Tend my Sheep: Caring for Those Who Suffer Moral Injury

Tend my Sheep: Caring for Those Who Suffer Moral Injury

[Originally published April 2022]


The Psalmist wrote, “I am feeble and crushed; I groan because of the tumult of my heart” (Psalm 38:8, ESV). His longstanding sickness left him isolated from family and friends and feeling as though he had been abandoned by God! His journey through illness led him to consider his spiritual well-being. Many of us will know the feeling of abandonment that such an experience with lengthy illness will bring. A closer examination of the psalm will reveal that a variety of symptoms are presented that are characteristic of a number of illnesses. The psalm is written as a plea for “every sufferer!”
The song’s value is powerfully needed in our contemporary culture where an ever-growing number of people suffer from a long-term physical, emotional, and soul sickness known as “Moral Injury.” [1] These people sit next to us in church and Bible studies and work alongside of us in crisis centers. They include combat veterans, healthcare professionals, police, first responders, and victims of institutional and personal abuse.

Their healing requires a holistic effort to minister to the physical, mental, spiritual, and social realities in the lives of the hurting. In fact, recovery for those enduring such moral hurt truly requires the whole people of God. Our churches, however, too often suffer from a lack of awareness and, even when moral injury is recognized, offer limited efforts to render assistance. This phenomenon cries out to us today to return to what the church throughout history has called cura animarum, the care of souls.
The Nature and Scope of Moral Injury
Most will have heard, at least, of Post-Traumatic Distress Syndrome (PTSD) which is to be distinguished from Moral Injury (MI). The former, a “trauma-and-stressor-related disorder” is a “fear-victim” reaction to danger and has identifiable trauma symptoms such as flashbacks, nightmares, hyper-vigilance, and dissociation.” [2]
Moral injury, in contrast, is not a psychiatric disorder. Counselors isolate three circumstances that give rise to moral injury: 1) a betrayal of what is right by someone, 2) who holds legitimate authority (e.g., a military leader), 3) in a high stakes situation. Moral Injury is character debilitating and robs individuals of their ideals, ambitions, and relationships. Their capacity to trust is sometimes destroyed.
The syndrome has two facets. On the one hand, it is “an inner conflict based on a moral evaluation of having inflicted harm, a judgment grounded in a sense of personal agency.” [3] Human action (i.e., agency) across the spectrum, whether in the form of commission or omission, is evident in moral injury. Moral judgment is attached to this active behavior, like a soldier killing someone, or failing to prevent harm or witnessing a close friend being slain. [4] On the other hand, moral injury also may emerge when we feel betrayed by someone in authority. An action may feel right at the time, but a person may later experience remorse or guilt for having had to inflict harm that “violates a sense of inner values.”

Regardless of its nuances in meaning, moral injury causes a deep spiritual wound that impacts the whole person. There is cause for alarm because the potential for moral injury is “relatively high” for combat veterans as well as health care workers, especially as a result of stresses experienced throughout the pandemic. Many caregivers exhibit mental health issues and demonstrate symptoms of burnout. [5] Similar mental health and spiritual issues are surfacing as well in churches and religious denominations following clergy-sexual abuse scandals.
Practical Examples
Soldiers may succumb to moral injury when they kill or harm someone in combat. Officers may experience moral injury when they make decisions that affect the survival of others. Medics may fall prey to moral injury when they are unable to render aid to all who are harmed.
Consider also nurses in healthcare environments. Ethical questions are part of the everyday operational life within care facilities, and many serve as catalysts for moral injury. Regular questions include: “Do I have enough staff to safely care for these patients? Should I report a near miss that didn’t harm the patient? Who is going to share the news with my patient that she has advanced cancer for which chemotherapy and other treatments will likely be of little benefit?

Add to this last scenario a family that insists the patient not be told the full diagnosis, and you have the tinder that may be ignited at any moment and flame into moral injury. Nurses often feel like they are lying each time they walk into a room to care for a patient in such a situation. They may become angry at families for placing them in such a situation that goes against their personal and professional values. [6] These, and many more questions, demand answers throughout a “typical” day in healthcare, but they were heightened exponentially throughout the pandemic.

This condition also impacts church members as well who were silent when those in religious authority in churches and denominations dealt with sexual abuse victims in hurtful ways. Clergy members who commit sexual abuse cause deep moral injury to those they are called to shepherd. Victims feel betrayed and suffer despair and loss when they consider that these leaders are God’s representatives. Churches that hide the truth, harm the victims by enabling and protecting sexual predators.
The Deeply Spiritual Nature of Moral Injury
Although Jonathan Shay pioneered the term “moral injury,” awareness of the occurrence has been evident for centuries. Evidence of such soul suffering, in fact, may be found in various religious and civil traditions. [7] Early research on soldiers with moral injury was conducted mainly by psychiatrists, but in time it was discovered that moral injury affected the whole person and was deeply spiritual in nature. [8]
In Jewish and Christian sacred writings, for example, it may be gleaned from the account of David’s sin against Bathsheba, the betrayal of Uriah’s trust in King David, the subsequent moral confrontation of the king by the prophet Nathan, and symptoms like David’s guilt, shame, and remorse (2 Samuel 10-12; Psalm 51). The narrative of Peter’s avowal of loyalty and then denial of Christ offers us a New Testament example of moral injury. The lead disciple denied Christ, and as the bruised and beaten Savior looked upon him, he wept bitterly and fled (Luke 22:54-62). Guilt, shame, and deep remorse were evident in his actions.

