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Abstract

Building on the anthropology of the good, this article seeks to apply a taxonomical approach inspired by analytical philosophy to the study of moral incoherence. The topic of moral incoherence is a growing concern in clinical contexts. Drawing on fieldwork and clinical data during the COVID-19 pandemic in Malta, this article brings together approaches from anthropology, psychiatry and psychology to look at the way in which such ‘moral breakdown’ has been studied in relation to mental health and existing diagnostic structures. Moral incoherence, it is proposed, can be conceived of as a problem in terms of rationality, which has implications for the imaginary coherence of the subject. This article, therefore, makes two primary contributions. It develops an approach to the anthropology of the good by means of an analytical reduction in terms of a series of ought statements. Secondly, it applies the approach to the problem of moral incoherence by engaging with various disciplinary perspectives, particularly those in psychiatry, psychology, and, to a lesser extent, philosophy. The implication of moral problems to mental health cannot be merely dismissed as the pathologisation of everyday life. Such problems are exacerbated in times of crisis, where the possibilities for coherence become increasingly challenged.

Keywords

Morality mental health moral distress double-bind Malta rationality psychiatry COVID-19 incoherence the good

Introduction

This article contributes to the study of the ‘anthropology of the good’. More specifically, it proposes a comparative approach to the study of moral incoherence. While disagreements over moral questions within the same communities are well known, as can be seen in objections of conscience (Mishtal, 2009; Weiss, 2014), this article focuses on intra-subjective moral conflicts. This article develops a taxonomy of moral incoherence by adopting an analytic reduction that considers the relation to the good as a set of ought statements. Such a contribution develops further and in new directions the anthropology of the good and the study of what has been described as ‘moral breakdown’. This moral incoherence can be seen in people acting in ways that are contrary to, or falling short of, their judgements (moral inhibition, which includes what philosophers call akrasia) or when one holds contradictory moral imperatives (a moral double-bind proper as well as simply cases of internally conflicting values). While potentially generating a reflective consciousness (Zigon, 2024), moral incoherence can also be the source of significant ‘moral distress’ and has been linked to psychopathology in different ways. I argue that moral incoherence poses a fundamental challenge to the subject to form a cohesive self-image but also a rational and coherent moral life. Drawing upon literature from mental health sciences, this article seeks to engage in a dialogue with different disciplinary conceptions of moral incoherence. I use two primary empirical sources to provide case illustrations: 110 ethnographic interviews led by the author and conducted as part of an international comparative COVID-19 vulnerability-assessment study (Baldacchino et al. 2021) and the author's clinical experience as a psychoanalyst working through the COVID-19 pandemic. These sources are discussed with literature from the mental health sciences that discuss similar phenomena. Malta¹ and COVID-19, in this sense, inform but do not form the subject of the article.

I start the article by providing a brief overview of the approach to the ‘good’ in the anthropology of moralities. In this discussion, I develop the contours of an analytical approach, which I contrast with the prevailing phenomenological approach to studying moralities. In the subsequent section, I outline how moral incoherence has been studied in the anthropology of moralities. I argue that the problem of moral incoherence can be usefully understood as a problem in the order of rationality, which can be systematised through an analysis of statements about the good. I then apply this approach to moral contradiction which includes holding two contradictory moral imperatives and situations where two opposing behavioural sequelae result from an accepted moral good (a good A should X/a good A should ∼X). In this discussion, I draw on my clinical work and Bateson's classical work (Bateson et al., 1956) on the double-bind to elucidate this first form of moral incoherence. I then proceed to briefly consider the possible role that such an experience can have in the experiences of psychosis and the symptoms commonly associated with psychosis.

In the subsequent section, I discuss the second major form of moral incoherence, which I describe as moral inhibition. This includes situations philosophers describe as akratic acts. These are situations where one does not act according to one's own recognised moral good either because one is forced to act contrary to such moral goods or because one is incapable of acting towards the realisation of the good (akratic acts proper). In this section, I apply the method of analytic reduction on selections from ethnographic interviews conducted by the author and his team in the context of a project on vulnerability in pandemics. I then compare this notion of moral inhibition with the concepts of ‘moral injury’ and ‘moral distress’ developed in psychiatry and psychology. Moral injury and moral distress have been associated with various adverse outcomes in mental health in studies from nursing practice to military psychology. Paying attention to developments in the mental health sciences can provide anthropologists with fruitful grounds for an interdisciplinary approach to considering the implications and applications of an anthropology of the good beyond its philosophical engagements. While anthropology has not shied away from engaging with philosophy, anthropologists have generally not looked towards literature in psychiatry and psychology in their discussions of morality.²

