Dawn Hood-Patterson, PhD, MDiv (Host): Welcome to the
Pediatric Ethics Podcast from the Bioethics Center at Children's Mercy, Kansas
City. My name is Dawn Hood-Patterson. I will be your host. For this episode, we
welcome Reverend Joshua Morris PhD. Dr. Morris is the Assistant Director of Spiritual
Services at Children's Mercy Hospital. He has served in pediatric chaplaincy
for over a decade, including as a Staff Chaplain at Children's Mercy and as a
Pediatric Staff Chaplain at Long Beach Memorial Medical Center, Miller
Children's Hospital in Long Beach, California. He is a Board Certified Chaplain
through the Association of Professional Chaplains. Josh has served as an Army
Reserve Chaplain since 2008, including one deployment to Afghanistan in support
of Operation Enduring Freedom.

He is the author of numerous peer reviewed journals and
articles and the book, Moral Injury Among Returning Veterans; From Thank You
For Your Service to a Liberative Solidarity. With Dr. Morris's background and
experience, he is well positioned to help us think more critically and deeply
about the topic of moral injury and how this idea applies within healthcare
context. Thank you for being with us today, Josh.

Joshua Morris, PhD, MDiv, BCC: Thank you so much, Dawn.
It's really an honor to be here.

Host: Well, let's just jump in with a few questions
about some of your past work and your experience. I hope you can get us started
by delineating the term moral injury. Where did it originate and historically,
how or with whom has it been used?

Joshua Morris, PhD, MDiv, BCC: So moral injury is
something that I sort of stumbled upon in my early days as an Army Reserve
chaplain. I was starting a PhD program. At that point, I thought I was going to
do doctoral work on post-traumatic stress. I found out in that first year of coursework
that I was deploying and that sort of changed the way my research was
developing and what I was thinking about.

So where moral injury emerges is in the early 1990s, through
the work of a VA psychiatrist named Jonathan Shea. So Jonathan Shea, had been
working with Vietnam veterans and in his work with Vietnam veterans in these
like traditional group setting of therapies, you know, he kept hearing this
phrase, what's right, like what's right, kept coming up for him.

So he kept to explore like what is it about these groups or
what is it about the war in Vietnam that was causing these themes to come up?
And so from that, merging into the 1990s, he, he starts to think about war
wounds. So he had been reading about post-traumatic stress, but then thinking about
what happens when what's right is violated. And so in the early nineties then
his kind of how we say, he coined the definition of moral injury as a betrayal
of what is morally right by someone who holds legitimate authority in a high
stake situation. So there's like a threefold definition going on. And so that's
in the early nineties and not much happens with the definition for about 20
years.

And so then early on in the wars in Iraq and Afghanistan, as
those early generations were coming back, a new definition was emerging of
moral injury where instead of it being a betrayal by somebody; this now becomes
about the perpetrating or the failing to prevent these deeply held moral
beliefs, thus expectations. So the literature really originates in the veteran
and service member population, and that's where it's been for, you know, this
first generation of research.

Host: Yeah, that's really interesting and I know that
that's one of the things that we're going to be talking about today is, is how
this research kind of emerges into perhaps some new arenas or institutions or,
or scenes. To kind of build upon how we're thinking about this conversation
today, I was hoping that you could help delineate a little bit better, because
many in healthcare settings have heard of the term moral distress, and I was
hoping that you could help differentiate between moral injury and moral
distress. Help us to understand, maybe places where they overlap or where
they're different.

Joshua Morris, PhD, MDiv, BCC: I appreciate that you say
that there's an overlap cause you're right that these two terms were kind of
developing sort of simultaneously, like in the early 1990s in the nursing
literature, we get those initial framework of moral distress. That there's this
feeling of like a complicity and wrongdoing that as a healthcare worker, that
we have a lack of a voice, that there's this wrongdoing associated with
professional values. So that I think is important as a caveat, is it's
professional, not necessarily personal values. And then there are like these
root causes and moral distress, and whether that's at the patient level, you
know, like as a nurse maybe that you are, you're providing care for a patient.
This family is demanding an overly aggressive treatment that you don't think is
ethically right. Maybe it's at the unit level, like the team level, like here
at within like a pediatric institution. Maybe you're working in the pediatric
intensive care and you feel like the communication and the leadership are doing
things that are conflicting with your professional values.

