To live in the United States today is to be constantly exposed to moral injury. Moral injury is not, however, equally distributed. Some people are vastly more injured than others, and some are not injured at all. Some people inflict moral injury on others. Lots of people are morally injured, and it is not always obvious.

One might argue that such a grand category, applying to so many, must result in pathologizing a normal experience. Moral injury may be normal, but it’s not good. The lives of the morally injured manifest in chronic sadness and despair, overlaying a rage that occasionally becomes dramatic.

From military trauma to everyday moral injury

Moral injury has become something of a hot topic among those who write about the trauma experienced by soldiers at war. So far, I can find nothing written about moral injury that applies to the experiences of civilians in everyday life. Yet, there is no reason it shouldn’t, particularly if it is interpreted properly.  Moral injury is the result of the use of  political power to deny the experiences of others. There is no more pernicious political power than this.

Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations,” as one of the first academic papers sponsored by the Department of Veterans Affairs put it. (Litz, et al., pp. 696, 700). A moral injury occurs when an act shatters moral and ethical expectations about fairness, the value of life, and the expectation that others will tell the truth. (See my previous post for more on moral injury in the military.)

Themis

The term moral injury seems to have been introduced by Jonathan Shay in Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994). Shay defines moral injury as a violation of themis, a term he borrows from the ancient Greeks. As Shay uses the term, themis means what’s right, proper, and customary. It is the mark of civilized existence.

Shay’s most poignant example of the violation of themis is that of a soldier who was awarded a medal for mistakenly killing children and fishermen. Command knew; it just didn’t care. The colonel just wanted “body count.” It made the soldier crazy. He knew he had done nothing honorable, but the standard of honorable had been turned upside down (pp. 3-4).

The result says Shay, is not only moral confusion, but disorientation, as soldiers were told, in effect, “you didn’t experience it, it never happened, you don’t know what you know.” (p. 171) Civilians have similar experiences.

How could moral injury apply in civilian life? 

Here is a short list:

• Politicians lie.
• Corporations promise to keep present employees after a merger and they don’t.
• Bosses exploit and mistreat their employees.
• Husbands beat their wives and their children, a pattern that can go on for generations.
• People are paid less than a living wage, generally for hard work. They see others earning millions of dollars.
• In a land of plenty, millions go to bed hungry. Millions can’t afford their medicine, or to see a doctor.
• Old people are isolated and devalued.

Not many people question that these things occur, though there is surely disagreement about how often, and who is at fault. The question is whether we want to consider them as falling under a new category, moral injury.

Shame

If we think about moral injury as the VA does, then it is primarily an experience of shame and guilt. If so, then the examples I have drawn on suggest that it is primarily the shame and guilt of the powerless.

Primo Levi wrote about shame in Survival in Auschwitz. He puzzles over why men who had been subjected to such cruelty and powerlessness, as well as their Russian liberators, should feel shame.

It was the same shame which we knew so well, which submerged us after the selections, and every time we had to witness or undergo an outrage: the shame that the Germans never knew, the shame which the just man experiences when confronted by a crime committed by another, and he feels remorse because of its existence, because of its having been irrevocably introduced into the world of existing things, and because his will has proven nonexistent or feeble and was incapable of putting up a good defense. (p. 74)

While there are multiple sources of shame, Levi’s insight into shame’s origin in powerlessness is important, and sometimes the extreme illuminates the normal. Every example of moral injury among civilians listed above evokes feelings of powerlessness, whether it is the powerlessness of the average worker before his or her employer, the powerlessness of children, or the powerlessness felt by the average citizen in the face of corporations and government.

Moral injury often evokes rage, which is particularly obvious among those soldiers who become brutal and callous, as Shay argues comparing Achilles with soldiers in Vietnam. But behind the rage is grief: grief at the loss of comrades in arms, and as importantly grief at not being able to live up to one’s own values. Living up to one’s values isn’t just a matter of not lying, cheating, and stealing. Living up to one’s values includes being the type of person one is proud of, or at least satisfied to be. Moral injury demoralizes, for it devalues the self. This is why shame is so central to moral injury.