An analytical approach to the anthropology of the good

Didier Fassin (2008: 334) famously called for a ‘moral anthropology’ that ‘explores how societies ideologically and emotionally found their cultural distinction between good and evil, and how social agents concretely work out their separation in everyday life’. Joel Robbins (2013) follows this up with a call for an ‘anthropology of the good’. In a 2015 debate, Robbins (Venkatesan, 2015) defines the good along two lines. Firstly, the good is ‘what people aim for in action […] the goals of their actions’ (Robbins, 2015: 455). Secondly, the good is not only the end of an action but ‘what people found desirable, what they found was pulling them, … even if they did not completely want it, they felt themselves drawn to it’ (Robbins, 2015: 455). Among anthropologists working on morality, this notion of the good has received mixed reactions. Veena Das (2015a: 434) has argued that a concept of the ‘good’ in anthropology is ‘symptomatic of a certain tiredness of having to deal with the quotidian forms of suffering’. She argues that Robbins' version of the anthropology of the good is detached from everyday life and prizes objectified reflection, showing ‘little concern for relations of power’ (Droney, 2024: 157). Worse yet, she finds there is an analogy between ‘colonial modes’ and the teleological model presented in Robbins’ conception of the good (Das, 2015a: 436). Zigon (2008) also believes one should avoid using terms like ‘ought’, ‘good’, or ‘right’ in discussions on morality.

While a ‘systematic theoretical application’ of the good remains underdeveloped (Knauft, 2019: 9), like others, I eschew definitions of the good in substantive terms in favour of the more modest aim of an a posteriori analysis based on empirical and theoretical studies of how people understand the good (Fassin, 2008: 339; Robbins, 2013). This article starts with the presumption that the ‘good’ can be studied in terms of moral statement/s and their interrelationship. As an analytical, formal category, the good can be construed as the intentional object of moral statements, what moral statements are about, and what gives them their moral character. These statements are not always and necessarily the result of explicit verbalisations. Veena Das argues that moral claims are reflective articulations of ‘dispositions and habits’ grounded in everyday life (2015: 65). If we follow Zigon (2024: 40), this ‘dispositional modality’ of everyday life means that much of our everyday life is lived ‘without thought’ where we are effortlessly attuned to our world. Beldo (2014), on the other hand, adopts a similar analytic approach to that undertaken in this article. She argues that embodied morality amounts to the ‘implicit or intuitive (if oft-unexamined) affirmation of a distinctly moral claim’ (Beldo, 2014: 26). In this article, I am not necessarily arguing that moral claims precede their reflective recognition but rather that relations to the good, whether articulated or otherwise, can be reduced to a series of statements about the good through a process of ‘analytical reduction’. In this case, given the focus on moral incoherence, such claims were often made by my interlocutors themselves. As analytical constructs, such statements are admittedly a simplification produced for the purposes of research. This analytical reduction can be contrasted with phenomenological reduction.

Anthropologists have increasingly drawn inspiration from phenomenology and the associated phenomenological reduction. Husserlian reduction (epoché) entails a process whereby attention is drawn to the constituting acts of consciousness. Simply put, the premise is that ‘attending to our perception of x helps us reflect upon or to account for how the perceived entity appears’ (Houston, 2022: 43). This entails a bracketing out of naturalistic assumptions. As applied in anthropology, Throop describes the process as the ‘ethnographic epoché’, a unique form of ‘bracketing’ in which ‘the otherwise unquestioned assumption about the factual, evaluative and meaningful existence of the world is suspended’ (Throop 2018: 204). Such a technique is particularly suited to describe individual experience, but it has been argued that it is not particularly well suited to explain (Robbins, 2009: 279). In contrast, ‘analytic reduction’, as proposed in this article, shares much with the structuralist approach. Admittedly, reducing people's moral experience to a series of ‘ought’ statements does not do justice to the full complexity of the lived experiences. To develop a broader taxonomy of moral incoherence, the taken-for-granted presumptions about the ‘good’ that accompany, and orient everyday life are reduced to a set of moral claims about the nature of the good and its im/possibilities. Such a reduction is also produced from an intersubjective encounter in the field or the clinic.

This article is, therefore, in part, a response to Robbins’ call for the development of an anthropology of the good. In contrast to the prevailing phenomenological trend, it adopts an analytic technique (as does Beldo, 2014) that analyses the good as a series of ought statements. These statements are analytic constructs even though they can also be encountered directly in the field. The aim of the resulting analysis is to develop a taxonomy of what I call ‘moral incoherence’. I use the general term ‘incoherence’ because it retains this notion of subjective decomposition that is denoted in notions of ‘moral breakdown’ and highlights the challenges to rationality that such moments bring.

