Leadership as Related to Moral Injury in a Military Context: A Systematic Scoping Literature Review

Abstract

The dominating emphasis of psychological research into moral injury has focused on clinical assessment, diagnosis, and treatment. This article focuses on the particular case of the role of the leader/leadership in moral injury in a military context. To address this objective, a systematic scoping literature review was conducted with the aim of investigating the scope of existing research to identify gaps and encourage future research and interventions. Thematic analysis was used to structure the data in an explorative inductive manner and an attempt was made to integrate the themes identified to gain a more holistic understanding of the subject matter. The results show that a significant portion of the literature views leadership failure or leader betrayal as a potentially morally injurious event (PMIE), a primary cause (predictor) of moral injury. However, a significant number also view leadership as a key factor in the prevention and mitigation of moral injury. Consequently, the lack of empirical evidence focusing on the role of leadership in moral injury must be regarded as problematic and should be given greater emphasis to advance understanding and guide the development of effective, evidence-based interventions.

Introduction

During military operations, officers, and soldiers frequently encounter moral challenges, compelling them to navigate ethically intricate decisions with potentially far-reaching consequences. These decisions often need to be made swiftly, in the face of uncertainty, time constraints, and under the pressures of stress (Holenweger et al., 2017; Kolditz, 2007). The military’s legitimate use of violence is thought to make handling moral challenges especially difficult (Värri, 2007). Olsthoorn and Kucera (2023) further argue that military leaders are “in a particularly difficult and challenging position” as they are expected to “intermediate between superior authorities and subordinate personnel, which can entail several contradictory responsibilities such as fulfilling the task, ensuring the well-being of subordinates, and safeguarding the appropriate conduct of operatives” (p. 4).

Moral injury describes “the suffering that may develop following a violation of deeply held moral beliefs and values” (Farnsworth et al., 2017, p. 391) or the adverse health effects that may arise when an individual “perpetrates, fails to prevent, or bears witness to acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 697). Thus, a potentially morally injurious event (PMIE) is “a situation that occurs in a high-stake environment when an individual perceives that an important moral value has been violated by actions of self or others (Farnsworth et al., 2017, p. 392). PMIEs may thus include self-directed moral injury (moral injury self), other-directed moral injury (moral injury other), and betrayal type events (Litz et al., 2022).

The psychological and social consequences of facing a moral challenge and being unable to act in accordance with one’s own morals and standards are, in most cases, moderate and short-term (Litz & Kerig, 2019). Whereas moral distress refers to milder stress reactions resulting from individual or accumulated morally challenging events (Jameton, 1984), moral injury emphasizes the intense, persistent, and long-term symptoms that arise from high-stake situations or moral trauma (Cartolovni et al., 2021; Grimell & Nilsson, 2020). Some scholars propose a syndrome definition—moral injury syndrome (MIS; Harris et al., 2024; Jinkerson, 2016). Moral injury is considered an important health outcome, constituting a more chronic negative health condition, associated with significant functional impairments in key areas, such as interpersonal relationships, professional functioning, quality of life, and overall well-being (Farnsworth et al., 2017; Griffin et al., 2019; Schein et al., 2021).

The term moral injury originated in research on the adverse health effects of military combat deployments as it became increasingly evident that the psychological implications of morally and emotionally challenging situations are complex, and the well-defined symptomology of the post-traumatic stress disorder (PTSD) framework (Weathers et al., 1993) was found to be insufficient in fully accounting for these experiences. Research indicates that PTSD and moral injury partially overlap; however, both conditions are proposed to be associated with distinct symptomatology (Battles et al., 2018; Bryan et al., 2016). It should be noted that while PTSD is a psychiatric diagnosis with a well-established symptom profile, moral injury is a relatively new concept and is not classified as a psychiatric disorder. Scholars are still in the process of delineating and conceptualizing moral injury to clarify its boundaries and clinical relevance. An additional rationale for examining moral injury among military personnel is its documented association with suicide (Jamieson et al., 2020).

Research on moral injury related to military service gained prominence 2000–2010. In its early stages, scholars faced challenges disentangling exposure to PMIEs from the actual symptomology of moral injury. This distinction is reflected in existing assessment tools, some instruments, such as the Moral Injury Events Scale (MIES, Nash et al., 2013), focus solely on exposure to PMIEs, whereas the Moral Injury Symptoms Scale (MISS, Koenig et al., 2018), aims to assess symptoms following such exposure. In recent years, research efforts have increasingly sought to capture both PMIE exposure and corresponding symptoms within integrated measurement frameworks (e.g., the Moral Injury Outcome Scale, MIOS (Litz et al., 2021; Litz et al., 2022); the Moral Injury and Distress Scale, MIDS (Maguen et al., 2024; Norman et al., 2024).

Molendijk et al. (2022) argue that the dominating emphasis of psychological research into moral injury has focused on clinical assessment, diagnosis, and treatment. A possible explanation for the current focus is that early research into the causes of moral injury was primarily conducted by scholars with expertise in individual soldier mental health. As a result, there is a lack of research highlighting the importance of the contextual factors relevant to moral injury (Bryan et al., 2016; Currier, McCormick, et al., 2015; Drescher et al., 2011; Maguen & Litz, 2012; Nash & Litz, 2013; Thompson, 2015; Vargas et al., 2013). Thus, few studies have explored the relationship between leadership and moral injury in a military context. Yet this relationship clearly warrants more in-depth exploration, given that ethics is integral to effective leadership, and because service personnel have proven to be less prone to combat-related psychological symptoms when they trust their leaders to make morally sound decisions (Olsthoorn, 2023; Shay, 2002). For that reason, this article focuses on the particular case of the role of the leader/leadership in moral injury in a military context. To address this objective, a systematic scoping literature review was conducted with the aim of investigating the scope of existing research to identify gaps and encourage future research and interventions (see for example, Munn et al., 2018). It is suggested that the findings might serve as, at least, a starting point for guiding military leaders’ reflection about their role in seeking to prevent and mitigate moral injury. Before turning to the results, the procedures used to select articles for the literature scoping review and the approach used to analyze and summarize the literature are outlined.

Methodological Considerations

The results obtained are based on two literature searches, the first in the following databases: PsycInfo, PsycArticles, Military Database, Sociological abstract, Psychology database, PTSD pubs, sociology database, and social science database; the second search was in PubMed. All databases included in the initial search were accessed through ProQuest Central. The key words guiding the searches were “military” and “leadership” combined with the concepts of “moral distress” and “moral injury,” respectively.

