Beyond PTSD – The Moral Casualties of War

Cyrano's Journal Online

June 4, 2007 – According to a study published in the New England Journal of Medicine, during the Iraq war, 56 percent of soldiers and Marines (henceforth I will use the term “soldiers” to include members of all branches, both male and female) have killed another human being, 20 percent admit being responsible for noncombatant deaths, and 94 percent had seen bodies and human remains.[i] According to Colonel Charles Engel, MD, MPH, director of the deployment health clinical center at Walter Reed Army Medical Center, between 15 and 29 percent of soldiers returning from Iraq and Afghanistan will suffer from Post Traumatic Stress Disorder. Because soldiers still on active duty are being deployed longer and more often to Iraq, experts say that the PTSD rate among Iraq veterans could well eclipse the 30{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} lifetime rate found in a 1990 national study of Vietnam veterans. While these numbers are staggering and should give any rational human being pause, the readjustment difficulties suffered by active duty military and veterans because of their experiences in Iraq are not exhausted by references to trauma and PTSD. Tragically, as soldiers experience the horror and cruelty of war, especially urban counterinsurgency war, the moral gravity of their actions – displacing, torturing, injuring, and killing other human being (henceforth “combat behavior”) – becomes apparent, soldiers suffer not only the effects of trauma, but what I will term “moral injuries,” i.e., debilitating remorse, guilt, shame, disorientation, and alienation from the remainder of the moral community.

The observation that some human beings become moral casualties because of their experiences in war is not new. Historically, many societies have recognized war’s deleterious moral effects and required returning warriors to undergo elaborate atonement and purification rituals, i.e., quarantine, penances, etc.[ii] These “therapies” provided the means and the opportunity to cope with the moral enormity of their actions in war. Tragically, the moral injuries of modern warriors, however, have been virtually ignored,[iii] overlooked, or disregarded by the conventional therapeutic community operating as it does within a Nietzschean-Freudian-Scientific legacy that views ethical concerns as clinically irrelevant – “autonomous man” ought [to] feel no guilt “nor bite of conscience” for his actions.[iv] Focusing, instead, upon stress and trauma, most moral symptoms presented by returning soldiers are either not taken seriously or assimilated under the diagnostic umbrella of Post Traumatic Stress Disorder. Consequently, the veterans receive the signal that an inability to forget, to put the war behind them, is either weakness or, perhaps worse, illness. Accordingly, veterans are advised to ignore what has occurred, to “de-responsibilitize,” i.e., to neutralize their feelings by accepting the “naturalness” of their behavior on the battlefield,[v] and/or to undergo a myriad of conventional therapies (psychoanalytic, behavioral, pharmacological, etc.) intended to enable them to deal with the stress and trauma of their experiences. In either approach, moral considerations are, for the most part, irrelevant.

Unfortunately, in most cases, moral injury neither responds well to medication nor can it be rationalized away. In fact, such methods, according to Robert Jay Lifton, tend to alienate them still further. Speaking about returning Vietnam Veterans, Lifton writes,

“The veterans were trying to say that the only thing worse than being ordered by military authorities to participate in absurd evil is to have that evil rationalized and justified by the guardians of the spirit . . . The men sought out chaplains and shrinks because of a spiritual-psychological crisis growing out of what they perceived to be irreconcilable demands in their situation. They sought either escape from absurd evil, or, at the very least, a measure of inner separation from it. Instead, spiritual-psychological authority was employed to seal off any such inner alternative.”[vi]

Such “therapeutic” advice as “forget it,” “live with it,” “act as though it never happened, or “don’t worry about it, human beings act that way in survival situations,” does little to alleviate the veteran’s moral pain and suffering.

As may be expected, the prevalence of moral injuries suffered by those who fought in a really ambiguous war, or in a counter insurgency/guerilla war, such as in Vietnam and Iraq, where, for example, the distinction between combatant and noncombatant is obscure at best, will be significantly greater and the symptoms more severe. However, all wars yield moral casualties. J. Glenn Gray, a philosopher, writes of his experiences as an Intelligence Officer during World War Two

“My conscience seems to become little by little sooted . . . .. (only) if I can soon get out of this war and back on the soil where the clean earth will wash away these stains! I have also other things on my conscience . . . A man named H., accused of being the local Gestapo agent in one small town was an old man of seventy . . . . I was quite harsh to him and remember threatening him with an investigation when I put him under house arrest . . . Day before yesterday word came that he and his wife had committed suicide by taking poison . . . The incident affected me strongly and still does. I was directly or indirectly the cause of their deaths. . . . I hope it will not rest too hard on my conscience, and yet if it does not I shall be disturbed also.”[vii]

Gray’s insights are especially valuable as they illustrate that even the actions and experiences of those involved in a “good” war and not directly confronting the enemy on the battlefield, can precipitate moral injury. Consequently, those military theorists who have argued that debilitating remorse, guilt, shame, etc., – what I have termed “moral injuries” – may be avoided by “educating” soldiers, probably convincing is better, about the justness and necessity of war and the “appropriateness” of their combat behavior,[viii] could benefit from Gray’s observations.

Psychologist and former Army Ranger, Lieutenant Colonel Dave Grossman[ix] and others have written extensively and insightfully regarding the profound debilitating effects of killing in war – combat behavior. However, for whatever the reason – probably the aforementioned scientific bias against acknowledging moral injuries or at least the propensity of not taking the possibility seriously – Grossman has alleged the etiology of such symptoms to be traumatic stress. Rachel MacNair agrees, postulating the existence of a variant of PTSD she terms “Perpetration-Induced Traumatic Syndrome (PITS).”[x] Both Grossman and MacNair argue that individuals who kill become traumatized as a consequence, not of being the victim of trauma as is the common interpretation of PTSD, but by being an active participant in causing trauma in others.

