Monday 9 October 2023

2023 Moral Injury

                                             MORAL INJURY


                                        Eduardo C. Gerding

“We thought we had managed all right,” he told Holmes, “we kept the awful things out of our minds, but now I’m an old man and they come out from where I hid them. Every night.”(Grossman, David. On Killing. New York: Little, Brown & Co. 1995.)



The link between mental illness and moral injury (MI) was explicity drawn in the 1990s by Jonathan Shay,a psychiatrist at the Department of Veterans Affairs in Boston,Massachusetts when attempting to explain the enduring nature of PTSD suffered by US veterans of the Vietnam war. 12

Police officers, media professionals and military personnel are required to make challenging ethical or moral decisions in their line of work which expose them to MI. 7,9,25

When someone experiences a moral injury, the guilt, sadness, and shame that come with it can be debilitating. It can create a deep wound at the center of a person’s identity.

In this article we insert testimonies from the 1982 conflict that could perfectly respond to the MI established criterisa. These testimonies come from opublished and widely disseminated books.



¨Suddenly we heard screaming, a high-pitched 'Mama, mama]' A dull shot was heard and we saw an Argentinian fall over the cliff.¨ ¨A group of our guys had assembled some Argie prisoners on a cliff above where we had dug a body pit for their dead. Now, with the battle over, they were shooting prisoners and toppling them down to be buried. It was an outrage and senior officers stepped in immediately before the executions could get out of hand. But in the cauldron of emotions after the battle they decided not to take further action. Court martials were the last thing we needed.¨ (Excursion to Hell, by former Lance Corporal Vincent Bramley) 3


Some guys collected Argentinian ears, but most regarded this as going over the top. Having collected trophies in the night, one person had been slighlty injured a Goose Green. The boys regarded this injury as a warning to him, and started to avoid him because he didn't change his behaviour. He was subsequently killed. (McManners ,Hugh-The Scars of War, p. 347, HarperCollins, 1993) 18

Although MI is most oftern associated with violence and aggression within the context of combat, military personnel may also experience inner turmoil secondary to non violent events such as exposure to dead bodies or human remains ,reported by 65% of Irak and Afghanistan veterans.4


Potentially morally injurious events (PMIE)

Potentially morally injurious events (PMIE) are events that violate one's deeply held moral values or beliefs, and that have the potential to create significant inner conflict and psychological distress.Significant degrees of such distress have been termed ‘moral injury’.


Moral Injury (MI)

Moral injury (MI) is when one feels they have violated their conscience or moral compass when they take part in, witness or fail to prevent an act that disobeys their own moral values or personal principles.

MI is based in judgments of conscience and emerges in the aftermath of traumatic events, when a person has time to evaluate the experience.

Although MI is not currently categorized as a form of mental illness, a systematic review of 13 studies made by Victoria Williamson et al, representing 6373 participants ,found that PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the variance in depression and 2.0% of the variance of suicidality. 16,25


MI is considered a syndrome separate and distinct from PTSD, although with some definitional overlap between the two (particularly in the affective domain)


 Avoidance and Isolation 23



Moral Injury

Veterans with PTSD may avoid persons, places or situations that remind them of the traumatic event. It is out of fear

Veterans with moral injury may also avoid others, however, it is not out of fear. This kind of avoidance is out of lost hope, disillusionment, and self-judgment

They remain concerned for their safety and are uncomfortable when they have less control over what “could” happen.

Individuals with moral injury judge that no one else would understand or accept what they have done. A life of secrecy develops, and they do not want to talk about the military or specific missions. Many persons with moral injury describe it as hiding the “real me” from others while seeing, in the mirror, a shattered or monstrous self.

Veterans with PTSD believe that the world is dangerous.


After the military, Veterans with PTSD avoid situations that “could” present danger, including crowds. They scope out “escape” routes. They have well developed plans for family and personal safety (home alarms, weapons, etc.).

Veterans with moral injury isolate themselves because they feel “unworthy,” and they may stop previous religious/spiritual practices.

Someone with PTSD may avoid talking about the military or specific missions because it raises anxiety. The person may avoid movies or TV shows about the military because they trigger memories of the trauma and raise anxiety or result in distress.



 Negative Thinking 23



Moral Injury

Veterans with PTSD believe that the world is not safe. They remain ready to protect and defend themselves and their families from harm. They believe they have to take extra safety measures

Veterans with moral injury develop hopeless, negative thinking over what happened.

Veterans generalize what happened in thecombat zone or deployment location to their current life.

