The most familiar moral and ethical dilemmas in warfare have to do with inflicting harm: deciding whether to fire on a person who represents an uncertain threat, for example, or living with the knowledge of civilian collateral damage of battle.

Marine veteran Peter Lucier, who served on active duty from 2008 to 2013, has lived through and written about these kinds of quandaries. But as a civilian working with the volunteer-run organization Team America Relief to evacuate former U.S. military interpreters and their families from Afghanistan during and after the U.S. military withdrawal and Taliban takeover in 2021, Lucier experienced another kind of moral conflict: deciding whom to save.

Over the course of one night in August 2021, Lucier said, he and a few other veterans within the organization were tasked with filling 40 seats on an evacuee bus with women and children who represented the neediest cases they’d managed. It was wrenching, emotional work, forcing Lucier to pass over some Afghans he knew and cared about to evacuate others he believed were more at risk. Why do I have this power? He recalled thinking, as the men debated, late into the night, which lives to save.

“That was a difficult, hard thing, and made all of us feel really gross,” Lucier said.

A few hours later, the veterans would learn that the bus had been re-tasked and filled with children from an orphanage, making their evening of heartbreaking choices irrelevant.

The episode was representative of a hidden and enduring cost of war: moral injury, or the aftermath of circumstances that force a person to participate in or bear witness to events that contradict their own moral beliefs and expectations. The military withdrawal from Afghanistan spurred a new rash of moral injury diagnoses, as troops and veterans questioned the meaning of what they’d fought for and grappled with the reality of Afghan allies left behind and in danger.

While not new, the phenomenon of moral injury and its implications are under-studied, with very little scientific research. The Department of Veterans Affairs is now working to lay the groundwork for better understanding and treatment by undertaking the first-ever large-scale population study of moral injury to be conducted among veterans of the post-9/11 wars.

According to a solicitation published in June, the VA office of Research and Development plans to conduct a mixed-methods study “to determine the U.S. Veteran population prevalence of moral injury.” The research effort will include an online survey of “a nationally representative probability sample of U.S. veterans,” expected to include 3,000 respondents; and a secondary comparison study in which 20 veterans who identify as having moral injury and 20 who do not, all with similar exposure to “morally injurious events” participate in a series of interviews about their thinking and experiences.

Brett Litz, a clinical psychologist at VA Boston Health Care System and Boston University who has pioneered VA research on the topic of moral injury, told Military Times via email that the concept of moral injury makes intuitive sense, even as it has not been studied in-depth as a separate phenomenon.

“People have harmed people they care about or have been harmed by others or they have borne witness to grave inhumanity and cruelty, etc., and understand from personal experience that these experiences can have lasting existential impact,” he said. “I think the public also has some understanding that the [post-traumatic stress disorder] model and the treatments that have been developed to address PTSD are limited and appreciate the explanatory value of traumas either colored by grave moral wrongs or traumas that entail moral transgressions.”

While PTSD and moral injury are often grouped together, they manifest differently: Litz has previously described the former as a “racing heart” and the latter as a “broken heart.” In Lucier’s experience, PTSD forces a sufferer to relive traumatic events of the past in memory. Moral injury, on the other hand, emphasizes feelings of ethical failure and self-betrayal.

“It was more about this sociological idea of, I have this system of values that I believe in, and being put in this meat grinder of war forces you to make imperfect decisions where no matter which decision you make, you are going to violate your own ethical code,” Lucier said.

A 2022 article, authored by Litz and 10 other researchers, cites a recent “explosion of interest” in moral injury within healthcare and mental health, the media and veterans’ organizations. Litz told Military Times that it would be hard to say for sure, but “one could argue the case” that the new surge in interest was driven by the Afghanistan withdrawal, which opened a national, veteran-led conversation about what the nation owes its troops and allies.

Better data on moral injury and its manifestations is not merely essential for public understanding: it also has real-world implications for treatment approval and coverage. As Litz wrote this year for an editorial in the Journal of Military, Veteran and Family Health, moral injury risks are dismissed as an illegitimate condition because it hasn’t yet been codified as a known mental disease.

An earlier and smaller-scale survey effort, also led by Litz, resulted in the development of a “Moral Injury Outcome Scale,” which helps to illustrate how the experience of moral injury can alter how a person views themself and the world around them. Under the category “shame-related outcomes” are statements such as: “I am not the good person I thought I was,” and “People would hate me if they really knew me.”

The second category, “trust violation-related outcomes” includes the statements “I have lost faith in humanity,” and “I am angry all the time.”

A VA-funded clinical trial of 174 veterans with PTSD that also preceded the upcoming population study suggests one possible treatment for moral injury symptoms: Adaptive Disclosure-Enhanced, a psychotherapy approach that emphasizes repair through activities such as writing letters to a deceased person from the event, “loving kindness meditation” to foster compassion, and mindfulness training. Litz said the planned survey will also advance this field of research.

“No trial to date has measured moral injury as an outcome. So, we do not know which treatments are efficacious for the symptoms and functional impairments of the moral injury syndrome,” he said. “Now that we have the Moral Injury Outcome Scale, this state of affairs will change.”

According to the posted solicitation, the survey will be deployed nationally and take 30-45 minutes to complete. At least 950 of the respondents will be veterans who served in a combat or war zone, and at least 400 will be within the ages 18 to 54. Respondents will be paid $20 for their time, the solicitation states. The entire data collection and assessment effort will take three years, Litz said.

Lucier said he believes in helping the larger society to understand the existence of moral injury in war veterans and to bridge the gap between those veterans and people who can surround them with compassion and without judgment.

“Just being there, being willing to listen … just having a society that acknowledges war in ways that are meaningful,” Lucier said, “I think those are really powerful sociological factors that can help.”

Editor’s Note: Hope Hodge Seck worked for Team America Relief as an unpaid volunteer in 2021 and 2022.

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