Hickeysan in Japan!

Moral Injury and Moral Repair

Scientists at Veterans Affairs clinics purport that these injuries come about as a consequence of experiencing a transgression of a deeply held belief that one’s humanity is grounded in. What one identifies as the self, characterized by this deeply held belief, is challenged by the experience of transgression—the defilement of something inherently sacred. Whether the transgression is brought upon by the self or by external events, this experience of betrayal brings the current self under jarring interrogation, calling into question the very identity of what one considers to be the self.

2 Major Theories on the Source of Moral Identity and their Moral Injuries

In its simplest form moral distress can be defined as the negative emotions experienced by an individual as a result of making a moral decision and the negative feelings the individual experiences that are associated with the assessment of a decision. These feelings are typically a sense of guilt or shame. This kind of distress is characterized by a sense of ownership for a negative outcome of a situation that occurs, that some people think of as morally or logically unreasonable to feel ownership over. Over time this moral distress can accumulate cause a moral injury. There are a number of ways that an agent can come into experiencing these feelings. One of these ways is a fracturing or abrupt altering of moral identity. There are various views on how an individual obtains a moral identity. I will attempt to entertain 4 major views on how this can happen and describe scenarios in which a “fracturing” or injury to that identity can occur.

Self-formed Moral Identity and its Moral Injury

One way in which a moral identity can be formed is through commitment, either to the self or to others. A commitment need not be formal in nature, but simply must be a set of values taken up by an individual. By accepting and endorsing these values, the taker of the oath assumes a moral identity that is in line with those values. This new sense of self remains unchallenged and intact so long as the agent acts within the conditions of the oath which he or she took up. The injury in this scenario occurs when the agent violates this assimilated identity. This violation can either be of the agent’s volition or can be completely unintentional. Regardless of intent, however, their moral identity is still damaged. I will give examples of both intentional volition and unintentional volition of moral identity to illustrate a clearer portrait of the distinction between the two.

Suppose that Jon, a healthy young man in the youth of his twenties considers, more than momentarily, his moral identity. In his self-reflection he decides that his most important view on living a moral life is to protect his immediate family at all costs. Secondary, but only marginally, to this belief Jon comes to realize that he is against taking another human being’s life, or his own life, and considers these morally unacceptable in any scenario. Human life to Jon is cardinally sacred and its sanctity is disintegrated when it is taken by the agency, both directly and indirectly, of another human being, or by oneself. In addition to the two aforementioned beliefs Jon seeks to avoid all negative confrontation with others. Jon commits himself to live a life avoiding conflict and confrontation with others so as not to “disturb the peace” or “rock the boat.” This is based, in part, on the belief that conflict between humans awakens the sinful nature of man that poisons the sanctity of his commitment. Naturally Jon will steer away from situations that conflict is likely to arise in.

Violation of Jon’s moral identity can occur in situations where Jon makes a decision that is in line with one of his committed values, but that decision conflicts with another one of his values. For example, Jon’s little brother is getting picked on at school in front of him, and Jon makes the decision to stick up for his little brother by telling the bully that that is an unacceptable way to be talking to his little brother. Jon doesn't like conflict and seeks to avoid it, but places the safety of his family above avoiding conflict. This violation of moral identity is easier to see here because Jon voluntarily makes the decision to violate one of his values by engaging in conflict with the bully. Although most of us would think that Jon made the logically right decision that any older brother who loved his younger siblings would make, Jon may not entirely feel the same way. Although Jon knows he made the right decision in engaging in conflict with the bully he still feels a bit at odds. He protected and ensured the safety of his family, but because he had to engage in conflict to do so he feels that he has committed a sin. Although we can expect Jon to be able to move on with his life and not mull over this betrayal of his identity we can still expect it to bother Jon and cause him trouble, and although small, cause moral injury to Jon.

The Community-formed Theory on Moral Identity and Its Moral Injury

Moral identity can be formed in other ways than from beliefs that we subscribe to. Moral identity can also come from communities that we belong to such as our religion, club, organization, or family. In this case our moral identity, at least a part of it, is in line with the beliefs of that community’s views on how we should live our lives. Inclusion into these communities is usually based on subscribing to the moral identity and is normally contingent on following the constituent values found by and common to that community. These values can range from the familial level where each member of the family takes care of a family member when they’re sick to a religious level where each member of the religious community is expected to pray every evening before going to bed. After practicing these values overtime you will find that you assimilate your moral identity with their values. This is very similar to the first source of moral identity, but it has a few subtle differences. This source of moral identity is given rather than self-generated. It may be that the values and ideas of living a moral life align with what you believe to be moral, and this is often the case. However, the important distinction is that the origin of these values are from the community and not from within.