They think that the world should be safe and that some things should never have happened. They become bitter over negative outcomes that, using hindsight, they think might have been avoided.

Veterans do not trust others, who remind them of insurgents.

Their thinking is more depressive than fearful.

Veterans with PTSD engage in negative thinking that is unrealistic and black-and-white.

They may judge that they have “failed” or that what they have done is “unforgivable.”

Their nightmares reinforce their beliefs about safety, and they “replay” situations that involve inescapable danger.

They lose faith in themselves and others and no longer trust their judgment. u They may have dreams about being hunted, haunted or chased by those they think they “failed.” They may dream about being helpless in the face of death.


 Mixed Event

A mixed event is when we have a simultaneously moral injurious and traumatic.25

Moral Dissonance

Moral dissonance arises when the displayed behavior is experienced to conflict with a morally more desirable behavior (ought).

Veterans who suffered a PMIE described that central to the distress caused by PMIEs was the experience of moral dissonance, or a clash between concurrently held sets of values (e.g. military values versus civilian values)which provoked considerable psychological distress.25




If I was to go into a town and shoot five people,I would be a mass murder.Yet,if I was to shoot five people in uniform overseas you are legally entitled to do that because you have rules of engagement and all the rest of the stuff.But murder is murder at the end of the day.Killling is killing (Verbatim quote in European Journal of Psychotraumatology 2020,Vol 11)25



As we went through the enemy positions, we saw gruesome sights — heads blasted off and faces with gaping holes. One man was still alive but his arms lay yards away from him on either side of the trench.It was staggering — and dangerous in the long run — how quickly we became used to these macabre scenes. We would take the boots, which were better quality, and wear them instead of our own, literally stepping into dead men’s shoes.

 I came home little more than two months later hard and cynical, tormented by harrowing memories. Back in my home town of Dundee, I spent long nights with only a bottle of whisky for company, drinking myself into a haze to evade the nightmares. I became angry, moody and difficult, and my marriage disintegrated as a result.


One day my mother sat me down and spelled it out to me. I had no heart any more, she said. I’d left it 8,000 miles away on the Falklands. For a long time, I doubted whether the sacrifice of my friends’ lives and the trauma inflicted on those of us who survived had really been worth it. But I came to see the value of what we achieved and be proud of it.Two hundred and fifty eight British servicemen paid with their lives for the recapture of the islands, and a further 775 were wounded. Many of the rest of us paid with our peace of mind. (ex-Para Tony Banks- Mail Online 2 March 2012) 1


Williamson observed that some veterans resolved this moral dissonance by identifying a different source to blame for the events rather tan themselves (e.g: Ministry of Defense or chain of command)

Discussion of the PMIE with Friends, colleagues or family members was considered cathartic but did not help to resolve their moral dissonance.


The MI Symptom Scale

The 45-item Moral Injury Symptom Scale-Military Version, Long Form (MISS-M-LF) is probably the most comprehensive, assessing ten dimensions of moral injury ,including the psychological and spiritual aspects. 4,12,26


MI Symptoms

Veterans who experience moral injury can be overwhelmed by negative feelings. Feelings of guilt, shame, remorse from past acts that violated their code of morals. Often they feel disinterest in previously enjoyable activities, or genuinely find it hard to feel happy.26

Moral Injury in US personnel

In 2020, Maguen et al examined PMIEs in a national sample of post-9/11 Veterans and found that 55.4% of Veterans reported any PMIE exposure. Veterans endorsed exposures stemming from perpetration (18.8%), witnessing (27.9%) and betrayal (41.1%). This was the first study to examine gender differences in PMIE exposures. 19

In 2022, Boscarino et al studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. 2

Most veterans studied were deployed to Vietnam (64.1%), while others were deployed to post-Vietnam conflicts in Iraq and Afghanistan and elsewhere.

Altogether, 95.1% of the veterans were male and their mean age was 61.6 years. Among the veterans, 24.4% had high combat exposure , 10.9% had PTSD, 19.8% had major depressive disorder, and 11.7% had a history of suicidal thoughts.2

MI was also associated with pain, sleep disorders, fear of death, anomie, use of alcohol/drugs to cope post-deployment, and poor unit support/morale during deployment.2

Having an in-service concussion, current pain, sleep problems, and a history of heavy marijuana use were positively associated with having a high MI score (all p-values p <0.01) .Having mental health treatment in the past year was also associated with high MI (OR = 3.23, p < 0.001).

