Moral Injury All the Way Down
Dealing with my country and countrymen in the age of Trump
Monday is Veterans Day.
One of the many, and in many ways perverse, reasons to thank veterans is for what their terrible experiences have given to the rest of us, by extension.
A lot of life-saving medical technology the rest of us enjoy and take for granted owes its existence to battlefields. It’s one of the reasons we see fewer deaths in combat for our military adventures (thanks to battlefield medicine, more survive who would have died in past wars), and one of the reasons amputees today are sometimes able to have truly amazing prosthetics.
Psychologically too, efforts pioneered to help veterans and active-service military have diffused outward into the civilian population. What used to be called “shell shock” came to be known as Post-Traumatic Stress Disorder, and PTSD is now widely understood to affect survivors of other traumas that don’t have to compete in some kind of severity Olympics with wartime combat. “Flashbacks,” “triggers,” and panic attacks, though often watered-down by pop discourse, are real and owe their recognition to work with servicemembers, and wide swaths of us weenie civilians are aware of these real problems faced by people from all walks of life. Stigma for such sufferers may still exist, but it’s counterbalanced by an appreciation that something very bad must have occurred in their pasts to so afflict them today.
During the worst days of the COVID, I noticed another militarily-pioneered psychological condition popping up in reference to a civilian population, in this case, health care workers. Doctors and nurses, inundated with the sick and dying, understaffed, under-resourced, wrapping themselves in trash bags, watched the country argue about masking and staying home, about taking elementary precautions that dated from the Spanish Flu pandemic of a century prior. COVID became politically weaponized and partisan’d, and both mis- and disinformation flourished. These poor servants of life and health worked themselves to exhaustion, to tears, to the point of breakdown and beyond, trying and failing to hold back a tsunami of death that overwhelmed our hospitals and health systems, while people ignored them and carried on, or worse, made the virus into a political football and a game of identity one-upmanship. Under Donald Trump, the public messaging was unserious, chaotic, politicized, and/or incompetent, depending on the day.
While I’m certain that many, many health care providers came away from COVID with severe PTSD issues, the term that caught my eye was Moral Injury.1
The concept of Moral Injury was developed through research into combat veterans, and is potentially or provisionally distinct from PTSD, though there is likely overlap either between the conditions and/or the symptoms. Shorthand distinctions are inadequate but include things like “PTSD is about fear, while Moral Injury is about being alienated from one’s deeply held beliefs” or “PTSD is about threats to one’s survival, while Moral Injury is about threats to one’s moral compass or conscience.”
The, I guess, paradigm case of Moral Injury in combat would be something like a soldier killing an unarmed civilian noncombatant, perhaps an innocent woman or child, and then having to come to terms with the fact that, despite whatever they had previously believed about themselves, they are the kind of person who committed such an act. Or that soldier witnessing their comrades commit civilian slaughter, especially in breach of rules of engagement and all training, compounded by tolerance, endorsement, or a cover-up by superior officers. Moral Injury can occur when one commits a moral transgression or witnesses such a transgression by others, or feels deeply morally betrayed by those seen as standing in legitimate authority.
These criteria can apply in all sorts of scenarios and need not be limited to military combat, as psychologists are discovering. I’ve found references in the literature to the application of Moral Injury to rape and assault survivors, survivors of natural and man-made disasters, journalists and war correspondents, health care providers, first-responders, police, therapists, teachers, survivors of political violence.
Ultimately, I see no real reason why Moral Injury must be contained within the bounds of commitment or witness of literal violence and death. The condition is described by the US Department of Veterans Affairs as a “dimensional problem” with “no definable threshold for its presence.”2 All that seems required is the following:
Strong conscientious, core beliefs that feel transgressed or violated by…
…something one has done (or failed to do) or…
…something one has witnessed others doing (or failing to do)…
and/or a feeling or perception of betrayal by those seen to be in positions of authority
If those elements are present, Moral Injury is potentially possible.
I first started looking into Moral Injury during the first Trump Administration. I was despondent, despairing. There really aren’t words.
Some biography: I’m white, 55, cis-straight, working-class, Christian-raised, Kansan, long-time married with pretty-grown kids. I’ve been through a lot of identity phases, most pretty awful, but as a white guy, I’ve been able to pick and choose who I see myself to be in a way a lot of folks can’t. To an extent, this translates to “I have no culture/identity.” In another way, this means, my culture and identity is what I inherited…as a white, cis-straight, working-class, Christian-raised, Kansan, long-time married with pretty grown kids. That means I have a load of cultural programming and inheritance that never got examined until I started to realize I had it and turned around and started questioning it, seeing what I thought was legit and what was bullshit.
