My final year in the Narrative Medicine Master's program at Columbia University focused on the study of moral injury. At the time, moral injury was a novel idea in the field of trauma studies, intended to expand the conversation beyond post-traumatic stress disorder and individualized pathology. Early investigations into this concept focused primarily on moral injury in veterans, as seen in my thesis. However, over the past seven years, moral injury has come to be a widely recognized construct and term. It has now been studied in many different populations, including healthcare professionals, and had a significant influence on clinical practice, policy, and contemporary trauma theory.
I have continued to deepen my understanding of moral injury since completion of my thesis. Recent work includes strategic advisory for Moral Injuries of War, an immersive sound installation that premiered at UNFINISHED festival in September 2019.
The situation: An overview
The United States-led military interventions in Iraq and Afghanistan are the two longest wars in American history. Both now surpass a decade in length. The United States initiated Operation Enduring Freedom (OEF) in Afghanistan on October 7, 2001, less than a month after the events of September 11th. The stated goals of OEF were to remove the Taliban regime from power; to thwart the operations and growth of terrorist factions in Afghanistan; and to capture key Al Qaeda leaders–most notably, Osama Bin Laden. Shortly thereafter, on March 20, 2003, Operation Iraqi Freedom (OIF) commenced in Iraq. In official statements given throughout 2002 and 2003, the Bush administration stated that Iraq financed and trained terrorists and was manufacturing weapons of mass destruction. Military aggression was justified on these grounds. The intelligence supporting such claims is now widely disputed.
The human and economic costs of these wars are stunning. Since September 11, 2001, over 2.4 million American men and women have served in the wars in Iraq and Afghanistan. More than 8,000 coalition troops have died in combat. Between 17,000 and 19,000 Afghan civilians and 112,000 to 122,000 Iraqi civilians have died as a consequence of the wars. To date, almost $2 trillion has been spent on OEF and OIF, with estimates of total economic impact ranging from $4 to $6 trillion (Bilmes, 2013, p.20).* Though often neglected, the ethical expense of war must be accounted for as well. The long- and short-term consequences of morally questionable military practices in Iraq and Afghanistan are considerably more difficult to quantify.
*This estimate includes operations to date, long-term veteran medical care and disability compensation, social costs for veterans’ families, military replenishment, and other macroeconomic costs. Bilmes’ analysis finds $4 million to be the most conservative estimate, which does not account for macroeconomic consequences of OEF and OIF (Bilmes 20).
Moral injury and collective moral violation
In order to evaluate the personal and public implications of unethical military practices in OEF and OIF, a construct beyond post-traumatic stress disorder (PTSD) is required. Although foundational to understanding the psychological consequences of exposure to a life-threatening event, PTSD does not engage questions of ethics. For this, the construct of moral injury is more appropriate.
There is a well-established body of work correlating combat exposure to PTSD. Per the DSM-IV-TR, to be diagnosed with PTSD, an individual must be:
“…exposed to a traumatic event in which both of the following were present: 1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. the person's response involved intense fear, helplessness, or horror” (Section 309.81).
As evidenced in the above diagnostic criteria, PTSD addresses the implications of harm inflicted upon or witnessed by an individual; it is predominantly a model of victimization. Different theories of PTSD articulate this in different ways. For example, in the social-cognitive perspective, an individual is unable to integrate a traumatic experience into prior assumptions about safety, trust, control, and independence. The world is no longer perceived as predictable or safe, and thus the individual cannot have confidence in their ability to keep themself (or others) out of harm's way. Enduring symptoms are a consequence of a loss of faith in self-efficacy. The cognitive model of PTSD focuses on fear-based, adaptive reactions acquired during life-threatening events. When the individual is no longer experiencing the traumatic environment, the survival reactions and fear persist, leading to ongoing emotional distress and maladaptive behaviors. Broadly, treatment of PTSD seeks to appropriately integrate the traumatic event into the present self and to restore a sense of control.
As a victim-based model, PTSD does not provide an adequate framework to address the full implications of perpetration in traumatic environments. Where PTSD attends to the long-term effects of experiencing a direct threat to life, moral injury addresses the psychosocial and spiritual consequences of participation in and exposure to ethical violation. Moral injury may be defined 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. This injury is brought about by bearing witness to perceived immoral acts, failure to stop such actions, or perpetration of immoral acts, in particular actions that are inhumane, cruel, depraved, or violent, bringing about pain, suffering, or death of others” (Drescher et al., 2011, p.2).
Military personnel exposed to combat are highly likely to have experienced events that may result in moral injury due to extensive exposure to violence and human remains. The ethical complexities of OEF and OIF, arguably place veterans of these wars at a greater risk of moral injury.
Individual affirmation, collective accountability
How does one begin to combat the forces of negation that sustain practices of torture and atrocity? How does a community initiate ethical redemption and revitalization? In systems of negation, the ritual relocation of ethical violation to the individual obscures the complex social, cultural, and political ecosystems surrounding the unethical event. This has profound implications for both the perpetrator, as well as the community-at-large. By isolating, or rendering invisible, ethical violation, the community forsakes a valuable opportunity to adapt toward more humane theoretical, socio-cultural, medical, and political practices. The affirmative ideology also allows for new configurations of ethical responsibility. To affirm individual experiences of moral injury is to open the space for a collective ethical dialogue and, ultimately, redirection of the ethical boundaries of a society.
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