COVID-19, Health, Top Stories

Moral Injury and the Battle against COVID-19

When Odysseus journeyed to the Underworld in search of advice about how to return home safely, he dug a trench into which he poured libations mixed with blood from the throats of a ram and a ewe to summon the dead. As his fallen comrades from the Trojan War began to emerge from the shadows and gather round, Odysseus tried to console mighty Achilles for his death by speaking of the authority he must now hold among the dead. But Achilles replied: “I would rather be alive and toiling as serf to another man, one with no land and nothing much to live on, than be a king over all the perished dead.” These words shatter the illusion that the wounds of heroes ever mend—one of the earliest commentaries on the lingering trauma of war for its combatants.

It is now far better appreciated that veterans return from war with psychological wounds in need of treatment. Post-Traumatic Stress Disorder (PTSD) has become the public face of such anxiety disorders. Far less diagnosed and understood, though, are moral injuries, sometimes described as a “wound to the soul.” These most often occur when a person commits, fails to prevent, or witnesses an act that is anathema to their moral beliefs. This breach of a person’s personal ethical code can inflict lasting behavioral, emotional, and psychological damage, burdening an individual with acute guilt and shame that distorts their self-identity and provokes reflexive distrust of others. Guilt has been identified as the crucial factor that distinguishes a moral injury, even as other symptoms—anxiety and despair, flashbacks, social isolation, and suicidal thoughts—overlap with PTSD.

Adam Linehan deployed to Afghanistan as a platoon medic in 2010. One day, while out on patrol, an Afghan man walked into the middle of the squad formation and self-detonated an improvised explosive device. Linehan was uninjured but found himself surrounded by multiple casualties, a mix of Afghans and Americans, wounded and dead. He quickly began triage to decide who to treat. Similar incidents followed throughout a tour that left him suffering from PTSD and what he refers to as survivor’s guilt. In a brutally candid New York Times magazine article he describes how that guilt produced nightmares, suicidal thoughts, excessive drinking, and behavior that jeopardized his career and relationships. Matters finally came to a head when after a particular drink- and drug-fueled night’s binge he found himself crawling in circles on his bedroom floor accompanied by the screams of his girlfriend. “I heard myself asking if I was in hell,” Linehan writes.

American research is revealing how moral injuries can be just as prevalent among civilians, especially first responders like police officers, firefighters, and health workers. “For the military, we have it better in a way, as we get this break between deployments,” says Noel Lipana, who was left with a moral injury from his 2008 Afghanistan tour. He now works as a social worker and promotes better understanding of moral injuries in the military and beyond. “Firefighters and cops have to reset themselves every 12 hours,” he tells me, “and go back out on their next shift.”

Lipana says such pressures are often compounded when first responders find themselves hindered from doing what they think is right or necessary by authorities such as unions and city councils, or the threat of being sued or investigated by internal affairs. Furthermore, he says, first responders often work in institutions where the majority of policies and regulations have more to do with protecting internal bureaucracies than the agency of individuals. “It amounts to a deficit of empathy, even among the general public, about the reality first responders face,” Lipana says. “Veterans are typically the focal point of a trauma discussion that needs be much wider.”

Veterans Affairs treats about 500,000 veterans a year with PTSD symptoms while the National Institute of Mental Health estimates that about 7.9 million civilians suffer from some form of PTSD (a figure corroborated by the National Centre for PTSD). The COVID-19 outbreak makes healthcare workers especially vulnerable to moral injury because they are increasingly likely to find themselves forced to make decisions to determine who gets treated and who doesn’t. In a forthcoming paper, HC Palmer, a former battalion surgeon during the Vietnam War who now works with American veterans with moral injury and PTSD, writes that overwhelmed hospitals are having to make decisions about who lives and who dies and are considering “do not resuscitate” orders to protect healthcare workers. “But these policies do not mitigate the moral impact on those who, after fighting to save people, must kill them because of an algorithm. Obeying orders can still result in self-condemnation.”

