnout could be the prolonged impact of an unhealed moral wound.
(Dr. C. Aravinda is an academic and public health physician. The views expressed are personal. aravindaaiimsjr10@hotmail.com)
Published – August 03, 2025 03:00 pm IST