Moral injury of this type of moral identity is very similar to injury of an identity that you take up yourself, the only difference being the way to live a moral life is given to you. It may so happen that you agree with the moral identity given to you by your community to such a degree where you decide for yourself that you will incorporate your community-given values with your personally formed values. I will discuss this case in a later section, but for the sake of simplification of categorizing sources of moral identity let’s decide to keep them separate for now. To get a better look at what moral identity and moral injury look like in this context I think it would be prudent to examine a scenario involving moral identity and moral injury within the community-given context.

Philip is nineteen years old and is one of seven children. Philip and his family all live in a small house in a run-down urban area of Chicago, with no mother and an alcoholic father who spends all of his money, at the local bar, rather than trying to provide for his family. The responsibility to feed the family falls on Philip and his older sister who is 22. Despite their hardships the family still remains religiously active and attends Roman Catholic mass every Sunday.

Most of the time the large family scrapes by on a combination of his own wages, his older sister’s wages, and luck. Then Philip’s sister falls ill and is unable to work, and because she works at a job with no benefits she receives no compensation for her missed work. In a desperate attempt to make ends meet Philip picks up another job and asks for any help he can get providing for the family. Eventually his luck and hard work have run out and the family has not had a meal of substance in days. Desperate for opportunities for food or money Philip scours the surrounding area, but to no avail other than to be snapped at for asking for handouts again or to be met with a sympathetic apology. It seems that everyone in the area can’t spare any extra resources with the current state of the economy in an already impoverished region.

One day while closing up the convenience store that he works at Philip finds that the door to the bulk storage wing is unlocked. Against his better judgment Philip goes in and steals a few routine food basics just to help the family survive until he gets paid. This act goes unnoticed by the store owner and doesn’t cause a large enough error in the inventory to raise suspicion. A week and a half later, when the family had gone days without a meal again Philip found relief in the bulk storage wing of the store, and continued to do so once or twice every few weeks until his older sister returned to work and consistent stability was restored in the family’s meals.

When Philip has time to himself again he begins to feel guilty about his various incidents of stealing. Personally he hadn’t given much thought to stealing and when it was and wasn’t okay. He only knew from being a practicing Roman Catholic that one of the religion’s Ten Commandments specifically prohibited stealing. He felt as though he did the right thing. He exhausted every other possibility that he could think of to provide for his family; he had already been working two jobs and a crazy amount of hours. When his little brothers and sisters would begin to lose sleep and cry over empty stomachs he thought it appropriate to take some of the convenience store’s inventory to help just get by. He never took any more than he absolutely needed and already worked overtime at the store and had done numerous favors for the owner. The owner owed him anyway for the extra plumbing he did to the employee bathroom and the advice Philip had given him on money saving energy efficient quick fixes to the store. To Philip it seemed like a fair trade, but he couldn’t quite shake the feeling of guilt for having specifically disobeyed one of the ten rules that his religion had laid out for him to follow.

Philip has a moral injury, although it is different from Jon’s. Philip’s injury is that of his community-given moral identity, whereas Jon’s was an injury of his self-formed moral identity. Philip seems to have his self-formed moral identity still intact, because he sees nothing personally wrong with stealing in times of great need, when you have already done more than your “fair share” of work for the person from whom you are stealing from. In Philip’s eyes the steal was an exchange waiting to happen. Despite whatever conditions theft is committed under, Philip’s religion specifically prohibits stealing of any kind. Philip still considers himself a devout member of his religion, but because of his living circumstances, feels that it is situationally okay to break his religion’s rules in order to survive. He has no regrets in his decision, but still seeks to make amends to his moral identity within his religious community to absolve the residual guilt that he feels.

Treatment of moral injury for this type of source of moral identity may involve a much more specific path than that of an injury to the self-formed moral identity. For the sake of our case of Philip and the religious soldier we can perhaps look to their respective religious texts to discover ways of reparation. In Philip’s case this may include a confession to the store owner, a refund of the stolen goods in money or in actual goods, a promise of renewed loyalty to the store owner, and a request for the store owner’s forgiveness. In the soldier’s case a confession to a religious figure may be required, followed by a combination prayer, self-reflection, and rededication to the religious texts, to absolve the spiritual burden of killing. These moral injuries may be easier and more straightforward to treat because they are not as deeply associated to one’s self as an injury to a self-formed moral identity is.

There is something largely therapeutic for humans to be told by a community that a certain set of actions will heal their wrongdoings. This practice seems to work just for the sake of someone else saying that it will work. To follow a certain set of actions with intent to gain penance, is to be wiped clean in the eyes of the community. Once seen as forgiven in the eyes of the community it can follows to forgive oneself of wrongdoing, especially in cases like Philip’s and the religious soldier’s where they personally believe they made the right decisions by going against their community’s commandments. Empirical tests of injury to this type of moral identity would again be required before we even consider coming up with any sort of methodological approach that therapists without significant study of philosophy and moral identity could perform.