Research on moral injury gained momentum around 2000–2010. Yet, some studies related to moral distress were conducted earlier. For that reason, the search was carried out from 1980 onwards to ensure that relevant material would not be overlooked. In order to maintain a standard of quality, the selection of material was limited to scholarly publications, excluding unpublished sources and gray literature. In the searches, inclusion criteria were “published between 1980 and august 1, 2025, written ‘in English’, and ‘peer reviewed’ only. The terms ‘military’ and ‘moral injury’ and ‘moral distress’ needed to be included in the article abstracts, whereas ‘leadership’” could appear anywhere in the journal articles. The search combinations were as follows:

Search 1:

(1) abstract (moral injury) AND abstract (military) AND (leadership)

(2) abstract (moral distress) AND abstract (military) AND (leadership)

Search 2:

(1) ((moral injury [Title/Abstract]) AND (military [Title/Abstract])) AND (leadership [Text Word])

(2) ((moral distress [Title/Abstract]) AND (military [Title/Abstract])) AND (leadership [Text Word])

The two searches were repeated, replacing the word “military” with “veteran,” “soldier,” and “armed forces.” This led to the identification of additional articles relevant to the study.

The searches produced 95 articles, after removing duplicate records, 59 articles remained relevant. These were read in full by the author. Nine were deemed irrelevant to the study’s purpose and were excluded from the analysis, while three others were inaccessible. All records were excluded by thorough manual review by the author, no automated tools were used. Consequently, 47 articles from the database searches were included in the systematic scoping literature review. In addition to the database searches, manual searching of reference lists and key journals was conducted to ensure comprehensive coverage of relevant literature. This led to the inclusion of an additional 10 articles, in total 57 were included in the literature review. Figure 1 gives an overview of the search processes in a PRISMA flow diagram (Page et al., 2021).

Figure 1.

PRISMA Flow Diagram of the Literature Search Processes (Page et al., 2021)

It should be noted that the selection criteria did not distinguish between articles focusing on activities conducted at home units and those related to military deployment or operations. However, to help the reader assess the potential generalizability across the identified themes, an overview of the contextual emphasis of each journal article is presented in Appendix 1.

Data Analysis

Thematic analysis was used to structure the data in an explorative inductive manner (see for example, Braun & Clarke, 2006). This type of approach is often used to explore and integrate new, understudied or complex issues, such as the issue here, the role of leadership related to moral injury in a military context. In such cases, overall themes emerge from the selected literature, which can be used to inform or formulate theories and identify opportunities for additional investigation. Accordingly, the articles were first read to get a brief overview of the material; they were then read more thoroughly to fully conceptualize the study results. Next, an initial coding was applied and the codes were sorted into different themes. Finally, an attempt was made to integrate the themes identified to gain a more holistic understanding of the subject matter. Thus, there was a progression from description to interpretation, with an attempt to theorize the significance of the patterns and their broader meanings and implications (Parker, 2004).

Results

The Role of the Leader/Leadership in Moral Injury

From the 57 publications included in this review, three themes were identified, which focus on the special case of the role of the leader/leadership in moral injury in a military context: (1) Leader(ship)-related PMIEs, (2) Leader(ship)-related moral injury health outcomes, (3) Leader(ship)-related moral injury preparation, mitigation and intervention. A fourth theme was identified, (4) Situational and organizational moderation factors, that are proposed to cut across the remaining themes, by moderating the relationship between individual experiences and health outcomes related to moral injury by elevating the likelihood of perceiving a leader’s actions as a form of betrayal. An overview of the themes is shown in Table 1, and this will be elaborated upon below.

Table 1.

Leadership Related to Moral Injury in a Military Context

The role of the leader/Leadership in moral injury
Theme 1	Theme 2	Theme 3
Leader(ship)-related PMIEs	Leader(ship)- betrayal related moral injury health outcomes	Leader(ship)-related moral injury preparation, mitigation, and intervention
- Leadership betrayal or failure	- Reactions, symptoms	- Ethical leadership
- Leader self-betrayal	- Moral orientation and sense of self-worth	- Education and training to enhance moral injury awareness
- Institutional/systemic betrayal or failure	- Alienation	- Fostering ethical climate and removing stigma
	- Military readiness and help-seeking behaviors	- Post-PMIE leader intervention
		- Integrated collaborative moral injury approach
Theme 4
Situational and organizational moderation factors
- Lack of time
- Inadequate and insufficient information
- Subordination and lack of accountability

A summary overview of themes and coders, with reference to the articles in which they were identified, is provided in Appendix 2 to illustrate the extent to which the various articles support the themes that have been identified.

Leader(ship)-Related PMIEs

The first theme identified in this literature scoping review, linking leadership to moral injury, is the leader as a PMIE in terms of violating their own or their subordinates’ moral standards in a high-stake situation. Three sub-themes were identified: leadership betrayal or failure, leader self-betrayal, and institutional/systemic betrayal or failure.

Leadership Betrayal or Failure

Previous research addresses what is known as other-directed moral injury, suggesting that moral injury symptoms arise from the individual’s response to actions committed by others, such as leadership failures or betrayal by someone in a position of authority (Battles et al., 2018; Blinka & Harris, 2016; Nash et al., 2013; Richardson et al., 2020; Shay, 2009, 2014). However, in considering leader betrayal as a potential or primary source of moral injury, Norman et al. (2024) note that leader betrayal must be related to a PMIE and not just any type of stressor or negative life event. The authors argue that the feeling of betrayal alone is likely a poor indicator of moral injury. Peris et al. (2024) clarify this by suggesting that for betrayal to occur, an individual in a leadership position must have violated another person’s moral standards.