So I read and thought and talked with friends and argued. There were a lot of awful phases, as I said. Hell, I may be in one now that I’ll regret later. But whatever identitarian clothes I tried on, the one thing that held constant was the fact that I was an American, which was both good and bad. I lived in a country that had so atrociously screwed the pooch over its lifetime, and yet claimed it had high hopes to be better.
Even now, when I think about it, that’s kinda cool, kinda human. Aren’t we all that way?
That’s what made me a liberal and then more and more a lefty. Because nothing chapped my hide more than folks either (a) insisting that America (or themselves) had never—would never—screw the pooch, or (b) refusing to try to be better, even if that meant some difficult work, soul-searching, personal sacrifice. Growing up and living most of your life in Kansas, you see a buttload of both.
So after all was said and done, after all the identities I’d dabbled with—a privilege I could indulge because of the lottery of my birth—I ended up patching them altogether into this loose American identity of hardscrabble “we fuck up a lot and we should damn well own it, but we always can, should, and need to try to do better.” I framed it as an American identity, but there’s no reason it has to be exclusive. It could apply to anyone anywhere. Probably should so apply.
So yeah—when folks tried to insist our shit didn’t stink, or that we should rest on our laurels or even go back to horrific ideas and periods from our history we should have learned from and definitively rejected—I felt an injury to my identity, a kind of personal assault. Such folks were coming for me…as an American. Folks wouldn’t do that unless they’d lost or forgotten their own identities as Americans, so I would labor mightily to try to remind them, to reactivate that American identity (at least as I understood it): We’re big lumbering oafs who’ve broken a lotta shit, and historical happenstance has cursed us with nukes, but we say we have good hearts and good intentions, so if that’s true, we need to remember it and fucking act like it.
The fact that I’m a nobody, just a custodian and a light-maintenance guy in my hometown after all these years instead of some high-paid pundit writing columns for a legacy newspaper, just kinda…fits. Regular folks like me are supposed to be the backbone of the country, speaking out, reminding their neighbors what’s what, shaming and upbraiding and calling bullshit and reminding people that we can do hard things and to the stars through difficulties. A well-informed citizenry gets a lot of ink, but I like the fact that I just try to…be one of them. There’s no goddamn reason I should be any kind of an outlier in America.
So when Americans elected Trump the first time (well, some of them, thanks to the immensely dumb and wrong Electoral College), I felt betrayed by my fellow citizens. I felt like the proper authorities—the People of these United States—had utterly failed me and this experiment called democracy. I witnessed violence done by millions, and by a system, to immigrants, to Muslims, to LGBTQIA+ folks, to women, to the press, to Black and Brown folks, to so many we should have known by now it’s wrong and poisonous to harm. The norms of our nation fell one by one, and only half the country gave a shit, but they didn’t do much beyond implore us to “vote harder!”
I would never compare my troubles to those of a combat veteran, but Moral Injury was one way I was able to make sense of the crazymaking, unmoored, gaslit, anchorless, foolish feelings I wallowed in.
Those who suffer from Moral Injury report symptoms that often depend on whether their experience stems from committing an act that violates their moral values or having witnessed such a thing and/or feeling betrayed.
Committers (or bystanders) are more likely to feel guilt, shame, and self-condemnation. These can be reported by witnesses and the betrayed as well, but they also report difficulty forgiving, loss of meaning, and loss of trust. Spiritual / religious / moral-ethical struggles and feelings of inner conflict over the moral implications of the transgressions / betrayals often affect all three. Worse still is that these psychological or spiritual symptoms can translate easily into physical comorbidities, literally making people sick in body as well as mind and soul. This is not something to dismiss or scoff at.
These plainly fit the way I responded to Trump Version 1. I wanted to write about this several times over those years, but Trump Version 2 seems an even more relevant time.
This time, he won the popular vote. This time, he made gains among chunks of the population he promises to target, folks he’s on record saying he’ll harm.
Who is the authority that has betrayed us believers in America, in democracy, in this experiment that at least provided some frameworks and legal and founding rhetoric we could hang our hats on as we tried to improve our world? The People. The supposed-to-be well-informed citizenry that’s essential for the experiment to have a chance to work. A lot of signs point to how they were duped, but those who got snookered chose to get their information from propaganda mills and liars and incompetents despite no shortage of warnings. They chose, due to laziness or indifference to their role in this collective endeavor called democracy to listen to cousin Dennis’s analysis of tariffs or immigration instead of people who know what the fuck they’re talking about.
