Moral Aspects of 'Moral Injury': Analyzing Conceptualizations on the Role of Morality in Military Trauma

Abstract

In clinical circles, the concept of 'moral injury' has rapidly gained traction. Yet, from a moral philosophical point of view the concept is less clear than is suggested. That is, in current conceptualizations of 'moral injury', trauma's moral dimension seems to be understood in a rather mechanistic and individualized manner. This article makes a start in developing an adequately founded conceptualization of the role of morality in deployment-related distress. It does so by reviewing and synthesizing insights from different disciplines into morality and trauma. This discussion will lead to three positions, namely that (a) values and norms are by definition characterized by conflict, that (b) moral conflict may entail important social dimensions, and that (c) moral conflict may lead to altered beliefs about previously held values. These insights provide important steps in further developing conceptions on the role of morality in deployment-related suffering.

Full text

1
Moral Aspects of ‘Moral Injury’: Analyzing Conceptualizations on the Role of
Morality in Military Trauma
Tine (T.) Molendijk, MSc
Eric-Hans (E.H.) Kramer, Dr.
Désirée (D.) Verweij, Prof. dr.
This is the authors’ Original Manuscript of an article
published by Taylor & Francis in Journal of Military Ethics available at
https://www.tandfonline.com/doi/full/10.1080/15027570.2018.1483173
Abstract:
In clinical circles, the concept of ‘moral injury’ has rapidly gained traction. Yet, from a moral
philosophical point of view the concept is less clear than is suggested. That is, in current
conceptualizations of ‘moral injury’, trauma’s moral dimension seems to be understood in a rather
mechanistic and individualized manner. This article makes a start in developing an adequately
founded conceptualization of the role of morality in deployment-related distress. It does so by
reviewing and synthesizing insights from different disciplines into morality and trauma. This
discussion will lead to three positions, namely that (a) values and norms are by definition
characterized by conflict, that (b) moral conflict may entail important social dimensions, and that
(c) moral conflict may lead to altered beliefs about previously held values. These insights provide
important steps in further developing conceptions on the role of morality in deployment-related
suffering.
Key words: PTSD, trauma, moral injury, military ethics, morality, shame and guilt
Introduction

2
Veteran Scott Ostrom, whose story is featured in a lauded photo series of photographer
Walker, is still proud to be a marine. On Veterans Day and Memorial day he decorates
his car with a marine battalion flag. Yet, he also feels severely guilty about what he had
to do as a marine. The Denver Post (2012) quotes him saying: ‘I was a brutal killer, and I
rejoiced in it. I was bred to be a killer, and I did it. Now I'm trying to adapt and feel
human again. But to feel human, I feel guilty. … That's why I can't eat: I feel guilty, I feel
sick’.
Ostrom is one of the many veterans who speak of experiencing severe feelings of
guilt. Ostrom is also one of the many veterans who are diagnosed with ‘post-traumatic
stress disorder’ (PTSD). ‘PTSD’ is currently the dominant, if not only, explanatory
concept of deployment-related suffering. Yet, the PTSD-concept is also increasingly
criticized for paying too little attention to the kind of suffering Ostrom’s account speaks
of, namely (potential) moral aspects of military trauma (see e.g. Shay 1994; Litz et al.
2009). Psychologists Litz et al. (2009) argue that, in the last decades, ‘there has been
very little attention paid to the lasting impact of moral conflict-colored psychological
trauma among war veterans in the clinical science community’ (Litz et al. 2009: 696). At
the same time, however, mental health practitioners do report that moral conflict is a
significant element of the suffering of many soldiers (Drescher et al. 2011).
Recently, the concept ‘moral injury’ has gained traction. The general idea is that
‘moral injury’ is the result of combat experiences that affect soldiers’ moral
fundamentals and as such cause suffering. Psychologists Litz et al. (2009) have
developed a preliminary conceptual model of ‘moral injury’, which is considered to be a
stepping stone towards a clinical care model. The model provides initial ideas about
what ‘moral injury’ entails, how it is caused, and how it can be treated.
Yet, the development of conceptualizations about moral conflict-colored distress
appears to be not only an important development, but also a complex one. Questions
about the nature of morality, about how morality can be injured and about its
consequences are complicated question, and should be taken into account when
working out conceptual models with regard to moral injury. When this complexity is not
addressed, implicit and unsubstantiated assumptions about the nature and role of
morality are easily incorporated, leading to a rather insubstantial basis for the
development of both the concept of moral injury as such and clinical practices based
thereupon.

3
This article analyzes different approaches to moral dimensions of deployment-
related distress. The ultimate aim of this undertaking is to contribute to an adequately
founded conceptualization of the role of morality in deployment-related distress. The
first part of this article provides an overview of whether and how morality is accounted
for in prevalent conceptualizations of deployment-related distress, namely ‘PTSD’ and
‘moral injury’. The overview shows that both PTSD-models and the moral injury-model
address moral emotions like shame and guilt, yet in different ways. Yet, the overview
also reveals that both psychological models employ one-dimensional conceptualizations
of morality; implicitly, both approach morality in a rather mechanistic and
individualistic fashion. The second part of this article aims to make a start in formulating
a more developed approach to morality’s role in suffering. Therefore, it reviews a
number of ‘alternative’ approaches to morality in the context of deployment-related
distress. This review will show that values and norms are by definition characterized by
conflict, that moral conflict may entail important social dimensions, and that as such
moral conflict may lead to altered beliefs about previously held values and norms. These
insights, we believe, provide important steps in further developing conceptions on
(deployment-related) moral conflict.
Shame and guilt in models of PTSD and moral injury
Moral emotions in prevalent PTSD-understandings
In the most recent version of the official classification and diagnostic guide of mental
disorders, the DSM 5, PTSD is formulated as ‘the development of characteristic
symptoms following exposure to one or more traumatic events’ (DSM 5 2013: 274). The
event is defined as ‘[e]xposure to actual or threatened death, serious injury, or sexual
violence’. The symptoms include re-experiencing of the event(s), negative mood,
outbursts of panic or anger, and avoidance of confrontation with the event(s) or
situations that remind of it (DSM 5 2013: 271–272).
The central emotion in PTSD-models appears to be fear. Earlier versions of the
DSM classified PTSD as an anxiety disorder, and while it is no more classified as such,
the most commonly used treatments for PTSD are still generally fear-based (Drescher et
al. 2011). It is this focus on fear and anxiety which has been explained as an important
reason why moral emotions (for instance shame and guilt) currently receive ‘very little