On rationality and moral incoherence

Anthropologists have utilised different terms to describe moral incoherence (see Zigon, 2024: 45). Building on Heidegger's phenomenology, Zigon (2007) describes as ‘moral breakdown’ those situations when the otherwise taken-for-granted dispositional morality of everyday life is put into question, ‘forcing one to reflect on and alter one's already acquired way of being in the world’ (Zigon, 2024: 42). This moment of ‘moral breakdown’ leads to freedom and ethics, ‘the process of once again returning to the unreflective mode of everyday moral dispositions’ (Zigon, 2007: 138).³ Robbins contrasts the ‘morality of reproduction’ with the ‘morality of freedom’ along similar lines (2009: 278). In Becoming Sinners, Robbins (2004) looks at the moral contradictions experienced by the Urapmin in Papua New Guinea. After converting to Christianity in the 1970s, the Urapmin were trapped between two conflicting moral systems, a traditional one based on relationality and a Christian individualist one, creating a situation of ‘moral torment’. I suggest that such ‘moments’ can be analysed according to the underlying structure of rationality in the moral statements involved.

In his recent volume (2024), Zigon delves deeper into the relationship between thinking and ethics. Thinking through moments of moral breakdown allows the subject an open space for ‘moral discernment.’ This thinking is at once critical and relational – an ‘ecstatic relationality of thinking that pulls one both into and beyond oneself’ (2024: 46). This is not an apolitical process (pace Das) because it is precisely through such thinking that one can develop the ‘possibility for political action’ (Zigon, 2024: 47). This moral-relational ‘thinking’, I argue, is rationally analysable and subject to the rules of logical coherence and consistency as defining features of minimal rationality (Taylor, 1982) qua minima moralia. The study of morality therefore requires an engagement with debates of rationality in so far as moral thinking is also rational.

In the field, as in daily life, what is irrational is often considered morally suspect. Anthropological analysis has generally developed on the premise that what is seemingly incomprehensible or morally reprehensible can, at the very least, become comprehensible by ‘discovering the tone and form of discourse in which their action takes on meaning’ (Rosaldo, 1977: 169). This raises the question of whether anthropology, in so doing, excludes the possibility of the truly irrational. The seemingly incoherent turns out to be simply a concealed form of rationality or one based on false premises as has often been argued in debates over the rationality of magic. On the other hand, if ‘we assign incoherence too glibly, we merely compromise our ability to diagnose irrationality’ (Davidson, 1982: 303). For Davidson (1982: 290), when we focus on the perspective of the experiencing subject, the problem of irrationality turns out to be a problem of ‘coherence or consistency in the pattern of beliefs, attitudes, emotions, intentions and actions’.

While lacking its systematic treatment, the question of contradiction has been a topic of anthropological interest, at least since the work of Levy-Bruhl (1910) (Segal, 1987). Contributors to a recent debate on the study of rational contradiction in Hau were repeatedly drawn to moral examples in their discussion. The contradiction was illustrated in terms of the inner clash of ethical voices encountered in the field or the contradictory attitudes of the anthropologist – being politically progressive at home but possibly an advocate for ‘oppressive’ cultural practices in the field. Berliner (2016) turns to Zigon to argue that self-awareness of such inconsistency can cause a ‘moral breakdown’. In his contribution, Shweder (2016: 9) contends that the law of non-contradiction is ‘universal’, ‘an indispensable tool for constructing any and every picture of reality’. Viewed in this light, moral incoherence can be analysed in terms of the ir/rational properties of moral statements. Incoherence in this sense results either from the contradictory relation between behaviour and intention or between intentions.

In so far as the law of non-contradiction is an indispensable feature of rational thought, and since we do not construe our interlocutors as ‘bloodthirsty savages’ (Rosaldo, 1989), then we presume that they are capable of rational thought. There are times, however, when rational resolution of moral conflicts becomes impossible and moral thinking becomes stymied. These situations are often experienced as distressing and, when particularly acute, manifest as symptoms, as we shall see in the second part of this article. In the following section, I discuss the first form of moral incoherence: holding two contradictory moral imperatives, either as a moral double-bind or as conflicting moral principles. In either case, the incoherence can be expressed in terms of a relationship between statements about the good (ought statements) through a process of analytical reduction.

Moral contradiction: Double-bind and psychosis

Paul, a man in his 50s, came to the clinic frequently stressed and anxious because he felt he could not reconcile the various demands he felt from his new relationship, his ex-wife, and his parents and children. During the height of COVID-19 in Malta elderly people were isolated in their homes. People over 65 were subject to a mandatory lockdown, and children were considered high-risk vectors of transmission. Paul was distressed because his elderly parents wanted to see him and their grandchildren. They felt it was their decision to take that risk. As Paul explained it to me, he felt torn because, on the one hand, he felt he should, as a loving son, visit his grandparents along with his children. ‘After all, who knows how many years they have left?’ he told me. On the other hand, he was horrified at the thought that he might expose them to the lethal virus by bringing his children over to visit and potentially transmitting the virus. What should a good son do?Paul, in the case discussed above, was caught between two competing moral statements that can be expressed in the following terms:

A good son ought to make his parents happy by honouring their wishes and visiting them.