Another parallel between military personnel and healthcare workers may well come from the potentially damaging role played by a sense of being betrayed by authorities. For many veterans the pride they once took in wearing their uniform collides with a feeling of futility about what their service achieved. The ongoing turmoil in Iraq and Afghanistan acts as a repudiation of the war efforts, and a belief that military leaders failed or deceived them and their fallen comrades. The resulting sense of violation can further fuel the lingering crisis of conscience and spirit, thereby deepening the moral injury.

“Betrayal wrecks trust, profoundly disrupts identity, and destroys relationships,” says Rita Brock, co-author of Soul Repair: Recovering from Moral Injury after War, and the director of the US-based Shay Moral Injury Center. “It is also suspected of causing or aggravating post-traumatic stress symptoms—nightmares, intrusive memories, hypervigilance, irrational angers, and depression. Our healthcare workers are working to save people, but they have been betrayed by the government’s inadequate response.”

While healthcare workers can be confident that they are doing the right thing helping people afflicted by COVID-19, the knowledge that they are involved in a virtuous endeavour—as opposed to how many veterans now view the wars in Iraq and Afghanistan—can “actually make it even worse,” she tells me. “You know you are on a life-saving mission, and so you can’t fathom how the president doesn’t seem to get it in the same way.”

An estimated 11 to 20 percent of the 2.7 million American men and women who deployed to Iraq and Afghanistan have received a PTSD diagnosis linked to their service. The percentage of former service members coping with moral injury appears comparable, although experts warn that the prevailing emphasis on PTSD means moral injury can often go unrecognized and ignored. The potentially destructive and lethal impact of this complex mix is illustrated by the numbers of veterans who kill themselves. Between 2005 and 2017, a staggering 78,875 veterans took their own lives, according to Veterans Affairs, which estimates that 17 veterans commit suicide each day. The figures for UK veteran suicides are not known, though there is growing recognition of the scale of the problem. In 2019, General Lord Richard Dannatt, the former head of the army, said that too little is known about the number of veterans committing suicide and that not enough is being done to prevent it.

Both Brock and Palmer fear that some healthcare workers will take their own lives because of moral injuries experienced during the pandemic, having been crushed by the decisions they were forced to make, unrelenting grief, and fury and humiliation at the authorities who failed them. “Moral injuries are not inevitable, everyone in the profession needs to recognize that they are trying to do the least harm possible in a situation in which it is impossible to provide the highest-quality care to every patient in need,” Arthur Markman, a professor in the department of psychology at the University of Texas in Austin, tells me in an email. “Leaders of hospitals need to communicate with the people working for them that they are using their training to make the best possible decisions under horrible circumstances.”

Another significant factor in mitigating the psychological fallout for healthcare workers will be how society reacts once the epidemic subsides, Brock says. As everyone is busy getting back to normal, that will be when healthcare workers start processing and reflecting on their experiences. Brock notes an advantage that healthcare workers might have over veterans when facing any reckoning over their actions is how most people can more easily relate to healthcare workers and empathize with the dilemmas they faced. Already, throughout the world, healthcare workers are being applauded for their bravery and sacrifices.

But Linehan cautions that he sees a parallel between this “lauding of healthcare workers” and the thank-you-for-your-service culture in America that can often prove so frustrating for many military and veterans. “One of the hardest things is being told you are a hero, yet feeling anything but a hero—it creates a disconnect,” Linehan tells me. “You are perceiving me as one thing, but I know I am the opposite: that’s at the root of why so many veterans feel alienated.”

Linehan also fears that some healthcare workers—especially those now moving around the US to help in COVID-19 hotspots before returning to their home communities—may encounter a problem familiar to those who returned from the Vietnam War and the military generations that followed them. These men and women returned to find a home that seemed irretrievably lost to them. “The COVID-19 outbreak is a traumatic event for everyone in society,” he says. “Many people won’t want to hear the messy stories of healthcare workers when it all calms down. People tend to want stories that can fit into a particular narrative, so they can move on. Those stories rarely tell the truth. Healthcare workers will just have to carry their memories isolated in the truth.”