4
attention … in the clinical science community’ (Litz et al. 2009: 696, see also Lee, Scragg,
and Turner 2001).
This does not mean that moral struggles related to traumatic experiences have
gone completely unnoticed, however. It has since long been acknowledged that moral
emotions like shame and guilt can be related to trauma. For instance, ‘survivor guilt’,
which refers to guilt felt when surviving combat while others have not, is a well-known
concept. Although after the first DSM survivor guilt was removed from the criteria of
PTSD, it did appear as an associated feature. Also, the latest DSM had included the
symptom: ‘Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or others’ (DSM 5
2013: 272). Prevalent understandings of PTSD thus do acknowledge guilt and shame.
That being said, guilt and shame are approached in a particular way in PTSD-
models. First, moral struggles seem to be predominantly treated as symptoms – as
consequences – of post-traumatic stress, not as potential sources of stress. Indeed,
potentially traumatic events as captured by PTSD are those that are characterized by
life-threat and fear, and not necessarily by moral conflict.
Second, and assumedly related to this particular focus on moral struggles as
symptoms, PTSD-models also appear to employ a particular approach to guilt, namely,
one that understands guilt as a result of so-called cognitive distortions. Such an approach
is not only indicated in the DSM classification of PTSD, but also central in the works of
influential psychologists on the topic of trauma-related guilt. Take for instance Edward
Kubany’s conceptualization of guilt. In an article on combat-related guilt, Kubany speaks
of guilt as based on ‘false assumptions and faulty logic’ (1994: 5). He not only explains
guilt felt by survivors in this way, but also guilt felt by soldiers who have killed in war.
According to Kubany, combat-related guilt is based on the false premise of ‘I should have
known better’ (6) or as the failure ‘to realize that the actions not chosen would have
probably had worse consequences than actions taken’ (9). In his latest elaboration of a
‘multidimensional model’ of guilt (Kubany and Watson 2012), Kubany continues to
conceptualize guilt as ‘irrational guilt’. Further, in a short closing paragraph, Kubany
explicitly opposes victims of such guilt to ‘perpetrators’, whom he defines as ‘socially
deviant individuals’ who do not experience remorse. In doing so, he approaches guilt as
either present but irrational or not present in a severely pathological way.
In some cases, guilt may certainly be understood as unfounded and irrational. Yet,

5
a sole focus on guilt as the result of erroneous thinking fails to reflect on how ‘germane’
guilt should be understood and dealt with. Undeniably, guilt can also be appropriate.
Now, some might be inclined to say that moral judgments regarding the
correctness of guilt are irrelevant in clinical practice, and perhaps even harmful.
However, a focus on alleviating guilt through efforts to make veterans feel less
responsible for their acts is a moral judgment as well. Furthermore, some veterans have
reported feelings of serious alienation when their expressions of guilt were met with
either implicit justification or suppression of subjectivity from the side of the
practitioner. These veterans perceived the negative judgment of their own actions as an
important way to make sense of those actions (Lifton 2005; Boudreau 2011, see also
Bica 1999). Thus, being recognized in one’s own moral judgments can be crucial to those
veterans that grapple with the belief that they have committed immoral acts.
This brings us to the concept of ‘moral injury’, which proposes that moral conflict
may lie at the heart of deployment-related suffering, and which complicates an approach
to self-blame as the result of distorted cognitions.
Moral emotions in ‘ moral injury’
In an essay that argues for the nascent concept of ‘moral injury’, Iraq veteran Boudreau
(2011) describes why he feels that PTSD cannot capture the key elements of his distress.
I accepted the diagnosis from the VA [Veteran Affairs] and from everyone
else, and I’m sure that my condition was in part that, but inwardly I knew
that the greatest pain I felt was not linked to those moments when violence
was being directed at me but when I was involved in inflicting it on others.
Post-traumatic stress just didn’t seem to fit. So what could I call this pain? It
felt a lot like guilt, so that’s what I started calling it, but in the Diagnostic and
Statistical Manual of Mental Disorders (DSM) under PTSD there is no mention
of guilt, except for ‘survivor’s guilt’… The term ‘moral injury’ has recently
come afloat, and it applies to exactly the kind of guilt I’m talking about.
(Boudreau 2011: 748)
Upon returning from Iraq, Boudreau started to struggle with a number of actions he had
performed, such as ordering to use ‘a heavy hand’ in house searches, and issuing

6
approval to shoot an unarmed man who appeared to be digging a hole for a roadside
bomb. While at the time he took pleasure in some of these acts, he now feels remorse for
them. In his autobiography, Boudreau states that ‘I chose to ignore the facts and to ride
blithely through the fantasy without critique’ (Boudreau 2008: 207). He says: ‘I should
have known better’, and he goes on to explain this idea as a revelation. This is a wholly
different view on guilt than Kubany’s notion of faulty logic.
As mentioned, the concept of moral injury is a relatively young concept.
Currently, the most influential conceptualization of moral injury has been developed in a
collaboration of Litz, Stein, Delaney, Lebowitz, Nash, Silva and Maguen (2009, see also
Maguen and Litz 2012). It seems that their conceptualization is also the only systematic
model of moral injury. The authors, all clinical or theoretical psychologists, provide in
their much-cited article titled ‘moral injury and moral repair in war veterans’ a
‘preliminary model and intervention strategy’. In the relatively scarce literature and
media accounts that discuss moral injury, one will virtually always encounter reference
to these authors, sometimes as the only source.
Litz et al (2009) do not aim to replace the concept of PTSD, and neither suggest
‘moral injury’ to be a new DSM-classification. Rather, they aim to bring forward a
concept that captures particular ‘kinds’ of suffering in ways that deviate from dominant
clinical PTSD-understandings. The authors argue that while some characteristics of
PTSD may overlap with what they call moral injury, in other ways the latter is unique.
They state that while ‘morally injured’ soldiers may display symptoms that are similar to
those described by PTSD, central in moral injury are feelings of shame and guilt. Their
definition of ‘potentially morally injurious experiences’ also deviates from the ways in
which PTSD defines potentially traumatic experiences. As a working definition of such
experiences the authors propose: ‘Perpetrating, failing to prevent, bearing witness to, or
learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et
al. 2009: 700). So, whereas PTSD-models focus on exposure to (threatened) violence,
‘moral injury’ captures those events that invoke moral conflict, which may or may not
involve threat.
In a short paragraph titled ‘what are morals?’, Litz et al explain morality as a
‘code’ that individuals use to ‘navigate through life’. They further define morality ‘as the
personal and shared familial, cultural, societal, and legal rules for social behavior, either
tacit or explicit’ and as ‘fundamental assumptions about how things should work and

