Healthcare workers across roles increasingly describe a form of distress that does not fit the categories typically used to explain occupational suffering. It is not exhaustion, though many are deeply tired. It is not depression, though their work may feel flattened or hollow. And it is not simply ethical conflict.
They say things like:
“I did what I was required to do, but something feels wrong.”
“I feel complicit.”
“I don’t recognize myself at work anymore.”
These statements are often offered quietly, even hesitantly, as though articulating the experience itself carries risk. What troubles healthcare workers is not only what they have done or failed to do in isolated moments. It is what prolonged participation in the system has done to them. Burnout language feels inadequate. Moral distress comes closer, but still does not fully capture the experience. What they are describing is moral injury—but not as a single event. Rather, as a cumulative process that alters how the self relates to work, authority, and meaning.
Moral injury is commonly defined as the harm that occurs when individuals are forced to act in ways that violate their moral code, or when they experience betrayal by legitimate authority. In healthcare, this definition is accurate but incomplete. Moral injury here rarely arises from dramatic ethical dilemmas or singular moments of wrongdoing. Instead, it develops through repeated exposure to situations in which healthcare workers are required to enact, explain, or normalize decisions they did not make and cannot meaningfully influence. Over time, the injury ceases to feel merely ethical. It becomes personal and enduring.
What makes moral injury in healthcare especially corrosive is not constraint itself. All healthcare work operates under limits. The injury emerges when ethical compromise becomes routine, compliance is expected, and responsibility for harm is displaced downward—onto those with the least authority and the greatest proximity to patients. In such conditions, healthcare workers are required to continue functioning as moral agents while being systematically deprived of moral agency. The result is not simply stress. It is damage to the integrity of the self.
For years, burnout served as the dominant language for this experience. Burnout allowed suffering to be named without assigning blame. It framed distress as depletion rather than betrayal, as overwork rather than moral harm. This framing was not accidental. Burnout is institutionally legible because it locates the problem in individual capacity rather than organizational design. It permits acknowledgment without accountability.
As burnout language began to ring hollow, moral injury entered the conversation. Healthcare workers were not only tired; they were anguished. They were not simply overwhelmed; they felt morally compromised. Something had crossed a line. Yet even moral injury discourse often stops short. It names the wound without fully explaining why it fractures identity itself, or why its effects persist even when specific roles, settings, or employers change.
To understand that, we need a framework that addresses not only ethics or emotion, but how authority interacts with the structure of the self.
Psychiatry has encountered this kind of injury before.
In the latter half of the twentieth century, Heinz Kohut, one of the most influential psychiatrists and psychoanalytic theorists of his era, fundamentally reshaped how psychological suffering was understood. Kohut was working within psychoanalysis at a time when prevailing theories emphasized internal conflict, repression, and instinctual drives. Yet he encountered patients whose suffering did not fit these models. They were not primarily anxious, fearful, or traumatized. Many were outwardly competent, productive, and successful. What they described instead was a quieter devastation: pervasive shame, loss of vitality, and the sense that something essential within them had quietly fractured.
Kohut argued that existing psychiatric theories failed to account for a central dimension of human psychology: the self does not develop or remain intact through internal strength alone. Psychological coherence, moral confidence, and a stable sense of meaning depend on sustaining environments—relationships and institutions that provide recognition, affirmation, and a reliable moral orientation. When such environments function adequately, individuals can tolerate stress, conflict, and even ethical tension without losing their sense of who they are. When they fail repeatedly, the injury is not episodic or emotional. It is structural. The self begins to lose cohesion.
A crucial aspect of Kohut’s contribution was his understanding of authority. Authority figures and institutions are not merely sources of rules, evaluations, or discipline. They serve a psychological function: they help organize the self by providing stable reference points for value, legitimacy, and agency. When authority is responsive and morally attuned, it supports cohesion. When it is dismissive, contradictory, or demands compliance without recognition, it becomes psychologically injurious. Shame, withdrawal, and emotional numbing are not signs of weakness in this framework. They are adaptive responses to environments that have become unreliable.
This framework offers a powerful way to understand moral injury in healthcare.