Richardson et al. (2022) criticize previous research into leader betrayal related to moral injury for being overly conceptual in nature and lacking empirical grounding. They argue that much of the work is based primarily on the perspectives of professionals or scholars, rather than on empirical evidence from those personally affected by moral injury. As a result, existing studies are criticized for lacking the depth and practical insights that empirical research involving affected individuals could provide. Yet, there are studies that show a positive correlation between leader betrayal and moral injury (Battles et al., 2018; Kelley et al., 2019; Richardson et al., 2022). In a study by Battles et al. (2018), 95.5% of the study participants reported having experienced at least one leadership failure or betrayal morally injurious event (MIE). Furthermore, Richardson et al. (2022) found empirical evidence of experiences of betrayal (of self, of and by others) being confirmed as a primary construct in their veteran sample, more specifically as a third MIE factor (in addition to events involving action/inaction by self/others). They go on to suggest that these findings support previous qualitative studies, more specifically that leadership failures, and violence in the ranks, may indeed result in moral injury (Drescher et al., 2011; Vargas et al., 2013).

Research gives accounts of situations in which military personnel face moral challenges due to leaders being incompetent, lacking operational understanding, displaying negligence, or demonstrating poor leadership (Currier, McCormick, et al., 2015; Hodgson et al., 2022). Examples include leaders not leaving secure areas because of fear after high-risk incidents and leaving personnel uncertain about the correct course of action. In such situations, leaders are portrayed as displaying cowardice, erratic behavior, and poor judgment. Another example includes leader betrayal arising from the execution of orders that fall outside accepted Rules of Engagement (RoE) (Litz et al., 2009). The literature also describes instances of leader betrayal through breaches of trust, failure in the duty of care, and failure to listen to or support their own troops. Further examples include leaders putting troops at unreasonable and needless risks or in harm’s way, without justification, and subordinates being sent into combat while leaders remain physically distanced, and not sharing the risks. Such circumstances can make service personnel question their work and wonder whether their efforts are truly worthwhile (McCormack et al., 2022; Peris et al., 2024).

The literature in this review also describes PMIEs where service personnel perceive their leaders as not prioritizing mission success and instead opting for poorly planned or unnecessarily risky missions (Currier, McCormack, et al., 2015; Hamrick et al., 2022; Hodgson et al., 2022; McCormack et al., 2022). In addition, the literature reviewed recounts situations where commanders have competed to prove themselves the “best” leader or made decisions driven by political motives and personal career advancement. Such actions, when perceived to be prioritized above the welfare of personnel, have been identified as PMIEs (Currier, McCormack et al., 2015; Hamrick et al., 2022; Hodgson et al., 2022; McCormack et al., 2022; Peris et al., 2024). Violations of trust are also apparent in incidents of sexual harassment, when the hierarchical rank structure or higher-ranking leadership is expected to provide a sense of protection (Hamrick et al., 2022).

Overall, current research indicates that many decisions and actions that place the safety of organizational members at risk, and lead to moral injury, are made by individuals in positions of authority (Hodgson et al., 2022). Hodgson et al. (2022) argue that, for subordinates, the dynamics and health-related outcomes of leader betrayal are intensified by the narrative that the military functions as a family.

Leader Self-Betrayal

The second code underpinning this theme is leader self-betrayal as a PMIE, which concerns an individual’s perception of failing to meet their own leadership expectations or of not adequately fulfilling the leadership role (Richardson et al., 2022). In fact, Hodgson et al. (2021) note that the moral injury literature indicates that betrayal very often encompasses an individual’s own lapses in judgment, of which there is qualitative empirical evidence. For example, previous research shows that failing in one’s duty may involve a perception of having committed or failed to prevent actions that violate one’s own moral principles (Bryan et al., 2016; Currier, McCormack, et al., 2019; Griffin et al., 2019; Hodgson et al., 2021; Litz et al., 2009). Zust and Krauss (2019) give an account of a leader feeling shame because of self-blame for poor decision-making, resulting from breaking a promise to bring everyone back home. Such actions can contribute to unfavorable perceptions of one’s character. Leaders may also feel responsible for failing to do more to prevent serious consequences stemming from decisions made by their superiors, such as loss of life (Wortmann et al., 2017). For example, a leader may regret not speaking up against an order they believed to be immoral (Zust & Krauss, 2019). Hosein (2019) points to fear as an underlying reason for some refraining from opposing superiors’ decisions, when these decisions do not align with their own morals and standards. Griffin et al. (2020) describe this moral challenge as an intersection of feeling personally responsible while simultaneously experiencing betrayal by others.

Institutional/Systemic Betrayal or Failure

Scholars point out a tendency in previous moral injury research to overemphasize or place undue focus on individual [leader] transgressions and consequently avoid systemic betrayal in the conceptualization of PMIEs (Hodgson & Carey, 2017; Molendijk, 2019; Scandlyn & Hautzinger, 2014). This, they argue, risks obscuring the broader systemic and societal responsibilities involved in moral injury. For instance, and importantly, it is political leaders who decide where soldiers are deployed, and define primary military objectives.

Thus, systemic betrayal or failure is identified as a PMIE and refer to the misuse of power across the greater hierarchical system as a whole, which leads to an overall lack of trust, driven by ongoing breaches of moral integrity. The theme of institutional or systemic factors resembles the content of Theme 1, but also emerges as a distinct sub-theme according to the systematic review methodology. It is suggested that this type of betrayal reflects a more generalized, diffuse sense of betrayal associated with the organization as a whole. Thus, Hodgson et al. (2021) argue that moral injury should be recognized not only as an issue impacting individuals, but also as an issue that entails responsibility at both organizational and governmental levels. Institutional or systematic betrayal may lead to leadership ignorance and foster a sense of powerlessness among military personnel at all levels as they struggle to readjust their moral compass in different situations (Richardson et al., 2022).

In support of the influence of institutional or systemic betrayal, a study by Molendijk (2019) shows that decisions by the Dutch political leadership created moral dilemmas on the ground in Afghanistan, and yet the political leadership refrained from taking responsibility for their share of the problem. It is suggested that common ways for political leaders to avoid problems [political failure] include political silence or referring to “the bigger picture” (Molendijk, 2019). Assigning tasks that are nearly impossible to complete or may conflict with service personnel’s personal values, can result in moral injury (Molendijk, 2019).

Other forms of betrayal, described as ‘systematic failures’, stem from inadequate resources and flawed processes that hinder troops’ access to necessary support. These include incidents where the organization fails to provide sufficient equipment or healthcare, leaving service personnel underserved. Service personnel may also experience moral conflicts when their military principles do not align with what they perceive to be unjust or disproportionate uses of force during particular missions or operations (Peris et al., 2024).

