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Introduction Moral injury among healthcare missionaries leads to negative consequences for the individual, healthcare team, patients, and sending agencies. Conflicting values in clinical care, culture, and spirituality provide unique potentially morally injurious experiences. The purpose of this qualitative study is to explore the phenomenon of moral injury among western healthcare missionaries to develop effective support and treatment strategies. Methods A qualitative interview guide was developed based on the existing literature on moral injury. Twenty-one key informant interviews were completed by two former healthcare missionaries. Participants were based in Africa, Asia, and Eastern Europe healthcare mission settings. Questions were based on clinical, cultural, and spiritual domains of potential ethical and moral conflicts. Protective factors were also explored based on one’s faith and spiritual practices. Interviews were transcribed and coded independently by two analysts. The team reviewed the codes and determined themes from across the three domains. Results Seven themes emerged from the interviews ranging from morally injurious experiences with cultural leadership practices and unfamiliar clinical care experiences to guilt over practicing outside of one’s scope of practice and addressing suffering alongside God’s sovereignty. The themes led to the development of an injury/growth pathway as a potential model for helping healthcare missionaries describe and move through potentially morally injurious experiences. Conclusion The themes allow for healthcare missionary sending agencies to develop strategies, training, and support systems for teams preparing to enter the mission field and for individuals already in the field. Recommendations for growing through potentially morally injurious experiences are suggested to guide practice and support for missionaries in the field. The growth values and strategies could inform the development of a screening tool to assess moral injury among healthcare missionaries.

As a career cross-cultural missionary in Southeast Asia, the author has seen first-hand and has personally experienced the devastating effects of colleagues, families, leaders, clinicians, and the sufferers themselves misunderstanding the symptoms and the reality of major depressive disorder, an increasing global health problem. This autobiographical case report reflects on twenty years of treatment-resistant depression and a journey through pharmacological approaches, psychotherapy treatment, Christian prayer counselling, and electro convulsive therapy without improvement in this condition. The primary concern is how to remain faithful and effective with this condition in a service-oriented occupation that requires regular emotional expenditure. In lieu of effective conventional and non-conventional therapies, the remaining option is to find a way to manage chronic depression; identify personal trends, weaknesses, and triggers; and find a personalized way to live that minimizes the effects of the condition. In any chronic, incurable disorder, the sufferer must inevitably come to terms with his or her reality and find peace in the acceptance of that reality. By expressing the journey through treatment-resistant depression, the author encourages readers to persevere in ministry and to respond more appropriately to the afflicted with clearer understanding and empathy. A companion article on mitigating depression symptoms through the spiritual discipline of identifying with Christ and His experience of human emotional pain during His passion is available.