7
how one should behave in the world’ (2009: 699). Liz et al explain that an experienced
violation of the ‘moral code’ can result in profound feelings of shame and guilt.
In line with their specific focus on certain ‘kinds’ of deployment-related suffering,
but not inevitably following from them, Litz et al also employ a specific understanding of
shame and guilt. Throughout their article they stress that while commonly used
therapies address judgments and beliefs about moral violations as distorted ones, such
judgments and beliefs may also be ‘quite appropriate and accurate’ (2009: 702).
Therefore, they argue that it is ‘important to appreciate that holding onto the idea of a
moral self or a moral code may require that a bad act be judged as such. … Rather, the
goal is to help the service member or veteran to move toward an appreciation of context
and the acceptance of an imperfect self’ (2009: 703). As such, Litz et al differ from
Kubany’s theoretical model, which tends to frame beliefs like ‘I should have known
better’ as a distorted thought that needs to be corrected.
In their own model, Litz et al (2009) use and adapt existing cognitive models and
cognitive behavioral therapies for PTSD. ‘Similar to social–cognitive theories of PTSD’,
they argue ‘that moral injury involves an act of transgression that creates dissonance
and conflict because it violates assumptions and beliefs about right and wrong and
personal goodness’ (Litz et al. 2009: 689). The key adjustment the authors make to
existing treatment models is that they place moral conflict at the centre, which they
approach as germane rather than pathological. The ultimate goal of the treatment they
propose is ‘to get service members and veterans to articulate ideas about the capacity to
do good and to talk about being forgiven and the need for self-forgiveness, even if they
don't initially accept these ideas’ (2009: 702).
Implicit assumptions about morality
The preliminary model of Litz et al pays substantially more attention to moral
dimensions of deployment-related suffering than currently prevalent PTSD-models
appear to do. Litz et al’s model of ‘moral injury’ takes into account that feelings of guilt
may in some cases and aspects be understood as the result of distorted cognitions, and
in some cases and aspects as the result of reasonable judgments. However, their model
seems to implicitly employ a rather one-dimensional approach to morality, and as such,
also to the experiences that may be involved in ‘moral injury’. Before elaborating on this

8
statement, it is important to take a closer look at what morality entails.
A well-accepted definition within the disciplines of philosophy, ethics and
anthropology, describes morality as a total of values and norms in a specific socio-
historical context. This minimal definition already indicates the complexity of morality.
It shows that morality is not only an intra-individual matter; it is also present on
different social levels (group, organization, nation) and in different social contexts (e.g.
different ethnic cultures, social and professional subcultures) (see also Baarda and
Verweij 2006: 2). An individual lives and acts on a daily basis, within a range of these -
often overlapping and sometimes opposing - social levels and contexts. As a result, an
individual incorporates multiple sets of values and norms, which may correspond but
also contradict one another (cf. Hitlin and Vaisey 2013).
Furthermore, even a specific set of values or value system cannot be understood as
an orderly and congruent entity. Values do not always join each other in perfect
harmony, they often co-exist in tension and sometimes, even in conflict. This becomes
most clear in confrontations with moral dilemmas. A moral dilemma entails a situation
in which one is confronted with competing moral principles that one considers
important, but which cannot simultaneously be honored; one principle has to be
violated in order to respect the other. In a moral dilemma, there is thus no unequivocal
‘right’ or ‘wrong’ decision (see also Baarda and Verweij 2009: 111).
This rudimentary description of morality can be used to evaluate how morality is
approached in different conceptualizations of deployment-related distress. This section
will analyze Litz et al’s approach to morality on the basis of this description. Despite Litz
et al’s nuanced explicit definition of morality (‘the personal and shared familial, cultural,
societal, and legal rules for social behavior, either tacit or explicit’ (2009: 699)), their
model nevertheless seems to fail to take morality’s complexity into account, in several
ways.
Morality as a consistent belief system
Throughout their article, Litz et al speak of morality as a firm ‘code’ or ‘belief system’,
and of morally tragic experiences as ‘transgressions’ of this code or system. As cited
before, they describe a morally injurious experience as an event that ‘violates
assumptions and beliefs about right and wrong and personal goodness’ (698). That is,
‘acts of transgression produce dissonance (conflict) because soldiers do maintain ‘an

9
intact moral belief system’ (701).
The conflicts that Litz et al describe are conflicts between, on the one hand, one’s
‘moral code’ or ‘moral belief system’ and, on the other, a transgression from outside that
violates this inner moral code. As a result, they speak of conflicts between beliefs about
how one relates to this code. To use the terminology of the cognitive models on which
they draw, we could say that they refer to for instance a conflict between the cognition ‘I
do/am good’ and the cognition ‘I do/am evil’. Yet, the authors do not speak of conflicts
within the so-called moral code or moral belief system. They speak of ‘transgression’ of
the code or system by an act, and in doing so, they approach morality as a system of
values which may be violated by intruding acts, but not by one another. Their model
thus approaches morality as a coherent and harmonious system rather than as
constellation of possibly conflicting values.
Morality as an individual belief system
Next to an implicit notion on the nature of morality (as a coherent belief system), Litz et
al’s model also reveals implicit assumptions on where morality is ‘located’. In their
model, the soldier experiences the self-directed emotions of shame and guilt, and
consequently, the goal of treatment is ‘holding onto the idea of a moral self or a moral
code’ through ‘the acceptance of an imperfect self’ (703). So, although the model’s
definition of morality explains that ‘a moral code’ develops in social contexts, it
eventually approaches moral injury as an inwardly directed experience that does not
‘speak back’ to its social contexts. As such, it locates moral injury solely within the
individual.
At the same time, Litz et al make statements that indicate that there may be more
to moral injury than damaged notions about the self. The authors state a number of
times that moral injury can lead to a view of the world as malevolent. This suggests that
soldiers may not only blame themselves for moral transgressions, but also others.
However, the authors stop at mentioning that world-views may change, without
reflecting on its possible significance and consequences.
Morality as a static belief system
Lastly, Litz et al speak of values and norms as ‘fundamental assumptions’. They stress
that morally injured soldiers maintain ‘an intact moral belief system’ (701). To repeat,

