This article/study in the UK is one of the first I have seen that actually involves veterans, especially directly. This is important and something that I called out in my dissertation: namely, that the definition of moral injury in the context of combat veterans was developed by clinicians who work for the VA rather than in collaboration with veterans themselves. My methodology was similar to this study, though I used quotidian poetry as a proxy for interviewing veterans directly. I took this step out of practicality–adding live subjects to a doctoral dissertation might have been an insurmountable ethics committee challenge as I am not a licensed clinician.
One of their main conclusions is that, as I have pointed out repeatedly, moral injury can be co-morbid with PTSD, stand on its own, or not be present when PTSD is. They write:
This study provides some of the first evidence that events experienced by UK veterans can simultaneously be morally injurious and traumatic or life-threatening
I have only a couple of minor quibbles with the study. First is how they determined whether or not someone had experienced a moral injury.
Participants were considered to have exposure to moral injury if the self-reported event was an act of omission or commission which violated their ethical or moral code and where the primary emotion expressed was of guilt/shame.
This is a pretty standard definition as established by Litz, Maguyen, et Al. My quibble is the “act of ommission or commission” part for it forestalls the elephant in the room. To wit, whether or not participating in war at all causes moral injury, rather than specific acts. Governments, of course, do not want anyone to ask these larger questions as it might lead to widespread non-participation and outright condemnation. Nevertheless, they do a good job of sorting out PTSD versus moral injury:
Participants were classified as having experienced a trauma-only incident if the event described was consistent with DSM-5 Criterion A and participants did not describe an act of commission/omission which violated their moral code.
Finally, this was their criteria for co-morbidity:
Participants were classified as ‘mixed’ if elements of both traumatic and morally injurious experiences were expressed; for example, the event was both potentially life-threatening and morally injurious (Stein et al., 2012).
The final sentence of this quote shows the larger questions being ignored by narrowly defining moral injury as “omission or commission:”
Both morally injured and ‘mixed’ veterans described that central to the distress caused by PMIEs was the experience of moral dissonance or conflict between their multifaceted value systems. Conflicts between sets of values (e.g. military values versus civilian), as well as conflict within a set of values (e.g. conflict between military moral obligations; e.g. respecting the lives of civilians and enemy combatants, protecting colleagues, successfully completing the mission) were most commonly described by both groups. For example, after killing an enemy combatant, some veterans experienced considerable distress where there was a moral conflict between their civilian values (e.g. ‘killing is murder’) and military values (e.g. ‘action justified within rules of engagement’).