VA Maryland Health Care System
Acknowledging Moral Injury
Since the Revolutionary War, American men and women have been answering the Nation's call to duty. Millions of Americans have fought and died on battlefields here and abroad, defending our freedoms and way of life. Today's military continues to make the ultimate sacrifices, following the footsteps of generations of Americans before them. Veteran's Day, originally Armistice Day, honored the end of World War I – "the war to end all wars" – on November 11, 1918. Legislation that created Veteran's Day was "dedicated to the cause of world peace and to be hereafter celebrated and known as Armistice Day."
A century later, peace continues to elude us: WWII, the Korean and Vietnam Wars, and the current 16-year conflict against terror have followed, with no hope of a lasting peace to come. Our Nation has awarded medals to the many soldiers, sailors, airmen, marines and coast guardsmen to honor their bravery and their sacrifices. Today, we express our gratitude to those who have served our country while wearing the cloth of the Nation – the 22 million men and women who serve and sacrifice in the name of America and our way of life. We have sent our men and women in uniform to faraway places, sometimes into the most arduous circumstances, with a duty to carry out missions that the average citizen cannot comprehend.
Service members and Veterans know that in the military, they must perform flawlessly with the understanding that they must get it right the first time because shipmates are depending on them with their very lives. There are no do-overs. Many Veterans carry a heavy burden born from this duty that often interferes with their ability to transition to civilian lives and successfully integrate back into their communities.
While we rightly address PTSD's impact on Veterans, as a society, we must also consider and address another invisible wound of service and war: moral injury. Moral injury has been defined as, "Damage done to one's conscience or moral compass where that person perpetrates, witnesses, or fails to prevent acts that transgress their own moral and ethical values and codes of conduct."
Larry Kent Graham, a professor emeritus of pastoral theology in Denver who has taught Air Force Chaplains, says, "People need help assessing moral alternatives, reconciling what they have done with what they think is right, recovering from burdens of guilt and shame, and imagining moral options to serve the common good."
Identifying moral injury and rendering aid, however, presents serious challenges since many Veterans may feel too ashamed to talk about the moral infractions that grate against their personal values and codes of conduct. The men and women in our military often find themselves facing an array of moral decisions and compromises for which they may be unprepared to address. War's inherent destructiveness corrodes the spirit and the moral fiber of our warriors who return with injuries based on feelings of guilt or shame and prevent our Veterans from successfully reintegrating into their communities.
To prevent the downward slide of our warriors as they battle the stifling effects of moral injury, we must recognize and acknowledge that moral and spiritual injuries exist. We must acknowledge that these injuries shatter moral and ethical expectations rooted in religious and spiritual beliefs and our culture-based rules about fairness and the value of life. As critical as any somatic or psychological injury, these wounds are the root of suffering and can be the cause of permanent debilitation of our Veterans. Moral injuries often go unrecognized, and thus, remain untreated or misdiagnosed.
Common problems among our combat Veterans include depression, anger, alcohol abuse, relationship problems, and suicide—all symptoms that could be related to or caused by unresolved moral injuries. Acknowledging moral injury and recognizing both its existence and potential for harm is the first step toward understanding, reconciling and healing.
"If we can share our burdens, we can bear them. If we can bear them, we can change the circumstances that brought them about. In a world where anything goes, people have a hard time deciding what is right and what is wrong," Graham also says. "The core issue of our time is how to embrace with grace and care the dissonance and diverse assessments of the moral issues calling for our guidance and healing."
This becomes a foundational message for all care providers who serve Veterans struggling with moral injuries. Precision and certainty are not attainable goals. The best we can hope for is to help guide our Veterans through the maze of absolutism and certainty to a place where they can feel inclusiveness, community and comradery with others on the same journey through the dark forest of moral dissonance to the plateau of enlightened self-understanding, forgiveness and a renewal of their spirit. This places them on the road to recovery and resilience, on a journey where they each arrive at the final destination in their own way and time. Veterans who find themselves on this journey are not alone. They also have the company of physical, psychological and spiritual caregivers.
At the VA Maryland Health Care System, we take our mission of serving veterans very seriously and we embrace the whole health, patient-centered care model by treating the mind, body and spirit. It is our moral obligation to do so. We understand that the dimensions of the human spirit and the healing that returns us to wholeness and contentment resides in our ability to know and acknowledge that we injure others; we are injured by others; and that we must become resilient in the moral discussion of these injuries in order to stay balanced and productive. This is the way to healing and wholeness. This is the way back for all of us—veterans and civilians alike—from the shadow world into one of light.
Dr. Adam M. Robinson, Jr., director of the VA Maryland Health Care System, served as the 36th Surgeon General of the United States Navy, overseeing both the US navy and Marine Corps health care systems.