Institutional betrayal is a term introduced by trauma scholars Smith and Freyd (2014) and concerns a breach of a trust-based relationship by an institution towards one of its members. Because there have proven to be moral conflicts between individual military veterans and the political level, Molendijk (2019) suggests that this should play a bigger role in military moral injury research. From a leadership perspective, Molendijk (2019) argues that it is beneficial to consider veterans’ experiences within the realm of political issues, rather than maintaining an ‘intentional silence’, because this allows them to seek meaning and validation rather than feeling abandoned.

Denov (2022) suggests that institutional betrayal by leaders is particularly traumatic in the military because service personnel depend on the organization for their own safety and well-being and that of their comrades (cf. organizational family betrayal). McCormack and Lauren (2017) discuss “organizational family betrayal” and refer to feelings of betrayal that may arise post-deployment, in response to how personnel have been treated by the deploying organization (McCormack & Lauren, 2017). Such “organizational family betrayal” is also evident among former military personnel, who struggle to make sense of betrayal that goes beyond isolated incidents of leadership misconduct and which they perceive as a lasting failure of the organization as a whole.

Leader(ship) Betrayal-related Moral Injury Health Outcomes

Based on the thematic analysis resulting from the scoping literature review, a link between leadership and subordinates’ health and well-being was identified, in terms of leader(ship) betrayal-related health outcomes, including subordinate reactions/symptoms, subordinate moral orientation and sense of self-worth, alienation, military readiness and help-seeking behaviors. In addition to outcomes directly linked to moral injury, the literature indicates that some outcomes are less directly linked to it.

Reactions/Symptoms

Several studies in this review examined variations in moral injury outcomes in relation to different types of MIEs. For example, it has been suggested that betrayal-based experiences lead to health-related outcomes that differ from those associated with perpetration-based experiences (Peris et al., 2024). This distinction is particularly relevant for understanding the role of the leader/leadership in moral injury.

For example, a study by Larsson et al. (2018) accounts for short-term reactions in morally challenging situations that include experiences of insufficiency, powerlessness, meaninglessness, and frustration, in the literature referred to as ambitious negative states (Lazarus, 1991). These reactions are often responses to hierarchical systems and power structures, emerging when individuals are prevented from acting in accordance with their own morals and standards in high-stake situations. These are suggested to represent a specific case of the general acute stress reaction, in which the moral conflict appears to be an aggravating circumstance.

Turning to more long-term reactions, the findings show that leader self-betrayal or violating one’s own moral codes seems to evoke a greater sense of responsibility, and consequently more guilt and shame, whereas individuals exposed to other-directed moral injury (betrayal) seem more prone to feel anger, disgust, mistrust, and disrespect, alongside feelings of hostility and resentment (Bryan et al., 2016; Currier, McCormack, et al., 2019; Griffin et al., 2019; Kalmbach et al., 2024; Litz et al., 2009). The literature shows that the latter form of leader betrayal is frequently seen as a moral violation of trust, which tends to leave subordinates feeling insecure, let down, viewed as expendable in life-threatening situations, or unsupported by their leadership under extreme conditions (Currier, McCormack, et al., 2015; Hodgson et al., 2022; Kalmbach et al., 2024; Richardson et al., 2022). Shay (2009) identifies the loss of social trust as the primary consequence. It should be noted, however, that one study, contrary to previous findings, demonstrated that guilt and shame were predicted not only by self-transgression but also by experiences of betrayal (Lancaster, 2018).

There are also studies, which show that leader deception may result in service personnel feeling discouraged and disappointed (McCormack et al., 2022) or disillusioned and embittered, which may develop into anger, and ultimately uncertainty about the motives behind their missions and a loss of trust in their leadership (Hodgson et al., 2022; Wortmann et al., 2017). For example, one study described how a person’s high ethical standards were intensified upon joining the military, but were later challenged by leaders’ ethical failures, resulting in anger, anxiety, and heavy substance abuse (Wortmann et al., 2017). Battles et al.’s results (2018) also show associations with substance use, including symptoms of hazardous alcohol and drug abuse. Although their results are preliminary, they suggest that MIEs in the form of leadership failure or betrayal may contribute to the onset and persistence of mental health challenges and harmful alcohol consumption.

Braitman et al. (2018) looked more specifically into the relationship between leadership failure or betrayal, moral injury, and long-term mental health. They found associations with MIEs and higher anxiety symptoms, depressive symptoms, and PTSD symptoms among military personnel. Perceptions of organizational invalidation and indifference also tend to shape homecoming experiences, resulting in reactions of self-loathing, withdrawal, and intense anger. Thus, negative perceptions of organizational support during post-deployment reintegration into society can drive intense emotional responses. When veterans feel unacknowledged or dismissed by their organization, it can compound feelings of isolation, frustration, or even self-directed anger, making the transition to civilian life challenging (McCormack & Lauren, 2017). These experiences are particularly significant when considered against the backdrop of the narrative of the military as a family, a concept rooted in mutual loyalty (McCormack & Lauren, 2017).

The literature also illustrates how institutional betrayal outcomes may involve an increased risk of attempted suicide (Monteith et al., 2016; Shay, 2009). Demoralization, hopelessness, and a sense of disconnectedness are thought to contribute to suicide behaviors following leader betrayal (Van Ordet/n et al., 2010). Hamrick et al. (2022) were the first to study associations between military sexual harassment, other-directed moral injury, and mental health outcomes, specifically among female veterans. The results align with previous research linking military sexual harassment to depression, anxiety, and suicidality. This may elevate the risk of PTSD, disability, and reduced quality of life.

Moral Orientation and Sense of Self-Worth

Previous research demonstrates that leader betrayal can influence veterans’ overall orientation toward authority (Kalmbach et al., 2024) and, in the long term, their personal values (Richardson et al., 2022). For example, some studies suggest that military personnel may lose trust in others, which can lead to the development of alternative global beliefs about their own worth and morality, eventually resulting in a perception of themselves as immoral (Litz et al., 2009; Shay, 2002). Shay (2009) argues that the most psychologically damaging consequence of leader betrayal lies in its deforming effect on the individual’s moral character. In turn, this may lead to moral disorientation, the erosion of moral character, the fragmentation of beliefs, the breakdown of trust, and lasting psychological harm (Molendijk, 2018; Shay, 2014).