I find Grossman’s and MacNair’s conclusions problematic for the following reasons. After having been programmed by psychologically sophisticated military training and indoctrination techniques,[xi] and experiencing the grotesque life threatening conditions of service in Iraq, especially with repeated tours of duty, many, perhaps most, may view combat behavior as quite “normal” under the circumstances. Others may believe it betters their chances for survival and for returning home alive and intact. Still others may find having control over life and death empowering, exciting, exhilarating and as reinforcing the military stereotype of the elite warrior, “the toughest mother in the valley.” With appropriate “education,” many members of the military may be convinced, at least temporarily, that combat behavior in Iraq is justified, satisfying, and fulfilling as it brings freedom and democracy to a repressed people, and rids the world of evil-doers and terrorists. Consequently, convinced of its appropriateness, justness, and necessity, such combat behavior – causing trauma in others – may not be experienced traumatically by the warrior. That is not to say, however, that displacing, torturing, injuring or killing another human being, whether combatant or noncombatant, in a just or unjust war, does not have grave repercussions. While I applaud Grossman and MacNair for bringing attention to the likelihood of becoming symptomatic as a consequence of behavior in war (by virtue of what soldiers have done, not of what they have suffered), I regret their inability or unwillingness to recognize such distress as morally based. More important, however, their attempt to manipulate PTSD to accommodate moral injuries is more than just unfortunate, it does veterans a disservice by either allowing their injuries to be, at best, misdiagnosed and mistreated, at worst, ignored because they lack the crucial diagnostic criteria for PTSD (the traumatic event).

To correctly identify and adequately treat the injuries suffered by our servicemen and women in Iraq, we must appreciate the relevancy of moral values and norms to defining ourselves as persons, structuring our world, and rendering our relationship to it, and to other human beings, comprehensible. We must understand that these values and norms provide the parameters of our being – – what I term our “moral identity.” Most importantly, we must recognize that combat behavior often violates our moral identity and negatively impacts our self-esteem, self-image, and integrity causing debilitating remorse, guilt, shame, disorientation, and alienation from the remainder of the moral community – moral injury.

The monster and I are one.
I have feasted upon the flesh
of decaying corpses,
and with their blood
have quenched my thirst.
The transformation is complete
And I can never return.
Mea culpa, mea culpa,
Mea maxima culpa.[xii]

Acknowledging the existence of moral casualties in war by no means diminishes the importance or prevalence of Post Traumatic Stress Disorder. Rather, it enhances our understanding of the war experience and its devastating effects, expands our area of concern beyond trauma and PTSD, and allows us to more adequately meet the needs of our returning servicemen and women.


[i] These numbers were accurate as of July 1, 2004. I suspect, with the escalation of hostilities, that the percentages are even higher today.

[ii] For an interesting and detailed discussion of this subject, see Verkamp, Bernard J., The Moral Treatment of Returning Warriors in Early Medieval and Modern Times, (Scranton: University of Scranton Press, 1993).

[iii] A few notable exceptions include Robert Jay Lifton, Home From the War: Vietnam Veterans, Neither Victims nor Executioners, (New York, Basic Books), 1973; and U.S. Department of Veterans Affairs (VA) Psychiatrist and author Jonathan Shay, Achilles in Vietnam, (New York: Simon & Schuster), 1994; and Odysseus in America, (New York: Scribner), 2002.

[iv] Kaufman, Walter, Without Guilt and Justice, (New York: Dell, 1973), pp. 114, 117, 125, 132-133.

[v] Deresponsibilization attempts a “cure” by convincing the patient of the “naturalness” of his behavior under the conditions of war. Stephen Howard explains.

Under the overwhelming threat of annihilation, our priorities regress to the survival state; all higher priorities, all ethical and moral considerations lose relevance, and only the survival of the individual and the immediate group retain significance.

Once the veteran realizes our primitive natures, he can “at last place into context some of his actions which he cannot comprehend or accept in any other way.” Consequently, Howard concludes, the veteran will come to accept that, as his actions were quite natural, his guilt, shame, etc., is irrational and totally unwarranted.

[vi] Lifton, Robert J., Home from the War: Vietnam Veterans, Neither Victims nor Executioners, pps. 166-167.

[vii] J. Glenn Gray, The Warriors: Reflections on Men in Battle, pp. 175-6.

[viii] Kilner, Peter G., “Military Leaders Obligation to Justify Killing in War,” Military Review, vol. 72, no. 2, Mar-Apr 2004.

[ix] Dave Grossman, On Killing, (New York: Little, Brown, and Co.) 1995.

[x] MacNair, Rachel, Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing, (Westport, CT: Praeger), 2002.

[xi] Nor should we underestimate the influence of a young lifetime of playing extremely violent interactive “point and shoot” arcade and video games[xi] – many frighteningly similar to the military conditioning of recruits to kill. See Grossman, Dave, Stop Teaching Our Kids to Kill : A Call to Action Against TV, Movie and Video Game Violence, (New York, Crown), 1999.

[xii] Bica, Camillo “Mac”, war journal entry dated November 23, 1969.

Camillo “Mac” Bica, Ph.D., is a professor of philosophy at the School of Visual Arts in New York City. His focus is in Ethics, particularly as it applies to war and warriors. As a veteran recovering from his experiences as a United States Marine Corps Officer during the Vietnam War, he founded, and coordinated for five years, the Veterans Self-Help Initiative, a therapeutic community of veterans suffering from Post Traumatic Stress Disorder. He is a long-time activist for peace and justice, a member of the Vietnam Veterans Against the War, and a founding member of the Long Island Chapter of Veterans for Peace.

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