On ‘moral injury’

Introduction

How do we begin to accept that Nick Rudolph, a thoughtful, sandy-haired Californian, was sent to war as a 22-year-old Marine and in a desperate gun battle outside Marjah, Afghanistan, found himself killing an Afghan boy? That when Nick came home, strangers thanked him for his service and politicians lauded him as a hero?

The object that Wood is describing is configured in terms of a series of contrasts and boundaries: between an established diagnostic category and an only newly recognized condition of injury; between inattentive, institutionally embedded practices and the morally and existentially urgent needs of veterans; between the troubling extremes of counterinsurgency violence and more conventional ways of waging war; and between those extremes and what an unspecified, presumably civilian ‘we’ can ‘accept’. Moral injury constitutes what the editors of this special issue refer to as a ‘fringe’ psychological condition: it both lies outside the bounds of conventional clinical categories and addresses itself to a socially marginal and transgressive set of activities (Henckes, Hess and Reinholdt, 2018). The psychological fringe it identifies is quite literally also a moral fringe.

In what follows, I turn to close, critical readings of the discursive field articulated by moral injury’s researcher, clinician, and advocate proponents and the journalists and commentators who write about them. This is a disciplinarily fluid field – what critics of the psy- disciplines have described as ‘generous’ or ‘promiscuous’ (Rose, 1998) – and it is because of this interdisciplinarity that I adopt the general term psychic, rather than the discipline-specific psychological or psychiatric, to characterize its site of intervention. It is a field where clinical research intermixes with therapeutic practice, activism, and psychodynamic, historical, and literary analysis, and where clinicians, researchers, advocates, and journalists seem to share a desire to talk back against mainstream psychiatric understandings of war trauma from a position of alliance and advocacy with veteran and military populations. Jonathan Shay, for instance, is a psychiatrist who has treated Vietnam veterans since the late 1980s and is typically credited with first popularizing the term moral injury. His two bestselling books (1995, 2002) examining war trauma through the lens of Homer’s epics are widely read by lay and therapist audiences, but largely ignored by mainstream psychiatry. The same applies to psychotherapist Edward Tick, whose widely read War and the Soul (2005) is based in an amalgamation of Jungian depth psychology, (somewhat superficial) ethnology, and an historically and geographically eclectic grab-bag of case studies; he has worked in private practice with veterans since the pre-DSM III 1970s. William Nash, a retired Navy psychiatrist, and Charles Figley, a Marine veteran and psychologist, are also clinicians with strong military connections (Figley and Nash, 2007). Figley, along with Shay, Robert Jay Lifton, and others, was among the psychiatrists in the 1970s who worked to secure PTSD’s addition to the DSM (Figley, 1978; Lifton, 1973). And Nash is now one of the most public voices on the topic of moral injury as well. The small body of peer-reviewed research on moral injury has been led since the late 2000s by a set of military- and VA-affiliated clinical psychology researchers, most prominently Brett Litz and Shira Maguen. David Wood’s account – rooted in decades of military and war reporting – receives special attention in this analysis as a distinctive in-depth portrait of those who advocate for the label or adopt it to describe their pain, rich in firsthand statements from scholars and clinicians whose writings are also analyzed here.

These scholars, researchers and writers are dedicated advocates for and sophisticated analysts of veteran experience, and I am at pains to emphasize that the goal of this article is not to dismiss or debunk the validity of moral injury and its therapeutic and diagnostic potentials. Indeed, formalized clinical interventions based on the concept of moral injury are relatively new, and there remains little published research on their deployment and efficacy. But the term’s enthusiastic uptake in recent years, anecdotal accounts (e.g. Brock and Lettini, 2013; Morris, 2015), other activist and ethnographic research among traumatized veterans (Finley, 2011; IVAW et al., 2014), the growing number of recent publications for clinical and lay audiences not examined here (e.g. Graham, 2017; Sherman, 2015; Yocum, 2016), and even my own ongoing fieldwork among Iraq and Afghanistan veterans suggest that it likely holds therapeutic appeal and potential for many veterans and clinicians. Broader studies in medical anthropology show that some but not all sufferers will find benefit from any of a diverse range of psychotherapeutic practices (cf. Moerman, 2002), and there is no reason to imagine that this would not be the case with interventions based in moral injury.