Alienation

From the perspective of “organizational family betrayal,” McCormack and Lauren (2017) have identified multilayered feelings of disillusionment and abandonment related to the organization’s post-deployment treatment in terms of “a sense of betrayal beyond leadership malpractice” (p. 240) due to a lack of reciprocal commitment. As a result of such maltreatment, participants struggle to reconcile their prior trust in the organization, which gives rise to feelings of hurt and a growing sense of cynicism and distrust. The core values of “their military family,” such as “camaraderie” and “teamwork,” risk being undermined, making them question the mission itself, the motives of their leaders, whether the mission [Afghanistan] was genuinely just or merely a set-up, and whether safety was truly prioritized or leaders were driven by their own self-interest. Consequently, individual service personnel may become increasingly alienated from “the [military] family.” Sometimes leader betrayal has been found to result in a profound sense of alienation and a rejection of social norms in civilian society upon returning home (Currier, McCormack, et al., 2015).

Military Readiness and Help-Seeking Behaviors

The literature included in this scoping review also demonstrates how leadership failures may have adverse effects on subordinate performance. For example, leadership betrayal and lack of accountability in small units may increase the probability of service personnel themselves committing acts that they consider to be morally incorrect (Currier, McCormick, et al., 2015). Similarly, Zust and Krauss (2019) point to performance related aspects following PMIE exposure and note that, not only is the well-being of the individual at stake, but so are military readiness and mission success. Shay (2009) emphasizes the critical role of sleep in ethical decision making among military commanders. He argues that sleep deprivation undermines ethical and emotional self-regulation, thereby heightening the risk of poor judgment and impulsive behavior. As a result, leaders may lose the ability to make sound tactical decisions, care for their troops, and maintain moral clarity.

Leader betrayal may also constitute barriers to treatment (Holliday & Monteith, 2019). In some cases, veterans avoid seeking help due to fear of being judged post-deployment (McCormack et al., 2022). McCormack and Lauren (2017) conclude that their research points to a potentially problematic military “environment” that may hinder personnel from seeking support and feeling heard and validated, thereby creating a barrier to care.

Leadership-Related Moral Injury Preparation, Mitigation, and Intervention

As already noted, current moral injury research predominantly focuses on individual-level approaches to understanding and addressing moral injury causes and consequences—clinical assessment, diagnosis, and treatment—rather than prevention and early intervention (Phelps et al., 2022). Some scholars argue that prevailing perspectives on moral injury must expand to include a broader understanding of trauma that goes beyond the individualizing and pathologizing focus of clinical practice (Molendijk, 2019), and redirect focus toward the broader context of the organization, leadership, and team dynamics (Nazarov, 2023). Scholars emphasize the need to develop evidence-based understanding of protective factors that shape moral injury processes and outcomes (Litz & Kerig, 2019; Zerach et al., 2023). Phelps et al. (2022) offer guidance, based on the current understanding of moral injury and contemporary approaches to psychological resilience, and point to the importance of building effective leaders. The third theme identified in this scoping review includes favorable aspects of leadership as a potential means of preparing for or mitigating the adverse health effects of moral injury.

Ethical Leadership

Ethical leadership is conveyed as a positive moderating mechanism in the moral injury literature included in this scoping review. For example, it is suggested that leadership by moral example is at the core of military moral health; “The [army] is a product of its senior leaders” (Peris et al., 2024, p. 214). Shay (2009) emphasizes that one of the three most critical factors in safeguarding the psychological and spiritual well-being of individuals deployed into combat is leadership, specifically expert, ethical, and supported leadership at all levels of command. He further asserts that preventative psychiatry within military institutions constitutes an ethical responsibility of leadership.

A qualitative interview study gives empirical evidence to leadership as an important contextual factor, particularly the practice of ethical leadership in terms of being a moral person (e.g., being secure in one’s own values, communicating the importance of values) in severely stressful situations, involving moral stressors (Hyllengren et al., 2016). Kilner (2023) argues that leaders must not underestimate the impact of their own moral character on the well-being of soldiers, a factor he suggests is “enormously magnified” during combat operations. As leaders give orders and hold authority to task their soldiers with, for example, taking the lives of other human beings, subordinates are compelled to place their trust in their leaders’ moral decision making. Kilner (2023) suggests that it is important that leaders act morally, because their behavior affects how their subordinates see their own actions in war. The choices leaders make will affect service personnel and their conscience. Thus, Kilner (2023) notes that leaders can mitigate service personnel’s moral injuries. Research also shows that it is important that leaders offer support to service personnel who seek approval of their morally challenging decisions (Hyllengren et al., 2016). If leaders offer their support, moral distress is often reduced. Conversely, leaders who lack role-model behavior, compassion, inspiration, and trust run the risk of causing moral distress among their subordinates (Larsson et al., 2018).

Hyllengren et al. (2016) also raise the importance of leaders being moral managers and correcting morally dubious behavior to reduce the risk of moral distress among service personnel. Similarly, Kilner (2023) argues that leaders who set and enforce ethical standards significantly influence their subordinates’ attitudes towards others, including whether, for example, they treat the local population or enemy combatants with respect. If leaders expect moral behavior, subordinates are thought to be in a better position to maintain empathy and counter dehumanization. Although dehumanizing language is often said to help subordinates overcome natural psychological barriers to killing, leaders should instead provide moral justifications for actions. This approach can help prevent cognitive dissonance and reduce the risk of moral injury, allowing soldiers to remain morally integrated rather than “divorcing their soldier selves from their moral selves” (Kilner, 2023, p. 4). Kilner (2023) also stresses the importance of leaders never lowering their moral standards of behavior, because the risk of immoral actions is heightened in extreme situations as military units become morally worn down. Leaders are expected to intervene in such circumstances (Kilner, 2023), focusing on moral reasoning to reduce the risk of so-called moral fading, a phenomenon where, for example, repeated exposure to combat can lead to habituation and desensitization, causing decisions that should be ethically grounded to fade into routine aspects of how the army conducts its operations (Zust & Krauss, 2019). In keeping with the concept of systemic betrayal, Hodgson and Carey (2017) also highlight the need for accountability within organizational leadership to prevent subordinates’ sense of betrayal from being undervalued, which may undermine trust and morale. This also applies to leaders’ relationship with their superiors. They need to challenge orders that may be wrong, to avoid moral distress themselves and among their team (Hyllengren et al., 2016).