10
they emphasize the importance of ‘holding onto the idea of a moral self or a moral code’
through ‘the acceptance of an imperfect self’ (703).
That is, their model does describe cognitive self-schemes, which include self-
perceptions regarding goodness and perfection, as dynamic and flexible schemes.
However, this does not appear to be the case for the ‘moral code’ as such. The moral
code, or moral belief system, is conceptualized as ‘intact’ after morally injurious
experiences. The experiences would only alter soldiers’ perceptions of the extent to
which their acts and personality conform to their moral belief system, it would not alter
their moral beliefs as such. In other words, values and norms would remain rather fixed
fundamentals, about which soldiers would maintain to think in the same way.
Inconsistent morality: Incoherence of values and norms
The model of Litz et al reveals a rather individualizing and mechanistic understanding of
morality, which potentially leads to a limited understanding of the role of morality in
deployment-related suffering. Since morality forms the core of ‘moral injury’, this is a
critical point, and a task lies in further developing conceptualizations of morality in the
context of deployment-related suffering. The next half of this article makes a start in this
undertaking, by using insights of several authors into moral conflict-colored suffering
that are more in line with the earlier provided rudimentary sketch of morality. In doing
so, it explores how the complex and multifaceted nature of morality may have particular
implications for soldiers’ experiences of moral conflict.
Central in the following exploration are the works of physician Jonathan Shay
(1994), veteran and philosopher Camillo Bica (1999) and psychiatrist Lifton (2005). All
three authors have written relevant works on the moral dimensions of deployment-
related suffering. Both Shay and Bica are cited as the ones who coined the concept
‘moral injury’ (Dokoupil 2012; Kirsch 2014). Lifton was a key figure in the introduction
of PTSD in 1980, and while he does not use the term ‘moral injury’ - which was not yet
coined at the time - he was partly responsible for the attention paid to moral dimensions
in the first definition of PTSD.
It is surprising that the model of Litz et al neither refers to, nor makes use of, the
insights of Shay, Bica and Lifton.i In the following part of this article, all three authors
will be linked to one particular aspect of the moral dimension of military practice. Bica’s

11
insights will play an important role in understanding morality’s contradictory character.
The next section on social aspects of moral conflict will mostly draw on the insights of
Shay. Lifton’s insights will underpin the last section on how moral conflict may alter
moral beliefs.
Moral dilemmas, conflicting sets of values
The conception of values and norms as a harmonious system, which appears to be
employed in the model of Litz et al, seems to be a belief that many people unconsciously
hold about their own values and norms. It may be partly due to this belief that a
confrontation with clashing values may have great impact on a person: a value conflict
can make someone painfully aware of the potential inadequacy of his or her moral code.
This section discusses three cases of clashing values, which elaborate on the
inconsistent aspects of morality and give insight into their potential bewildering
implications. As such, this section will show that moral conflict may be more
complicated than straightforward feelings of guilt and unambiguous experiences of
wrongdoing.
Clashing values are most obvious in moral dilemmas. These may be everyday,
‘innocent’ dilemma´s, such as the ones in which a person has to choose between a white
lie and insulting honesty. However, there are also dilemmas that imply a forced choice
between two opposing values that both have tragic consequences, which philosopher
Sartre referred to as a situation that will by definition create ‘dirty hands’ (see Walzer
1973). Such situations can be quite ‘everyday’ for deployed soldiers.
An experience that is often reported by soldiers is that of having denied medical
care to civilians in need, because providing such care would have collided with
operational rules (Baarda and Verweij 2006; Bouchard et al. 2010). Often, operational
rules prohibit the provision of medical aid to civilians because of limited medical
supplies. Sometimes, providing medical aid is also prohibited because of strategic
considerations. This was the case in the following event, recounted by a Dutch soldier to
one of the authors.
In Afghanistan, the soldier and his unit were carrying out a so-called good will
operation in a rural area, when the unit was confronted with a child who was burned op
to his neck. However, it soon became clear that the tribe elder was responsible for this;
the burning was explained as a form of punishment. In the context of this particular

12
operation, it was especially important to gain the trust and respect of the tribe elder,
since tribe elders generally play an important role in creating good relations with the
local population. The military medic that was part of the unit was therefore ordered not
to interfere, and conforming to these orders, the medic refrained from providing care.
Soon after, the boy died as a result of his injuries. Even today, the medic struggles with
this event.
Although such a situation is an obvious tragic moral dilemma, it is important to
note that the significance that dilemmas acquire are strongly shaped by the beliefs and
expectations of the involved soldier, which are linked to the values and norms that he or
she has developed within specific contexts. These values and norms shape not only the
decision taken, but also the meaning of the decision. Although all soldiers in the
discussed event were affected by the event, the military medic was particularly
disturbed. For him, the event entailed a conflict between his military and medical oath.
He chose, or was forced to choose, to abide by his military oath, which left him in doubt
with regard to his medical oath, and maybe also his humanitarian ethos as a person.
Conflicts within a set of values
Whereas the preceding case concerned a conflict between two different sets of values
(which in the former example concerned professional value sets), an experience of
moral conflict can also entail a clash within a single set of values. Take for instance
military standards. Even if soldiers would only abide by the beliefs and expectations
they have incorporated as a member of the military, they can be confronted with
profound dilemmas.
Such a dilemmas is present in the experiences of ex-marine Sarra (see Sherman
2011). On 26 March 2003, an Iraqi woman approached the convoy of which Sarra was
part. The marines shouted at her in Arabic to stop, but the woman did not respond and
kept approaching. This event was especially alarming because the marines had heard
stories of suicide bombers disguising as innocent civilians. Should they fire or not? Sarra
describes the following thoughts going through his head.
So she’s walking and walking and walking… I’m like, OK, we’ve had reports of
suicide bombers, she’s wearing all black, she’s carrying a bag under her arm.
One of two things is going to happen... Either she’s going to stop or we’d

