Moral Injury: What Leaders Don’t Mention When They Talk of War

By Lt. Col. Douglas A. Pryer

I received a Combat Action Badge because, for a short time in Iraq, I seemed to be a magnet for enemy fire. Years later, explosions still cause me minor discomfort. The sounds of fireworks, gunfire and engines backfiring are unsettling. But was I traumatized by enemy fire? No, I was not.

What caused me to suffer some symptoms associated with post-traumatic stress disorder (PTSD) does not actually meet the criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders for this condition. My most significant combat experiences are sewn together with a thread other than extreme, life-threatening violence. This thread is moral dissonance. It is clear to me today that I and others sometimes failed to make wise choices. To our shame, we should have known better.

A growing number of mental health experts argue for the existence of a condition that may explain my symptoms better than PTSD. In a 2009 article in the Journal of Traumatic Stress, a team of experts defined moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

PTSD, they contended, is physical in origin, while moral injury is a “dimensional” problem. Physically stressful experiences may cause PTSD, but nonthreatening events may still serve as a source of moral trauma. Some traumatic events serve as a source of both PTSD and moral injury. The two conditions share some symptoms, but others are unique to moral injury, such as shame, guilt, demoralization, and the potential for self-harm. Those who suffer from PTSD can be helped by such physiological remedies as drugs and rapid eye movement treatment, but the morally injured require counseling.

Moral injury is not unique to warriors, the experts contend. Those who fight wars simply tend to feel it more deeply. In the strange world that warriors enter, they may assume an identity—a posture toward large groups of fellow human beings—that seems just as alien and remote to them as the land and war in which they fight. This alien identity may or may not be something they can easily live with.

Moral injury is real, and any nation that desires to truly honor its warriors must place perceptions of “what is right” at the forefront of its deliberations on when and how to wage war.

Moral Injury Isn’t New

The psychiatrist Jonathan Shay popularized the term moral injury in his 1994 book, Achilles in Vietnam: Combat Trauma and the Undoing of Character. At the heart of Homer’s The Iliad, Shay says, is a story of sullied honor. Agamemnon, the Greek army’s commander, “betrays ‘what’s right’ by wrongfully seizing Achilles’ prize of honor,” the captured princess Briseis. Achilles is outraged, withdraws from the Greek army and the war, and “cares about no one but a small group of combat-proven comrades.” When the Trojan hero Hector kills Patroclus, Achilles “is tortured by guilt and the conviction that he should have died rather than his friend,” and “he goes berserk and commits atrocities against the living and the dead.”

“Moral injury,” Shay writes, “is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as ‘what’s right’ has not also been violated.”

The classics are rife with examples of warriors suffering grievously from moral distress. Ajax, driven temporarily mad by a perceived insult, slays a herd of sacred animals. When he recovers, he “is doubly humiliated, religiously defiled, and kills himself by falling on his sword.” Many of Shakespeare’s warriors—driven by guilt—kill themselves, including Othello, Cassius and Brutus.

Literature’s most famous sufferer of moral injury may be Kurtz in Joseph Conrad’s 1899 novel, Heart of Darkness. Initially an idealistic imperialist, Kurtz witnesses and perpetrates atrocities. His soul becomes as afflicted as his body, which succumbs to jungle fever. As he dies, he seizes Marlow, the book’s narrator, and cries out madly at Marlow and life: “The horror! The horror!”

In our era, many mental health studies have concluded that warriors’ moral distress can cause enduring problems. Studies of Vietnam veterans linked guilt to PTSD, depression, violent actions and such self-handicapping behaviors as drinking and suicide. Similarly, a study of Gulf War veterans found guilt over killing others is a significant predictor of PTSD symptoms and alcohol abuse.

Such studies are supported by a staggering amount of anecdotal evidence. Some stories have gained much media attention. There is, for example, the sad tale of Alyssa Peterson, a young intelligence analyst who committed suicide in 2003 after being reprimanded for refusing to participate in “torture-lite” interrogations. Peterson’s case points to an important truth about moral injury: Unlike PTSD and traumatic brain injury, it is sometimes preventable. If Peterson had not felt tortured by what she had been ordered to do, she might not have felt so distressed as to take her own life.

Moral injury results in mental torture to the troops, whose care is entrusted to American leaders. It leads servicemembers to try to drown their sorrows in alcohol or drugs, to be involuntarily separated from the service due to disciplinary action, or to voluntarily leave the service—or the world, by killing themselves. It greatly burdens the U.S. military and civilian health-care systems. It hurts the ability of veterans to positively contribute to society. It distresses and may lead to the physical harm of those who interact with afflicted soldiers.

Operation / Excerice NameCredit: U.S. Army/Sgt. Jonathan W. Thomas

Links to Suicide

Of the adverse effects of moral injury, the role that moral injury may play in the U.S. military’s high suicide rate has attracted the most attention. Prior to the wars in Afghanistan and Iraq, the active duty suicide rate of each service remained steady at about 10 suicides per 100,000 servicemembers. Since 2003, this rate has doubled for the Navy and Air Force, making it comparable to the rate among U.S. civilians of like age and gender, but this rate has more than doubled among marines and tripled among soldiers.