 

James Jeffrey is a freelance journalist and writer. He previously served in Kosovo, Iraq, and Afghanistan with the British Army. You can follow him on Twitter @jrfjeffrey.

Comments

  1. Whilst it’s important to acknowledge that a significant percentage of veterans suffer from PTSD at some point after deployment, it’s also important to remember that these issues are far less likely to become a problem for an potential employer than the average college graduate- who are suffering from record levels of anxiety, depression and other more chronic mental health problems. The last thing we want is for these individuals who have demonstrated such a willingness to sacrifice for their countries to be stigmatised, when college graduates represent a far greater risk for employers.

    PSTD can often be triggered by stimuli such as loud noises, but in general veterans can be relied upon to follow therapeutic CBT advice to slowly acclimate themselves to such stimuli, whilst students are more likely to demand a ban on clapping:

    Veterans should be a preferred source of employment, in an era when many young people are becoming a liability to an employer. A friend recently told me of an incident where a recent entrant complained to HR because she was excluded from a coffee run at work. Not surprising, given that kids are taught that exclusion, even on reasonable grounds, is bullying- as are best friends. I am sure that a veteran would have politely asked to join the kitty, and even volunteered to make the first run, instead of making an issue of it with HR.

    Thank you for your service to the author, and we will remember.

  2. An estimated 11 to 20 percent of the 2.7 million American men and women who deployed to Iraq and Afghanistan have received a PTSD diagnosis linked to their service.

    As Sebastian Junger observes, this is larger than the proportion seeing combat, and thus having had the opportunity to experience or inflict physical trauma, and combat arms have lower rates of PTSD than non-combat arms. As well, PTSD tends to appear not X time after the triggering events, but after service is ended. He notes too that in times of disaster, rather than Mad Max Havoc (as commonly expected by government and media) we see co-operation - and a drop in rates of mental illness presentations to hospitals, etc.

    That’s why I like his thesis in Tribe, that the real cause of PTSD for many is the loss of sense of community and common purpose, which is stronger in combat arms than non-combat, and which is absent in most of the civilian world - except in times of disaster.

    This does not mean, of course, that physical trauma experienced or inflicted does nothing to a person’s psyche, nor does it invalidate the experiences of any individual you care to talk about, such as the unfortunate person in the article. Moral injury is a real thing.

    However, as the article notes,

    These men and women returned to find a home that seemed irretrievably lost to them.

    thus speaking to the issue of returning to an alienated society. It was an alienated society before you joined up, but… well, one training saying is, “if you look over your shoulder to see if the other guy is doing what he should be, one of you shouldn’t be there.” You may not even like that guy, but you’d die for him. Most people will in their lives never experience that level of trust and closeness, expect perhaps in a very good marriage.

    Coming from that back to alienated Western society makes the alienation all the more stark and depressing. That’s why a significant number of guys leave and then rejoin within a couple of years - yes, even the guys who’d been diagnosed with PTSD.

    Now, if you want to talk about the psychological effects of covid-19 on people… the shutdown has killed various economies, and we know that a 1% rise in unemployment leads to a 1% rise in suicides - and for every person who kills themselves, dozens more tumble off into depression, substance abuse, have their marriages and workplace relationships fall apart, and so on.

    What frightens me this time is that normally in difficult times people can call on the support of their friends and family, or some community they’re part of like a church. Because of physical distancing guidelines and decrees, they can’t do that now. Take away a person’s job and they lose a large chunk of their sense of meaning and value - but make them sit around at home not allowed to go out, and they lose the rest of their sense of meaning and value - other people.

    This worries me. I think the consequences of this will be with us for a long, long time.

  3. “says Noel Lipana, who was left with a moral injury from his 2008 Afghanistan tour. He now works as a social worker and promotes better understanding of moral injuries in the military and beyond.”

