WHAT IS MORAL INJURY?
Moral injury is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.
Within the context of military service, particularly regarding the experience of war, “moral injury” refers to the lasting emotional, psychological, social, behavioral, and spiritual impacts of actions that violate a service member’s core moral values and behavioral expectations of self or others (Litz et al., 2009). Moral injury almost always pivots with the dimension of time: moral codes evolve alongside identities, and transitions inform perspectives that form new conclusions about old events.
While the concept itself is not new—throughout history philosophers, poets, and warriors themselves have long wrestled with the ethical dilemmas inherent in war—the term “moral injury” is more recent, and is thought to have originated in the writings of Vietnam War veteran and peace activist Camillo “Mac” Bica (Brock & Lettini, 2012; Bica, 1999, 2014), and Jonathan Shay (Achilles in Vietnam: Combat Trauma and the Undoing of Character, 1994) as the aftermath of warzone trauma.
Moral injury is increasingly a focus of discussion and study across disciplines and settings. Returning veterans, and those who care for them, are struggling to understand and respond effectively when experiences of war result in levels of anguish, anger, and alienation not well explained in terms of mental health diagnoses such as Post-Traumatic Stress Disorder (PTSD.)
Drescher et al. (2011) define moral injury as “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner” (p. 9). Litz et al. (2009) further describe moral injury as “the inability to contextualize or justify personal actions or the actions of others and the unsuccessful accommodation of these . . . experiences into pre-existing moral schemas” (p. 705).
Shay (2014) emphasizes leadership failure and a “betrayal of what’s right, by a person who holds legitimate authority in a high stakes situation.” Silver (2011) speaks of, “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society”.
EXAMPLES OF MORAL INJURY IN WAR
Using deadly force in combat and causing the harm or death of civilians, knowingly but without alternatives, or accidentally
Giving orders in combat that result in the injury or death of a fellow service member
Failing to provide medical aid to an injured civilian or service member
Returning home from deployment and hearing of the executions of cooperating local nationals
Failing to report knowledge of a sexual assault or rape committed against oneself, a fellow service member, or civilians
Following orders that were illegal, immoral, and/or against the Rules of Engagement (ROE) or Geneva Convention
A change in belief about the necessity or justification for war, during or after one’s service
WHAT ARE THE CONSEQUENCES OF MORAL INJURY?
Moral injury can lead to serious distress, depression, and suicidality. Moral injury can take the life of those suffering from it, both metaphorically and literally. Moral injury debilitates people, preventing them from living full and healthy lives.
The effects of moral injury go beyond the individual and can destroy one’s capacity to trust others, impinging on the family system and the larger community. Moral injury must be brought forward into the community for a shared process of healing.
In the context of a soul, with respect to the diversity of beliefs and religious perspectives held by those involved with moral injury, consider this:
Moral injury is damage done to the soul of the individual. War is one (but not the only) thing that can cause this damage. Abuse, rape, and violence may cause similar types of damage. “Soul repair” and “soul wound” are terms already in use by researchers and institutions in the United States who are exploring moral injury and pathways to recovery.
WHY HAVEN’T WE HEARD ABOUT THIS BEFORE?
Traumatic brain injury (TBI) and post-traumatic stress disorder (PTS or PTSD) became household terms over the last decade thanks to the maturation of attitudes about the costs of war; moral injury is now the object of growing focus by researchers and academics in the same manner.
Moral injury does not, by its nature, present itself immediately. Some will experience questions of moral injury days after an incident; for many others, difficulties will not surface for many years. An experience with potential for moral injury is typically realized after a change in personal moral codes or belief systems.
WHAT SHOULD WE DO ABOUT MORAL INJURY?
Moral injury must be acknowledged in the same way that we acknowledge the physical and mental costs of traumas experienced in war and other places of danger. Moral injury is subjective and personal. Research on moral injury is younger than research on PTSD – the definitions, ideas, and practices we’re working with are both experimental and varied.
Trauma of a type and severity that cause PTSD* are likely to cause moral injury, too. This does not mean treating PTSD will “treat” moral injury, nor vice versa. We favor the tenet that “treatment” of moral injury must be defined by the individual according to their beliefs and needs. Outlets for acknowledging and confronting moral injury include talk therapy, religious dialogue, art, writing, discussion & talking circles, spiritual gatherings, and more.
Therapists, counselors, social workers, and clergy are often at the front lines of addressing moral injury; however, the larger community can also take part. Consider that moral injury affects, and is affected by the moral codes across a community. In the case of military veterans, moral injury stems in part from feelings of isolation from civilian society. Moral injury, then, is a burden carried by very few, until the “outsiders” become aware of, and interested in sharing it. Listening and witnessing to moral injury outside the confines of a clinical setting can be a way to break the silence that so often surrounds moral injury.
*PTSD is a clinical diagnosis, identified and treated according to criteria and methods prescribed by the American Psychiatric Association (APA). The APA last updated its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.
SO, WHAT ARE WE DOING?
1. Fostering public dialogue about moral injury.
2. Providing opportunities for veterans to design and participate in programs that explore moral injury.
3. Researching and educating on moral injury.
Raising awareness is a prerequisite to creating change. We are building the space and capacity for those who have moral injuries to start their search for healing.
This is not just an academic pursuit. We are addressing the needs of the wounded through multiple healing modalities including mindfulness exercises, finding a life purpose and connecting with our ‘higher power’. Our endeavor is unique in this regard; through the use of artistic and literary formats for public engagement, we can serve those who need healing while addressing the public need for understanding of this topic.
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