Making straw men out of other classifications

To assert the relevance of the concept of moral injury, scholarly and lay descriptions virtually always contrast it with PTSD. Although relevant and insightful, too often this comparison is reductive, leaving readers with several erroneous impressions about the PTSD literature. First, that all PTSD models are only focused on direct exposure to life-threatening situations and fear responses, and consequently do not pay attention to moral emotions such as guilt, shame and anger.^{Reference Barnes, Hurley and Taber1} And second, that practitioners do not see PTSD as something other or more than pathology in the mind of the patient.^{Reference Barnes, Hurley and Taber1} Although many models of PTSD are indeed focused on fear conditioning and usually interpret symptoms in terms of distorted cognitions, a number of PTSD treatments do explicitly address guilt. Self-blame and blame of others are also explicitly listed as potential symptoms in DSM-5. And although PTSD is indeed conceptualised as a disorder – hence the approach to blame of self and others in terms of distorted cognitions – some practitioners also describe post-traumatic stress as ‘a normal reaction to an abnormal event’, thus acknowledging that PTSD is more complex than a completely inappropriate reaction to a perfectly normal situation.

So while it is certainly valid to state that moral dimensions of trauma and non-pathological interpretations deserve more consideration, attacking straw men reifies and simplifies PTSD while research on moral injury is busy reinventing wheels.^{Reference Barnes, Hurley and Taber1} First, moral injury researchers tend to disregard existing knowledge on trauma-related guilt, shame and anger. Second, previously articulated deliberations on whether and how to distinguish potentially traumatic events from more ordinary stressors, which is a topic of extensive ongoing discussion in relation to PTSD (called the ‘criterion A problem’), seem to go unnoticed. Meanwhile, moral injury researchers struggle to articulate what actually constitutes moral injury and how to prevent the interdisciplinary approach to moral injury – while crucial to the concept – from resulting in what has been called concept creep: the expansion of the concept beyond a meaningful scope.^{Reference ter Heide2} Integrating research on moral injury with the extensive body of existing studies on trauma-related suffering would benefit the literatures on both PTSD and moral injury, and is a prerequisite for consideration of whether or not moral injury should become a diagnosis or diagnostic feature of one or more psychiatric classifications.

Overlooking affected individuals’ desire for responsibility

Several scholars have convincingly argued that moral injury should in part be understood as a tragic loss of innocence, as burdensome knowledge about the world, rather than as a psychiatric disorder. Although insightful, this point is sometimes overstated. Traumatised veterans, for instance, have been depicted as unequivocal heroes and victims of war, and been attributed ‘prophetic insight’ into the ethical and political problems of current wars.^3,4 Yet, research shows that morally injured persons often want to take responsibility for their actions and judge bad acts as such, not despite but because they want to hold onto the idea of being a moral person with a conscience.^4,5 Thus, to completely release them from responsibility is in some ways just as problematic as portraying them as villains, because in both cases their need to truly repent of their actions while maintaining a humane self is undermined.^{Reference Molendijk4}

Risks of primary and secondary gain

At the same time, there are risks of primary and secondary gain. That is, the direct and indirect benefits of ‘being morally injured’ may paradoxically perpetuate the injury. Of note, this is not a matter of malingering, but concerns a complex mechanism that generally occurs without the person in question being aware of it. Specifically, perceiving oneself as morally injured can help transform a self-image of ‘I am a monster’ into a less negative self-image of ‘I suffer from what I have done because I have a conscience’, even without having to carry a label of mental illness. Also, the notion of moral injury can validate as reasonable a person's desire for recognition and compensation by, for instance, the organisation that put them in morally compromising circumstances. All this may disappear once the person is ‘no longer morally injured’, and consequently the notion of moral injury may get in the way of envisioning a future beyond it.^{Reference Molendijk4}

The notion of moral injury, then, may become a hindrance to healing if this leaves affected people stuck in feelings of guilt and anger, in a vicious circle of repentance, victimhood and dependency. It may make matters worse if individuals seeking recognition, help and compensation are instead confronted with negative social responses, uncooperative institutions and exasperating bureaucratic procedures.^{Reference Molendijk4} Iatrogenic effects of ‘gains’ associated with moral injury should therefore be a specific point of attention. To address these issues, it is crucial to draw on insights not only from psychology and psychiatry but also from philosophy, theology and social sciences. These disciplines have the expertise and vocabulary to tackle such questions as how to do justice as individuals and as a society to feelings of guilt without simply turning perpetrators into helpless victims, which is to no one's benefit.^{Reference Molendijk4,Reference Tessman5}

Risks of tertiary gain

A final concern involves the risk that the concept of moral injury can be usurped by third parties, directing attention toward specific organisations and ideologies in ways that misrecognise the experience and needs of morally wounded individuals. Regarding moral injury in soldiers, on which most moral injury research to date has focused, the concept has been embraced by both supporters and opponents of the military. Reminiscent of the politically laden advocacy for PTSD's recognition in the Vietnam era, pro-veteran advocates use it to make the case that soldiers do not get the recognition they deserve, while anti-war critics take moral injury as evidence that soldiers are exploited victims of the immoral enterprise of present-day military intervention.^{Reference Wiinikka-Lydon3,Reference Molendijk4}

Employed as such, moral injury may be considered a form of tertiary gain. That is, the concept's advantage for third parties, however good their intentions may be, can have counterproductive consequences because moral injury is thereby promoted in ways that tend to say more about the moral beliefs of the promoters than those of the morally injured veterans. Indeed, research among both Dutch and US veterans shows that many veterans actually feel alienated by pro-veteran societal praise while at the same time only a minority become anti-war; their experience is usually more nuanced.^{Reference Molendijk4} Misinterpretations like these seem a risk in politically sensitive settings in general, especially as moral injury is gaining the appearance of a concept that can only be applauded.

Reflection

So, the concept of moral injury not only refers to morally significant experiences but has great moral significance as a concept, carrying normative claims about the nature and causes of moral conflict-coloured suffering, with both positive and negative consequences. The concerns about negative consequences outlined here have to date not received explicit consideration, and this is understandable. The sensitivity of the issue makes it difficult to express critical considerations regarding, for instance, risks of primary and secondary gain, especially for those who (like me) have had morally injured individuals share their traumatic experiences with them and who empathise with their pain and calls for recognition.

Yet, thorough evaluation of the concept – including research on the issues raised in this editorial – would benefit all stakeholders in moral injury research and intervention, not least the morally injured individuals. Just as a critical attitude is not the same as passing judgement, empathy is not the same as refraining from criticism. The help and recognition called for by moral injury sufferers and proponents of the concept may certainly be considered well-deserved and helpful, and it is indeed important to reflect on the ethical and political significance of moral injury, but the potential risks should also be an explicit concern, precisely because of this.