BUT

A good son ought to protect his parents from harm, and therefore, he should not visit them.

We could analyse Paul's moral dilemma into three parts: the moral relational self that constitutes the subjective good, the moral principle that follows the subjective role – that is, the predicate of the ought to statement – and the course of action that results from the moral principle. Both statements were equally true for Paul, placing him in an impossible position since the moral principles entailed being a good son were irreconcilable due to the contradictory course of action they required. In both cases, the principles followed were based on the moral interpretation of what his behaviour as a son (relational self) should be. Whatever Paul does, he must contend with the inevitable conclusion that he is a bad son by one of these standards. He is ultimately caught in a particular form of moral incoherence, a double-bind. As Shweder points out, the law of non-contradiction proper means that nothing could be ‘both itself (A) and not itself (∼A) in the same place and at the same time in the experience of the same person’ (2016: 10). If we apply this law to moral statements this would mean that nothing could be both ‘good’ and ‘not good’ to the same person at the same point in time.⁴ Any attention to ordinary human experience will quickly reveal situations where people experience such a moral contradiction in their lives.

Together with a multi-disciplinary team at the Veterans Administration Hospital in California, Gregory Bateson became a prominent name in the 1950s and 1960s in proposing the double-bind theory of the aetiology of schizophrenia. According to the theory, the person who becomes unwell is subject to a communicational matrix wherein messages contradict each other over time. The contradiction takes the form of a primary negative injunction with associated negative consequences accompanied by a secondary conflicting injunction enforced by negative consequences. This secondary injunction is often communicated to the child by non-verbal means. As a result, the child is trapped. Once this pattern is instantiated, the child interprets the world in terms of double-bind patterns, whereby any single part of the preceding formulation ‘may then be sufficient to precipitate panic or rage’ (Bateson et al., 1956: 253–254). Interestingly, Bateson also further proposed that these prohibitive injunctions may then be taken over by auditory hallucinations, a symptom commonly found in schizophrenia.

The presence of auditory hallucinations is not necessarily a pathognomonic feature of psychosis (Waters et al. 2018). The experience of two or more hallucinatory voices in disagreement or voices providing a running commentary on one's life does nonetheless appear as one of the criteria A symptoms for schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR). Barrett's comparative study among the Iban of Borneo and Australian patients identifies a common way in which they described their auditory experiences: ‘commenting, disagreeing, derogatory, commanding’ (Barrett 2003: 101). Luhrmann's et al. (2015) comparative study found that in Chennai, more than half of the sample reported voices originating from both good and bad kin. In California, people were more likely to experience voices as upsetting and violent. In contrast, in Accra, the subjects emphasised the moral quality of the voices, with people emphasising the ‘good voices’ while de-emphasising the ‘bad’ voices (Luhrmann et al., 2015: 652).

Without delving into arguments over the aetiology of schizophrenia,⁵ we can draw upon this work to highlight two specifically relevant factors. Firstly, contradictory injunctions are a phenomenological feature of certain kinds of experiences recognised as being psychopathological. Secondly, the contradictory injunctions described by Bateson (but also by Luhrmann) have a moral dimension. We may find that a deeper study of the specific moral structures of the phenomenology of psychoses reveals further experiences of subjects caught in a moral double-bind. To emphasise once more, my aim here is not to support Bateson's controversial claims about the aetiology of schizophrenia but rather to highlight the way enduring moral contradiction is associated with mental health.

At this point, it is worth noting that discussions of aetiology and symptomatology might be jarring to specific anthropological sensitivities to pathologising cultural actors. Many anthropologists have drawn upon psychological terms in ways that, at times, are ‘more metaphorical than technically useful’ (Good, 2012: 518). Genuine interdisciplinary work on mental health encounters a fundamental hermeneutic dilemma. It is doubtful whether we can achieve a truly external perspective as we utilise the language of the mental health sciences (Baldacchino, 2024: 158). I share with Good (2012: 526), however, the conviction that we need to engage with ‘more complex psychological and psychoanalytic conceptions of the subject’. This might entail working with symptoms and diagnostic categories rather than limiting ourselves to embedding them within their political contexts. Bateson's work represents a fascinating look at the insight which genuine anthropologically inspired interdisciplinary work can provide. It is a shame that his insightful observations were dismissed because of his aetiological claims.

Zigon and Throop's (2014) call for greater attention to moral experience has led to studies of moral experience in psychosis. Myers (2019: 13) shows how in young adults the initial psychotic break also entailed a loss of moral agency. Myers (2019: 23) speaks of ‘moral breakdown’ since the ‘moral values communicated in any account of hallucination or delusion … lack basis in a shared ethical universe’. Myers argues that key to recovery is the capacity to morally reorient, feel safe and find comprehensibility with intimate others (moral repair). In many treatment settings, however, the sufferer's capacity for moral agency is oftentimes further eroded (Myers, 2016: 438). Healing requires that one is equipped with the necessary resources to achieve what one understands to be a ‘good life’ (Myers, 2016: 435). Moral coherence, I argue, is a fundamental pre-requisite in this regard.