The goal of this article, following the editors’ call, is to explore what kind of world, and what kind of actors within it, this category imagines and helps to ‘make up’ (Hacking, 2007) as it circulates across different domains – and what implications it might hold for collective understandings of veteran wellbeing and the moral economy of war violence. Sociologist Marian Allsopp notes that the discursive construction of ‘invisible wounds and psychic trauma…produces particular forms of the self’ that play out in the subjective experiences of sufferers, the relational and institutional practices of diagnosis, treatment, and the broader social reckoning of suffering – though these diverse registers are collapsed, confusingly, into the language and space of the individualized psyche (Allsopp, 2013: 1). As Nikolas Rose (1998) points out, it is precisely the collapse of cultural narrative and governmental apparatus into an individualized form that makes of the self an unreproachable good and fundamental source of truth – one that becomes the site of action and responsibility and therefore also constraint and control. As Allsopp convincingly argues, the configuration of this self as ‘injured’ – increasingly common across any number of idioms of psychic distress, not only moral injury – raises both the stakes and the seemingly self-evident necessity of management and care of the self by medicalized categories and therapeutic experts. Collective and moralized demands of ‘support’ for American servicemembers and veterans materialize this dynamic in an especially acute way, with every special claim of veteran suffering both elevating their status and slotting them into a regime of institutional control and scripted cultural expectation (Millar, 2015; cf. MacLeish, 2013; Stahl, 2009; Wool, 2015). In such constructions and the problems around the meaning of violence that they present, the metaphor of the psychic wound ‘migrates’, in Allsopp’s words, becoming ‘the psyche not just of an individual, but of a group, a nation…the bearer of the wound and scars becomes a whole people’ (2013: 32). It is in the spirit of challenging potentially reductive idioms of ‘injury’ and expanding the range of possible individual and collective becomings for all who must make sense of war’s violence that my critique is offered.

In what follows, I argue first that moral injury theory is engaged in a kind of morally charged conceptual and professional boundary work within the psy- disciplines around moral injury’s status as ‘not a mental disorder’ (Maguen and Litz, 2012). Moral injury’s proponents speak from their positions as psychologists, psychiatrists, and pastoral caretakers, as well as veteran activists, advocates, and commentators, located both within and outside VA and military medicine, but almost all at the margins of mainstream evidence-based military and VA mental health care. They distinguish the condition from the scientistic configuration of PTSD, with its abstract inventory of symptoms and generic assumptions about psychic process, by situating it in the context of military culture and institutions. I then explore how this distinction between injury and disorder hinges in part upon the distinction between war violence that is routine and legitimate and that which, like the death of the child fighter described above, is somehow beyond the pale and thereby morally injurious. Defining moral injury depends on distinguishing ‘good’ war violence from bad, but this distinction is complicated by the way that authors in this field treat war violence as both morally valorous and fundamentally transgressive. Finally, I argue that that while moral injury theory is invested in identifying, in Wood’s words, damage to ‘a person’s moral foundation’, it can be read as producing a moral vision of contemporary war. This is a vision that normalizes and even allies itself with the military apparatus that empowers, disciplines, and exposes soldier bodies and lives in the first place (MacLeish, 2013) – forms of harm that are elided in favor of a locating trauma and evil in enemy actors and places and containing their origins and impact in individual actors. Ultimately, moral injury’s vision of anguish born of battlefield transgression reveals the kind of humanity we believe to be the proper subject of war and the broader stakes of what is understood to be right, wrong, and normal in war and its aftermath. But it confines the implications of these collective and profoundly political questions to the individualized and naturalized bounds of soldiers’ afflicted psyches.

A partial genealogy

Theories of moral injury are set in a landscape of contentious, ongoing boundary work, one in which the nomenclature, etiology, and politics of war trauma are profoundly unsettled. The rise of industrial-scale warfare is roughly contemporaneous with that of the psy- disciplines – psychiatry, psychology, and kindred fields in their clinical and research guises – approximately 130 years ago. And since that time, the labels deployed to explain the effects of war on the psyches of those who fight it have been sites of struggle over professional authority, classificatory boundaries, and questions of sufferers’ legitimacy and deservingness. This range of historical instantiations and contemporary applications, and their associated boundary work, is the object of a veritable library of critique and analysis (see for example Caruth, 1995; Horwitz and Wakefield, 2012; Leys, 2000; Morris, 2015; Pupavac, 2001; Shephard, 2001; Watters, 2011; Young, 1995, 2014). But for the purposes of this discussion, it is productive to situate moral injury in the context of the lead-up to and codification of PTSD diagnosis – as Allan Young puts it, the first and only ‘standardized and obligatory version of a posttraumatic syndrome’ in the US (Young, 2014: 73) – in DSM III in 1980 in the wake of the Vietnam War.

While the invention of PTSD diagnosis was the product of political struggle on numerous fronts, the vein associated with combat trauma was meant to address the rage, shame, guilt, depression, and lack of available treatment and compensation confronting American Vietnam War veterans. The label ‘Post-Vietnam Syndrome’ was coined by a coalition of veteran activists and their psychologist and psychiatrist advocates meeting in self-organized ‘rap groups’ to describe a condition that, like moral injury, was framed by contentious war politics, brutally asymmetric counterinsurgency battlefield conditions that many American civilians had witnessed via TV news coverage, and the felt need for new psychological nomenclature (Figley, 1978; Shatan, 1972). But with DSM III, this highly specific condition was dissolved into the far more generic and encompassing new definition of PTSD (Fassin and Rechtman, 2009). Morally and interpersonally laden symptoms like guilt and anger were included in DSM III but revised out in subsequent editions (American Psychiatric Association, 1994; see Fassin and Rechtman, 2009; Leys, 2006). Medicalized trauma became generic and increasingly inclusive.