Healthcare systems do not merely coordinate labor. They function as authoritative moral environments. They define what counts as good care, responsible practice, efficiency, and success. Administrative decisions about staffing levels, productivity expectations, documentation requirements, utilization limits, and discharge timelines are often framed as operational or financial necessities. For healthcare workers, however, these decisions function as moral directives. They shape what care is possible, what advocacy is permitted, and what compromises must be absorbed.
Crucially, healthcare workers are required to embody these directives. Nurses, aides, social workers, therapists, technicians, care coordinators, and front-line staff are the ones who explain delays to patients, enforce policies they did not design, translate denials into humane language, and absorb the emotional consequences of decisions made elsewhere. Over time, they become moral intermediaries for a system whose values may diverge sharply from their own.
From a Kohutian perspective, the central injury here is not frustration or disagreement. It is the repeated demand that individuals lend their moral authority to decisions they neither made nor can meaningfully challenge. Authority, instead of functioning as a sustaining environment for the self, becomes a source of chronic misattunement. The system depends on the moral integrity of its workers while simultaneously undermining the conditions required to sustain it.
This produces a double bind: comply and violate one’s moral standards, or resist and risk professional harm. Sustained exposure to this bind does not usually result in protest. More often, it results in shame.
Shame in this context is not excessive self-criticism or personal fragility. It reflects a breakdown in moral recognition. When healthcare workers raise concerns about unsafe staffing, inadequate time, premature discharge, or ethically troubling policies, they are often met with silence, deflection, or procedural acknowledgment without substantive response. Over time, many stop speaking—not because they no longer care, but because speaking no longer protects the self. The internal question shifts from “Why is this wrong?” to “What is wrong with me for not being able to tolerate this?”
As moral recognition erodes, trust in leadership collapses. Early in their work, many healthcare workers assume—often implicitly—that institutional authority is aligned with the moral mission of care. When leaders prioritize margins over safety, or ask workers to publicly defend decisions they privately oppose, that assumption fails. Moral anger may appear initially, but anger is difficult to sustain when it carries risk and yields no response. Eventually, resignation takes its place.
Healthcare workers continue to function. They meet requirements. They comply. But the relationship that once sustained their moral identity no longer does. Emotional distance emerges—not because they have stopped caring about patients, but because maintaining moral investment in an invalidating environment has become psychologically unsafe. What appears as disengagement is often a form of self-protection.
Isolation deepens the injury. Moral injury thrives in silence. When ethical concerns are individualized, privatized, or subtly discouraged, healthcare workers begin to doubt their own perceptions. Solidarity erodes. Withdrawal becomes adaptive. The self pulls back from environments that have proven unreliable.
At this point, healthcare systems often turn to resilience. Mindfulness programs, wellness initiatives, and self-care workshops are offered as remedies. These interventions are not inherently misguided, and some individuals find them genuinely supportive. But when resilience is positioned as the primary response to moral injury, it represents a category error. Resilience frameworks treat injury to the self as a deficit of individual regulation rather than as the predictable outcome of sustained relational failure by authority.
From a Kohutian standpoint, this response compounds the injury. What has been damaged is not the healthcare worker’s capacity to cope, but the external structures required to sustain a coherent moral self. Asking individuals to adapt internally while leaving the injuring environment unchanged reinforces shame and withdrawal rather than repair.
Moral injury requires moral repair. And moral repair cannot occur solely within individual psychology. It requires changes in how authority is exercised and how ethical concerns are received. Healthcare workers need more than permission to speak; they need evidence that speaking matters. They need leadership capable of acknowledging harm without defensiveness, assuming responsibility for the moral consequences of policy decisions, and tolerating the discomfort that ethical accountability entails.
Seen this way, moral injury is not a diagnosis to be managed away. It is information. It reveals where healthcare systems have become misaligned with the values they depend on workers to enact. When moral injury becomes widespread, it is not evidence of fragile professionals. It is evidence of systems that sustain themselves by drawing down the moral and psychological integrity of those within them.
Kohut’s contribution is not to rename moral injury, but to explain why it fractures identity rather than merely causing distress. Moral injury injures the self because it arises when authority fails to provide the sustaining moral environment on which the self depends. Until that failure is addressed—structurally, not rhetorically—no amount of individual resilience will be sufficient.
The question moral injury ultimately poses is not, “How can healthcare workers endure this?”
It is, “What kind of healthcare system requires their endurance in the first place?”