And then there's this third level of like a system level that
you feel that the hospital administration or the bigger system is the one
that's working against your values. And so there is a difference. There are a
lot of similarities. Like there's almost like, there's like an entanglement
between moral distress and moral injury of like well, what's the difference? I
mean, are they interchangeable? I think in some senses they can be
interchangeable, but I think there are important distinctions of moral injury
over moral distress that I, I think it's an important thing to like kind of
have in our toolbox as caregivers as we're thinking about what it is that
either we're going through or that our staffs are going through.

And so I think for me as a chaplain in particular, that I
think, moral injury brings in like a broader conceptualization that includes
the violation of our personal, moral and our spiritual beliefs. What are we
saying in those moments where we feel the things that we hold to spiritually
are being betrayed in moral injury? Like it, it gives language to have an
honest conversation about multiple commitments. Like what you're doing in this
situation feels wrong, but then when you go home you're like, I don't know if
that was wrong. And so this initiating in the combat literature, in the war
literature is so important because those things you do in war that you're told
are the quote unquote right thing to do, when you come home, they're not the
right thing to do. And so you have this dissonance between them, these moral
orienting systems, and trying to reconcile those things back at home. And so
those are some of the differences that I see.

Host: So this may be too simplistic of a summation, but
it almost seems like within the context of moral distress, it really is paying
attention to our sense of morality and what is right to use to borrow language
from the moral injury camp, within the professional realm. But then what you're
suggesting is that moral injury brings to the conversation a lot of similar or
overlapping tools, but that it really takes into account some of the ways that
it impacts us personally or spiritually. Is that one way to kind of summarize
the overlaps?

Joshua Morris, PhD, MDiv, BCC: Yeah, that's really
helpful. That's really well said, I think.

Host: I feel like I hear these two terms, but I'm, I'm
always a little bit wondering where, where they reside and how the conversation
differentiates or how it overlaps. And so I appreciate you helping to explain
that and expound upon that. You had a recent article that came out, Contours of
Care and Community, and you say that moral injury is quote, "living with
and reconciling traumatic experiences." And you say that on page two. What
do you mean by this? What do we learn about traumatic lived experiences when
viewed through the lens of moral injury?

Joshua Morris, PhD, MDiv, BCC: Yeah, I think one of the
things I've been thinking about with moral injury especially, which I, I'm sure
we'll get to in a moment, of how these things impact us within healthcare. It's
thinking about that these experiences we have, it's trying to find a way as a
caregiver that when I'm talking to people, it's normalizing the experience,
that you bring these things with you into the way you provide care. You bring
these things with you into your relationships and into your self-care. And so
like, it's not that you just like can immediately treat these things and then
you're quote unquote, healed. You're living with and reckoning with you're a
new person, on the other side of these traumatic experiences.

And so how are you making space for that and how are you caring
for yourself in the event of what it is you've gone through? Cause I think for
many of us through the pandemic, it was, it felt like moral injury because it
was now the thing that is doing the infecting, we can bring that home with us.
And so we're reconciling and trying to figure out like, where's my
professional, like where's my own personal boundary of the care I provide when
now I might be infecting my family back home. I might be responsible for
bringing that to you know, an immunocompromised parent maybe. And so it's
normalizing and being able to name the things that are going on beyond the
surface that I think help people have some empowerment in moving towards
healing.

Host: So what you're really saying then it seems like is
that owning the fact that sometimes there's overlap between our professional
spaces and our personal or home life spaces and having a way of working through
or imagining life where these spaces intersect and overlap and not always
having to find room to put them in different silos, so to speak.

Joshua Morris, PhD, MDiv, BCC: Yeah. Cause overlap
works. I mean, it's maybe it made us aware of something that we've been not
thinking about, but has always been present in the caregiving relationship. But
these overlap of spaces, has always been there. Like we're always impacted and
affected by this mutuality of the caregiving relationship. And so, moral injury
was a way to, or is a way to think about that relationship in new ways.