Some scholars raise the importance of leaders’ selfless commitment (as opposed to self-serving) and it being the most important of all military values and standards. This reasoning finds support in a prospective study by Zerach et al. (2023), examining associations between pre-enlistment characteristics, pre-deployment psychological factors, exposure to PMIEs, post-traumatic stress disorder (PTSD), and psychiatric symptoms, and the moderating role of ethical leadership and ethical preparation among combatants. Results show that when combatants report high levels of ethical preparation and ethical leadership at the initial time point in the study (T1), the associations between exposure to PMIEs, symptoms of PTSD, and other psychiatric symptoms, after deployment, tend to diminish or even disappear. In other words, it is suggested that strong ethical preparation and ethical leadership constitute protective factors, which buffer individuals from the negative psychological impacts of PMIEs, a notion that is also supported by Shay (2014). Zerach et al. (2023) conclude that the favorable role of ethical leadership in mitigating psychopathological outcomes is a military-related contextual protective factor that may guide both clinicians treating combatants and leaders preparing for moral challenges. Levin (2021) proposes that there is an increasing need to more thoroughly explore ways to promote leadership that avoids both real and perceived betrayal.

Education and Training to Enhance Moral Injury Awareness

The literature reviewed holds that education, training and strong leadership are key moral injury preventative measures (Frankfurt & Frazier, 2016; Kilner, 2023; Litz et al., 2009). Above all, Phelps et al. (2022) stress that leaders at all levels must be educated to understand the concept of moral injury, operational moral dilemmas, and the associated risks and be provided with the time and resources necessary to effectively address those risks. Zust and Krauss (2019) note that addressing moral concerns requires systemic resources for proper identification, and response. Since it is often the youngest and least experienced who face the harshest realities of combat, the authors acknowledge that it is important to recognize that junior officers, in particular, must receive adequate training.

Kilner (2023) is critical of the military’s institutional training and education systems, and doctrinal vocabulary, which he believes lack moral reasoning; “killing is sanitized of its moral meaning” (p. 2). He argues that prevailing approaches are not immoral, but amoral, as they focus primarily on legal and professional norms, for example, training soldiers to adhere to laws of armed conflict, while overlooking moral considerations. Therefore, he suggests that leaders are responsible for integrating moral reasoning into tactical training to prepare them tactically, morally, and psychologically. Integrating moral reasoning includes educating soldiers about the moral frameworks of war to help them understand its moral purpose. Similarly, Zust and Krauss (2019) advocate for integrating moral reasoning into combat skills training. Currier, McCormack, et al. (2015) highlight the risks of what they see as a current focus on violence in military training. They believe this focus, often reinforced by leaders, can create a culture of increased aggression, especially in high-stress or extreme situations.

Phelps et al. (2022) agree with Zust and Krauss (2019), arguing that preparation for exposure to PMIEs requires a whole organization approach, where moral injury prevention and early intervention are integrated into ethics, resilience, and leadership training. Operational leaders are thought to be in a good position to develop and deliver such training and thus should not rely solely on chaplains, legal advisors, and medical personnel to address these issues.

The literature studied also raises the importance of leadership and training in battlefield ethics as a means of reducing the risk of rules of engagement violations and consequently, the risk of illegal acts, for example, killing civilians, committing atrocities, etc. (Frankfurt & Frazier, 2016). For that reason, the US Army has provided a manual for leaders and soldiers (the Combat and Operational Stress Control (COSC Manual, U.S. Department of the Army, 2009) with strategies for identifying and mitigating risk factors for misconduct (Frankfurt & Frazier, 2016). The authors state that sound leadership is an important factor in preventing stress-related misconduct. This is supported by a study showing that individuals who experienced positive leadership were more likely to follow rules of engagement during conflicts. Thus, Frankfurt and Frazier (2016) call for interdisciplinary research into the leadership and training that would most effectively promote battlefield ethics and prevent moral injury. While combat exposure is thought to be unavoidable, improved leadership and training could mitigate certain transgressive actions, such as the illegal killing of enemy combatants or noncombatants (Castro & McGurk, 2007; Frankfurt & Frazier, 2016). It is important to note that a study analyzing the implementation of a multi-disciplinary, evidence-based resilience intervention for moral injury syndrome found that barriers to effective implementation included insufficient staffing for group leadership, as well as limited receptivity, skepticism, and reluctance among leaders. To address these challenges, it was recommended that a commander speak in support of the program to enhance its credibility, highlight its benefits, and emphasize the value of including chaplaincy, making the initiative meaningful for both faith and non-faith participants. Additionally, coaching and consultation were identified as strategies to increase leadership engagement and willingness to support the program (Harris et al., 2024).

Fostering Ethical Climate and Removing Stigma

The literature included in this review raises the importance of encouraging peer support and building unit cohesion in pre-incident resilience training because cohesive units have been shown to experience fewer health-related problems (Ascencio et al., 2017; Phelps et al., 2022). A study by Plouffe et al. (2023) showed that workplace support and perceptions of an ethical work environment mediated the relationship between leadership and moral distress.

Support from the chain of command is also described as an important element in fostering an organizational climate that prioritizes the prevention of moral injury (Griffin et al., 2020). Accordingly, the current focus on developing individual moral competence in U.S. military ethics training should be complemented by efforts to create a sustainable organizational environment that promotes ethical reflection and action.

The role of leadership in reducing the risk of moral injury is also linked to reducing the stigma surrounding psychological ill health by, for example, acknowledging individual suffering resulting from combat experiences and actively supporting the affected personnel (Molendijk, 2019; Stern, 2014) or o encouraging subordinates to seek professional help (Zust & Krauss, 2019). McCormack and Lauren (2017) describe an enduring culture of silence, an emphasis on masculinity within the military and the stigma surrounding mental health as ongoing challenges. They argue that dedicated commitment by military leaders and continuous education initiatives are required to address these issues.