13
better drop her or [else] she’s going to blow up and kill a bunch of guys... So
she’s walking. She’s walking. She’s walking. I perceived her as a threat. You
know what, I’ve got a shot. Two shots. The first one I think I missed her.
Second one, I saw her buck. And then the Marines from the other amtrak
[assault vehicle] opened up on her. And I was the only guy in my platoon to
fire. And she hit the ground and when she hit the ground, there was a white
flag in her hand, a piece of white flag in her hand. And I was like, ‘Oh my God’.
(Sarra cited in Sherman 2011: 109)
According to an official investigation of the incident, Sarra indeed was the only man in
his platoon to fire. However, the woman was killed not by Sarra’s fire but by the fire of
the other platoon. Also, the shooting was considered justified within the Rules of
Engagement. Yet, it did not matter to Sarra. He was not able to work as a soldier any
more. He quit his job at the end of 2003, and co-founded ‘Iraq Veterans against the War’
in the year after (Kiernan 2004). As he later explained, this event changed the course of
war for him (Chaudhry 2004).
Sarra felt remorseful for not having waited longer before opening fire, and he felt
responsible for the woman’s death (Aronson 2005; Sherman 2011). At the same time, he
did recognize the reasons why he decided to fire. In his notebook, he listed seven
reasons why he had done the right thing (Kiernan 2004). Sarra’s tragedy thus not
merely entails the fact that he tried to shoot an innocent woman because he failed to see
her white flag, but also that he was involved in a moral dilemma. Sarra could not have
waited until he was entirely certain about the woman’s intentions; if she was a suicide
bomber, the troops would have only found out when it was already too late. The key
conflict that emerged here was between two moral obligations of which we can assume
that soldiers particularly feel they should abide by: respecting the lives of non-
combatants and protecting one’s ‘brothers in arms’. In situations like these, a soldier
cannot do both at the same time.
Crumbling warrior mythology
As the discussed examples indicate, the experience of particular values conflicts can also
generate more fundamental conflicts concerning one’s deeply held convictions and
principles. Soldiers may start to question the moral standards in which they once deeply

14
believed. Take, for instance, the following reflections of a US soldier. ‘I'm 22 years old
and I must have killed 30 people. The same thing that you were given badges for, over in
Iraq, you would be considered a serial killer over here. That's a very weird thought to
have running around in your head when it's dark, going to sleep, or late at night’ (US
soldier in the documentary ‘Beer is Cheaper than Therapy’, directed by De Vries, 2011).
Or take the words of veteran Ostrom, who was cited in the introduction. Ostrom said he
‘was bred to be a killer’ and ‘rejoiced’ in being one However, in trying to re-adapt to
civilian life and to feel ‘human’ again, he feels guilty.
Camillo ‘Mac’ Bica, a Vietnam veteran who became doctor in philosophy,
describes these kinds of conflicts as well. According to Bica, the etiology of moral injury
lies in the inherent conflict between civilian and military values (Bica 1999). Drawing
inter alia on the famous argument of Grossman (1995), Bica maintains that it all starts at
military education. Here, soldiers are transformed from civilians, who are raised with an
aversion to killing, into warriors, who are ‘desensitized’ regarding the killing of others.
In the ‘warrior mythology’, war is necessary and just, and the warrior is noble and
righteous.
However, Bica argues, this mythology is the complete opposite of the ‘existential
reality of war’. In war, he says, a soldier is hit by the realization that war is chaos, and
sometimes completely pointless. War is a world in which personal survival and revenge
prevail, facts that go against the values in which the soldier deeply believed. As a result,
the soldier’s mythology of warriors as righteous men crumbles down, and ‘serious
doubts arise regarding the necessity and justness of the enterprise and the nobility and
righteousness of the warriors’ involvement in it’ (Bica 1999: 87).
Bica argues that when soldiers have had their warrior myth crumbled by the
‘irreconcilable demands of the combat situation’ (1999: 89), they experience profound
disorientation after returning home. What the soldier quoted earlier describes about the
difference between moral standards held in Iraq and the US, seems similar to what Bica
terms ‘moral identity confusion’. By this, Bica refers to the feeling of being torn between
a civilian world, with values about killing which they recognize as once being their own,
and the martial world of war and killing, which the soldiers now are part of. In the worst
case, Bica argues, this disconnection could lead to the feeling that one’s life no longer has
meaning, one’s world has become disjointed and relations with others have become
incomprehensible.

15
The above examples show that morality is a multi-faced phenomenon. An important
implication of morality’s complex nature is that soldiers may be confronted with value
conflict on several levels. These may involve, among others, conflicts within a single set
of values (e.g. respecting and protecting human life), conflicts between two professional
sets of values (e.g. medical and military), and conflicts between societal sets of values
(‘military’ and ‘civilian’). Importantly, these different conflicts cannot be neatly
separated. Instead, an event often is significant at several moral levels at the same time.
Also, a moral conflict surrounding a particular event can engender fundamental moral
conflicts that go beyond that event, as also indicated in Bica’s argument and Sarra’s
account. Sarra experienced severe guilt and, at the same time, he understood his actions
within the context of the inevitably conflicting moral obligations of that situation and of
war itself; the event led him to co-found ‘Iraq Veterans against the War’.
The moral conflicts described above are of a more complicated kind than those
that Litz et al describe. To be sure, it remains true that in some cases, an event may be
experienced as a straightforward transgression, and that in some cases, this experience
as well as the resulting feelings of guilt and shame can be understood as either distorted
or accurate. But in many other cases, the conflict appears to entail not only a
contradiction between an act and one’s ‘moral code’, but also contradictions between or
within moral codes as such. Such conflicts complicate the above distinctions between an
inner moral code and a transgression that violates this moral code, and between
distorted or accurate guilt.
Social dimensions of moral conflict: Embittered by an imperfect military and
society
Moral conflict has so far been discussed as an individual and inwardly directed conflict.
Yet, the preceding section showed that the values involved in moral conflict as well as
potential transgressions of those values are not completely intra-individual matters.
Instead, moral conflict was shown to be embedded in a social context.
This social dimension of moral conflict indicates that ‘moral injury’ may also
entail moral thoughts and emotions like blame, which are generated by an exterior
cause and thus are outwardly directed. The following anecdote suggests this indeed to