Host: Yeah, cause I was taken by the fact that in your
writing, it seems that you were starting to expand the scope of moral injury
asking, is it really just something that lives within these military
experiences? And it seems to me that you're saying that it really isn't that,
it is starting to find its way into other spaces. Are there cautions that we
need to take whenever we start moving it out of the discipline of the military
experience?

Joshua Morris, PhD, MDiv, BCC: For me, I had wanted to
keep them separate for a long time, and then those initial months of COVID and
the lockdown and just everything we were experiencing as people, it felt like
that original definition from Jonathan Shea, like it felt like there had been a
betrayal of what is morally right in these high stake situations by people in
authority. It felt like the betrayal language for me, made sense and it didn't
feel like it was trivializing to the experience. I did feel like I could say
this feels morally maybe even potentially morally injurious in similar ways as
the combat experience because there was this feeling of feeling helpless and
feeling betrayed by those who, who we placed our trust in to be able to get
through this, this early months of not having enough PPE. Or for physicians and
nurses who were deciding who was going to get a ventilator or who was going to
get extra layers of care that we are put in these situations to make decisions
where that betrayal language. I think it really helps and I think it helps
normalize that you're not alone when you're feeling those things. That there is
something else bigger maybe that's going on at a human level that we can all
kind of band together in this.

Host: Yeah. Cause it really seems like you're speaking
about, you know, you use the term someone in authority, these authority figures
or even institutions or systems. And it seems like you're pointing to multiple
layers of systems. Not only something where it could be, you know, departmental
or institutional, but it could also be something that is on like a national or
a social level in which there's a sense of betrayal around particularly the
context of what you were describing around COVID-19 and the pandemic.

 I was wondering, you
spoke about this briefly and I wanted to open up the opportunity to say more if
you have more to say, but you initially were speaking about the COVID-19
pandemic and how there was this infection that you could potentially bring home
to immunocompromised parents or someone in, a loved one in your family or that
you lived with. And then you also spoke about having to make decisions related
to ventilators and PPE. Are there other ways in which the concept of moral
injury frames the discussion around the traumatic experiences faced by
healthcare workers in clinical settings or during the COVID-19 pandemic? Are
there other things that surface as you reflect on this era of COVID-19 that we
are slowly emerging from or other experiences within the healthcare setting?

Joshua Morris, PhD, MDiv, BCC: I do, I found an overlap.
So when you mentioned the title of my book, the subtitle is from Thank You for
Your Service to a Liberative Solidarity. And what I was thinking about in those
contexts, in the military context is when the book was published, we had been
in Iraq and Afghanistan for 20 years. And so we talk about appreciation and
thanking veterans for their service. And it felt to me that I wasn't sure what
the appreciation was doing, like if we were moving our military, like out of
these wars, like what were we actually saying? And so then when I think about
COVID and I think about institutional responses, so maybe beyond the
conversation of PPE, beyond the conversation of ventilators, but on staff
support. Like how are we taking care of our staffs who are truly on these front
lines dealing with this, you know, like when we have pizza parties or when we
have little breaks to breathe deeply that aren't attending to like the systemic
challenges that our staff members are facing; it can feel like a betrayal cause
it can feel like it's a bandaid over a knife wound.

Like this isn't doing anything to truly move us through this
with grace and healing, but it's kind of papering over the cracks of a system
that betrayed us on the one sense and now is, is betraying us in new ways. So
the moral injury literature, I hope going back to its initial roots can have
like a broader critique of the way we move and operate within systems, the way
we are within city government and like all the way up to like a federal
government that's a little bigger than this conversation, I think.

Host: So what you're saying is that the moral injury
literature can really help us think about how it goes beyond just the
day-to-day work that we have here in the in the hospital or in the clinic; and
start to think of it outside of the walls of the hospital, how we take care of
self, others, and community beyond that scope. Is that somewhat what you're
saying?

Joshua Morris, PhD, MDiv, BCC: Yeah, it has to. I mean,
cause I think that that's where so much of the pain and the isolation is
because I can remember those early, maybe the first year, you know, like when
the vaccines first started to become a reality for us, that we would leave
work, we would be here for eight or 12 hours. We'd have all the PPE, you know,
you'd be wearing N 95 and gloves and gown, and then you'd leave and you'd be
having conversations about the efficacy of masks or you'd be having, having
conversations about the politics around vaccines. And there was such a
cognitive dissonance of what you were seeing every day in your clinical setting
and then what was happening outside these walls.