At the same time, DSM III's new definition of trauma as a normal reaction to something ‘outside the range of usual human experience’ (American Psychiatric Association, 1980) rather than a reflection of underlying pathology or predisposition had important political effects. It highlighted the distinctive extremity of veterans’ experience, imbued their rancor and alienation with medical legitimacy and the prospect of compensation, and offered a way of seeing servicemembers as themselves victims of war – perhaps the primary victims – rather than solely as its perpetrators. Didier Fassin and Richard Rechtman write that an American public horrified by images of US military brutality was comforted by the notion that soldiers themselves were damaged by the events they perpetrated. PTSD diagnosis appealed to both the war’s critics and its opponents, making it possible to denounce war without denigrating soldiers; it mitigated the horror of what soldiers had done and been exposed to in the nation’s name by confining its effects and implications to the apolitical domain of the psyche (Allsopp, 2013; Fassin and Rechtman, 2009: 92; Howell, 2013).

In the years since, the array of potential subjects, objects, and mechanisms of PTSD has only grown more diverse, expanding the reach of the ‘empire of trauma’ (Fassin and Rechtman, 2009) into ever more domains of experience and explanation, becoming a problematically generic and unequal language of ostensibly common human suffering (Watters, 2011), and prompting anxieties about the overdiagnosis of a condition that ‘everyone wants to get’ (Horwitz and Wakefield, 2012: 175). PTSD has become a domain of suffering seemingly lacking in fringes altogether. And even as combat retains an arguably outsized role in shaping lay understandings of post-traumatic stress as a whole (Purtle, 2016), those fringes are being reasserted against the diluted specificity of combat trauma and its symptomatic entailments.

Not PTSD: Expertise, authority and a military condition

Nearly all scholarly and lay descriptions of moral injury begin by asserting that it is ‘not PTSD’ – nowhere is the condition described without this distinction being invoked. Popular media accounts echo the claims of scholars that the condition is distinct, more profound or ‘existential’ than PTSD (Jelinek, 2013); that it is ‘not clinically defined’ and is not a ‘formal diagnosis’ (Wood, 2014c); that it represents improved knowledge in the form of ‘a new theory of PTSD’ (Dokoupil, 2012); or that it transcends ‘beyond PTSD’ (Guntzel, 2013). In such characterizations, PTSD seems to furnish a familiar source of authority but also an unsatisfactory status quo for lay and clinical audiences alike, and moral injury is offered as an antidote to its simultaneous hegemony and incoherence. This boundary work, I argue, has simultaneously to do with the condition’s etiology and symptoms and with the kind of scientific and therapeutic authority that is equipped to address it. Unlike PTSD, which is defined in DSM as a basic and generalizable human response to feelings of intense fear and terror, moral injury is situated not in abstract processes of mind or the pharmacologically mediated neurobiology to which contemporary psychiatry hews, but rather in values, meaning, and subjective self-concept that are specific to military experience and culture. Jonathan Shay describes the stress of combat as ‘like no other’ (Shay, 2007), and while shock, horror, and grief are central aspects of war experience, ‘moral injury is an essential part of any combat trauma that leads to lifelong psychological injury’ (Shay, 1995: 20). In this attention to value and meaning, moral injury’s proponents position themselves not as detached observers of the morally injured, but as advocates and allies sensitive to the particularities of life at war. That is, the framing of moral injury carries within it a set of moral claims about the special nature of war-related suffering and psychiatry’s apparent indifference to that special nature.

Moral injury is consistently described in media and clinical accounts as both the event and the effects of an individual witnessing, participating in or being subject to a violent act that violates their beliefs or betrays their sense of right and wrong (e.g. MPR News, 2014). VA clinical psychology researchers Brett Litz and Shira Maguen define moral injury as ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et al., 2009). They write elsewhere that it is ‘an act of serious transgression that leads to serious inner conflict because the experience is at odds with core ethical and moral beliefs’ (Maguen and Litz, 2012).

It is this focus on belief, meaning and conscious inner conflict that these writers say distinguishes moral injury from the more familiar diagnosis PTSD and other deployment-linked mental illnesses like depression and anxiety. Moral injury can ‘manifest as PTSD-like symptoms’ (Maguen and Litz, 2012: 1) like anger, depression, anxiety, insomnia, nightmares, and self-medication with alcohol and drugs (Wood, 2014a). But moral injury’s ambit extends to value-laden emotional and cognitive symptoms like regret, sorrow, grief, shame, and alienation, and excludes other symptoms of PTSD such as flashbacks, fear, startle reflex, and memory loss (ibid.). The etiology of the two conditions differs as well. Moral injury is premised explicitly on the feelings of relational and emotional investment in or responsibility for violence that have been steadily revised out of DSM definitions of PTSD, and which as of DSM V are devoid of any emotional or interpretive qualification at all (American Psychiatric Association, 2013). In a return to the post-Vietnam focus on the traumatized perpetrator, moral injury researchers argue that PTSD’s inattention to the meaning or intentions of relevant actions and actors cannot account for the ‘moral and ethical distress’ they have seen in their veteran patients (Litz et al., 2009). Features such as ‘shame, guilt, demoralization…and self-harm’ bespeak direct links to the sense of wrong haunting the suffering person (Maguen and Litz, 2012: 1). Moral injury scholars regard this not just as refinement, but as a fundamental perspectival shift: the conventional focus in traumatology on those who are the victims of harm, according to Litz and colleagues, has ‘not considered the potential harm produced by perpetration (and moral transgressions) in traumatic contexts’ (Litz et al., 2009: 699). Most significantly, they say, both diagnosing and treating this sort of distress must go beyond generic symptom interpretations and ‘take account of social systems in which the individual is based’ (Maguen and Litz, 2012).