16
be the case.
College student Joey Glick … was halfway into his presentation when
Quentin, a soldier who came as part of a local PTSD support group, raised
his hand. ‘I have a question for you, but I'm not sure if you can answer it
for me,’ he asked as he gestured at the PowerPoint slide on the screen. ‘I'm
listening to you say all this stuff about PTSD, and TBI, and the ABCs. But,
can you tell me why we are in Afghanistan?’ (Scandlyn and Hautzinger
2014: 14)
Although student Joey had studied how chaplains respond to soldiers’ mental health
problems, his research had not enabled him to answer the question. As he later wrote in
his thesis: ‘none of my informants saw a reason to engage political or moral questions
when counseling soldiers or their families’ (Scandlyn and Hautzinger 2014: 15).
Scandlyn and Hautzinger remark that the question of soldier Quentin shows the
‘narrow focus of PTSD’, but also note that ‘moral injury’ – in its current
conceptualization – is limited as well, ‘for it encapsulates suffering and keeps the
emphasis on the individual soldier and his or her actions and away from the political and
military leaders who ordered them into combat and the civilians, willingly or not, who
stand behind them’ (2014: 15).
We saw that Bica does contextualize the moral dimensions of combat-related
suffering, in understanding moral conflict as being profoundly disillusioned by
previously held military values. The book ‘Achilles in Vietnam’ by Jonathan Shay (1994),
a psychiatrist and former VA clinician, sheds further light on possible social dimensions
of moral conflict. Moreover, unlike Bica, Shay’s insights also show the complicated ways
in which morally injured soldiers relate to civilian morality.
Disenchanted by the army’s morality
Shay argues that the army can be seen as a moral construction. The shared expectations
and values of the army form a moral universe that are seen by soldiers as ‘legitimate,
“natural”, and personally binding’ (1994: 6). The morality of a soldier is thus intimately
linked to and dependent on the morality of the military organization, which goes so far
as that the army can make soldiers willing to jeopardize their own lives.

17
Because of the specific and strong moral relation between a soldier and the army,
Shay explains, its violation by the latter can have catastrophic consequences. In one
section, Shay quotes a sergeant telling about an experience of such a violation. At one
morning after a night of fighting, the sergeant and his unit found out that the enemy they
thought they had killed consisted of fishermen and children, an experience of horror to
the sergeant. However, the sergeant’s superiors merely said ‘that’s the hazards of war.
They were in the wrong place’. They said: ‘you guys party’. ‘Erase that’, ‘Move on’. And
so, however terrible the sergeant found the realization that his unit had killed innocent
people, the sergeant also told his men not to ‘worry about it’. (1994: 71). This event had
seriously affected the sergeant. What happened here was that the sergeant’s own
experience and perception of the event were completely denied by his commanders.
Further, the sergeant had complied with this denial by also telling his own men ‘don’t
worry about it’. It was an experience of what Shay calls ‘the betrayal of “what’s right”’,
committed by individuals who symbolically and literately personify the military
organization, and who thus form a central moral authority in the soldier’s world (1994:
71).
Shay discovers the consequences of moral betrayal to be devastating. In his
clinical practice, he was confronted with soldiers who experienced the loss of being able
to think of a meaningful future, who had an overall mistrustful or even hostile attitude
towards people, and experienced feelings of helplessness and hopelessness and mistrust
of ideals. In other words, Shay observed a persistent shrinking of soldiers’ ‘temporal
horizon’, their ‘social horizon’, and their ‘moral horizon’ (1994: 176).
To Shay’s understanding of ‘the betrayal of “what’s right”’ we may add that moral
betrayal can also be less explicit. Boudreau, the veteran who believes that ‘moral injury’
better applies to his experiences than ‘PTSD’, explains in his biography: ‘I just wanted to
… follow orders. I was content with that. But then I went to Iraq, and all those ideals that
saturated my leaders’ rhetoric, and saturated my mind, went rotten. … I knew my ideals
had slipped away’ (Boudreau 2008: 189). Besides the feeling of being betrayed by false
impetus, Boudreau describes how he now realizes that he was trained to kill without
reflecting on what killing entailed: ‘when a Marine shoots better than his peers, he’s
admired and he’s handed metals and badges and promotions – all to encourage him to
pull the trigger with another man in his sights and kill him. Like it or not that’s
desensitization. But desensitization doesn’t eliminate morality from the consciousness.

18
It merely postpones cogitation’ (ibid).
Disenchanted by society’s morality
Shay also discusses, although more briefly and less systematically, how the reactions of
civilians connect to deployment-related suffering. Shay speaks of US society as covered
with a ‘cloak of safety’ - a cloak that soldiers struggling with moral conflicts have lost.
This cloak would make that the majority of people do not want to hear the raw accounts
of trauma, as it puts the correctness of their moral beliefs into question, and ‘leaves us
terrified and disoriented’ (1994: 37). Although Shay finds this attitude understandable,
since it stems from the moral construction of ‘normal human life’ (1994: 194), he
stresses how it can hinder healing.
Being blamed for the war can be particularly harmful. In the introduction to his
book, Shay cites a soldier saying: ‘When I first came back it was I was living under a
toilet and every five minutes somebody had diarrhea on me’ (1994:xix). In another work
more specifically on veteran’s homecoming, Shay discusses how veterans blame civilians
and politicians for refusing to take any responsibility for the war, and thus for indirectly
putting all blame on the veterans (2002: 102–103).
The observations of Shay indicate that most people do want to have their armed
forces to protect their interests, but are simultaneously uncomfortable with violence and
death. To Shay’s arguments we may add the following. A ‘cloak of safety’ does not merely
shape society’s general attitude towards soldiers, but also affects them in a very direct
way. In democratic societies, decision-making on military missions lies in the hands of
politicians, and since politicians are elected, also in those of society’s citizens. Indirectly,
society thus influences the conditions and operational rules under which soldiers have
to operate. The direct involvement of politicians and civilians in military missions, and
the simultaneous denial of this involvement by many of them, seems to be what a soldier
like Quentin describes when asking civilians ‘why we are in Afghanistan’.
To turn back to Shay, his overarching argument appears to be that ‘war can destroy the
social contract binding soldiers to each other, to their commanders, and to the society
that raised them as an army’ (1994: 17). Shay understands moral injury as not merely
the result of committing moral violations, but also of the experience of moral betrayal by
others. The military organization may tend to justify those events that are experienced