It should be obvious that moral injury is deeply rooted in human moral values and is profoundly spiritual. I find it especially significant that forgiveness and soul repair were essential elements in helping both broken lives to heal (see 2 Samuel 12:13; Psalm 51:7-10; Luke 22:32; John 21:15-19). It will be a significant element in healing for those in our faith communities as well.
A Pathway to Healing and Hope
John T. McNeill writes, “The soul is the essence of human personality. It is related to the body, but it is not a mere expression or function of body life. It is capable of vast ranges of experience and susceptible of disorder and anguish” (italics mine). [9] Walking alongside those who suffer from moral injury provides a pathway to help them overcome the disorder and anguish in their souls. There is a long historical approach to caring for the broken and wounded. It follows in the pattern that the Lord set with His followers.
Jesus made a resurrection appearance to the disciples as they were fishing by the Sea of Tiberias (John 21). It was here that He shared a breakfast with these close followers, and restored Peter who had terribly failed Him. Jesus commissions the recently broken Peter, who carried a burden of guilt and shame, to a life of blessing others when He models, and then instructs, Peter in “Tending my sheep.” The word means to care for them wholly, and I believe that He gives Peter a ministry of soul care in this moment. How is such a ministry shaped?
Pastoral care historically has been grouped into four functions: healing, sustaining, guiding, and reconciling. [10] Churches do well when they equip disciples who display the qualities necessary for the care of souls. Those who care for souls genuinely love people regardless of their circumstances, actively empathize with them, know when to speak and when to walk alongside in silence, and are trustworthy. [11]
A Way Forward for Christians
Soul care is a first step toward healing. Pastoral caregivers know the significance of this sacred ministry. In it, we acknowledge that a person’s wounds are not taken from him. Healing may be long in arriving for the sufferer of moral injury, but care should be their constant companion along the way. The aim is a new level of spiritual insight and welfare. Surely physical healing takes place, but this type of care is distinguished by an advancement in the soul’s ability to reflect upon illness and health as experiences that are laden with spiritual significance.
Companionship, also termed sustaining, is also an important element in providing soul care for those who suffer moral injury. The care of souls is not the simple “fixing” of a wounded person. Those who truly care for souls know that both they and the wounded person share the common reality of being sinners in a broken world. This spiritual partnership has been termed “compassionate commiseration.” [12] Companions through suffering know how to mourn with hope (Matthew 5:4)! The caregiver guides a sufferer to such choices that not only affect the present but impact the future state of the soul. Both are bound together in common dependence upon God’s grace and hope for His healing. [13]
The Cross of Christ demonstrates God’s solidarity with a suffering world. It was on the cross that Jesus took upon Himself the “sinful brokenness of the world.” Caregivers point sufferers toward reconciliation where broken relationships between humans, and also with God, are repaired. When sufferers and those who care for them take up the cross together and follow Christ in discipleship, Christ enables them to bear it in their sorrows and joys. Though we suffer greatly, nevertheless, we “live” in Christ (Galatians 2:20). Community is created when we demonstrate our connected-ness throughout this type of shared suffering! [14]


Simon Peter left the seaside that day a changed man. I wonder if the scars that Christ bore in His hands and side served to remind this disciple that, while the scars remain, new life and fresh hope are possible through Jesus Christ. Those who suffer from the scars of moral injury may find renewed hope when we show our wounds and walk hand in hand together toward the Wounded Healer, Jesus Christ.

Larry C. Ashlock
Click here for a helpful guide to understanding and responding to moral injury.
1. Cf. also the rubric, “Moral Distress,” that is used in healthcare. Moral Distress in the Health Professions, 13: “Most understand moral distress to occur when a healthcare professional, as a moral agent, cannot or does not act on his or her moral judgment(s) (or what he or she believes to be right in a particular situation) because of institutional or internal constraints” (14). The terms moral injury and moral distress often refer to the same condition. See Papadopoulos, Moral Injury and Beyond, 133, 144-5. I will use the term "moral injury" in this article.
2. James M. Childs, Jr. “Moral injury and the priesthood of all believers,” Dialog (2018; 57:111-119)].
3. Ibid., 111.
4. Cf. Litz and Nash.
5. Jason A. Nieuwsma, et al, “Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers,” in Journal of General Internal Medicine (5 April 2022).
6. Moral Distress in the Health Professions, 17-19.
7. Exploring Moral Injury in Sacred Texts.
8. Moral injury and Beyond, 14.
9. Childs, "Moral Injury and the Priesthood of the Believer," 113.

10. Clebsch and Jaekle, Pastoral Care in Historical Perspective, 8-9.
11. Oden, Pastoral Theology, 188-189.

12. Pastoral Care in the Historical Tradition, 9.
13. "Moral Injury and the Priesthood of the Believer," 114.
14. Ibid.