Staking out this space of specific traumatic experience and critiquing the limits of what PTSD diagnosis can explain establishes not only a boundary between labels and the experiences of sufferers, but also between different domains and sources of professional knowledge and authority. Moral injury theory’s claim to the latter is based on its therapeutic practitioners’ ability to relate empathetically to veteran and soldier experiences rather than treating them with the suspicion, judgment and managerial technicism for which they (and other critics) condemn mainstream military and VA psychiatry. Edward Tick’s widely read War and the Soul, for instance, refers to PTSD by the damning and oft-quoted epithet of ‘a name drained of both poetry and blame’, and he suggests that the diagnosis is freighted with implications of weakness or cowardice for many veterans (Tick, 2005: 100). A veteran advocate cited in one recent news report on moral injury asserts in frustration that PTSD diagnosis ‘renders soldiers automatically into mental patients instead of wounded souls’ (Jelinek, 2013). Shay rails against the ‘gratuitous stigma’ of labeling a mental ‘disorder’ that which might be more ‘honorably’ framed as a legitimate and remediable injury (Shay, 2011: 181). Retired Navy psychiatrist William Nash suggests that the burden imposed by a diagnosis of mental disorder constitutes nothing less than an ethical dilemma for clinicians, who must balance the potential harms of acute stress against ‘the danger of crippling normal warriors’ (Nash, 2007: 36) by medicalizing their experience. These characterizations pose the poetics, responsibility, spirituality, and honor of moral injury against the uncritically stigmatized threats of debility, psychological deficiency and moral abdication posed by PTSD diagnosis.

The overwhelming majority of military and VA mental health policy and programming take the ontology of PTSD as given (cf. Young, 2014) and are chiefly concerned with encouraging medicalized forms of help-seeking. This diagnostic realism is arguably reinforced by moral injury theory’s exercises in distinction – the disavowal of PTSD treats the latter’s coherence as given. On the other hand, moral injury’s military exceptionalism resonates with efforts within the military to taxonomically normalize the transient psychological impacts of combat, such as the widespread description of the latter under the non-diagnostic terms ‘combat stress injury’ (cf. Figley and Nash, 2007) and ‘Combat and Operational Stress Reaction’ or COSR (Department of the Army, 2006; Management of Post-Traumatic Stress Working Group, 2010; US Army Public Health Command, 2014; cf. Howell, 2013: Ch. 6) or the campaign by military leaders and medical personnel to normalize posttraumatic stress via the term ‘PTS’ – free of the stigmatizing ‘D’ and its connotations of disorder (Katchen, 2014; Whooley and Smith, 2015; Wittkop, 2014). While the Pentagon ‘does not formally recognize moral injury’, it has funded a $2 million clinical trial led by Litz at the US Naval Medical Center in San Diego (Wood, 2014b), the DoD’s Defense Centers for Excellence for Psychological Health and Brain Injury regularly blogs about moral injury, and many of the concept’s key theorists, including Litz, Maguen, Nash, and others, have positions at military and VA facilities. Moral injury resides for the moment at the fringes of the bureaucratic recognition on which US veterans’ ‘service-connected’ diagnosis, treatment and compensation depends. But as the genealogy of PTSD demonstrates, along with that of disorders connected to Gulf War Syndrome, Agent Orange exposure and illness linked to waste burn pits in Iraq and Afghanistan (Kilshaw, 2010; Percy, 2016; Uhl and Ensign, 1980; cf. Trundle, 2011), it is precisely from the fringes that many new claims about compensability and state and collective responsibility for the effects of war have emerged.

This boundary work around diagnostic labels recovers the specificity of combat trauma – and arguably its cultural nobility – from the genericizing reach of PTSD diagnosis. But that violence itself turns out to the object of yet more boundary work.