19
as moral transgressions, and society may not want to hear about it at all. Both can be
seen as a form of denial, leading soldiers to deeply distrust their world, and even to turn
against war itself, as ex-marine Sarra did. This conception indeed corresponds with a
study of veterans’ accounts, which found loss of trust or a sense of betrayal to be the
most frequent theme in veterans’ accounts (Vargas et al. 2013).
Litz et al argue that the self-blaming of suffering soldiers should in some cases be
understood as accurate rather than distorted, and therefore they aim to work toward
‘the acceptance of an imperfect self’. Shay’s insights can be read as an addition
concerning the blaming of others. The view of some soldiers that the world is not as
benevolent and just as previously thought is described by Shay not as a distorted view,
but a real one. What follows is that moral conflict may not only result in acquired insight
into the ‘imperfect self’, but in some cases also into an ‘imperfect’ military or society.
Changed views on morality: Questioning previous moral beliefs
When soldiers have been agonizingly confronted with the moral ‘imperfection’ of
themselves and/or others, what may happen to their ethical views? That is, what may
happen to the ways they think about the phenomenon of morality as such?
According to Litz et al, feelings of guilt and shame indicate that one’s moral
beliefs and expectations are maintained, because the experience of a transgression as
‘dissonance is only possible if the service member has an intact moral belief system’
(2009: 701). While moral emotions indeed indicate the presence of moral standards, the
idea that soldiers’ ethical beliefs remains unaltered after morally confronting events
requires investigation. The work of psychiatrist Lifton provides interesting insights into
this question.
Counterfeit universes
In line with Bica, Lifton (2005) describes how soldiers may be confronted with the
bizarre and morally absurd reality of war, a reality which is in direct conflict with the
romantic notions of heroism that prevail at home. Soldiers may witness, experience or
cause suffering to which they cannot possibly attribute a meaning or purpose. Such
experiences lead the soldiers to ask themselves ‘what the fuck are we doing here?’ on
the battlefield, or after having returned home, ‘what the hell was going on?’ (2005: 37).

20
We saw that moral conflicts tied to a specific event within a mission may generate
moral confusion about the mission at large. Lifton’s work shows that this process can
also work the other way around; Lifton argues that soldiers will develop serious inner
conflicts when they cannot interpret specific war experiences of injustice as something
that happened within a war that itself was just and necessary. Lifton was confronted
with veterans who could not believe that the Vietnam war was ‘dirty but necessary’
(2005: 39), and who thus lacked any means to justify and come to terms with specific
experiences during that war. Although Bica shows that moral conflict can also be caused
by experiences in wars that are seen as just, it may be more severe when justification
can neither be found beyond direct events of injustice. The soldiers that Lifton spoke
experienced the Vietnam war itself as absurd and pointless – some soldiers afterwards;
others already during their deployment. They perceived the war to be like a movie, and
themselves as ‘boys playing soldiers’ (2005: 168). They lacked any means to tie the
killing they witnessed and committed to an overarching purpose. As a result, they came
to see the universe of war, including themselves, as ‘counterfeit’.
Later in his book, Lifton describes situations that are similar to what Shay
subsumes under the name ‘moral betrayal’, which Lifton labels ‘false witness’. Lifton
shows how ‘betrayal’ or ‘false witnessing’ may not only be done by military leaders, but
also by others. After homecoming, soldiers went to chaplains and military psychiatrists,
as part of their attempts to convert their numbing and isolating guilt into a guilt with
which they could live. By trying to understand their killings as pointless and immoral,
and as part of a meaningless war, they sought ways out of their self-perceptions of being
an immoral person. However, the chaplains and psychiatrists would instead justify and
rationalize their actions. The struggles of soldiers were framed as personal problems, in
their heads, for which they had to find a ‘cure’ (2005: 166). As a result, the soldiers came
to experience the ‘counterfeit universe’ not only to lie in the jungles of Vietnam, but also
here, in the home to which they had returned.
Lifton’s observations both correspond with and question the idea of moral beliefs as a
system that remains ‘intact’. Lifton’s work does correspond with Litz et al’s argument
that experiences of shame and guilt indicate that someone has not lapsed into absolute
nihilism – it seems that shame and guilt can help someone to preserve one’s feeling of
being ‘human’. Yet, Lifton’ work also shows that in some cases, the issue is more

21
complicated. His insights show that if soldiers feel that the moral significance of events is
corrupted by themselves or others, they may come to view their world as not only
morally impaired in the sense that it is ‘imperfect’, but also morally impaired in that it is
‘counterfeit’.
Counterfeit experiences appear to entail that soldiers have started to question the
aptness of their own morality and that of the world around them. In the chapter called
‘The Counterfeit Universe’, Lifton quotes former marine medic and Vietnam veteran
Philip Kingry. ‘The war isn’t just an excuse. It was everything. I am a lie. What I have to
say is a lie. But it is the most true lie you will ever hear about a war’ (Kingry cited in
Lifton 2005: 187, emphasis in original). What we read here seems to be the following.
Moral conflict can not only alter perceptions about the extent to which people actually
‘practice what they preach’. In some cases, it can also alter one’s beliefs about what is
‘preached’. That is, a soldier may start to believe not only that people fail to live up to the
values and norms they preach, but also that those values and norms as such do not suit
reality; that they are ‘counterfeit’.
Conclusion
Models of PTSD and ‘moral injury’ show that some forms of trauma-related guilt can be
understood as unfounded, while others might instead be understood as accurate. Yet,
the analysis of the moral dimension of deployment-related suffering has demonstrated
moral conflict to be a lot more complex than this.
It became clear that ‘moral injury’ does not always entail the experience of
straightforward transgression. In cases of clashing values, soldiers may grapple with the
question whether the acts they witnessed or committed were good or bad. Such a
struggle may also engender moral conflict with regard to the overall purpose and
righteousness of the mission in which they were deployed, which in turn may hinder the
process of coming to terms with particular deployment events.
These insights also indicate that moral conflict may have important social
dimensions. An individual incorporates various moral codes, learned in different social
environments. When soldiers experience an event that makes them painfully aware of
conflicts between or even within different moral codes, this may not only result in the
blaming of self, but also in the blaming of others. Such an altered world-view might be as

