Building Pathways of Refuge for Moral Injury
During peak surges of the COVID-19 pandemic, healthcare providers regularly found themselves in morally complex situations. With too few beds or necessary supplies, physicians were forced to turn people away—even when they knew how to help them.
People who had dedicated their lives to healing others suddenly faced situations that violated their deepest values—sometimes leading to identity crises and severe mental health struggles. The voices of these struggles sound like:
“How can I live after not being able to prevent someone from dying”
“Why do I deserve to live a good life?”
“Am I not human anymore?”
“Am I a failure?”
These are the sounds of moral injury—the invisible wounds of conscience, borne by beautiful souls in distress.
In a groundbreaking article, science writer Elizabeth Svoboda shared that pandemic healthcare workers are among the millions of people struggling with this “invisible epidemic.” Svoboda writes: “The condition affects millions across many roles. In an atmosphere of rationed care, doctors must admit a few patients and turn many away. Soldiers kill civilians to complete assigned missions. Veterinarians must put animals down when no one steps up to adopt them. The trauma is far more widespread and devastating than most people realize.”
Dr. Brett T. Litz defines moral injury as the “lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” Working in high-stakes environments such as hospitals or war zones requires people to make split-second life-and-death decisions, often under orders in morally complex situations. Even those with the most ethical intentions can find themselves in scenarios that violate their values.
While “moral injury” is a modern term, the experience is ancient. One example appears in Parashat Shoftim: the case of unintentional killing and the community’s responsibility to establish cities of refuge—places where people could live safely after such a morally injurious event. Recognizing the risk of vigilante justice, biblical society was required to establish these cities to halt cycles of harm and bloodshed in the aftermath of tragedy.
The Torah not only mandates the creation of these places of refuge—it also commands the community to prepare accessible roads to them, so that those in danger could find safety and support without delay.
The Rambam explains that the Jewish court was obligated to ensure these roads were at least 32 cubits wide, kept clear of obstacles, and well maintained. Where there were hills, valleys, or rivers, bridges had to be built to make the path as easy as possible.
It wasn’t just the roads themselves that needed to be accessible—there also had to be clear and visible signage pointing the way toward the city of refuge.
Although the biblical mandate for cities of refuge is no longer practiced, its wisdom feels more relevant than ever. I believe the Torah is calling on us to prepare pathways of healing for those who have experienced moral distress, harm, or injury. It recognizes how difficult it can be for someone in distress to reach out for help, and places responsibility on the community to ensure that resources are accessible and readily available. By acknowledging and caring for the suffering of the unintentional killer, the Torah gives visibility to the otherwise invisible pain of moral injury.
So how can we prepare pathways of refuge in our modern society?
- Learn the language of moral injury. In a way, words describing moral injury are like the biblical signs pointing toward refuge. Finding language for one’s inner struggles is the first step toward healing—yet it can feel impossible in the depths of despair. The more people who understand what moral injury is, the more accessible support will become. A helpful resource is this nine-minute video by Dr. Rita Nakashima Brock on the basics of moral injury.
- Equip spiritual and mental health leaders. Rabbis, chaplains, and spiritual care providers can explore resources like Dr. Zachary Moon’s video teaching on moral injury and chaplaincy practices, or Dr. Wesley Flemmings’ Moral Injury Experience Wheel. Mental health professionals can turn to works such as The Moral Injury Spectrum: From Conflict to Healing in Individual and Cultural Contexts. With proper training, these caregivers can become vital guides on the path to recovery.
- Support organizations providing care. We can donate to or refer people to groups offering coping tools and community. For example, Ripples of Healing provides group water therapy to foster recovery, balance, and renewal, helping trauma survivors regain functionality and return to an optimal quality of life.
As Rabbi Tarfon taught: “It is not your duty to finish the work, but neither are you at liberty to neglect it.” (Avot 2:16) The need for this support may feel overwhelming, but if each of us does what is within our capacity, then together we can prepare accessible pathways of refuge for those suffering from the invisible wounds of moral injury.