Mental health after the sirens: moral injury in responders and survivors of disaster, mass casualty, and crisis care.

Healthcare professionals responding to disasters, mass casualty incidents, pandemics, and sustained high-acuity clinical environments face extraordinary ethical and emotional demands. While burnout and post-traumatic stress disorder (PTSD) have historically framed clinician distress, these constructs incompletely capture the moral and existential harm experienced when clinicians are forced to act in ways that conflict with deeply held professional and ethical values. Moral injury has emerged as a distinct framework to explain this phenomenon. This review synthesizes current understanding of moral injury in disaster, mass casualty, and crisis care settings, distinguishing it from burnout and PTSD, examines prevalence and impact on clinicians and healthcare systems, identifies unique individual, organizational, and situational risk factors, and reviews mitigation and recovery strategies across the disaster continuum. Critical gaps in measurement and research are highlighted, particularly in command-driven healthcare environments. Addressing moral injury requires system-level interventions, ethical transparency, and leadership accountability to sustain the healthcare workforce beyond the immediate crisis.