Other betrayals? I think we can see here a lot of the scrambling in the blame game that reveals our various priors. A lot of folks are blaming the Democrats. The ostensibly “nobody’s at fault” explanation is inflation, which supposedly created a no-win scenario. But nothing about the Harris campaign felt or sounded like a hard-slog scenario against the backdrop of inflation. It’s not like inflation was ever acknowledged as this great mountain they had to climb to achieve victory. I feel betrayed by the Dems in many ways, but this goes back in time so far that it feels almost silly to litigate it exclusively on Harris’ doorstep. Besides, the real ethos of democracy is supposed to focus on the people. But I can understand and sympathize with folks who feel like they were taken by a ride by the Harris campaign or the Dems in general this past year, including Biden and those who didn’t force his ouster much earlier.
For those who want to acquit the Democrats—or The People even—we can point to the disinformation environment run by the right wing and its billionaire-funded platforms and interlocking networks: Those baddies are the ones who undermined our heroes and whispered Wormtongue’s poison in the ear of our brave countrymen. Well, sure. This has the benefit of ascribing blame and agency on the worst actors in the equation, after all. And some of us have been screaming about this for a long while. But to fight powerful bad guys, you kinda end up appealing, sooner or later to the powerful people who claim to be good guys (and base their calls for our votes on this claim), only to be disappointed when the bad guys seem to grow stronger.
Kinda like health care workers trying to actually treat patients as well as they know how, but the system’s imperatives say No, and the people in charge shrug and say “There’s nothing we can do…it is what it is.” Insert Manchin. Insert filibuster. Insert SCOTUS. Insert Merrick Garland stans saying prosecutions have to go slow and dot all the Is and cross all the Ts. Insert, insert, insert.
The bad news about Moral Injury is that, as far as I know, there isn’t a consensus on what’s good, effective treatment. Lots of approaches are being tried, all in clinical or spiritual settings. Things to get folks to reconnect to meaning and community in their lives, for instance.
I don’t do church, and I can’t afford a shrink, so I tend to go with the suck-it-up, tough-love approach: remembering that the luxury of believing in the goodness of the American people, or their ability to resist the siren song of demagoguery, is something reserved largely for privileged, insulated white people who have never had the misfortune of being targeted for the worst we are capable of delivering.
Realizing this in the last Trump administration made me feel—yet again in this increasingly long life of mine and despite all my work to wake the hell up from my various, parochial, inherited naivetes—like a rank dumbass for clinging to another myth any number of my friends could have disabused me of ages back, a myth I didn’t realize I still clung to so much that it formed a part of my identity. But such is whiteness, I guess.
The good news, if there is any, is that at least you now know there is a name for something very much like what you may be feeling, at least if you’re anything like me: Moral Injury. You’re not alone. Lots of other people, in various fields, have experience with this. Shrinks know about it, though the variant I’m talking about, a kind of civic, blanket Moral Injury, may be more metaphor than clinical presentation.
There’s a temptation to feel like a sucker for ever having any moral beliefs at all, to rocket to a worldview where it’s all a jungle, and we should just embrace that. Well, I think it probably is all a jungle, but I continue to reject simply living there.
There’s a lot of truth to the story of the two wolves living inside us, with the one we feed getting stronger. The right-wing isn’t operating from an entirely wrong theory of human psychology when they mash the buttons that activate hate and fear of the Other—that stuff’s pretty deeply ingrained. But we never, ever, ever could have made it this far in civilization if there wasn’t a pro-social canis lupus inside as well.
But even if none of that were true, even if I were left with only sheer force of will, I still want a better world for my kids. For yours, too. If people are indifferent or lazy, we need to get them off their asses to care. If leaders suck and lie and shine us on, we need to expose them ruthlessly and demand better. If we go down fighting for something like this, I say it’s an honorable way to go, and regardless of any other moral, ethical or spiritual beliefs one holds, I think we all have to be able to look at ourselves in the mirror each day without flinching.
If, over the past several years, I have gotten any kind of handle on my own feelings of Moral Injury, the harm I’ve witnessed my fellow Americans inflict on themselves and others, the betrayals of their creed they and the institutions that are supposed to represent them have embraced, it’s just stubbornness and a kind of doubling down, perhaps with a clearer understanding of the world. I’m still in the “we’re big, blundering, nuclear oafs who’ve done and do great damage” camp. I still believe some of us have good hearts and good intentions, but now I have lowered my estimates of the overall numbers. Lowest in all my estimates is my guess about how savvy and serious we are, how resistant to lies and cons, how much fun so many of us think it is to feed the wrong wolf.