So far, I have sought to describe a moral double-bind as a distinct type of moral incoherence. Additionally, I have described how this double-bind features in the symptomatology of psychosis. In much of the clinical literature on psychosis, the specific moral dimension of psychosis and the double-bind remained underdeveloped. The experience of conflictual moral imperatives, however, is not exclusively a feature of psychotic states. Paul, discussed at the beginning of this section, did not meet any of the diagnostic criteria for schizophrenia even though he too experienced two conflicting authoritative ‘voices’ – the superintendent of public health's recommendations as broadcast authoritatively through the media versus the voice of his parents on the phone demanding to see their children and grandchildren. These ‘voices’ have a moral quality as they prescribe what Paul ought or must do to act in a manner consistent with his moral personhood as a son.

A moral contradiction can emerge either as two opposing behavioural sequelae to a recognised moral good (a double-bind proper; a good son should visit his parents/a good son should not visit his parents) or else it can result from a conflict between two moral goods that entail incompatible courses of action (conflicting values). The latter, I suspect, is much more commonplace and has been more extensively studied. This could be seen in the contradiction entailed between certain ideas about human rights, for example, the tension between cultural and individual human rights over cases of female genital mutilation (Kalev, 2004). One may find oneself equally beholden to both moral values and therefore likewise find oneself caught in a moral conflict even though such a case is not a contradiction proper. In the following section, I discuss the second form of moral incoherence, namely that of moral inhibition, which includes situations where people are unable to act towards the subjectively recognised good or are somehow ‘forced’ to act in ways that directly contradict the acknowledged good.

Moral inhibition and its effects: Moral injury and distress

Moral inhibition does not entail a conflict over the nature of the good or the means to achieve it. Moral inhibition describes situations where the individual knows what ought to be done but is unable to accomplish it. This could stem from extraneous variables (such as some form of authority) or endogenous variables (weakness of will, fear). In philosophy, akrasia refers to an act against one's better judgement. In Plato's Protagoras, Socrates argues that it is impossible to act intentionally against one's better judgement ‘because to act intentionally is precisely to act on your judgement’ (Burch, 2018: 940). Akratic acts, therefore, in this view (Judgement internalism), are the result of a lack of self-control or excess of desire – you know what you ought to do but lack the fortitude to act accordingly (what I am calling endogenous variables). The argument can be made that moral inhibition is ultimately the result of internal limitations, though I suspect such an approach to be somewhat reductive, if not unkind. For example, in places with no recognised right to conscientious objection (an exogenous limitation), people may still opt to refuse but at a significant personal cost (Houston, 2023; Weiss, 2014). This is usually what characterises many accounts of moral heroism and sacrifice.

On the other hand, judgement externalists argue that there is a functional distinction between will and evaluative judgement.⁶ While functionally distinct, if you sincerely judge that one ought to do X, then this should lead to the motivation to do X, and if not, you are irrational (see Shpall, 2022: 417). This could be seen as an extension of the principle of logical consistency in so far as ‘someone who wills the end wills the means’ (Taylor, 1982: 87). The judgement behind an ought statement inevitably activates the motivating desire to act accordingly (Shpall, 2022: 412). External limitations can inhibit the subject from acting in accordance with the motivation, often resulting in negative self-evaluations and sentiments.

The following extract from an ethnographic interview exemplifies moral inhibition during COVID-19 in Malta. Francesca is a mother in her late 30s. She gave birth to twins during the pandemic. They were born early after a seven-month pregnancy, and they had to spend four weeks in the intensive care unit in the hospital. The following is her account of the experience drawn from an extended ethnographic interview:

It's horrible because you're sort of dependent on the hospital's services, on their care; I can't very well leave with my children at the intensive care unit. They need me to be there, and yet I don't have any control over who is in contact with them, who's wearing a mask and who isn't. There are people who are meant to be watching out … but there were a couple of moments here and there, which caused anxiety, and lots of anxiety; I mean, you see staff not wearing masks sometimes and all. As a parent, you just sort of, I don't know, you want your kids to be with you, and you want to protect them. You have to place much trust in the institutions and the people there. They were born on all sorts of machines and tubes and pipes coming out, and there's something about seeing your child like that that brings out the protective mama bear sort of instincts. There's so much that you can't control, that you couldn't control regarding the pandemic, I mean.

Under normal circumstances within that unit, parents could almost always stay. With COVID, we were given a 2-h visiting slot, and we were lucky in that my husband and I were allowed to be there together. So, they revised it from the earlier rule of just one parent. I still remember our slot was 1−3 every day.

