Moral Injury, Moral Identity and Warfighting

This article is only published online and does not appear in the PDF file of the full issue.

The traumatic effects of warfighting on combatants in the form of psychological injury in general, and post-traumatic stress disorder (PTSD) in particular, are well-known even if not necessarily well understood. PTSD in combatants (and others, such as front-line police officers and firefighters) is a consequence of highly stressful, traumatic events, notably events that threaten the life of the combatant (or police officer or firefighter) or cause serious injury, or that cause the deaths or serious injuries to others in close proximity. The traumatic event(s) in question cause: (1) extreme mental distress, such as fear, horror, anger, shame and, perhaps ultimately, depression and nervous breakdown; and (2) physical/cognitive impairments, such as memory loss and poor attention. The symptoms of PTSD include intrusion symptoms, such as recurrent memories, nightmares, and flashbacks; avoidance of memories, thoughts, or other reminders of traumatic events; negative changes in cognitions and mood; negative emotions or beliefs about oneself or others; feelings of detachment; and marked alteration in arousal and reactivity, such as aggression and excessive vigilance.^[1]

The traumatic effects of warfighting on combatants (and potentially of policework, firefighting and related activities on front-line police officers, firefighters and others (respectively)) in the form of moral injury is now a recognised phenomenon^[2]but is nevertheless not, I suggest, well-understood. On the standard view moral injury is a species of psychological injury as, of course, is PTSD, albeit PTSD is an especially damaging species of psychological injury. Moreover, on the standard view moral injury is differentiated from other species of psychological injury, including PTSD, in that moral injury to a combatant, police officer, firefighter etc. results either from that individual perpetrating some serious moral transgression (e.g., killing an innocent civilian) or from that individual being seriously morally wronged (e.g., betrayed by a superior officer during armed conflict).

If we assume the correctness of the standard view (as presented here) then prima facie moral injury (at least in the most damaging cases) is a species of PTSD.^[3] For, as with PTSD, moral injury can result from highly stressful, traumatic events, such as threats to one’s life or serious injury to one’s self from others, and such as killing or seriously injuring others (albeit these traumatic events have the distinctive feature of being moral transgressions by one’s self or against one’s self). Moreover, as with PTSD, in the case of such moral injury caused by highly stressful, traumatic events, those morally injured suffer extreme mental distress (e.g., anger, shame, depression etc.), physical/cognitive impairments (e.g., memory loss, poor attention) and intrusion symptoms (e.g., flashbacks, negative moods, negative feelings about one’s self, detachment). However, some have argued that PTSD, while related, is nevertheless significantly distinct from moral injury (and not merely because some cases of moral injury might be less psychologically injurious than PTSD). The implicit assumption of the view that moral injury is significantly different from PTSD is that PTSD is not per se a moral phenomenon but merely a (non-moral) psychological phenomenon with a physiological dimension (and on an extreme version of this view best understood as an essentially medical condition); and PTSD is not per se a moral phenomenon because it does not necessarily involve any moral wrongdoing (either on the part of the morally injured themselves or on the part of someone else who morally wrongs the morally injured).

In this article I argue against what I have referred to as the standard view of moral injury (and in passing against the related standard view of PTSD); and do so in part by rejecting the narrow ‘voluntaristic-legalistic’ conception of morality that underpins it. In place of the standard view, I argue for a moral-psychological conception based on the notion of caring deeply about what is worth caring deeply about.^[4]

Caring Deeply, Self-Identity and Moral Identity

Elsewhere I have argued that the notion of caring deeply about what is worth caring deeply about has explanatory power in relation to moral injury and PTSD and does so because it is conceptually connected to self-identity and, specifically, moral identity – self-identity and, specifically, moral identity being that which is seriously (psychologically) injured in cases of moral injury and in cases of PTSD.^[5]

