This article in the BBC is one of the first I’ve read that addresses moral injury in the medical profession while still referencing its initial roots in veterans:
The Department of Veterans Affairs website likens it to psychological trauma involving “extreme and unprecedented life experience”, that can lead to “haunting states of inner conflict and turmoil”.https://www.bbc.com/news/world-us-canada-52144859
It is also the first time that I’ve seen the US Department of Veterans Affairs drop some of the “evidenced based” language that therapists associated with VA must adopt in order to legitimize it within government when describing moral injury. Dr. Wendy Dean is at the vanguard of the US medical establishment in applying moral injury to medical personnel in the US. Dr. Bob Meagher has studied and written about moral injury from a classics and Catholic theological perspective. When I first read about moral injury back when I was in graduate school working on my PhD, I had this to say about my reaction vis a vis PTSD:
The military is masterful at activating the warrior energies through the ritual death and rebirth process of boot camp. Unfortunately, there is not a corresponding ritual cleansing of the combat veteran upon his return from a combat tour. Instead, he or she is left to find their own way home: to deal with guilt, boredom, depression, and other maladies of combat. Morally and spiritually, it seems that today’s combat veterans are left in the wilderness to find their own way back. Lifton (1973), speaking about US Vietnam veterans wrote:
“Combat veterans tend to see their experience as an exercise in survival rather than a defense of national values….one undergoes the ‘ideal’ or test without the possibility of that ‘idea of glory’ or ‘decision of holy validity,’ there is all of the pain but none of the form” (p. 41).
As in the Vietnam veterans’ experience, captured by Lifton above, I sensed that my higher-level warrior was not the force at play in my psyche. The heroic struggle against an invading army is not what I was engaged in. In fact, I realized that I was the dragon rather than the knight and all honor belonged to the enemy:
“Nor could the patrols seeking out an elusive enemy, the ambushes in which Americans were likely to be the surprised victims, or the ‘search and destroy missions’ lashing out at noncombatants achieve the psychological status of meaningful combat ritual….the men were adrift in an environment not only strange and hostile but offering no honorable encounter, no warrior grandeur….Men who fight wars inevitably become aware of the terrible disparity between the romantic views of heroism expressed ‘back home’ and the reality of the degradation and unspeakable suffering they have witnessed, experienced and caused” (Lifton, 1973, p. 38).
Intuitively and instinctively, I was already moving away from the PTSD model espoused by the Veterans Administration (VA) and the clinical psychology community. There was something about their approach that did not resonate with me. Frankly, their explanation lacked soul.Lifton, R. J. (1973). Home from the war. New York, NY: Simon and Schuster.
Fisher, D. L. (2019). Dulce et Decorum Est: Moral Injury in the Poetry of Combat Veterans.
Of particular interest in this article is pointing out that moral injury often arises from “playing God.” In combat, this is guaranteed. In my case, as a Special Warfare Intelligence Specialist, my job was the first two parts of the tripartite of find, fix, and finish. My job involved “playing God” by finding “bad” people, fixing them at a time and place, then sending special forces or the 3 letter agency equivalents to “finish” the “target(s).” In the beginning of my deployment, I had to recommend whether to capture or kill…in other words, I had to triage whether or not the person I was sending Navy SEALS after were “worth” capturing alive for potential intelligence information, or whether it was better to just kill them outright. In the environment of the Covid-19 outbreak, “young doctors being asked to play god” by performing a similar triage function: who are they fairly certain they can save and the concomitant scarce resources necessary to do so vs. those whom they believe, recovery is out of reach. It is often subjective, as in the case I faced of capture or kill.
There is no easy resolution to moral injury. In the end, it comes down to individual conscience and the moral/ethical framework that they have internalized. Did I do enough? Did I make the “right” decisions. The answers to these questions are unfortunately ambiguous and come down to individuals internal frameworks of meaning.