‘An act of serious transgression’: Morality on the battlefield

War is a routinized and valorized social institution that entails doing things that in other circumstances would be illegal and beyond the collective pale. And this is a contradiction that Maguen and Litz seem to be wrestling with when they write, in a bulletin addressed to fellow VA practitioners and researchers, that ‘even in optimal operational contexts, some combat and operational experiences can inevitably transgress deeply held beliefs’ for veterans (Maguen and Litz, 2012: 1). Across the board, moral injury theorists locate trauma in the way that war demands that its participants do, endure, and witness intolerable things – acts of violence that not only would be collectively regarded in other settings as illegal or beyond the pale, but that in the moment go against some sense of right and wrong that is felt by individual soldiers and recognizable by sympathetic therapeutic allies. There is a tension in this assertion, though, that is telegraphed by the qualifiers peppering Maguen and Litz’s syntax: the provisionality of ‘even’, ‘some’, and ‘can’ collide awkwardly with the ‘inevitability’ of transgression, begging the question of whether all war violence is traumatizing, or only that which is excessive or gratuitous. Is moral injury an incidental feature of war, or an inescapable one?

Litz and colleagues situate morality as a primordial element of individual and collective humanity. They cite Freud’s Civilization and Its Discontents and a range of contemporary developmental and evolutionary psychology literature to argue that ‘Moral behaviors are functional because certain primitive drives and instincts (e.g., aggression) may be destructive to the group and the culture’ (Litz et al., 2009: 699). While anticivilizational drives may be the source of violence and ‘social systems’ the source of ideas of right and wrong (Maguen and Litz, 2012), the most important unit of analysis in this scheme remains individuals and their thoughts and practices. A consistent semantics of depth, interiority, and individuality pervades the elaboration of moral injury. It is an ‘inner conflict’ (Litz et al., 2009; Wood, 2014a) or a ‘cognitive dissonance’ (Wood, 2014a). Litz and Maguen’s own definitions of moral injury, for instance, flag the ways that external circumstances threaten ‘core’, ‘deeply-held’, ‘undergirding’ beliefs (Litz et al., 2009; Maguen and Litz, 2012). These ostensibly social and cultural norms find their ultimate home deep within individual persons rather than above, among, or between them.

The tactically ambiguous battlefields and politically contentious narratives that characterize the US interventions in Iraq and Afghanistan are central to defining the distress described by moral injury theorists. As Maguen and Litz write, counterinsurgency warfare in Iraq and Afghanistan confronts US servicemembers with a range of ‘experiences that fail to conform with schematic beliefs about warfare and roles for servicemembers’ (Maguen and Litz, 2012: 1) – experiences like the horrifying narrative of the Marine obliged to shoot the young combatant described in the introduction. The list of such experiences is extensive. They include aspects of combat itself, such as fighting in the midst of populated areas, remotely detonated bomb attacks that could come at any time, and enemies indistinguishable from civilians or friendly forces. Firing on civilians or civilian structures or vehicles, or being ordered to or unable to prevent fellow soldiers from doing so, are also potential sources. Standard non-combat counterinsurgency practices like manning checkpoints, providing aggressive convoy security, the management and interrogation of prisoners, and conducting nighttime house raids are rife with the risk of moral injury. Being unable to protect or save the lives of friends and comrades is understood to be a significant potential source, especially if coupled with the obligation to leave the battlefield oneself. And the ‘demoralization’ of being unable to or actively prohibited from intervening in the brutalization of innocents by local bad actors falls under the ambit of this phenomenon as well (Wood, 2014a).

The battlefield is not inherently immoral, these characterizations suggest, but it is rife with risks of ‘bad moral luck’ (Shay, 2011), a danger that can be navigated ‘successfully’, especially with the benefit of good leadership (Maguen and Litz, 2012). In fact, moral injury theorists identify military culture and value systems as the source of the standards of right and wrong that are most meaningful to sufferers. Chief among these values is a professional ethic that equates competence with discipline and obedience (cf. Huntington, 1957), such that, according to Litz, ‘service members have to follow orders, and if [they are] ordered to do something it is by definition legal and moral’ (Wood, 2014c). Obedience constitutes its own form of moral sovereignty, it seems. Moral injury proponents point to the rigid moral codes emphasizing a spirit of ‘mission-first’ loyalty and duty across the military service branches (e.g. ‘Army Values’, 2014; ‘Principles and Values’, 2014). These codes figure powerfully in soldiers’ experiences and self-conception. They motivate and validate exercising violence and placing oneself in harm’s way (Shay as quoted in Wood, 2014b). Against the possibility that dogmas of obedience and duty simply turn soldiers into unfeeling automatons, Shay emphasizes that the ‘bright line between murder and killing’ is something soldiers ‘care deeply about’ (Wood, 2014b). Indeed, as much as the distinctiveness of military experience is emphasized by these authors, military values are presented not as some alien set of beliefs, but rather as an extension or even apotheosis of civilian values, or what Nash describes as ‘the best of what human beings can do’ (ibid.). This characterization resonates with the broader tendency that Catherine Lutz (Lutz, 2001) has noted in American culture to imagine military virtues as both elevated above but also continuous with civilian ideals. In reproducing this idea of a standard to which civilians may continually aspire but cannot ever hope to achieve, moral injury affirms soldiers as figures in whose goodness everyone is intimately invested.