The notion of care that I am invoking is of an emotion constituted in part by cognitive states, such as beliefs, as well as, of course, by affective states such as feelings and desires. It is also constituted in part by conative states, such as intentions, e.g., a standing instinctive intention to protect one’s-self against threats to one’s life or to support a significant other. So this emotion of caring is not a simple feeling, such as a bodily sensation of pain or pleasure, or a simple desire that might attach to such feelings, such as a desire that the pain desist or the pleasure continue, or a combination of such feelings and desires. Moreover, being an emotion worth having, it is subject to evaluative rationality. Further, evaluative rationality is internal to the emotion of caring in question in part by virtue of the beliefs held about the person or thing that is the object of caring. Accordingly, if the caring person comes to believe that the object of caring is not worthy of being cared deeply about, then this caring attitude is likely to wane and all the more so if the caring person is highly sensitive to rational considerations and if their belief in the unworthiness of the object of their initial caring attitude is well founded. However, this is not to say that what one cares deeply about is determined by one’s voluntary action. That one cares deeply about, for instance, one’s own life or, indeed, about the well-being of one’s children is not simply a matter of choice, although how one expresses or otherwise responds to these emotions often involves voluntary actions.

Many of the objects of the emotion of caring deeply are very familiar, indeed universally cared about. For instance, most human beings care deeply about their own life and will take extreme (even if in typical instances morally justifiable) measures to avert death, including killing in self-defence. Moreover, they care deeply about the lives of their close relatives and friends and, in the case of combatants, of their comrades-in-arms, and will take extreme measures to protect their lives. Moreover, in doing so they seek and will find moral approval (and perhaps moral disapproval if they fail to do so). Most human beings care deeply about their own autonomy and well-being and the autonomy and well-being of significant others (at least) and will take drastic (again, even if morally justifiable) actions against severe threats to autonomy and well-being, notably the threats of enslavement and torture. Moreover, when others unjustly threaten one’s life, well-being or autonomy, or the life, well-being or autonomy of a close relative or friend, then this generates moral outrage and anger prior to the taking of drastic action in response. This moral outrage is a more or less involuntary expression of the fact that not only do they care deeply about these things, but that they believe, indeed rightly believe, that they are worth caring deeply about. Further, an inability to successfully prevent ongoing threats to one’s life or adequately to cope with torture or enslavement, or to prevent the death, torture or enslavement of close relatives or comrades-in-arms may generate a sense of helplessness, low self-worth, depression and lead to mental breakdown, the loss of self-mastery (and, therefore, autonomy) and, potentially, the onset of suicidal tendencies. In short, life, well-being, autonomy and self-worth are related properties. Obviously, without life there cannot be either well-being, autonomy or self-worth. But it is also true that without autonomy there cannot be well-being; the exercise of one’s autonomy is in part constitutive of one’s well-being, as the trauma produced by enslavement demonstrates. Moreover, without self-worth there cannot be well-being (and self-worth is in part dependent on the recognition of one’s self-worth by at least significant others). Further, without a minimal degree of physical and mental well-being autonomy is compromised, as the effects of the practice of torture demonstrate; the extreme physical and mental suffering inflicted by the torturer ultimately breaks the will of the victim (at least in most cases), thereby undermining the victim’s autonomy and with it their self-worth.^[6] It is only the most resilient of individuals who can preserve their self-mastery (a fundamental aspect of autonomy) and their self-worth when subjected to torture.

One’s life, one’s autonomy and central features of one’s physical and mental well-being (including self-worth), and the life, autonomy and well-being of significant others are constitutive in part of one’s self-identity as a human being. Naturally, one’s self-identity is in part constituted by the central activities and ends that one pursues and, importantly, how well one undertakes them and, therefore, the virtues associated with the activities in question. So a combatant’s self-identity is likely to be in part constituted by his soldierly physical skills but also by his physical courage and commitment to his brothers-in-arms. By contrast, a scholar’s self-identity is likely to be in part constituted by her intellectual skills but also by her commitment to evidence-based truth seeking and a desire for the scholarly respect of peers. However, while the content of the self-identity of the combatant and that of the scholar are somewhat different, they are also similar in a number of respects relevant to our concerns here.