Usually, grandparents, for example would be allowed to visit, but obviously, they couldn't, and that 2-h time slot wasn't always 2 h long because sometimes, the doctor's rounds would be late or the ward was being cleaned, and they would keep you from going in. So, you're just waiting outside for about half an hour until you can go in, and it's the only 2 h in the day you can see your children. You know, somebody's guarding my access to my kids was just, it was torture, it was absolute torture. You know, you have no choice, really, but to cooperate because you rely on the staff for your kids to have the care they need, so the last thing you want is to have a bad relationship with the staff because you didn't have an extra 20 min. Dealing with that was rough.

If we apply the same analytical reduction, we could reduce Francesca's moral inhibition as follows:

A good mother ought to be next to her children.

BUT

I am not next to my children.

In this case, Francesca is not with her children because an external force bars her access. Even though she cannot be with her children this does not necessarily relieve the burden of guilt.

The case of Francesca is an apt illustration of the limitations to moral action, where the source of the inhibition comes from institutional obstacles. Jameton (1984) coined the term ‘moral distress’ to describe situations when one knows what one ought to do, but, due to institutional constraints, one cannot act by that good (Morley et al., 2019: 647). Moral distress is a pressing concern in nursing since it seems to be increasing in prevalence and intensity, raising fears for job retention. This ‘ought’ may have very subjective qualities – such as views of end-of-life care, which can place nurses at odds with physicians.⁷ Some have argued that moral distress should be broadened as an umbrella concept to account for the psychological response to morally challenging situations, including moral indecision (Fourie, 2015). The emphasis is therefore on the experience of distress considered as a negative emotional accompaniment which includes feelings of powerlessness, depression, anxiety, bitterness, anger, guilt, dismay and emotional exhaustion (Holtz et al., 2018: e489; Rushton et al., 2016: 43). While not directly associated with any diagnostic category, moral distress is linked to several conditions, such as post-traumatic stress, insomnia and depersonalisation (Lake et al., 2022: 802). The broader definitions of moral distress seem to converge on the combination of the experience of psychological distress arising from the experience of a ‘moral event’ (such as moral dilemma or moral uncertainty) (Morley et al., 2019: 660). Uncertainty, however, can have a very different quality based on the source of the indecision.⁸ More recently, ‘Moral Resilience’ has been used to highlight how the negative experience of moral distress can be transformed into a positive catalyst for growth (Holtz et al., 2018: e489; Rushton et al., 2016: 44).

The COVID-19 pandemic has been associated with increased levels of moral distress among nursing professionals with long-lasting effects on mental health (Lake et al. 2022: 806; Ripp et al., 2020). Various modifications of a moral distress scale (MDS) have been developed to measure the degree of moral distress (Corley et al., 2001; Cramer et al., 2022; Hamric et al., 2012). Studies have shown that increased patient loads, poor communication from leadership and lack of availability of personal protective equipment were associated with increased moral distress among nurses during the COVID-19 pandemic (Lake et al., 2022: 807). The modified COVID MDS was proposed to account for the unique ethical challenges faced by healthcare providers during the pandemic (Cramer et al., 2022). The concept has also slowly begun to be applied to other professions, such as social work. Within anthropology, Armin (2019) has used the concept in her ethnographic study of a primary healthcare clinic in Arizona. She argues that ‘moral distress occurs when individuals shoulder the responsibility for rationing health care in the context of public policies that construct deserving and undeserving patients’ (Armin, 2019: 194). The healthcare staff in this specialised cancer ward become individually responsible for reconciling policies that limit patients’ access to healthcare leading to moral distress.

This distress could be considered an instance of incoherence because it creates an inconsistency between an acknowledged good and the capacity to achieve it (Taylor, 1982). Additionally, it leads to an inconsistency with one's image of oneself as a good person. As in the case of Armin's nursing staff, one knows what one ought/wants to do, but one is frustrated in their capacity to realise it. In such cases, the limitations resulting from the actions of the other represented by an institutional authority nominally entrusted to uphold the good. Francesca, with whom I began this section, knows that to be a good mother, she should be with her children, but the institution that is being trusted to safeguard their lives is preventing her from acting accordingly. This is compounded by the feeling that the institution may be cutting corners and compromising standards of care due to the strains of the pandemic.