Not all veterans of our recent conflicts suffer from moral injury, but the potential for it is great. The military’s 2006 and 2007 mental health surveys of marines and soldiers in Iraq and Afghanistan found that 10 percent believed they had mistreated noncombatants or damaged property “when not necessary.” This percentage did not include those who may have been afflicted with other sources of moral injury, such as the legally justifiable killing of enemy combatants and the unintentional killing of noncombatants. Even legally justifiable actions can greatly trouble warriors.

Some leaders—especially those who hold a self-delusory faith in “American exceptionalism”—can and do protest that moral injury cannot possibly apply to U.S. servicemembers. Despite their protests, large numbers of American troops clearly believe they did or witnessed something wrong downrange, perhaps terribly wrong, and what matters here is how the individuals judge their experiences, not what others say.

Moral injury cannot be the sole reason for our military’s growing suicide rate. Other factors include PTSD and traumatic brain injury, which have also been linked to increased suicide risk. Another factor has been the increased operational tempo of all units, including recruiting, training and test units. This high tempo can damage servicemembers’ relationships with the very people they depend upon for emotional support.

Still, it is troubling that the military does not even acknowledge moral distress can lead to suicide, as literature, numerous empirical studies and a massive amount of anecdotal evidence overwhelmingly indicate. This is exactly what is happening, though. Millions of dollars are spent collecting suicide-related data, but this data largely involves misbehaviors that are rightly considered effects of psychological injury rather than root causes. We know, for example, some suicide victims drank too much before they died, but we rarely know what drove them to drink.

Until we understand deeper causes, we will not meaningfully reduce or prevent such negative outcomes from psychological injury as suicide.

Moral Injury and the U.S. Servicemember

Ethics does not consist of purely academic, impractical restraints. It is firmly rooted in human biology. Our capacity for seeing others as beings like ourselves, who should be treated as we want to be treated, is an important reason our species dominates the planet. Indeed, without innate moral forces, Homo sapiens would be unable to live in large, powerful nations. America’s very existence would be impossible.

War is a moral contest, and the last side to believe that it is right to fight is the side that most often wins. Only wars in which an enemy population is exterminated, broken or scattered are decided by another calculus, and, in the information age, such cruel tactics are rarely (if ever) possible for mature democracies like America.

Beyond “victory,” another enduring effect of war’s moral dimension is psychological injury. Technology is unlikely to limit such injuries. Although remote-controlled warfare reduces or prevents PTSD and traumatic brain injury, cases of moral injury will only increase as sensors become more advanced and killing becomes more intimate for drone operators.

In his 2009 book, Packing Inferno: The Unmaking of a Marine, former marine Capt. Tyler Boudreau declares it obvious that moral concerns deeply impact the psyches of warriors, and he rails against the inability of societies to learn from their own literature. Until citizens take responsibility for their wars and the invisible injuries of combat veterans, Boudreau argues, they will mistakenly see these injuries as resulting from veterans’ moral or mental deficiencies.

Leaders, not mental health professionals, play the key role in reducing moral injury. Adopting a morally focused approach to war would reduce dissonance by causing servicemembers to align who we say we are and who we often believe we are with who we actually are. During my combat deployments, I never once witnessed a staff debate the perceived justice of an act. Unless a lawyer says a tactic is illegal, the typical U.S. military leader believes he or she has the moral “green light” to do it.

Our military’s narrow, legalistic approach to waging war is tragically ironic because it undermines what should be our nation’s greatest strength—our strong tradition of respect for basic human rights. The Declaration of Independence established this tradition and codified it in the Bill of Rights. Gen. George Washington set a modern precedent for treating prisoners with dignity and respect, a tradition U.S. soldiers have adhered to more often than not. More than any other nation, the U.S. is responsible for the Law of Armed Conflict, publishing this law’s foundation as General Order 100 of the Union Army during the Civil War. That record stands in stark contrast to that of our nation’s jihadist foes today, who have no similar tradition and have shown little capacity for accommodating different cultures and faith groups.

Will our nation and military learn to see the pursuit of perceived justice as absolutely essential to success in modern war? Will we come to see morally justifiable actions as the crucible in which the psychological cost of war to America’s warriors is lessened and redeemed? It is not at all obvious these things will happen. Human beings are creatures of passion, and war displays this passion at its noblest and cruelest extremes. It stands to reason that our nation will not always choose only just wars to wage and that servicemembers will not always perform just combat actions. Nevertheless, human beings are also governed by moral forces. The great cost of underestimating these forces in the information age is surely too great to go long unnoticed and inadequately addressed.

Our nation will not always be able to wage just wars justly, but we must try much harder to do so.

Lt. Col. Douglas A. Pryer has held numerous command and staff positions in the U.S., the U.K., Germany, Kosovo, Iraq and Afghanistan. He currently serves as a planner for the Joint Chiefs of Staff. He has a master’s degree in military history from the U.S. Army Command and General Staff College and is the author of the book The Fight for the High Ground: The U.S. Army and Interrogation During Operation Iraqi Freedom, May 2003–April 2004 as well as numerous essays on the human and moral domains of war.