Firstly, both combatants and scholars care deeply about their respective (albeit in some important respects different) self-identities and believe that they are worth caring about. Secondly, both combatants and scholars care deeply about their respective self-identities in part because they deeply care about the activities, ends and associated virtues that are in part constitutive of their self-identities. However, their autonomy and well-being are implicated in the (quite different) activities, ends and virtues that are in part constitutive of their self-identities. Of course, in the case of combatants, their lives are implicated in their activities in a profound and direct manner, given that they are putting their lives at risk (whereas, of course, scholars typically are not). Thirdly, and notwithstanding some important differences in the content of their self-identities, both combatants and scholars deeply care about their self-identities in large part because they deeply care about their own life, autonomy and well-being, and the lives, autonomy and well-being of significant others; and believe also that all these fundamental (and I suggest) moral features of human beings are worth caring about.

To reiterate, most human beings care deeply, albeit perhaps implicitly, about their own self-identity in large part because they care deeply about the morally significant constitutive features of that identity, notably self-worth, autonomy and well-being. Accordingly, self-identity in this sense itself has a normative dimension, indeed a moral dimension, and a fundamental moral dimension at that. As such, self-identity underpins certain human rights, as does individual autonomy, e.g., various moral and legal rights to freedom. However, self-identity is not reducible to individual autonomy, although the two notions are sometimes conflated (and, as argued above, autonomy is a constitutive feature of self-identity).

In order to get a better handle on the distinction between identity and autonomy, consider the psychological damage that a child may suffer if it is taken from its mother and, indeed, that the mother might also suffer. Presumably, in the case of the child at least this is not an assault on its autonomy since it does not yet possess autonomy (at least to any great extent). Of course, the mother’s autonomy may be compromised by the child being taken from her, but this is because she cares deeply about the child and about her relationship to her child.

It has been argued above that self-identity, autonomy, well-being and so on are not only cared deeply about but worthy of being cared deeply about. However, it is also true that some people care deeply about things that are not worth being cared about; indeed, that are worthless or evil, such as Hitler’s Nazi regime in Germany or Islamic State in Iraq and Syria. Moreover, these people typically believe that these things are worth caring about, and they might become greatly distressed if what they care about ceases to exist. However, this would not, on my account, be a moral injury, even if it is a psychological injury. A person’s psychological injuries that result from the failure of his or her evil (or worthless) enterprise are not, on my account, per se moral injuries. On the other hand, if a person cares deeply about something that is in fact evil (or worthless), then they are, to that extent, morally defective. However, to be morally defective is not necessarily to be seriously psychological damaged or to have suffered psychological trauma; and is not necessarily to be morally injured. This is consistent with a parent suffering moral injury when their son who is engaged in evil actions is killed, e.g., a son who has joined ISIS. In such cases we need to distinguish the care that the parent has for their son and, therefore, their son’s life – something worth caring about - from the evil actions that their son is doing – something quite worthless. That said, it may well be that the degree of care a parent ought to feel for their son is diminished by virtue of the great evil that he does and, therefore, the degree of the moral injury that they suffer from his death is, thereby, diminished.^[7]

A person’s moral identity can be narrower in some respects and wider in other respects than their self-identity

It has been argued that self-identity has a fundamental moral dimension. Let us now distinguish identity (a descriptive notion), self-identity (a subjective normative notion) and what I will refer to as moral identity (an objective normative notion). Consider a parent who loses a child, or a person who is unjustly incarcerated for a lengthy period, or whose reputation is unjustifiably destroyed. Let us refer to the identity of the caring self as that person’s moral identity, where the term “moral” connotes something or someone deeply cared about and worthy of being deeply cared about. Note that moral identity is an objective notion; and, therefore, is in contrast with the subjective notion of self-identity – subjective in that its contents are not necessarily worthy of being cared deeply about, notwithstanding that they are believed by the person in question to be so. Accordingly, a person’s moral identity can be narrower in some respects and wider in other respects than their self-identity. For, as we saw above in relation to Hitler and his ilk, a person’s self-identity can include properties that are critically important to a person which, nevertheless, ought not to be important to the person (or, indeed, to anyone) and exclude properties which ought to be critically important.