Post-PMIE Leader Intervention

This scoping review shows that it is essential for leaders to support service personnel in understanding their own role in war. Leaders play a crucial role in helping subordinates process their experiences by nurturing or reforming a shared story (a unit or combat narrative) that encourages individuals to frame their actions in a way that promotes moral awareness and enhances the potential for post-moral injury growth (Kilner, 2023; Zust & Krauss, 2019). Examples given include reminding service members that suffering from grief and shame reflects morally sound individuals who possess and uphold deep ethical convictions (Kilner, 2023) and thus suggests a well-functioning moral compass engaged in navigating the unavoidable tensions between core values and situational perceptions that arise in combat (Zust & Krauss, 2019). In keeping, Hamrick et al. (2022) advocate that, in the aftermath of exposure to PMIEs, leaders and subordinates should talk with one another to help repair trust and relationships, which may help individuals to reevaluate their beliefs about others, while fostering a sense of trust and understanding. Similarly, Phelps et al. (2022) propose that leaders should address moral distress in After Action Reviews (AARs) as a form of early intervention. One effective way of coping with guilt, recommended in the literature, is to contextualize decisions through constructive feedback to reassure individuals that their choices were indeed in accordance with their military training. Additionally, creating opportunities for forgiveness by encouraging reflection and finding meaning retrospectively can also help mitigate feelings of guilt, by for example, reassuring the individual that they acted in accordance with the directives of the leadership or hte mandates of the government (Harris et al., 2015). Similarly, Kilner (2023) argues that leaders should express gratitude toward their subordinates and take responsibility for the orders they were required to carry out. Leaders should also emphasize that, even though service personnel act as individuals, they ultimately serve on behalf of the collective society, which holds the ultimate responsibility. Phelps et al. (2022) point to disclosure and discussion, individually or shared, as means of learning and moral repair.

West and Cronshaw (2022) conducted a phenomenological case study on moral injury and soul repair in the context of to the Warrior Welcome Home (WWH) retreats, a program that integrates spiritual care to address spiritual woundedness and moral injury, while exploring how leadership contributes to a nurturing community. They argue that WWH requires leadership that models vulnerability and empowers both individuals and groups. The authors emphasize the importance of employing a range of leadership styles, acknowledging that commanding approaches can be effective and appropriate in certain contexts. However, they caution against overreliance on these styles due to their limitations and potential for misuse. “While effective leadership is no guarantee of positive participant experience, poor leadership will sabotage these outcomes” (West & Cronshaw, 2022, p. 183). Empowering individuals, they suggest, involves cultivating a safe space and fostering a shared language, both of which are essential for participants to feel secure enough to express vulnerability.

Integrated Collaborative Moral Injury Approach

Addressing post-traumatic stress symptoms is often the priority of the healthcare system. Admittedly, a medical mental health perspective has guided a great deal of empirical research into moral injury. Phelps et al. (2022) propose that leaders ought to take greater responsibility for PMIEs, particularly PMIEs involving transgression, and avoid routinely referring affected individuals to healthcare providers. Instead, a more integrated approach to spiritual care within the military context has been proposed. It is suggested that operational commanders and healthcare providers should collaborate with members of the clergy or other religious figures within their local community to address the spiritual or religious dimensions of suffering and healing (Currier et al., 2024; Moon, 2019). However, if social or occupational dysfunction persists, individuals should be referred to professional help (Phelps et al., 2022).

Situational and Organizational Moderating Factors

The final theme identified comprises situational and organizational factors: lack of time, inadequate and insufficient information, and lack of accountability. It is suggested that such contextual factors may serve as moderators between the individual’s experiences and health outcomes related to moral injury, by elevating the likelihood of perceiving a leader’s actions as a form of betrayal.

Lack of Time, Inadequate, and Insufficient Information

The literature included in this study suggests that perceptions of leader betrayal are more common in situations characterized by lack of time and leaders having inadequate and insufficient information to make critical decisions (Currier, Holland, et al., 2015; Currier, McCormick, et al., 2015; Pyne et al., 2021).

Subordination and Lack of Accountability

This scoping review also shows that the military’s hierarchical structure is characterized by power relations where subordination and strict obedience of superiors are expected, placing service personnel in a vulnerable and often powerless position. Kalbach et al. (2024) note that service personnel are used to listening and following orders, which may make them vulnerable to moral injury.

Pyne et al. (2021) suggest that experiencing leader betrayal is more likely to occur in contexts characterized by a lack of accountability. Kalbach et al. (2024) thus raise concerns about leaders that misuse their power and avoid taking responsibility for their actions. As noted, a lack of accountability may increase responses related to institutional betrayal. So being the case may be particularly traumatic in the military because service personnel depend on the organization for their own and their peers’ safety and well-being (Denov, 2022).

The concept of systemic betrayal and broader systemic implications of moral injury illustrate the need for accountability within organizational leadership. Hodgson and Carey (2017) suggest that failing to hold leaders responsible for such breaches risks diminishing the validity of the moral challenges experienced by service personnel, potentially undervaluing their sense of betrayal. Lack of accountability is thought not only to perpetuate harm but also to weaken trust and morale within the organization.

Discussion

This article focused on the special case of the role of the leader/leadership in moral injury in a military context. To address this objective, a systematic scoping literature review was conducted with the purpose of investigating the scope of existing research to identify gaps and encourage future research and interventions. It was suggested that the findings might serve as a starting point for guiding military leaders’ reflection about their own role in seeking to prevent and mitigate moral injury.

This scoping review shows that a significant portion of the literature views leadership failures to act in accordance with moral principles and standards in high stake situations, specifically, leader betrayal as a PMIE, a primary cause and predictor of moral injury, positioning leadership as an integral component of the moral injury construct. This study also demonstrates that these assumptions have been consistently supported by both qualitative and quantitative empirical research. In keeping with this, Currier, McCormick et al. (2015b) suggest that the perception of “leadership malpractice is an under-researched topic in the military trauma literature, which may represent a major concern among veterans struggling to recover from moral injury” (p. 115).

The studies examining the connections between military sexual harassment, other-directed moral injury, and mental health outcomes, particularly among female veterans, give evidence to betrayal and violations of trust and stresses the critical role of leadership support and are of particular significance as higher-ranking leadership is expected to provide a sense of protection and institutional support (Northcut & Kienow, 2014). Numerous investigations have examined associations between military sexual trauma (MST) and adverse health consequences. Hamrick et al. (2022) propose that other-directed moral injury has emerged as a salient factor explaining the relationship between sexual harassment and adverse mental health outcomes within the military. There is an urgent need for further research in this area.