Conversely, serving in the National Guard/Reserve (OR = 0.67, p = 0.009) was related to lower MI scores.


The reasons why some veterans are at greater risk for MI is still unclear and may involve personality and moral value issues, as well as factors related to sensory processing of stimuli. 2

MI among UK military veterans 25                                            

Victoria Williamson et al published in 2020 a most thorough research on PMIEs among UK military veterans (93.3% British Army) which included mistreating civilians or enemy combatants, being ordered to break rules of engagement, and disrespecting dead bodies (Williamson et al., 2019).

To determine whether a participant had experienced a moral injury, all participants were asked whether they had experienced an event(s) during military service that challenged their view of who they are, the world they live in, or their sense of right and wrong and to provide a brief summary of the event

All participants (average age of 46.3 years ) reporting having been deployed during their military service on average five times, with deployment areas including Iraq, Afghanistan, Sierra Leone, Bosnia, Kosovo and the Malvinas. 25

Fifteen participants experienced exposure to a PMIE, nine had experienced a ‘mixed’ event where the event was both potentially morally injurious and traumatic/life-threatening, and six experienced a traumatic or life-threatening (non-morally injurious) event.

In both the ‘mixed’ and moral injury samples, veterans who experienced PMIEs reported that their feelings of shame and self-loathing contributed to poor self-care as well as risk-taking behaviours (e.g. driving while intoxicated, speeding).

There was also substance misuse (i.e. alcohol, illicit drug use)and efforts to atone or make amends for the PMIE like being involved in organizations to support fellow veterans, visiting the grave of enemy combatants they had killed and actively campaigning against bullying.

Morally injurious events among aid workers 6

Aid workers frequently encounter human distress and witness numerous injustices that are inherent to humanitarian crises . Aid workers are exposed to ethical issues and moral conflicts.

Dewar et al found that struggling to “understand global injustices and acts of inhumanity,” to “bring meaning to confronting situations,” and to cope with “a sense of helplessness in horrific situations” were major issues that resulted from the participant’s aid experience.

McCormack and Joseph (2013) reported that many aid workers questioned their own actions, particularly when they chose to prioritize their own safety over that of others. Such situations generated a great deal of shame and the fear of being judged.


Experiencing PMIE in the context of aid work appears to be the norm rather than the exception, as 81.1% aid workers reported PMIE.  22.8% reported having committed a PMIE, 75.3% reported having witnessed others committing a PMIE, and 27.4% reported PMIE that stemmed from being betrayed.


A total of 583 nurses and 2423 physicians were recruited from across mainland China. An online survey was conducted from March 27 to April 26, 2020 (during the middle of the COVID-19 pandemic) using the Chinese version of the MISS-HP(Moral Injury Symptoms Scale-Health Professional)


The MISS-HP is unique in that it assesses both psychological and religious/spiritual dimensions of MI. The results indicated that the MISS-HP is a reliable and valid measure of MI in both nurses and physicians. the MISS-HP can be used to screening for MI symptoms and follow response to treatment among healthcare professionals in China. 27


 MI and Religiosity

In Williamson’s research, veterans in the mixed and MI with religious beliefs prior to the PMIE reported losing their faith or trust in a just God. Notwithstanding, a small number of veterans with exposure to PMIE described a growth in their spirituality or religious beliefs which was a source of great comfort.This was not described in non-MI injured veterans.

Koenig et al studied 103 Active Duty U.S. Military (ADM) and examined the association between moral injury (MI) and religiosity, the modifying effects of PTSD severity on this relationship, and the receptivity to a spiritual intervention.

Among those with significant PTSD, two-thirds were interested in a spiritually-integrated treatment for their MI. Symptoms of MI were common in these ADM.14

In a study on Vietnam veterans those who had a positive view of God and sought forgiveness faired better that those who felt alienated by God for various reasons.This seems to coincide with religious “common sense.”


The fase of the enemy


The thesis developed by Seth is that the process of recognizing the face of another person, including an enemy, brings one into a position of responsibility for the person being faced and that denying this responsibility by killing creates an ethical and religious conflict leading to moral injury. 24


The value of religious authority as found in the Old and New Testaments, in addition to teaching responsibility for the other, is an acceptance of accountability that lies beyond the self for every action taken. For where there is accountability, there is the possibility of reconciliation, and where one finds reconciliation there lies the essence of religious authority, not as a tool to be mastered, but as source of love that dismantles the grip of fear.

Risk and protective factors 25

  • ·       Veterans perceived the lack of social support as a factor increasing their vulnerability to distress.
  • ·       Predeployment briefing can be somewhat protective against later psychological distress during deployment.