22
accurate and reasonable as judging the self for moral transgressions.
Furthermore, moral conflict may not only entail confrontation with the
imperfectness of self or others, but also with the imperfectness of values as such. That is,
when soldiers have been painfully made aware of the fact that different values or value
constellations can be incompatible, this may shake the moral beliefs and expectations
they used to hold. Soldiers may start to wrestle with the question whether there is such
a thing as good and bad, and such a thing as purpose. Some may come to view both their
own moral conventions and those of the worlds around them to be ‘messed up’, in the
double meaning of impaired and illusory.
Finally, in all cases – remorse, anger, counterfeit experiences – it seems that to
interpret soldiers’ moral battles too quickly as erroneous thinking is to fail to take
serious their battles as existential, real struggles. However well-intended, responding to
thoughts like ‘I/they should have known better’ with efforts of justification and
rationalization may amplify rather than alleviate feelings of misrecognition and
counterfeit experiences. Most probably, this not only applies to deployment-related
moral struggles, but to moral conflict experiences in general.
This article was meant as a general exploration, and the resulting considerations
call for in-depth research on moral conflict. It is yet unclear what different conflicts
soldiers experience, what consequences such conflicts may have for soldiers’ beliefs and
behavior, and how moral conflict experiences may be shaped by different factors, such
as training, rank, political practices, public opinion, and so on. Indeed, our analysis
indicates that although the risk of moral conflict is inherent to the soldier’s job, it also
depends to a considerable extent on how soldiers are sent to war and received back
home. And so, our considerations also call for further research on how mental health
professionals, political leaders and society at large tend to deal and struggle with the
moral significance of war and violence, and with the discomforting topics of guilt and
blame.
References
Aronson, R. (2005) The Soldier’s Heart [documentary] 60 min (Boston: WGBH
Educational Foundation).

23
Baarda, T. A. van & Verweij, D. E. M. (2006) Military Ethics: The Dutch Approach - A
Practical Guide (Leiden: Martinus Nijhoff).
Baarda, T. A. van & Verweij, D. E. M. (2009) The Moral Dimension of Asymmetrical
Warfare: Counter-terrorism, Democratic Values and Military Ethics (Leiden: Martinus
Nijhoff).
Bica, C. C. (1999) A Therapeutic Application of Philosophy. The Moral Casualties of War:
Understanding the Experience, International Journal of Applied Philosophy, 13(1), pp.
81–92.
Bouchard, S., Baus, O., Bernier, F. & McCreary, D. R. (2010) Selection of Key Stressors to
Develop Virtual Environments for Practicing Stress Management Skills with Military
Personnel Prior to Deployment, Cyberpsychology, Behavior and Social Networking, 13(1),
pp. 83–94.
Boudreau, T. E. (2008) Packing Inferno: The Unmaking of a Marine (Port Townsend, WA:
Feral House).
Boudreau, T. E. (2011) The Morally Injured, Massachusetts Review, 51(1), pp. 646–564.
Chaudhry, L. (2004) A Soldier Speaks: Robert Sarra [article online] accessed 23 June
2015, available at:
http://www.alternet.org/story/20337/a_soldier_speaks%3A_robert_sarra; Internet.
Dokoupil, T. (2012) A New Theory of PTSD and Veterans: Moral Injury, Newsweek, 3
December [article online] accessed 5 March 2015, available at:
www.newsweek.com/new-theory-ptsd-and-veterans-moral-injury-63539; Internet.
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K. & Litz, B. (2011) An
Exploration of the Viability and Usefulness of the Construct of Moral Injury in war
Veterans, Traumatology, 17, pp. 8–13.
DSM 5. (2013) The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition:
DSM 5 (Arlington, VA: American Psychiatric Association).
Friedman, M. J. (2013) Finalizing PTSD in DSM-5: Getting Here From There and Where to
Go Next, Journal of Traumatic Stress, 26(5), pp. 548–556.
Grossman, D. (1995) On Killing: The Psychological Cost of Learning to Kill in War and
Society (Boston: Little, Brown and Company).
Hitlin, S. & Vaisey, S. (2013) The New Sociology of Morality, Annual Review of Sociology,
39(1), pp. 51–69.
Kiernan, L. (2004) Coming Out on the Other Side, Chicago Tribune [article online]
accessed 23 June 2015, available at:
http://www.chicagotribune.com/lifestyles/health/chi-0407020125jul02-story.html;
Internet.
Kirsch, B. (2014) Preventing Suicide in US Veterans Remains Challenging, The Lancet,
383(9917), pp. 589–590.

24
Kubany, E. S. (1994) A Cognitive Model of Guilt Typology in Combat-Related PTSD,
Journal of Traumatic Stress, 7(1), pp. 3–19.
Kubany, E. S. & Watson, S. B. (2012) Guilt: Elaboration of a Multidimensional Model, The
Psychological Record, 53(1), pp. 51–90.
Lee, D. A., Scragg, P. & Turner, S. (2001) The Role of Shame and Guilt in Traumatic
Events: A Clinical Model of Shame-Based and Guilt-Based PTSD, British Journal of
Medical Psychology, 74(4), pp. 451–466.
Lifton, R. J. (2005) Home from the War: Learning from Vietnam Veterans (New York:
Other Press).
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C. & Maguen, S. (2009)
Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention
Strategy, Clinical Psychology Review, 29(8), pp. 695–706.
Maguen, S. & Litz, B. T. (2012) Moral Injury in Veterans of War, PTSD Research Quarterly,
23(1), pp. 1–6.
Nash, W. P. & Litz, B. T. (2013) Moral Injury: A Mechanism for War-Related Psychological
Trauma in Military Family Members, Clinical Child and Family Psychology Review 16(4):
pp. 365–375.
Scandlyn, J. & Hautzinger, S. (2014) Collective Reckoning with the Post 9/11 Wars on a
Colorado Homefront. Paper written as part of Costs of War project (Providence: Watson
Institute for International Studies).
Shay, J. (1994) Achilles in Vietnam: Combat Trauma and the Undoing of Character (New
York: Simon and Schuster).
Shay, J. (2002) Odysseus in America: Combat Trauma and the Trials of Homecoming (New
York: Simon and Schuster).
Sherman, N. (2011) The Untold War. Inside the Hearts, Minds and Souls of our Soldiers
(New York: W.W. Norton & Company).
De Vries, S. (2011) Beer is Cheaper than Therapy [documentary] 78 min (Netherlands:
Zeppers Film).
Walker, C. F. (2012) Welcome Home, The Story of Scott Ostrom, Denver Post, 1 May.
Walzer, M. (1973) Political Action: The Problem of Dirty Hands. Philosophy & Public
Affairs 2(2), pp. 160–180.
i In a 2013 article on moral injury in military family members, Nash and Litz (2013) do refer to Shay’s insights on
the impact of betrayal, which we will also discuss in this article. However, the authors do not seem to
adequately integrate into their model Shay’s emphasis on the social dimensions of ‘moral injury’, nor do they
explicitly point out what we believe is a crucial insight, namely that blaming of others can be just as accurate as
self-blaming.