But not a single one of these adjustments changes one whit what I believe is right and necessary. I’m just clearer about the terrain around me.
Victories may seem harder to achieve, but really, isn’t operating under naive fantasy versions of the world a bigger barrier to making things better? Doesn’t even a brutally harsh wake-up call to clarity improve our chances?
Let’s close with Gertrude Stein:
You are so afraid of losing your moral sense that you are not willing to take it through anything more dangerous than a mud-puddle.
Losing your moral sense is a real risk when things get ugly, and things have gotten ugly. We like to believe us Americans are these fierce individualists, but so much of our individual moral identity is bolstered by a belief that our values are widely shared. So if they aren’t—and maybe they aren’t—you gonna punt? You gonna cave, retreat, return those ideals to the store?
How will you look at yourself in the mirror if you do?
See the footnotes3 for more resources on Moral Injury, especially if you’ve gone through the more clinically indicated traumas normally associated with it.
In fairness, the application of Moral Injury to health care predates COVID. Picture health care workers, dedicated to giving the best possible care to their patients, running again and again up against the walls of cost-cutting, bureaucracy, hospital procedures, efficiency mandates that require less and less time spent per patient, wise care or tests not covered by insurance—the system working over and over against the deep moral calling that drew them to the profession, and their superiors enforcing the dictates of that system, despite knowing its costs in human health and longevity.
Additional resources on Moral Injury:
“Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review,” Frontiers in Psychiatry, 28 June 2019 | https://doi.org/10.3389/fpsyt.2019.00443, Harold G. Koenig, Nagy A. Youssef and Michelle Pearce
“Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different,” The Journal of Neuropsychiatry and Clinical Neurosciences, Volume 31, Number 2, https://doi.org/10.1176/appi.neuropsych.1902003
Haleigh A. Barnes, Ph.D., Robin A. Hurley, M.D., Katherine H. Taber, Ph.D.
Published Online: 23 Apr 2019, https://doi.org/10.1176/appi.neuropsych.19020036
“Untold Stories of Moral Injury: What We Are Learning—And Not Learning—From Military Veterans in Transition,” Frontiers in Communication, 09 December 2020, Barton David Buechner, https://doi.org/10.3389/fcomm.2020.599301
https://www.frontiersin.org/journals/communication/articles/10.3389/fcomm.2020.599301/full
Psychology Today, “Moral Injury,” https://www.psychologytoday.com/us/basics/moral-injury
“What Is Moral Injury?” Syracuse University Moral Injury Project, https://moralinjuryproject.syr.edu/about-moral-injury/
“Moral injury: the effect on mental health and implications for treatment,” The Lancet, Volume 8, Issue 6, Victoria Williamson, Dominic Murphy, Andrea Phelps, David Forbes, Neil Greenberg, https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00113-9/fulltext
“Moral Injury FAQ: Frequently Asked Questions about Moral Injury,” Volunteers of America, https://www.voa.org/services/moral-injury-faq/
“Moral Injury: An Increasingly Recognized and Widespread Syndrome,” Journal of Religion and Health, Vol. 60, 2021, Koenig, H.G., Al Zaben, F. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270769/ or https://link.springer.com/article/10.1007/s10943-021-01328-0#citeas
“Moral Injury,” Science Direct, https://www.sciencedirect.com/topics/psychology/moral-injury
“Moral Injury Among Nurses: Stories of Fractured Hearts & Wounded Souls,” Fitzhugh Mullan Institute for Health Workforce Equity at The George Washington University, https://www.gwhwi.org/moralinjury.html
“Physicians aren’t ‘burning out.’ They’re suffering from moral injury,” StatNews, July 26, 2018, Simon G. Talbot and Wendy Dean, https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
“Employees Are Sick of Being Asked to Make Moral Compromises,” Harvard Business Review, February 21, 2022, Ron Carucci and Ludmila N. Praslova, https://hbr.org/2022/02/employees-are-sick-of-being-asked-to-make-moral-compromises
“Moral injury: violating your ethical code can damage mental health – new research,” The Conversation, April 30, 2019, Victoria Williamson, Dominic Murphy, Neil Greenberg, Sharon Stevelink, https://theconversation.com/moral-injury-violating-your-ethical-code-can-damage-mental-health-new-research-115654
“Moral Injury,” Atlas Institute for Veterans and Families, https://atlasveterans.ca/knowledge-hub/moral-injury/
“Moral Injury: The Psychological Wounds Of War,” NPR, Talk of the Nation,
November 21, 2012, https://www.npr.org/2012/11/21/165663154/moral-injury-the-psychological-wounds-of-war