‘Moral injury’ is a cognate concept that developed independently within the field of military psychiatry, leading to diagnostic debates in trauma studies. In the 1990s, Jonathan Shay, a staff psychiatrist who worked with U.S. war veterans, made a compelling case for introducing moral injury into clinical discourse. Shay felt that the language of ‘disorder’ in post-traumatic stress disorder (PTSD) confers a ‘gratuitous stigma’ (2011: 181). He argued that ‘injury’ is more appropriate since the effect is comparable to a war wound. In his initial definition, moral injury explicitly referred to the impact of a betrayal of what is right by someone who holds power. In his revised formulation, he defines it in three parts: Moral injury occurs when there has been a betrayal of what's right, by someone who holds legitimate authority in a high-stakes situation (Shay, 2011: 183). When all three features are present ‘the body codes it in much the same way it codes physical attack’ (Shay, 2011: 183) leading to moral injury. The concept has gained significant popularity in the psychiatric community. Working with a nationally representative survey of U.S. veterans, Wisco et al. (2017) found a positive correlation between the incidence of potentially morally injurious events (PMIE) and the risk of mental health disorders and suicidality. Changes to the criteria for PTSD in the DSM-5 introduced in 2013 went some way to incorporating moral injury. One of the main ongoing diagnostic debates revolves around whether moral injury in a traumatic context is to be regarded as a variant of PTSD (Currier et al., 2021: 6; Jones, 2020: 127). Moral injury often co-occurs with PTSD (Barnes et al., 2019) but, from a neurobiological perspective, is seen to be distinct. Like in moral distress, several scales have been developed to measure moral injury (Currier et al., 2015; Koenig et al., 2018; Nash et al., 2013), but there is still a lack of consensus on its definition and how to measure it in a clinical setting (Jones, 2020: 127).

While the term was initially applied to war veterans, much like moral distress, it has also been expanded to other occupational groups (Williamson et al., 2018). The COVID-19 outbreak led to moral injury research among ‘front-line’ workers.⁹ Some argue that the complexity of COVID-19 ‘erased many of the distinct differences between military and medical workers’ experiences’ (Hossain and Clatty, 2021: 27). The volume of deaths and the number of patients in critical care give rise to war metaphors to describe the clinical scene and the ‘results seem to be the same or eerily similar’ (Hossain and Clatty, 2021: 27). Front-line workers were seen to be especially vulnerable to exposure to PMIEs during the pandemic. Lack of resources meant that they were unable to provide adequate care, resulting in suffering and loss of life (Williamson et al., 2020: 317). Moral injury, they argue, might be more appropriate to characterise the long-lasting effects of COVID-19 with its increased likelihood of post-traumatic responses. Leaving aside diagnostic debates, there seems to be a broad consensus that moral injury is connected to various conditions and a deterioration of mental health. It may elicit strong moral emotions (such as guilt and shame) that can endure ‘and motivate unhelpful or dysfunctional behaviour that impacts social or relational, psychological, and spiritual well-being. In many cases, mental health diagnoses such as PTSD and major depressive disorder can co-occur and be interrelated’ (Currier et al., 2021: 13).

Second-wave moral injury scholars have expanded the scope of Shay's term to include ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et al., 2009: 700). This broadens the concept considerably but also shifts the focus away from the betrayal by those in authority to the role of the injured subject per se as both site and agent of the injury (Wiinikka-Lydon, 2019: 159). There are, however, some crucial differences between passive (learning about) and active (committing an act) roles in relation to moral injury.

The philosopher Wiinikka-Lydon (2019: 170) considers moral injury (but we can extend this to moral incoherence more broadly) as a form of violence since such experiences are ‘injurious to ways of seeing, ways of imagining, and ways of relating, pointing to a disruption in one's ability to live reasonably well in everyday life’. Crucial to this process is how we see ourselves and our relation to others. Such an imagination is intrinsically moral because our identities entail how we see ourselves as ‘good’ or ‘bad’ persons. As such, moral injury ‘can be understood as a harm to one's imagination, and through this, to one's identity and the possibility of identity’ (Wiinikka-Lydon, 2020: 648). Wiinikka-Lydon argues that moral vulnerability is an inherent condition of being human ‘as a species that needs to be able to strive toward the Good that needs to feel it is a possibility in the world, and where striving for goodness is part of one's identity’ (2019: 172). Wiinikka-Lydon's interpretation of moral injury in terms of harm to one's identity and imagination can be re-interpreted in light of the idealised image of oneself (ideal ego) as the variable object of a moral drive in the context of moral incoherence.¹⁰ Moral incoherence destabilises the possibility of relating to others on the basis of a positive moral identity. Similar conclusions can be drawn from the anthropological study of moral experience in psychosis (Myers, 2019: 106).

Interestingly, the two concepts (moral injury/moral distress) were proposed in different fields within less than a decade (1984–1990s). The late Jameton was a philosopher working on ethical issues in nursing practice, while Shay was a psychiatrist working in military hospitals. In the narrow sense, both drew attention to the psychological effects of feelings of betrayal by institutions and those who represent them. Likewise, the broadening of both moral injury and moral distress considerably expanded the scope of the original terms to minimise the institutional role in limiting the moral horizons of the subject.