             One way to prepare combatants for war is to teach respect for the  

            enemy as a means of responsibility that holds the enemy within the

            boundaries of  humanity.

  • ·       Collaborative,informal support from military chaplains was linked to better mental health in service personnel
  • ·       How the psychological consequences following morally injurious events compare to those encountered after a traumatic,but not morally injurious events,remain poorly understood.25

MI and the 1982 South Atlantic conflict

The 1982 conflict has become a heavily morally charged subject. Its unfolding remains difficult to assess and its lessons hard to learn (Tessey, Citation2020), partly because the hegemonic narrative of Malvinas tends to exclude the military from the social memorialization of the conflict. This ultimately assigns them a pre-confected role without questioning of their experiences.10, 17,22,

Mount Longdon, which occurred in Malvinas (11 jun 1982 – 12 jun 1982), was the bloodiest battle fought by the British Army since the Korean War .

It was fought between the British 3rd Battalion, Parachute Regiment and elements of the Argentine 7th Infantry Regiment.

Allegations  emerged of incompetence, cowardice and murder by British soldiers. 3,10,11,17


British war veteran Tim Lynch described in Vincent Bramley´s Two Sides of Hell how Sargeant John Pettinger shot twice Argentine prisoner José Carrizo in the head. 3 (Taught to kill,not to pity:Falklands veteran Tim Lynch believes Army training creates men capable of atrocities-The Independent-Sunday 21,March 1993)


“The causes of war and the way it is fought have to be judged independently. You can be right to go to war and fight it in a stupid way, and you can be wrong to go to war and fight it in a very intelligent way.” (An interview with Sir Hew Strachan-The Telegraph-17 Jul 2014)


“Where a society has lost the ability to make sound moral judgments and there are no restraints on what is considered evil; when human life is not accorded dignity and people are treated as commodities; when expectations of civilised conduct are ignored and the imposition of political will becomes paramount, the likelihood of moral injury is increased substantially in each instance.” (pp.193-94) 8

Father’s war: An anecdotal story from Madeleine L'Engle:


“Father's war was not like our wars today. In his war the enemy still had a face. Once, a good many years after the war, my parents were eating dinner in a Spanish inn, and suddenly Father got up from the table in great excitement and rushed across the dining room to a man who, in his turn, was hurrying to greet Father. The two men embraced warmly, and Father brought his friend over to the table to meet Mother: the man was a

German; he had been an officer in the Kaiser's army; he and Father had fought against each other at the front. It is difficult to understand such an incident today. These two ‘enemies’ were genuinely happy to see each other; they had shared an extraordinary experience; they respected and honored each other. I wonder if that can happen today."   ( L'Engle, Madeleine. The Summer of the Great-Grandmother. The Seabury Press: New York,1974)



In America, specific treatments have been used like acceptance and commitment therapy and adaptive disclosure. In UK, trauma focused, cognitive behavioral therapy and compassion-focused therapy have been used.12

These findings indicated too that there may be a role for chaplains in supporting the wellbeing of morally injured personnel. MI in the absence of PTSD might plausibly be resolved by a priest or an ethicist. 12

The Moral Injury Psychoeducation Group published a Program Handbook whose material was developed at the South Texas Veterans Health Care Service.

The Handbook analyzes the types and sources of MI.23

Moral Injury can result in problems with body, mind, community and spirituality. Resolving moral injury requires a moral repair, a healing of the whole person. kind of multidimensional restoration . 15,21


The multidimensional Veteran care considers:

·       BODY: Sleep, Stress Load, Physical Health (diet, exercise, play), Restoration of Focus and Concentration

·       MIND: Emotions, Guilt, Distorted Thinking

·       COMMUNITY: Connecting with Others 

·       SPIRITUALITY: Meditation, Forgiveness, Beauty/Nature, Prayer, Higher Power/God From

(William P. Nash, “Common Goals for Preventing and Repairing Moral Injury,” DCoE Chaplains Working Group Teleconference, 4 March 2015)


 There are many excellent books on this issue such as:5,20





1-Banks,Tony-A very dirty war:British soldiers shot dead by enemy tropos waving the White flag and Argentinian prisoners bayoneted in cold blood. An exPara tells of the horrors of the Falklands. Mail Online 2 March 2012.

2-Boscarino, Joseph A, Adams, Richard E., Wingate, Tiah J., Urosevich, Thomas et al. -Impact and Risk of Moral Injury Among Deployed Veterans: Implications for Veterans and Mental Health. Front Psychiatry. 2022; 13: 899084.

