DSM recognizes moral injury, thanks to Human Flourishing Program research
by the Human Flourishing Program
In the midst of the COVID-19 pandemic, frontline physicians, nurses, and first responders were confronted with impossible choices: who would receive a ventilator, whether to continue working without adequate protection, and how to safeguard their families while serving the public. In those moments, a phenomenon once associated with the military, moral injury, became an everyday reality in healthcare.
Recognizing the urgent need to better understand and address this challenge, the Human Flourishing Program at IQSS, under the direction of Dr. Tyler VanderWeele, launched a global initiative to advance research and equip leaders across healthcare, military, and first responder sectors with tools to identify moral injury and promote healing.
Moral injury arises when individuals in high-stakes roles must navigate wrenching ethical dilemmas where no option feels right, leaving lasting scars on conscience and well-being. For those affected, the consequences are profound, persistent anxiety, depression, and post-traumatic stress are common, alongside substance use and an erosion of trust and meaning. Left unaddressed, these wounds can lead to burnout, fractured relationships, diminished professional commitment, and in the most tragic cases, suicide.
To confront the growing prevalence of moral injury, HFH worked closely with members of the American Psychiatric Association (APA) to integrate “moral problems” into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This historic update, approved by the APA and published in the September 2025 annual update, expands the existing category of “Religious or Spiritual Problem” to “Moral, Religious, or Spiritual Problem.” The inclusion acknowledges moral struggles as legitimate conditions warranting clinical attention, without pathologizing them, and creates new opportunities for research, screening, and intervention.
“The APA’s action acknowledges the urgency of addressing the deep social and moral dimensions of suffering that are often unrecognized but can lead to self-harm and suicide,” said Dr. Francis Lu, Professor of Cultural Psychiatry at UC Davis Health System and co-leader of the APA proposal.
“We must address moral injury with the same urgency we apply to physical injuries,” added Dr. Jennifer Wortham, a scholar at HFH who led the initiative. “I launched this effort after years of struggling to find meaningful support for my brothers, who were abused by our parish priest. This is the first step toward ensuring that those struggling with moral problems and the adverse impacts it has on their mental health and wellbeing, receive the help they need to heal.”
Experts emphasize that moral injury is a distinct condition with severe psychological and spiritual consequences. Dr. Harold Koenig, Director of the Center for Spirituality, Theology, and Health at Duke University, noted that moral injury can profoundly alter one’s worldview, while Dr. John Peteet, Associate Professor of Psychiatry at Harvard Medical School, stressed that recognizing these struggles is essential to preventing further harm.
The impact is evident across sectors. Dr. Seth Mattson, a resident at Massachusetts General Hospital who assisted with drafting the APA proposal, highlighted data showing first responders and healthcare workers face heightened risks of burnout, PTSD and moral injury.
By shedding light on moral injury and formally recognizing it in the DSM, the APA has taken a decisive step toward equipping clinicians and institutions with the tools to respond. “This recognition not only provides us with the framework to understand moral struggles, it enables us to chart a roadmap for healing that can make a lasting impact on our world,” said Dr. Jonathan Sherin, who is leading efforts to establish a Moral Injury Center at the VA in Los Angeles.
Founded in 2016, the Human Flourishing Program at Harvard’s Institute for Quantitative Social Science aims to study and promote human flourishing, and to develop systematic approaches to the synthesis of knowledge across disciplines. The program’s research contributes to the broad question of how knowledge from the quantitative social sciences can be integrated with that of the humanities on questions of human flourishing and how best to carry out this synthesis of knowledge across disciplines.