The experience of moral distress/injury is not limited to front-line workers and involves challenges to one's moral agency, which go far beyond job retention rates. I remain sceptical of the utility and purpose of the drive to quantify and metricise moral distress and moral injury. While I believe we can create a more refined taxonomy of moral incoherence, the push to measure and quantify the resulting distress lends itself to new forms of governmentality through instrumentalising the moral. Many of the solutions proposed to tackle the crisis posed by moral distress entailed developing programmes for ‘resilience training’ such as mandatory comprehensive ethics training for nurses and developing clearer and more comprehensive policies and rigid guidelines (Lake et al., 2022: 807) without considering the possibility that it is precisely through the rigid clarity of some policies and procedures that careworkers can experience heightened moral distress (Armin, 2019).

The experience of moral distress is something that we may encounter in our everyday lives and, if sufficiently protracted and severe, threatens our sense of coherence as moral subjects, that is subjects capable of acting in accordance with the good on the basis of a rational moral agency. These different models of moral harm can be usefully integrated and help us develop a cross-disciplinary language. Moral double-binds or forms of moral inhibition (which we encounter in psychiatry and psychology as moral injury and moral distress) draw attention to people's relationship to the Good and its significance in various mental health diagnoses and care.¹¹

Concluding remarks

In this article, I have argued that an anthropology of the good can be further developed by adopting a form of analytical reduction, that is through the study of morality in terms of a series of ought statements. Such statements concerning the good are rational and relational and, therefore, are subject to an analysis according to the criteria of coherence and the logic of non-contradiction. Situations of ‘moral breakdown’ have been conventionally understood as opening up the space of reflective thinking about moral goals and possibilities. This article has developed an application of the analytical reduction to such situations of moral incoherence. These take two primary forms: (i) holding two contradictory moral imperatives (either a moral double-bind or a conflict in values) (ii) acting in ways that are contrary to, or falling short of, one's judgements (moral inhibition due to endogenous or external impediments). In either case, the incoherence can be expressed in terms of limits to the rational relationship between statements about the good (i.e. ought statements). However, this incoherence also destabilises the subject's ‘sense of self’ and his capacity for a coherent moral image of self.

This article, therefore, makes two primary contributions. It develops an approach to the anthropology of the good and it applies the approach to the problem of moral incoherence by engaging with various disciplinary perspectives (psychiatry, psychology, and, to a lesser extent, philosophy). The increasing attention being paid to the moral dimensions of mental health cannot be dismissed purely as a manifestation of the pathologisation of everyday life. Such problems are exacerbated in times of crisis and social breakdown, such as the COVID-19 pandemic, where the possibilities of moral agency and coherence become increasingly challenged. Even though discourses of vulnerability have been used as a political tool to shield the interests of oppressive elites (Huth, 2020: 572), anthropologists can enrich our understanding of the good and its comparative articulation through cross-disciplinary conversations with mental and health sciences.

Footnotes

Acknowledgements

These ideas which were subsequently developed in this article benefitted greatly from discussions with the members of the Sonar Global Team in particular I would like to thank Prof. David Napier, Dr Tamara Giles-Verneck and Dr Anna-Maria Volkamm who led the project but also my colleagues from the University of Malta Dr Gisella Orsini and Dr Maurice Said. I would also like to thank Prof. Chris Houston and Dr Gisella Orsini for reading and commenting on an earlier iteration of this article, which I wrote while working as a visiting professor at Macquarie University. Their feedback and discussion helped me develop this article further. While I felt the article benefitted from their insights, its limitations remain utterly my own.

ORCID iD

Jean Paul Baldacchino

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Part of this research was funded by the European Union's Horizon 2020 Programme entitled ‘A Global Social Sciences Network for Infectious Threats and Antimicrobial Resistance’ with the Acronym SoNAR-Global (Grant No. 825671).

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Notes

Author biography

Jean Paul Baldacchino is a professor of anthropology at the University of Malta and a Lacanian analyst. He has published in a variety of fields and has conducted fieldwork in Malta, Australia, Italy and South Korea in the anthropology of religion, morality, emotions, popular culture, and ethnicity as well as on more clinical subjects. His latest publications are a book co-edited with Christopher Houston Self-alteration: How People Change Themselves Across Cultures (2024) published by Rutgers University Press and an article with History and Anthropology (2024) ‘Questions of conscience in a confessional state: From “freedom of conscience” to “objections of conscience” in Malta’.

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Analytic approaches to the anthropology of the good: Moral incoherence and mental health in the wake of COVID-19

Abstract

Keywords

Introduction

An analytical approach to the anthropology of the good

On rationality and moral incoherence

Moral contradiction: Double-bind and psychosis

Moral inhibition and its effects: Moral injury and distress

Concluding remarks

Footnotes

Acknowledgements

ORCID iD

Funding

Declaration of conflicting interests

Notes

Author biography

References