This use of the term “moral” might be regarded as unduly permissive by some because they want to reserve the term for a much narrower set of considerations—especially prohibitions against serious wrongdoing. The notion of serious wrongdoing implies that the wrongdoer is, at least in typical cases, morally responsible for the wrongdoing, and that the wrongdoing (since it is a serious wrongdoing) is likely to be unlawful, indeed criminal. Hence, this narrow conception of morality can be referred to as a voluntaristic, legalistic conception. However, this narrow conception somewhat distorts our understanding of morality by diverting our attention away from the fundamental moral phenomena themselves, namely, moral identity, life, autonomy, well-being etc., and onto the prohibitions expressed in the criminal law that exist to protect some of these phenomena from deliberate attacks, notably, from murder, enslavement and torture. But ultimately murder is, or ought to be, prohibited in moral and legal systems because of the moral value that attaches to life; ultimately, enslavement is, or ought to be, prohibited in moral and legal systems because of the moral value that attaches to autonomy, and so on. By contrast with the voluntaristic, legalistic conception, on the more capacious and, I suggest, appropriately grounded conception of morality favoured here attention is focused on what is deeply cared about because it is worth caring about, namely, life, moral identity, autonomy, well-being etc.

So the term “moral” in use here refers in part to self-regarding features of a person—notably, the person’s own life, well-being, or self-worth. Moreover, the loss of, or threat to, these self-regarding features might not involve any wrongdoing on the part of oneself or others. For instance, a musician whose life revolved around his music might lose his hearing, and hence his ability to play or listen to music, as a result of an accident that caused traumatic brain injury, and, as a consequence, his moral identity (as I am using the term) might be damaged. Again, a woman whose children are killed in an earthquake that struck her home might be so traumatized and grief-stricken that her moral identity (again, as I am using the term) is severely damaged. Notice that this damage to her moral identity might manifest itself in ongoing severe distress and functional impairments, such as memory loss. In short, the traumatic event of the death of the woman’s children in the earthquake might cause PTSD, as has in fact occurred on many occasions.^[8]

In summation, then, there is a three-way relationship between the caring self, the moral identity of the caring self, and moral injury, including PTSD as a species of moral injury. Moreover, on this conception traumatic events can cause moral injury (and, therefore, PTSD). However, such traumatic events are traumatic in large part because they strike at what a caring self most deeply cares about and knows is worth caring about (for example, events that cause the loss of loved ones or threaten the caring self’s own life). Moreover, the trauma in question consists in damage to the moral identity of a caring self (for example, a mother’s loss of her child), and manifests itself in ongoing severe distress and functional impairments. Bearing in mind this three-way relationship, let us now focus the discussion on military combatants, in particular.

Warfighters and Moral Injury

Many combatants who have killed, and been under fire from, enemy combatants have experienced flashbacks, suffered from insomnia, constantly been in an unnecessary hyper-alert state and, more generally, suffered ongoing stress and distress many years after the cessation of hostilities. For them, although the war is over, their stress and distress continue. Moreover, this is so in cases where the combatants in question have only engaged in morally justifiable killing and otherwise not engaged in serious moral wrongdoing or suffered serious moral wrongdoing. Perhaps, therefore, there is an unresolved tension in many combatants between their natural – and, typically, morally reinforced – aversion to killing another human being and putting their own lives at risk, on the one hand and, on the other hand, their occupancy of a role as a combatant not only trained to kill and to suppress his own fear of death, but institutionally required, indeed morally obliged, to have the courage under fire to kill in defence of himself, his comrades-in-arms and (let us assume) in the service of a greater moral good, such as national self-defence against unjustified military aggression.^[9] In short, perhaps there is an inherent socio-psychological tension at the heart of the occupational role of combatant. Naturally, as Shay points out, this tension is exacerbated if the combatant comes to doubt that the war he fought in was in fact morally justified or if the community he was fighting for (i.e. killing and risking his life for) comes to doubt this, as in the case of the war in Vietnam.^[10]

Perhaps there is an inherent socio-psychological tension at the heart of the occupational role of combatant

Arguably, therefore, while combatants obviously deeply care about many things that most, if not all, human beings deeply care about, there are important differences that exist by virtue of their institutional roles, notably their willingness to routinely put their own lives at risk and deliberately take the lives of others. Moreover, these differences generate not only high levels of stress, but also psychological tensions conducive to psychological injury and, in extreme cases, PTSD – which is to say, on the care-based account, psychological-moral tensions conducive to moral injury.

