Moral Injury: Life After War

When we harm someone directly or commit a misdeed we feel guilt - our biological moral alarm that signals we have done something wrong. This feeling motivates us to appraise its presence and to perhaps take reparative action or to think twice the next time we are faced with a similar situation. But what about when this guilt is based on actions taken in life-or-death situations—such as guilt felt after war or failing to save a patient on the operating table. What happens when an act that was, or at least seemed to be, crucial and justified in a moment of extreme adversity is reanalyzed after the fact? Killing on the battlefield under siege may have seemed morally rational at the moment but afterward, when one is able to face their actions, their moral alarm sounds and cripples one's mentality. Guilt after these actions is crushing.

This is the kind of guilt that is associated with life or death action is referenced as "moral injury" in the science community. Moral injury (extreme, devasting guilt) causes depression, disconnection, and it is largely expressed in patients with long-term PTSD. Understanding the nature of moral injury may just be the key to demystifying war trauma. Though PTSD and moral injury often occur together they are not the same. Patients with PTSD avoid reminders of the traumatic event whereas patients with moral injury avoid shame triggers. Furthermore, PTSD is found to excites fear and activates the primary motor cortex (the part of the brain that controls movement and physical response) whereas moral injury activates the prefrontal cortex (the part of the brain that handles emotion)

Treating moral injury, however, proposes ethical dilemmas to the science world. Treating moral injury would involve talking people out of guilt following their involvement in traumatic incidents. Treating the moral injury would help the patient relieve their psychological suffering and self-destructive behaviors; however, “treating” this condition without allowing the patient to process their moral wrongdoings and learn from them could whitewash the conflict and consequently alter their moral compass.

In recent studies it has been shown that treating patients by teaching them to understand and work toward personal values, which may have been violated during service, helps with moral injury. There is, however, still much to understand about this treatment and how it may be addressed separately from PTSD.