Not just despite but because of the power of the codes and discipline that bind them, soldiers are also imagined as more vulnerable to the anguish of transgression when it does occur, trapped on the wrong side of a Manichaean order in which they are deeply invested. Military values offer ‘a chance of doing something good in war’, says Nash, ‘but war will break those values’ (Wood, 2014b). Some theorists suggest that moral injury can extend to questioning the purpose of a particular war or war in general (Brock and Lettini, 2013), though others claim that moral integrity depends more directly on the narrower moral economy of unit cohesion and leadership (Shay, 2002, 2011) and the coherence and meaningfulness of soldiers’ immediate experience in their mission and area of operations. Psychotherapist Michael Castellana, for instance, who is part of a moral injury initiative at the US Naval Hospital in San Diego, says that soldiers ask what went right and wrong ‘in my little sphere of influence, how well did I or didn’t I live up to [my] ideals?’ But he adds that this has ‘nothing to do with the rightness or wrongness of war’ more broadly (as quoted in Wood, 2014b). At the same time, the nature of the wars in Iraq and Afghanistan can make these two frames of judgment hard to differentiate, as soldiers may return to the same areas over the course of multiple deployments to find that little has improved for US interests or local populations (Wood, 2014a).

For some who work on moral injury, contradictions between ideals and reality are simply something to work through and get over, whether by focusing on positive outcomes, abandoning dualistic self-condemnation in favor of more nuanced accountings (Wood, 2014b, 2014c), or the notion that, in the words of moral injury proponent and retired Marine General Thomas Jones, who runs a private rehabilitative program for current and former servicemembers, ‘A democracy is dependent on having guys that will…do things that others decide [need] to be done’ regardless of the moral toll such deeds may exact (Wood, 2014a). For others, though, the tension between expectations and experience seems to be an inescapable feature of war itself. ‘There is an inherent contradiction between the warrior code,…what they expect of themselves—to be heroes, the selfless servants who fight for the rest of us—and the impossibility of war of ever living up to those ideals’, according to Nash. Ultimately, he suggests, ‘It cannot be done’ (as cited in Wood, 2014b). The very military values that give soldiers purpose and coherence also prime them for devastation.

These characterizations variously assert and assume the boundaries between and the relative normalcy or ‘fringe’ status of moral and immoral war violence and between the immediate moral worlds of soldiers and the broader scope of particular wars or war itself. But the morality of standard war practices remains unclear. A range of accounts testify to the routine character of house raids, aggressive checkpoint security, the destruction of civilian property and various other practices associated with intelligence-gathering, force protection, and other elements of counterinsurgency (e.g. Bissell, 2006; Gregory, 2010; Grove, 2016; Hedges and Al-Arian, 2009; Mejia, 2011). While a handful of especially spectacular and gruesome instances of violence against civilians – the Abu Ghraib prisoner abuses, for instance, and the eponymous atrocities committed by US servicemembers in Haditha, Mahmudiyah, Kandahar, and elsewhere – have been the targets of criminal prosecution and official and public condemnation, the military’s dominant approach to civilian casualties in increasingly complex war-making settings focuses largely on procedural and legal technicalities rather than explicitly moral concerns (Crawford, 2013). Moral injury seems to take the fraught character of counterinsurgency practices for granted, but then allows that they are only injurious to some soldiers, some of the time. This is the uncertainty that Maguen and Litz seem to be wrestling with in the assertion cited in the opening paragraph of this section, with its opposition between ‘some’ experiences and ‘inevitable’ transgression – war’s troubling violence is at once incidental and inescapable.

For theorists of moral injury, however, the most immediate stakes of this contradiction seem to lie not in the morality and politics of war violence in general, or of counterinsurgency in particular, but within the psyches of combatants. The simultaneous excess and inevitability of moral injury are articulated through a range of perspectives on the consequences of the condition for its sufferers. General Jones, for instance, posits that guilt, anxiety, and uncertainty about dead friends and innocents are common, ‘and most guys reconcile that fairly rapidly’; even their persistence in the form of moral injury is ‘just part and parcel of combat action’ (Wood, 2014a). Others are not so sanguine, however, seeing moral injury as an affliction of ‘definitely a majority’ of returning veterans (Nash as quoted in Wood, 2014a), a fundamental deformation of ‘character’, and the underlying cause for most or even all war-related mental anguish and behavioral problems (Shay, 2002, 2011; Tick, 2005). Nash attributes a near-total reach to the condition, suggesting that ‘if we had the wherewithal to do this kind of research, we’d find that moral injury underlies veteran homelessness, criminal behavior, suicide’ (Wood, 2014a). The question of what to make of those who are untroubled by their participation in that violence – are they especially morally robust? Alarmingly amoral? – is left largely unaddressed in this body of work, though Nash has asserted that ‘psychopaths don’t experience moral injury’ (Schwinn, 2015).