And so I hope that moral injury like gives us the courage and
the ability to say that there has been a betrayal and like we can stand in that
gap and do something about it.

Host: So is it a matter of truth telling, or is it a
matter of advocacy or is it a little bit of both? Or is there something else
that you see happening as a result of engaging with moral injury kind of on
this contextual or social level?

Joshua Morris, PhD, MDiv, BCC: I feel like my answer is
yes, I feel like it, because it is about truth telling it also about telling
the story. We've all been in those conversations where I don't think you're
necessarily going to convince anybody sometimes with just rattling off facts,
but it's the telling of stories. And I think that's one of the coolest parts
about being a chaplain is we exist in these spaces where we are processing
these stories, we're living these stories, and so we can tell the narrative of
like what is really going on, that it is not a coverup, it's not some
government conspiracy that there are real people experiencing real trauma, real
pain in these walls.

And so like, to be able to like flip the script is I think it's
a journey instead of just trying to convince people with statistics. Cause if
that was the case, I think we would've already had this conversation. It
would've ended differently. But, facts aren't necessarily moving us forward.

Host: So it's really putting kind of the flesh and bones
on the statistics that you hear building it out as lived experiences or lived
stories, like what we talked about. Are there other obligations that we have to
pay attention to moral injury? Is it a part of being a moral person? Is a part
of being moral health caregiver?

Joshua Morris, PhD, MDiv, BCC: I think so. Cause I think
once, if you use it like a paradigm or like you start to think about it as a
lens, I think it opens up other ways to see other there opportunities to see
where we're traumatizing communities. I think the moral injury literature helps
us outside of a traditional clinical setting, but out in the community, whether
that's with police brutality, in the murder of you know, black and brown
bodies, that moral injury gives us a way to think about the betrayal of
institutions that are supposed to be protecting and serving. But for certain
communities they're not doing that. And so I think moral injury gives us the
courage, the moral courage to step up and to offer a critique of that, like in
solidarity with those communities.

Host: Yeah. And then kind of what you said at the
beginning, not only is a critique, in a sense of solidarity, but then it's also
a way of dealing with the spiritual and the personal or emotional issues that
arise when we see these issues of injustice pop up as well.

Joshua Morris, PhD, MDiv, BCC: Yeah. Well said.

Host: I was wondering, Josh, if there are other things
about moral injury within the context of healthcare that you would like us to
know about or think about?

Joshua Morris, PhD, MDiv, BCC: There's a way through.
Critique is helpful and critique is important to kind of shine the light on
stuff. But as a chaplain, as a care provider, like there's a due element too,
you know, like, well, how do we do things differently, maybe at the individual
level or at the unit level or the system level, that I think there's like an
externalization that the moral injury literature, if it's so much about how we
internalize trauma or how we internalize shame or guilt, that moral injury
gives us the language to get that story out, to externalize it, to externalize
the event, to think about what you've been asked to do, to create an image, a
collective ritual with your, your unit here at the hospital. What might a
guided meditation look like with your unit?

Like, it doesn't necessarily have to be overtly spiritual, but
there are interventions to get through this together as a people that I think
is helpful to think about instead of just pointing the finger and saying we've
been betrayed. We've been betrayed. But now it's like how are we going to move
through this together on the other side of whatever healing looks like from
this?

And so I think that's what just recognizing how slowly that
might take, but how to be a presence amongst your staff and with yourself.

Host: That's really helpful. I really appreciate the
fact and the wisdom that you have in pointing out the fact that we can raise
critique and we can dissect what may be happening and we can point to different
ways in which we have injuries because of different interactions that we have
within healthcare systems. But the fact that you're reminding us that there is
something hopeful and something that can be done in the midst of these
instances that can cause injury and cognitive dissonance. Josh, I really
appreciate you taking time with us today to think through how the literature
and how the history of moral injury comes to bear within the healthcare system.
Thank you so much for your time today.

Joshua Morris, PhD, MDiv, BCC: Yeah. Thank you again for
the invitation in this really rich conversation. I appreciate it, Dawn.