Psychologically this allows for a separation of identity between the wrongdoing associated with the injury and the afflicted individual. When a separate identity from the self exists to hold the wrongdoing, the individual with the moral injury is less likely to believe that the wrongdoing is an intrinsic part of who they are. This results in more effective of treatment methods when comparing an injury to a self-formed moral identity to that of an injury of a community-given identity. At this point I think that it would be advantageous to talk a little more about treatment methods of injuries to our two types of sources of moral identity in order to more clearly define the small yet undisputable difference between the two.

Before jumping right into treatment methods and approaches let’s review the basic fundamentally distinct differences between the self-formed moral identity and the community-given moral identity. In a community set of moral values, there usually exists a way to rectify moral wrongdoings when they are committed. With personally generated values there is no concrete, step-by-step way to right a wrong in order to wipe your moral slate clean. However, within a community in which you receive a moral identity there is almost always a given set of directions you must follow to absolve your moral wrongdoing. While this may seem like a small distinction between the two, it poses a large difference in the treatment of moral injury to the two types of moral identity. Let’s now consider the treatment differences in individuals with self-formed moral identity and community-given moral identity.

Although the moral injury of a self-formed moral identity and a moral identity formed by belonging to a community may be similar in its cause, the way to approach treatment for the moral injury can depend on how the moral identity was formed. An injury of a self-formed moral identity may require a treatment approach that is less clearly defined and is unique to the individual. Because of this, effective treatment of an injury from this type of moral identity is more difficult to come by. Effective treatment in this scenario may require a greater degree of personal reflection on the individual’s behalf and also a series of trial and error treatment methods.

In contrast, it is likely that an equivalent injury of a moral identity formed from belonging to a community might be significantly more straightforward in terms of how to effectively treat the injury. Hints to point treatment methods in the right direction or even methods to partial treatment of a moral injury of a community formed moral injury exist within the community itself. Ways in which we can correct misdeeds within communities can offer a partial moral repair. This can exist in an explicit way like serving a specific sentence of punishment as tribute for a misdeed or performing various acts of kindness within a religious community to absolve sins. They can also exist in an implicit way like continued observation of expectations in families or organization to build trust, or apologizing in an effort to gain acceptance and understanding among community members.

To get a more tangible example of the contrast in treatment methods, let’s examine a theoretical case. Let’s look again at Jon, our family man who is against killing and conflict. Let’s recall the specific example of Jon and his family being held at ransom. Recall that the only conditions in which Jon’s family will be returned to him unharmed are that he must kill a drug lord who is in competition with his family’s kidnappers. Let’s suppose Jon does everything as prescribed by the kidnappers, his family is returned unharmed and Jon is in no way associated or charged with the murder of the drug lord in any investigation following the incident. After the incident Jon is left feeling overwhelmed by what he had to do to get his family back. He adhered to his primary value−his family, but betrayed a close second value in killing the drug lord. He knows he made the right decision, especially when he looks at his family happy and healthy, but he still can’t move past committing murder. This leaves him revisiting the events of the murder in forms of flashbacks and night terrors. Even when sounds are similar to the greasy drug lord’s struggled last breaths Jon is consumed with painful guilt and memories of the incident. The feelings of remorse and flashbacks are debilitating to his quality of life and keep him from being the best Jon that he can be.

Let’s first suppose, in consistency with the original case, that the moral injury here is to a moral identity that Jon has self-established. Jon has decided for himself that the values of caring for his family, abstinence from killing, and avoiding conflict are the keys to living a moral life. Jon has indeed killed another human and in doing so engaged in conflict, but has kept his most important value, the safety of his family, wholly intact. When treating Jon we must keep in mind that the ultimate goal of the treatment is for Jon to be able to reconcile with himself that he traded his two other core values for his most important, and that giving up these two values (at least situationally) was more important than giving up his ultimate value−his family. The ways in which we can allow Jon to come to realize this can have endless possibilities.

One method we might employ would be to ask him to consider what values make a man moral and ask him to explain why he chose the values he chose. Ideally this will allow him to see himself as equivalent to “the moral man” he describes and will hopefully find some relief that he did what he thought was right in the given circumstances. There is also the possibility that Jon describes the opposite of himself and causes him to associate himself with “the immoral man,” causing his symptoms to be exacerbated and his moral distress worse. The therapist treating Jon would then have to “go back to the drawing board” and flesh out a new treatment approach to Jon’s issue ensuring that there is no possibility of Jon associating “the immoral man” with his own self. This is all part of the complicated intricacies in treating a wound that is self-identified and is present in a self-formed moral identity. As stated before treatment of a moral wound that is so closely associated to the personal identity requires a unique and very personal approach. It requires careful action and much deliberation before being carried out. Very rarely will the first method work completely if at all, and there will be a series of trial, error, evaluation, and re-evaluation before a custom-tailored treatment plan is effective in treating an injury to the self-given moral identity.

