Although we run the risk of oversimplifying complex realities, the common symptoms of PTSD and Moral Injury can be usefully described as anger, depression, anxiety, insomnia, nightmares, as well as addictive and other self-destructive behaviors. Symptoms more specific to PTSD, on the other hand, are flashbacks, fear, memory loss, hyperalertness, and startle reflex, while those suffering from Moral Injury are far more likely to experience grief, sorrow, regret, alienation, despair, and shame. It is important to remember that combat veterans commonly suffer from both PTSD and Moral Injury.

Most theologians and chaplains (as well as many others) think it unhelpful to medicalize Moral Injury. They think to do so risks misunderstanding the core problem and causing harm to those afflicted with this soul-damaging wound. To them, PTSD—a psychological ailment rooted in physical trauma and physiological effects like flashbacks—does not belong in the same conversation with Moral Injury. Some scientists view PTSD and Moral Injury as two different things: PTSD, they believe, is a physical ailment caused by the rush of extreme fear-producing hormones that affects my brain’s amygdala and hippocampus (the areas that regulate emotions), resulting in fears being linked to specific memories and perceptions, while Moral Injury is a problem rooted in the cerebrum that is not as easily observed or managed with pharmaceuticals. Other scientists see Moral Injury as part of PTSD, arguing that the definition of what makes an event “traumatic” must be broadened to adequately address all the sources of Moral Injury. All these views are well-argued and well-represented in War and Moral Injury.

“Wrong” and “unacceptable” are not the same thing. Judging whether an act is right or wrong is a matter of moral insight and understanding; but accepting or not accepting it is a deliberate decision. The truth is that violence, even killing, in a violent and murderous world, can be “necessary” without being right or good. Dietrich Bonhoeffer came to believe that “innocence” is not the only or highest calling of a Christian and that to be “sinless” in a sinful world can be irresponsible. Thomas Merton too struggled with pacifism and responsibility and was concerned not to be a “guilty bystander.” Neither governments nor churches are empowered to offer moral “waivers” or licenses to kill.

The traditional and mostly unquestioned answer to this question is that there can’t be. The idea that dutiful service to one’s country in a just war can be simply “wrong,” putting at risk one’s humanity and very soul, is blasphemous and unthinkable to nearly everyone except those who have experienced it to be the case. It is an idea that many or most veterans are unwilling to express, for they know the anger and resentment they will provoke with their words.

The answer to this question lies in the very nature of war. War is about killing and destruction. In the West, the concept of Just War has been misleading and widely misunderstood from its inception in the Christian Roman empire of the 4th century. “Just,” the Latin ius, is primarily a legal term connoting legitimacy, action in keeping with an oath taken, a pact made, or a law passed. Just killing, then, is killing according to accepted rules, killing for which one cannot or should not be prosecuted, decriminalized killing. Just killing, then, is legalized killing, killing within the law; and the law, as recognized by Plato long before the dawn of Christianity, mostly enshrines the self-interest of the powerful. The enduring question here is whether any permit or license to kill, issued by a secular or a religious authority, or both, can effectively waive or absolve the violation involved in taking a human life.

To suffer from Moral Injury does not suggest that one has committed a war crime. What we must recognize is that war sets its own rules and recalibrates the conscience of those engaged in combat. What is a crime back home can be a duty in a warzone. This “recalibration” is easier said than done. The deeper one ponders that fact and the longer one listens to veterans laboring to reconcile the dissonance war entails, the more personally compassionate and the less judgmental any civilian is likely to become. In practice, when wars are fought, what matters most to the morally injured is not whether an action is wrong but whether it seems so profoundly wrong that it shatters the conscience, the identity, the peace of soul of the veteran, possibly forever. We must also emphasize that the recognition of Moral Injury does nothing to deny or impugn the extraordinary selflessness, commitment, valor and sacrifice displayed by so many of our men and women in uniform. Those who go to war know well that they are placing their lives, their limbs, and their psyches at risk. The recognition of Moral Injury simply adds to this list the acknowledgement that engaging in combat can also place one’s very soul and humanity in peril.

Throughout history, warriors of all cultures have had to deal with Moral Injury. This truth is evident throughout the range of world literature, from the ancient war epics of Greece, India, and the Middle East to the modern day. The English expression “Moral Injury” is of relatively new coinage, now and again surfacing in primarily clerical circles, such as in the sermons of Bishop Joseph Butler in 1720s England. Since at least the 1960s, the condition has been described in mental health studies, though such studies did not call it “Moral Injury” until recently: typically, what we now know to be “Moral Injury” was associated in these studies with the causes and symptoms of PTSD. It was a contributor to War and Moral Injury, the psychiatrist Jonathan Shay, who popularized the term “Moral Injury” and began the process by which the condition become the focus of scientific interest as well as renewed theological interest. It was only this century that the mental health community began specifically addressing Moral Injury in empirical studies, studies that are increasing in both number and quality. 

Moral Injury is still not listed in the Diagnostic Statistical Manual of Mental Health Disorders (DSM), and there is much debate as to whether it should be. Clearly, more research is needed to determine if, how, and to what degree Moral Injury should be medicalized. In America, the concept is gaining traction within both the US Veterans Administration and the US military. Chaplains are playing a key role within the ranks in promoting, applying, and teaching the concept. Some even attend formal military courses on the topic. Among the services, it is probably accurate to describe the US Marine Corps as leading the charge to better understand and deal with Moral Injury. This is due at least in part because Bill Nash, one of the world’s leading researchers on Moral Injury and the co-author of the “Foreword” to War and Moral Injury, serves as the Marine Corps’ Director of Psychological Health.

Nowhere is data being systematically collected that could tell us the extent of Moral Injury in veterans. This is at least in part because Moral Injury is not in the DSM: the US government, for example, routinely collects data related to DSM disorders like PTSD on service members and veterans. 

We can safely assume, though, that Moral Injury is widespread among veterans. This assumption is safe in part because of the “small” wars that western militaries are engaged in across the world. In such wars, insurgents often hide among civilians, leading counterinsurgents to commit many honest mistakes that lead to civilian deaths and injuries. Also, since non-combatants and enemy combatants often look and act the same to service members, there is the risk that service members will mentally lump the two groups together. As in infamous cases like Haditha, such mental conflation can encourage service members to misdirect rage and violence against civilians—a fact these service members may later have a tough time living with. Another modern circumstance that encourages Moral Injury is the physical and psychological distance between civilian life and the battlefield: is it any wonder, for example, that drone operators can struggle to reconcile their wartime and civilian identities, when, a couple hours before they might take their kids to soccer games, they were firing missiles at insurgents in Afghanistan?

In short, while there is strong reason to believe that Moral Injury is the signature invisible wound of modern armed conflict, the truth of this statement is a finding that awaits systematic research.