    Wow, we are becoming an increasingly fragile lot, aren’t we? I would approach the term “moral injury” with the same caution I approach the term “lived experience”. I am not sure if you can sit next to a soldier who had his legs blown off and say, “Hey brother, I was wounded too. Morally. That shit cuts deep, man.”
    Also, on the issue of medical workers, my father was a doctor. He saved lives, but he saw death too, and he kept going. If he spent all his time in therapy, he would have had no time for his patients.

  4. Interesting article. Over the last decade, “physician burnout” has been receiving increasing press as the prevalence of early retirements, suicides, career changes, and rates of depression have been increasing. Many physicians railed against the term “burnout” because the implication was that they couldn’t mentally or physically handle the demands of caring for sick patients, when in fact, it had far more to do with “moral injury” as outlined in this article. This was Pre-COVID, and the moral injury occurred as a result of practicing medicine based on the standards set by an employer, or the constraints imposed by insurance companies. The end result is finding yourself in a position where you are providing care that you believe is substandard. Add to that a fragmented relationship with patients as their list of “preferred providers” may change annually, the rise of the EMR with a attention divided between a screen and the patient who is seeking your help (not to mention the unsettling feeling that you spend more than half your time as a physician doing mindless data entry), and the end result is what others deemed “burnout”. Please don’t misunderstand: I am not equating the stress of practicing medicine to that of a soldier in battle, or a first responder arriving at a domestic dispute or a fire; however, the chronic pervasive sense that you are not practicing at a level that patients deserve can lead to a tremendous sense of guilt and the “moral injury” outlined in this article.

  5. Veterans Affairs treats about 500,000 veterans a year with PTSD symptoms while the National Institute of Mental Health estimates that about 7.9 million civilians suffer from some form of PTSD (a figure corroborated by the National Centre for PTSD).

    I think a reader should be careful with information like this, casually dropped into an article without scrutiny.

    Yes, a Google search may confirm that the VA treats about 500,000 veterans a year with PTSD, but that is not the same thing as saying that all those veterans have PTSD.

    And shouldn’t we be a little bit cautious when the salaried, benefitted employees of two organizations - the National Institute of Mental Health, and the National Center for PTSD - say there are nearly 8 million Americans with PTSD?

    Would these salaried, benefitted employees have anything to gain by exaggerating the numbers that they themselves have generated? Certainly, but in the absence of any solid evidence of fraud in their funding, we, as ordinary citizens, are not supposed to even think about their methodologies, are we?

    I would think it is clear by now to everyone that the mental health care industry sets a level of trauma severity that is so low, almost anyone can join. Did you once see a dead person? You have trauma. Did someone once punch you in the face? Trauma. Hate your job? Yes, you have trauma, too.

    I do not question whether PTSD and moral injury exist. I believe they do exist. But at the same time, I believe there are an awful lot of malingerers out there, and an increasing number of professionally licensed facilitators. I am not buying the 7.9 million number for PTSD.

  6. That’s interesting and aligns well with theories I’ve heard floated over the past decade or so around both trauma and drug addiction. It seems that we humans can endure an unbelievable amount of suffering if it’s embedded within a deep framework of purpose and community. But take that purpose and community away and we can barely stand our own loneliness without resorting to drugs, alcohol, or suicide.

  7. “Of all that number, the veterans of my acquaintance who experienced the greatest total amount of killing violence were among the men who most successfully created families and careers when they returned to the US.”

    This. My father was a navigator in Coastal Command in the RCAF in WW2. A more anxiety inducing task could not be imagined since he had to sit in the rear cockpit of a Beaufighter basically waiting to see if he would be killed, while his pilot dove the plane toward German destroyers firing rockets, cannon and machine guns at them as they fired exploding AA shells back, and keeping watch on the sky above for counterattacks by Fokkewulf 190’s. He was awarded the DFC at the end of the War together with his pilot for having flown twice as many combat missions as any other crew in their squadron. After the war he earned an MD degree and practiced medicine for 40 years, delivered almost 1000 babies, raised several children while remaining married to their mother, served his community after retirement as a municipal alderman, and died of the emphysema which was the consequence of all the cigarettes he smoked during the war and for a couple of decades afterward. Did he suffer from PTSD? Well, I know he had nightmares from time to time, and once he described to me looking out from his cockpit at the other planes in his squadron as they dived together and seeing the plane next to his simply disappear in a flaming fireball, a memory which he told me was as vivid to him in his 80’s as when it happened. Was he ever treated? Well, he was a faithful church-goer but apart from that, no. Like many others of his generation, he coped by striving with conscious intention to live a morally successful life.