Ultimately, then, moral injury theory does not advance an argument about the morality of war, but about how best to understand the moral subjectivity of its participants. The grimly realist position expressed by Jones suggests that the demands of US counterinsurgency war, or of war in general, may be trying but are nevertheless in sync with soldiers’ training and expectations, and that the conflicts that do arise affect only a small fraction of those who fight. The more common position, the alarm voiced by Shay, Nash, and Tick, affirms that the underlying humanity of soldiers is so powerfully and enduringly good that its devastation and injury beyond the moral fringes of war is unavoidable.

Producing moral subjects

This normative, prescriptive perspective on the violence of war and the intuitive but elliptical rhetoric by which it is expressed reveal what anthropologists Catherine Lutz and Katharine Millar (2012) describe as the paradoxically co-constitutive relationship between war and morality. Moral injury theorists describe war as a place where morality is ‘broken’ and destroyed, but Lutz and Millar point out that war is a ‘uniquely privileged venue for the production of morality’ (ibid.). It is a venue in which collective ideas about what counts as national purpose and what causes are worth staking human life on are actively worked out, debated, and given material force through injured and dead bodies (cf. Scarry, 1987). Certain modes or instances of violence are relegated to the ‘moral margins’ of war and made the objects of interdiction and anxious policing (chemical weapons, child soldiers, suicide bombers). But many others occupy a legalized and largely unquestioned ‘moral center’ of conventional war-making that legitimates all violence that is not explicitly forbidden (Lutz and Millar, 2012). Medical and psychological labels do not stand outside this distinction, but traffic in it, defining normal and excessive forms of violence and healthy and pathological reactions to it in ways that seize upon the individual actor as the primary site of both responsible action and psychic damage (Crawford, 2013; Howell, 2013: Ch. 6). Moral injury theory’s conceptions of uniquely damaged perpetrators and the exigencies of the battlefield uneasily perform exactly this sort of distinction between the morally injurious ‘fringes’ of war violence and its coherent moral center of uniformed combatants, reasoned and responsible conduct, and clear and lawful rules and orders. Moral transgression is understood to originate primarily from foreign battlefields and inscrutable enemies, and American soldiers are made into the privileged victims of that harm but also its contained, decontextualized loci, disconnected from the powerful institutional apparatuses in which they and American civilians are both implicated.

One significant feature of the world imagined by moral injury is what might be called the ‘Orientalizing’ of war violence – locating it in a terrifyingly Other culture with attendant forms of violence that are uniquely horrific to Western liberal sensibilities (Asad, 2007), and in settings where the physical environment itself is imbued with sinister and hostile character (Gregory, 2016). The challenging setting and foreign inhumanity of the wars are understood to pressurize and distort familiar moral standards in intolerable ways – whether the jungle and the relentless, collectivist, ideological Viet Cong, or the cities and towns and villages crowded with vulnerable but untrustworthy civilians and enemies who are un-uniformed and cast as variously fanatic, mercenary, and indifferent in their brutality toward invading and occupying forces and one another. Wood’s survey of moral injury dwells at length over stories of soldiers literally ‘demoralized’ by witnessing Afghan men keeping young boys for sex or by enemy militants who deliberately used civilians as human shields (Wood, 2014a). ‘These men and women have seen incredible evil’, moral injury researcher and Navy psychologist Amy Amidon tells Wood of Iraq and Afghanistan veterans, ‘and [they come] home with that weighing on them and not knowing how to fit back into society’ (as cited in Wood, 2014a). Even therapeutic battlefield rituals in which soldiers reflect on troubling experiences in order to ‘leave them behind in Iraq’ – as if the place itself is the proper home of violence – affirm this separation (Wood, 2014c; cf. Shay, 2011). This vein of discourse resonates with a broader perspective that sees the violence of liberal superpowers as automatically legitimate, especially when accompanied by sufficient guilt and reflection, while the violence of enemy others is a psychological and civilizational threat in addition to a physical one (Asad, 2007). The evil of war appears as geographically and culturally but also experientially and existentially alien to civilians and civil society, rather than something in which that society is directly and complicitly involved.

The transgressive traumas of Vietnam affirmed the fundamental humanity of those who saw and did what civilians regarded as unspeakable violence because of the way their traumatic memories credited them with ‘a residue of humanity evidenced by the traumatic memory they retained’ (Fassin and Rechtman, 2009: 95). In the world envisioned by moral injury too, soldiers’ pain is a sign of their humanity. In Castellana’s words, veterans’ ‘efforts to punish themselves [are] just further evidence of their goodness’ (Wood, 2014c). This vigorous assertion of humanity is a balm to therapists who listen to soldiers’ stories even when they ‘make your toes curl’ (Nash as cited in Wood, 2014c), and arguably serves a similar function for civilian readers of non-scholarly accounts of moral injury who are confronted with evidence of violent acts committed or endured in their name. Having been cast in a role in which they are both elevated above and exiled from non-military personhood (cf. Lutz, 2001), a status further affirmed by the boundary work that distinguishes moral injury from PTSD and non-military traumas, the category furnishes a way to welcome soldiers back into the fold, but only by affirming the possible evil and inhumanity of their actions in a way that accords with cultural expectations.