Moral injury and moral narrative

Moral injury destroys the meaning of life because life is fundamentally moral, as are most of the stories we tell each other. The narratives of human life are moral narratives not in the sense of admonitions to be morally good, but because we all live in a moral universe, that is a universe of meaning. In a moral universe there is a connection between what people say and what people do. It is not hopelessly naive to believe that “there are people in charge who know and care, even if they sometimes make mistakes,” or “the people who love me would not deliberately hurt me.”

Life is not built on a lie when these beliefs can be counted on to be generally true. Not always true, there are lots of exceptions, but generally true. Moral injury occurs not when one is lied to (though it may if the lie is important enough), but when the connection between words and deeds is severed. Promises made and kept are perhaps the most important connection between word and deed. When promises are kept word and deed become one. Honesty is a promise.

For some, the earth moves when they discover that people in authority routinely lie. Once one knows this one lives in a new world. Some people remain aliens in this world forever. The result is demoralization.

Severe, prolonged [violations of themis] can bring wholesale destruction of desire, of the will to exist and to have a future. Betrayal of “what’s right” is particularly destructive to a sense of continuity of value in ideals, ambitions, things, and activities. When some major ideals have been betrayed, the trustworthiness of every ideal or activity may be called into question. (Shay, p. 178)

It takes a group to overcome moral injury

Consider African-Americans in the American South during the era of segregation. Recognizing the injustice of segregation, and organizing to do something about it, first required the recognition of moral injury: that the narrative of those in power was a lie, and it resulted in generations of African-Americans feeling less deserving, less worthwhile, less human.

Because moral injury is alienating and isolating, it is best addressed by group action. It is particularly helpful when existing institutions can take on this function, in this case the African-American church. In such circumstances, inspirational leaders can arise, and many are stirred to action. Cooperative action heals moral injury. So does talking and working with others. Moral injury thrives on alienation and anomie. Much as “rap groups” among Vietnam Veterans became and remain the best treatment for PTSD, so groups of the morally injured are the best defense against demoralization.

Conclusion: PTSD and moral injury

It is an accident of history that moral injury has become so closely aligned with PTSD. They arose together because Shay first recognized moral injury among Vietnam Veterans, and because the Veterans Administration funds virtually all of the research on moral injury. This does not reflect an intimate connection between the two disorders. It creates the connection in the first place, as PTSD researchers turn their attention, and the VA its dollars, to moral injury.

Nevertheless, the connection between PTSD and moral injury is not merely political and economic. It has an intellectual basis. As Fassin and Rechtman put it in The Empire of Trauma, trauma today is not a clinical but a moral judgment. Its advantage is that it has given us “this unprecedented ability to talk about—and hence experience—the violence of the world.” (p. 276) In other words, the intellectual link between PTSD and moral injury is not medical but moral. Both legitimize invisible injuries, and invisible violence.

It is much easier to identify invisible injuries among soldiers than among wide swaths of the population. Soldiers are legitimate victims of injury, even if it took generations to recognize invisible wounds. To talk about moral injury among civilians is to criticize our way of life, a combination of mass democracy and corporate capitalism. But if moral injury is a form of violence, inflicting shame and demoralization upon its victims, then it would be careless, in the literal sense of being uncaring, not to recognize its presence among us all. Some more than others, but everywhere.

This does not mean that everyone needs to be “treated.” As the example of the desegregation movement suggests, the best treatment is the organized action of afflicted groups.

References

Didier Fassin and Richard Rechtman, The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton, NJ: Princeton University Press, 2009.

Primo Levi, Survival in Auschwitz. New York: Simon & Schuster, 1996. [published in England as If this is a Man]

Brett Litz, et al., Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review (2009), 29, 695-706.

Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner, 1994.