On the care-based account, as we have seen, traumatic events either destroy or threaten what the traumatized person deeply cares about. For example, traumatic events can put at risk one’s life or autonomy, or those of significant others. Such traumas are magnified when the events in question are experienced repeatedly. There is risk of further trauma when the objects of one’s care are critically important to one’s self and, indeed, in part constitutive of one’s moral identity. In such cases, damage to one’s moral identity is not easily compartmentalized and contained.

Let us now turn to the relationship between PTSD and moral injury. As we saw above, both PTSD and moral injury are defined in terms of severe distress and functional impairments caused by traumatic events. However, on the standard account there is an important distinction between them: moral injury (but not necessarily PTSD) involves either: (1) the traumatized person’s own wrongdoing (e.g. a combatant who deliberately kills civilians), or (2) a moral wrong done to the traumatized person (e.g. a combatant who is betrayed by his or her superior).^[11]

On the care-based account, the moral injury might involve the traumatized combatant doing wrong (or being wronged). However, it might not involve wrongdoing on anyone’s part. For instance, as mentioned above, the morally injured can include survivors of earthquakes. The point is that central to the care-based account of trauma is the threat or loss to someone or something deeply cared about (and deeply cared about because it is worth deeply caring about). On this account, such threats or loss damage the person’s moral identity by undermining core elements of that identity. Accordingly, those who suffer moral injury can lose some or all abilities to care deeply. They might, for instance, suffer emotional emptiness after grieving the loss of loved ones. They might also suffer damage to their autonomy by losing some or all abilities to live their lives by their own lights because of ongoing fear and feelings of helplessness. A further point here is that the loss of the ability to care deeply appears to be connected to the distancing from the traumatic events suffered. Distancing is, of course, a natural and often necessary process. However, if the traumatized person never comes to terms with the traumatic event, then distancing may become part of the problem.

On the care-base account moral injury is not merely a feature of some cases of PTSD; rather it is a necessary condition for PTSD because it is a constitutive feature of PTSD. For PTSD results from traumatic events that bring about the removal or threatened removal of what one cares deeply about, e.g., one’s own life or the lives of significant others.

While, on the care-based view, PTSD necessarily involves moral injury, nevertheless, the moral injury that is manifest in PTSD is of two types. The two types in question mirror the types referred to on the standard view as (respectively) PTSD and moral injury. The first type involves moral responsibility for an action or omission which is a causal factor in the moral injury—the moral responsibility of either the morally injured person or of someone else for his or her injury. The second type does not involve moral responsibility of the injured person nor of some other person for an act or omission that is a causal factor in the moral injury in question. I suggest that it is the lack of moral responsibility in play in the second type of psychological injury (and, by my lights, moral injury) that leads to the tendency to exclude it from the sphere of morality and, indeed on extreme versions of the standard view, medicalize it as PTSD conceived in nonmoral (psychological and physiological) terms. This is, as I have argued above, a mistake.

Given the existence of the second type, on the care-based account one’s moral identity can be undermined or substantially diminished by traumatic events beyond one’s own control. Moreover, the sphere of morality is not coterminous with the sphere of moral responsibility. What one most deeply cares about can be threatened or destroyed by the acts of enemy combatants or by repeated exposure to horrific losses. Indeed, one’s moral identity can be undermined by traumatic events beyond anyone’s control such as natural disasters. Moreover, the traumatic events in question might be such that no human being could avoid being substantially psychologically damaged by them. As is often said, everyone has a breaking point. However, the moral significance of these traumatic events is not extinguished by their non-human source in the form of, for instance, earthquakes or tsunamis; for natural disasters can have damaging effects on a human being’s moral identity, indeed effects that the human being is unable to resist or endure.

Accordingly, on the care-based account, as argued above, human beings are not necessarily fully morally responsible for their undamaged moral identities, i.e., what they deeply care about, nor for damage done to their respective moral identities, i.e. for the moral injury they suffer as a result of traumatic events. Of course, it does not follow from this that those who suffer from serious moral injury, including that involved in cases of PTSD, are in principle unable to undergo psychological-moral repair.