Cultural common sense and military doctrine and laws of war regard the individual soldier as the most fundamental locus of action and responsibility (Crawford, 2013; Lutz and Millar, 2012), but it is military institutions that discipline soldiers, empower them to kill, and expose them to harm – that, in Michel Foucault’s (1979) terms, ‘make’ them as individuals in the first place. Obedience, embodied discipline, and engrained technical competence are sources of moral value in themselves, tools of survival and mutual protection as well as the expression of a professional ethic. And violence is just as often the fulfillment of the social contract rather than its violation, even in circumstances that might appear horrific to distant, onlooking American civilians (MacLeish, 2013). In many of the stories soldiers have shared with me in the course of ethnographic fieldwork on the everyday experiences of war-making, the proverbial ‘fog of war’ is something both less and more than the morass of potential moral and existential hazards highlighted in talk about moral injury. The battlefield is frequently a chaotic and ambiguous environment, but one in which discipline, training, mission objectives, and rules of engagement provide both a technical, procedural rubric and a sort of embodied, affective pedagogy that makes otherwise benign behavior and objects into deeply felt mortal threats (MacLeish, 2015).

From this perspective, the rightness or wrongness of specific acts of war violence demands contextualization within the fundamentally constructed character of combat’s seemingly straightforward life-and-death stakes. E.P. Thompson, in his analysis of 18th century English bread and grain riots, cautions against being satisfied with overly simplistic relationships between violence, transgression, and distress – in his case, the ‘self-evident truth’ that ‘people riot when they are hungry’ (Thompson, 1971: 77). The self-evident truth of the present case is that when people participate in routinized violence, they imbue it with emotional, psychological and moral significance. But simply asserting this monocausal relationship is far less important than asking, ‘being hungry’ – or being violent – ‘what do people do? How is their behavior modified by custom, culture, and reason’, and how does it feed back into these things (ibid.)? How, in Lutz and Millar’s words, do war and morality constitute one another in the ‘meaningful striving’ of combatants and the morally laden tales – whether folkloric, scientific, or bureaucratic – that are spun about them? Such questions are uncomfortable, but they are not unprecedented, as all manner of memoir, reportage, and ethnographic scholarship testifies to soldiers’ profound identification with this disciplinary subjecthood and solidarity, not to mention the ludic or sublime aspects of combat (Brown and Lutz, 2007; Herr, 1991; Swofford, 2003; Wright, 2004), and the modern West’s rich history of civilian and military enthusiasm for killing in war (Bourke, 1999; Delori, 2014; Lutz, 2001; Slotkin, 1992).

Moral injury theory and its proponents and documenters are admirably attentive to the problem of how best to recognize and respond to soldiers’ intense or overwhelming experiences of violence, including by situating them in the very particular local cultural world of military values and experience. But they seem notably silent on the broader institutionally and culturally engendered moral contradictions, forgoing – perhaps out of felt necessity – interrogation of the violence that inevitably inheres in the ‘moral center’ of war. All of war violence becomes a moral and social ‘fringe’ that is the property of individuals rather than a phenomenon deliberately produced by unquestioned, culturally valorized institutions.

Conclusion: Injury and accounting

Moral injury’s proponents, in their sensitive and sympathetic explorations of what war violence might mean to (some of) those who make and endure it, draw attention to the intensely felt contradictions of combat and its attendant suspension of normal protection and dignification of life. In the passage quoted at the beginning of this piece, Wood asks ‘how can we accept’ that a young servicemember should suddenly ‘find himself’ killing an enemy fighter who is no more than a child. Opening his own investigation of moral injury with this question, Wood seems to signal without saying outright that an unspecified ‘we’ – civilians, citizens – have a significant stake in soldiers’ moral condition. As Allsopp puts it (2013), such rhetoric takes the metaphor of the psychic injury and metaphorizes it again, casting not just the self or the soul but an entire society as wounded. This metaphorization works in the opposite direction as well: staking out a novel form of psychological harm, moral injury makes that harm available for expert intervention and management, and thereby also serves to ‘morally renovate’ the conflicts that gave rise to such harms in the first place (Lutz and Millar, 2012). Affirming the goodness of those who carry it out, the evil of enemies, and the inevitable transgressions of the battlefield, moral injury affirms that war possesses a coherent ‘moral center’, a place of ends-justifiable means and regrettable excesses where some lives and some anguish simply carry more moral weight than others. The authors whose work I have examined here are not the originators of these inclinations. Americans have a lot invested in war’s moral center: they consistently express more trust in the military – sometimes multiples or orders of magnitude more – than they do in other institutions, including religion, private enterprise, or their own government (Gallup, Inc., 2016). At the same time, the simultaneously pathological and elevated character of soldiers’ psychic pain, suggested by moral injury’s diagnostically fringe status, affirms their socially fringe status – the mutual alienation of soldiers from those in whose name they fight by the very work of violence that defines war in the first place.