In order to view the differences in the treatment of a moral injury based on the source of the injured moral identity let’s use Jon’s case again. The same moral injury exists, the only difference now being that Jon’s moral identity and three major values of caring for his family, refusal to kill others, and aversion to conflict are given to him by his religion. For the sake of this case let’s call it Purism.

Jon may personally agree with the Three Pillars of Purism, but fundamentally they were given to him as a means to “live the good life.” Like most religions, Purism has a sacred text called “The Book of Purity,” which includes any and all aspects on how to live the good life. Let’s say the events happen just as they have before. Jon kills the drug lord, his family is returned, but he consequently feels horrible about committing murder. Just as before Jon’s quality of life suffers and he turns to a therapist for help with his moral distress. The initial treatment approach of Jon’s moral injury now would have a much different plan of attack.

Knowing that Jon is a member of a religious community we can look to that community as a means of finding some type of relief for Jon’s distress. In this case we turn to the chapter in “The Book of Purity” on “Reparation for Betraying the Three Pillars of Purism.” This chapter details a process of fasting, praying, and self-reflection that Jon must under-go over the next three weeks to absolve the sins of betraying the Pillars of Killing and Conflict. Upon aiming treatment of Jon’s injured moral identity around its religious text it is likely that Jon’s treatment will be more successful. This will give the therapist a direction in which to at least start Jon’s treatment, and runs a significantly slimmer risk of adverse effects of attempted therapy techniques like in the earlier self-formed identity treatment scenario.

This is a fascinating distinction because although Jon has sustained a moral injury that is not only caused by the same exact set of circumstances in both cases, the moral injury occurred from a violation of the same moral values in each case. However, the truly fascinating part is the difference in treatment approaches lie solely in the source of our moral identity. This may indicate that future approaches to treatment of moral wounds should start primarily with determining the source of the moral identity that is injured and not just the moral identity itself. Could it be that failure to consider the source of the wounded moral identity is the missing dimension in healing moral wounds? I believe it is well worth investigation to find out. Future empirical tests should involve a juxtaposition of the efficacy of treatment methods when the source of injured moral identity is taken into consideration versus when just the injured moral identity is taken into consideration.

It may so happen that Jon has also concurrently adopted the Three Pillars of Purism into his own self-formed moral identity which could also be injured from Jon’s misdeeds. If this is the case we can expect the “Book of Purity’s” instructions for reparation to offer some relief, but due to the self-formed moral identity injury that cohabitates with the community-given moral identity injury we cannot expect it to heal Jon completely. If this is indeed the case it would seem as if a carefully calculated and personalized trial and error approach would be the next step after using the directions found in “The Book of Purity.” This would require a hybridized treatment approach to Jon’s moral injury. Often in the therapeutic world we find that significant healing of a patient’s wounds, of any kind, require some hybridization of techniques to be the most effective in returning the patient to normal functioning.

With these cases of applied therapeutic knowledge now in hindsight I think we can agree that moral injury and effective treatment of it are far more complex and intricate then it first appears. We would first need to be able to run empirical tests that would lead to effective ways to treat moral injuries associated distinctly and solely with each source of moral identity. Only then can we combine the empirically supported and effective treatment methods specific to the source of moral identity together to even attempt treatment of hybridized cases where injury exists to multiple moral identities of different sources. As complicated as that all sounds unfortunately these two sources of moral identity are only half of the moral identity equation. What’s more is that the treatment of these wounds is significantly more definitive than the second half of the moral identity equation.

Moral Repair

What can we do to relieve the suffering of those with moral wounds? What can be done to close these open wounds of our soldiers? Aristotle in Nicomachean Ethics gives us a potential answer. He discusses in great detail the power of the emotion of hope. Hope becomes the “scaffolding” that allows us to rebuild our self-image from the crippling moral emotions of guilt and shame. Radiating positive potential, it lights the way to the possibilities that we are capable of—the possibilities that we knew were always there, but whose memory became vilified by poisonous guilt and damning shame in the wake of falling short of expectations.

Perhaps its moments like these—moments of hope—that we need to begin to heal the moral wounds of our soldiers. We must work within our abilities to touch their hearts with our own hope. No longer can we sit back and watch as guilt tighten the noose or shame load the gun that kills our soldiers. Regardless of the origin of moral injury, these experiences are real and they are painful. They deserve not only to be recognized, but to be rectified. Those that endlessly suffer deserve relief. While not all moral injuries result in a war of good versus evil, they are still characterized by the pain found within the suspension of certainty in one’s identity. Anyone who has experienced any type of uncertainty of the self can relate to this unique agony.

Nancy Sherman's talk at the Ethics of War Conference can be found here