  8. @skepticus What a compelling and awesome remembrance of your father! My grandfather and great uncle survived the Great Depression by building dams as they migrated West from Kentucky. They both took a year long break on Shasta dam to assist in raising ships from the bottom of Pearl Harbor. No exploding planes but hundreds and hundreds of dead, decayed bodies.

    My grandfather never went into an open body of water after that experience. But he and my uncle did build a successful residential construction business together and both raised honorable families.

    Maybe this is due, in large part, to the fact that people of that generation knew what a morally successful life looks like - even if they didn’t always live it, they knew the standard well. This knowledge has been slowly torn out of our collective framework of purpose in subsequent generations because it’s too “oppressive and patriarchal”. And now our kids are triggered by jokes and can’t figure out if they’re boys, girls, unicorns, or rainbows. It makes me really angry and sad but all I can do is fight it where I find it.

  9. Not sure about this neologism. Moral injury? Are we not simply subdividing depression here? And for what purpose? To set up better groups for therapy? Because if not, each individual depression is unique.

    As for this:

    “You know you are on a life-saving mission, and so you can’t fathom how the president doesn’t seem to get it in the same way.”

    Wtf? If this is what passes for “moral injury”, I’d say the bar is pretty low.

    Life is pain, but sadly we’re seeing generations being raised to believe that a pain-free life is not only possible, but is their right.

    (No offense meant to our combat vets.)

  10. The author talks of PTSD and moral injury in the same breath, as though the two had the same empirical standing. But the evidence for moral injury being a genuine psychological condition is pretty weak. Moral injury looks a lot like the medicalization of the human condition—namely, the life lesson learned when ideals encounter the limitations of the real world. None of this is to diminish the suffering attendant on the realization; on the contrary, it’s a cruel lesson we all learn, even if only at the end.

    On a more mundane note, one has to be careful of PTSD figures because the condition is a number of symptoms. Many veterans have or have had one or more of the symptoms (e.g., nightmares, insomnia, hyper-vigilance), but very few have had all of them persistently and to an extent that they’ve affected their lives in a meaningful way.

  11. Interesting article, despite the almost obligatory anti-Trump sonar ping that seems to be so important among Quillette contributors.

    A couple of things:

    Back in the 1980’s I worked as a graveyard-shift pharmacist at a local hospital. One night the ER doc on shift brought a friend, an ER doc from Germany. At some point during the night the EMTs brought in a heart failure patient, a woman in her 80’s. She had acute pulmonary edema, and, as normal, was intubated and quickly moved to the critical care unit.

    The German ER doc looked at us all like we were nuts. “In my country we put her on morphine and move her to a nursing ward. You keep her alive! No wonder health care is so expensive here!”

    Things have changed a lot since then, we have “no code” orders that limit the kinds of interventions we do during acute events like respiratory or cardiac arrests, as well as living wills where many older people specify what treatments they do and don’t want, that kind of thing. I think any discussion of “moral injury” needs to take into account that people already are “killed based on an algorithm” all the time. It’s become pretty normal.

    Secondly, my dad was a POW during WWII. A B24 co-pilot, he and his crew were forced to bail out over occupied Holland. He was found and hidden by the Dutch underground, caught by the Germans six months later, and spent the final six months of the war in prison camps - first Stalag Luft III, then Stalag VIIA.

    PTSD? And how! A good productive life? Absolutely. He remained in the USAF until the mid-sixties, retired and worked for Boeing, got laid off in 1970 and became active in local politics.