3-Bramley,Vincent-Two sides of Hell-p9 Bloomsbury Publishing Limited 1994

4-Bryan, Craig J, Bryan,AnnaBelle, Anestis, Michael D et al. Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. Assessment, 23, 557–570.

5-Denton-Borhaug,Kelly-And then your soul is gone: Moral injury and US war-culture.Equinox Publishing.


6-Dewar, Michelle Dewar,Paradis, Alison, Brillon, Pascale. Morally injurious events among aid workers: examining the indirect effect of negative cognitions and self-care in associations with mental health indicators. Psychol., 13 April 2023.Sec. Personality and Social Psychology.Volume 14 - 2023 .

7-Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28, 318–330.

8- Frame,Tom, discussing “Moral Injury and the Influence of Christian Religious Conviction”.in Meagher,Robert War and Moral Injury.

9-Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Maguen, S. (2019). Moral injury:  An integrative review. Journal of Traumatic Stress, 32, 350–362.

10-Guber,Rosana, Ortega Breña, Mariana-The Malvinas Executions: (Im)plausible memories of a .Power.Force and Social Perspectives-Vol 35.Sage Publications Inc.

11-Jennings, Christian-Green-Eyed Boys:3 Para and the Battle for Mount Longdon.HarperCollins Publishers 1996.

12-Jones, Edgar-Moral injury in a context of trauma. The British Journal of Psychiatry (2020) ,216, 127-128. Doi:10, 1192/bjp.2020.46.

13-Kashtan.Miky-Moral Dissonance-Psychology Today.July 27,2013


14-Koenig,Harold, Volk,Fred- Moral Injury and Religiosity in Active Duty   U.S. Military with PTSD Symptoms- https://doi.org/10.1080/21635781.2018.1436102        

15-MacCraken,Vik-Can love walk the battlefield?:A reply to Nigel Biggar- Journal of the Society of Christian Ethics.Vol. 38, No. 1 (Spring / Summer 2018), pp. 59-76 (18 pages)

16-McDaniel,Justin T et al-Moral injury is a risk factor for substance use and suicidality among US military veterans with and withpout traumatic brain injury.J Relig.Health 2003,Sept 7.

17-Mcintyre,Donald-Falklands’ war crimes claim: MoD investigates allegations that Paras shot Argentine prisoners.The Independent.Sunday 16 August,1992.

18-McManners ,Hugh-The Scars of War, p. 347, HarperCollins, 1993

19-Maguen,Shira, Norman,Sonya B-Moral Injury-PTSD Research Quarterly. Volume 33/No 1.

20-Meagher, Robert Emmet , Pryor, Douglas –War and Moral Injury-Cascade Books.April 2018

21-Molendijk, T., Kramer, E.-H., & Verweij, D. (2018). Moral aspects of “moral injury”: Analyzing conceptualizations on the role of morality in military trauma. Journal of Military Ethics, 17, 36–53.

22-Natale,Eleonora- From Campo de Mayo to Malvinas, and Back: The Falklands/Malvinas War from the Perspective of Argentine Veterans Accused of Crimes Against Humanity. Journal of War & Culture Studies

Volume 15, 2022 - Issue 3: Reflections on conflict and culture on the 40th anniversary of the Falklands/Malvinas war.


23-Pernicano,Pat ,Haynes,Kerry-Moral Injury Psychoeducation Group Program Handbook: Introduction to Acceptance and Forgiveness.


24-Seth, George CH(Maj)-CGSC Ethics Symposium-20-23 April 2015-Moral Injury and the problema of facing religious authority.

25-Williamson, Victoria,Murphy, Dominic, Stevelink, Sharon A.N., Allen,Shannon, Jones,Edgar and Greenberg, Neil.- The impact of trauma exposure and moral injury on UK military veterans: a qualitative study.  Eur J Psychotraumatol. 2020; 11(1): 1704554.

26-Wingerter,Robert-The Adult Moral Injury Scale: An Initial Validation Study- https://digitalcommons.georgefox.edu/cgi/viewcontent.cgi?article=1488&context=psyd    

27- Zhizhong, Wang, Koenig ,Harold G., Tong Yan, Wen Jing, Sui Mu, Liu Hongyu & Liu Guangtian- Psychometric properties of the moral injury symptom scale among Chinese health professionals during the COVID-19 pandemic- BMC Psychiatry volume 20, Article number: 556 (2020)