Institutional or systemic betrayal also emerged as a theme in this review. Although this theme is closely related to Theme 1, some argue that institutional or systemic betrayal should be distinguished from leader betrayal or failure per se, because it refers not to the actions of a single destructive or unethical leader, but rather to structural shortcomings embedded within the broader systemic context. Therefore, preventative measures for moral injury cannot rely solely on an individualized or pathological approach. In fact, Talbot and Dean (2018) caution that such a focus may even be counterproductive when addressing the complexities of moral injury, because moral injury has shown to sometimes reflect a fractured system, resulting from a complex network of conflicting loyalties that can weaken service personnel’s resilience. Ultimately, principled and managerial leadership within professional organizations should be encouraged to listen to individuals sharing their experiences, because this may reveal underlying organizational failings (Walshe & Shortell, 2004) and create learning opportunities and growth.

The literature reviewed also considers leader self-betrayal as a factor related to moral injury. Just as subordinates may feel betrayed when their expectations are not met, so may leaders experience similar feelings, where they believe they have failed to uphold their own standards or ideals of what constitutes good leadership in high-risk situations. This perspective deserves further exploration. For example, it may be valuable to ask military leaders to reflect on what factors contributed to situations where they experienced a sense of self-betrayal. Specifically, how often did such feelings in high-risk situations stem from their own ethical lapses, rather than situational factors beyond their control.

It should be noted that this review points to challenges in distinguishing between different types of PMIE (self, other and betrayal). In fact, empirical research increasingly supports the idea that PMIEs aren not mutually exclusive categories, but rather often involve elements of both transgression and betrayal (Nazarov, 2023; Nilsson et al., 2025). For example, the literature indicates that individuals may experience shame and guilt related to their own actions or inactions (self-direct moral injury/moral injury self), particularly when they feel that leadership betrayed them by placing them in situations where they saw no alternative course of action (other directed moral injury/moral injury other). This of course may also apply to the leaders themselves. It is important to note that exposure to multiple forms of adversity may place individuals at a heightened risk of poor health and impaired functioning (Saba et al., 2022). Thus, the case becomes more than just an academic question; operational leaders should be made aware of the potential hybrid nature of PMIEs, as it could have practical implications.

Given the critical role of leadership in addressing moral injury, this scoping review highlights the importance of preparing and training leaders and encouraging them to support subordinates in preparing for moral challenges. Effective preparation, for example, can help leaders avoid creating perceptions of betrayal, reduce the likelihood of transgressive actions and alleviate others’ sense of betrayal. Of course, it can also mitigate moral injury outcomes related to the different categories of PMIE. Additionally, the favorable aspects of ethical leadership in preventing and mitigating the health effects of moral injury are particularly relevant. By modeling moral behaviors and encouraging ongoing ethical discussions, there are opportunities to foster an ethical climate while removing stigma. However, it is worth noting that Thompson and Jetly (2014) caution that heightened moral awareness may increase some individuals’ vulnerability to moral injury. For that reason, they suggest that leaders and peers need to be alert to signs of psychological distress among their comrades. Potential relationships between moral awareness and vulnerability to moral injury constitute another research area warranting further inquiry.

The literature review also highlights the importance of fostering peer support and strengthening unit cohesion during pre-incident resilience training, as cohesive units have been shown to experience fewer health-related issues (Ascencio et al., 2017; Phelps et al., 2022; Plouffe et al. (2023)). However, it is worth noting in this context that group cohesion can also negatively impact an individual’s moral capacity, as it may reinforce ethnocentric beliefs and reduce empathy towards perceived out-groups. The pressure to conform is sometimes so powerful that individuals may participate in group behaviors they internally believe to be wrong, only to later reframe them as acceptable to reduce the psychological [moral] discomfort they produce (Zimbardo, 2007).

Finally, it is proposed that the organizational and situational factors identified may moderate the relationship between individual experiences and health outcomes related to moral injury by elevating the likelihood of perceiving a leader’s actions as a form of betrayal. In accordance, Plouffe et al. (2023) note that the associations between leadership and psychological outcomes are often influenced by external variables. It is therefore important that leaders are informed of both the risk factors that may increase the potential for moral injury among subordinates and of the protective mechanisms that may help to mitigate such risks.

Although a role for leadership in moral injury has been proposed, this association requires further empirical investigation. It should be noted that this review is not exhaustive, as the literature included is limited to research retrieved from the specific database searches. However, the need has been highlighted for further research and training to explore how leaders can foster leadership practices that prevent both actual and perceived moral conflicts, as suggested by Levin (2021). For instance, Bell (2024) presents empirical evidence indicating that high intensity ethics training (increased hours and diversified pedagogical methods) significantly enhances the ethical conduct of military leaders and their units during subsequent combat missions. Yet, given the significance of leadership in the moral injury construct, it is noteworthy that leadership theories, apart from ethical and moral awareness leadership, have remained largely absent in the moral injury literature. It therefore appears important for future research to, in line with other health science research, explore moral injury in relation to leadership theories, such as, for example, transformational and destructive leadership, as a means of advancing the discussion on the role of leadership to a more profound level. Also, the limited findings related to Theme 4, specifically situational and organizational factors, appear to indicate an area where further research is warranted. Studies on leadership in extreme environments may potentially provide valuable insights (see for example, Geier, 2016; Hannah et al., 2009; Kolditz, 2007).

Moreover, current research, which centers on individual clinical assessment, diagnosis, and treatment, must expand to include a broader understanding of trauma. Now may be the time for researchers examining the role of military organizations to explore additional sources more comprehensively, also enabling the integration of systemic perspectives into the field, and offering a deeper understanding of the diverse origins of moral injury. An important aspect of engaging the political level is to establish clear and consistent awareness at the highest levels in order to inform government and military mission planning.

Given the importance of fostering psychological growth in response to morally challenging situations within the military, it is essential to recognize that leadership may play a dual role, both as an active participant in PMIEs, potentially contributing to moral injury and as a key agent in its prevention and moral repair through the mitigation of its negative effects.

Conclusion

This article focuses on the particular case of the role of the leader/leadership in moral injury in a military context. To address this objective, a systematic scoping literature review was conducted with the aim of investigating the scope of existing research to identify gaps and encourage future research and interventions. The results show that a significant portion of the literature views leadership failure or leader betrayal as a PMIE, a primary cause (predictor) of moral injury. However, a significant number also view leadership as a key factor in the prevention and mitigation of moral injury. For that reason, there is a great need for additional empirical research on the role of leadership in moral injury to advance our understanding of moral injury and guide the development of effective, evidence-based interventions.