    I think huge factors for him leading a successful life were 1) staying in the military as a career officer, surrounded by others like himself, and 2) getting his health care at the VA. When he was older I used to drop him off at his appointments there, he always wanted to be dropped off early and “don’t hurry back, take your time.” He loved sitting around the waiting room swapping stories with the other vets.

  12. “You know you are on a life-saving mission, and so you can’t fathom how the president doesn’t seem to get it in the same way.”

    "Our healthcare workers are working to save people, but they have been betrayed by the government’s inadequate response.”

    I am reminded of November 9, 2016. I can’t find the post anymore, but it went viral among Leftists on that day - the day after Trump won the election. Supposedly a third-grade teacher in Los Angeles told his largely Hispanic class that their parents were all going to get deported now, and that it was Trump’s fault. He asked them to write about how that made them feel, then shared their results, claiming that all of these children were being “traumatized” by Trump.

    They weren’t being traumatized by Trump. They were being traumatized by their teacher - a man so immature and selfish that he processed his own petulant tantrum by trying to make the children that he was responsible for feel pain so that he could feel justified in feeling the same way.

    We need a new circle of hell for such a pathetic excuse for a human being.

    Unfortunately, he is not alone. All around the world, Leftists traumatize their audiences with tales of woe that are not real, but are flattering to their politics. They do not care that they are harming their audiences, even to the point of making them suicidal. They care that they are winning the political game.

  13. I almost feel that the community should create some sort of merit badge we can award to the few articles that avoid this verbal tic. Criticize Trump all you want, but is it so much to ask that you actually put a little effort into it and make your case?

    These drive-by virtue signals are getting very irritating.

  14. It is interesting to read about some of the stories of PTSD and trauma that come from earlier times in our history, WWII and Viet Nam specifically. I can’t speak for all of my fellow veterans of the most recent wars, but I know a lot of us just keep quiet, so I expect the numbers on PTSD cases is probably inaccurate. We know how to answer the questionnaires and know what to say to the health screeners to avoid that all-to-easily-applied PTSD diagnosis. People can get the same diagnosis for not getting their way at school or work. Some, like @jdfree49 describes, can probably get it for losing an election. Why would we lump our selves in with them? A few of us do, the POGs as we call them, looking for a paycheck. But they can have it as far as I’m concerned. I’ll stick with the nightmares and insomnia, thank you.

    As a U.S. Marine, I was trained to fight and to take care of my fellow Marines. When it came time to go home, I was trained to suck it up and contribute. If I need help, I know who to call, and it isn’t the VA mental health clinic… Its the people I served next to. I don’t know what a moral injury is, but I’m sure the VA will have a disability rating for it.

  15. Yes. Combat arms tend to be a bit tighter than non-combat. I imagine the groups others have mentioned were pretty tight, too - the same bunch of guys in the same aircraft for a couple of years. That’d give you some resilience.

    I’m sure others have written on it, but if as many assert there’s been an increase in PTSD from one conflict to the next - despite overall lower intensity of operations - then the growing alienation of society, as talked about in Bowling Alone - well, that’d go a long way to explaining it.

    I do think that we’re increasingly pathologising ordinary human misery, too. But perhaps that’s just a symptom of our alienated society. Where once you’d turn to fellow members or elders of your community, now you turn to a professional. Many surveys show people reporting fewer friends from one generation to the next - with 10 friends, someone will listen, with 2 friends, maybe not, and with no friends, certainly not. The psychologists in diagnosing people with problems are perhaps just responding to the demands of their market.

    Here in Victoria with the lockdown authourities have belatedly realised: “oh yeah, people need, like, human contact and stuff, so now they feel bad.” Their response has been to chuck more money into telehealth psychological services. Now, that’s good and all, but… I don’t really want to talk to a psychologist over a computer screen, I want to talk to my friends and family - in person, over a dinner and drinks. Loneliness isn’t a psychological problem the way a broken leg is a medical problem, it’s more like hunger. Hunger isn’t cured with medicine, it’s cured with good food.

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