Beyond the Battlefield Moral Injuries and the Pandemic

Research in America is parsing the depths of psychological trauma, revealing invisible injuries beyond the traditional diagnosis of PTSD. This has important applications for healthcare workers caught up in the COVID-19 pandemic.

Amid myriad tragic stories accompanying the COVID-19 outbreak, one that grabbed headlines at the end of March was how a top New York City doctor on the front line of the coronavirus pandemic had taken her own life. Dr. Lorna Breen, who was medical director of the emergency department at New York-Presbyterian Allen Hospital in Manhattan, died of self-inflicted injuries, the police reported. In an interview with the New York Times, her father said that when he last spoke to his daughter, she had seemed detached and had told him how COVID-19 patients were dying before they could even be removed from ambulances. At that point, fifty-nine patients had succumbed to coronavirus at the 200-bed hospital in Manhattan.

Typically experienced by military veterans, moral injury is a type of invisible wound distinct from the more widely recognized psychological condition known as post-traumatic stress disorder (PTSD). Research into moral injuries is revealing how they can be just as prevalent among the likes of first responders and healthcare workers as soldiers, especially given the torrid circumstances and decisions having to be made during the COVID-19 outbreak. Healthcare workers are finding themselves in positions similar to combat medics on a battlefield—conducting triage to prioritize who gets treated and who doesn’t, in essence deciding who might live and who dies.

“Moral injury is an affliction of conscience,” says Rita Brock, co-author of Soul Repair: Recovering from Moral Injury after War, and the director of the Shay Moral Injury Center. “It happens especially in high stakes situations where no good choice is possible or when emergency situations require rapid responses by instinct or training with no time to weigh a decision.”

It’s now far better appreciated how veterans can return from war with hidden psychological wounds that need healing. Post-traumatic stress disorder (PTSD) has become the public face of such anxiety disorders. Far less diagnosed and understood, though, is moral injury, sometimes described as a “wound to the soul.” This likewise invisible injury most often occurs when a person commits, fails to prevent, or witnesses an act that is anathema to their moral beliefs. This breach of a person’s personal ethical code can inflict lasting behavioral, emotional, and psychological damage, burdening an individual with acute guilt and shame that both distorts their self-identity and provokes reflexive distrust of others, notes a 2019 Christian Science Monitor article about veterans trying to heal moral injuries. Guilt has been identified as the crucial factor that distinguishes a moral injury, even as other symptoms—anxiety and despair, flashbacks, social isolation, and suicidal thoughts—overlap with PTSD.

HC Palmer, a former battalion surgeon during the Vietnam War who now counsels American veterans with moral injury and PTSD, writes that during the coronavirus pandemic, overwhelmed hospitals are having to make decisions about who lives and who dies and are considering “do not resuscitate” orders to protect healthcare workers. “But these policies do not mitigate the moral impact on those who, after fighting to save people, must [let them die] because of an algorithm. Obeying orders can still result in self-condemnation.”

Amid reports of New York City’s emergency services getting overwhelmed and states struggling to provide enough ventilators, first responders and healthcare workers potentially faced having to decide who got put on a ventilator and who didn’t. Thousands were dying in their care, with medical workers reporting that they were facing scenarios they had never anticipated.

“Few people in healthcare have had real-life experience with triage in which a significant number of life-and-death decisions had to be made because of equipment shortages,” says Arthur Markman, a psychology professor at the University of Texas at Austin. “That increases the chances that they may experience moral injury as a result of their jobs.”

Even before COVID-19, there was growing recognition that US physicians were experiencing moral injury (previously portrayed as burnout) due to the nature of the American healthcare system.

“In an increasingly business-orientated and profit-driven heath care environment, physicians must consider a multitude of factors other than their patients’ best interest when deciding on treatment,” states an article co-authored by Simon Talbot, an associate professor of surgery at Harvard Medical School, and Wendy Dean, a psychiatrist and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand.

Talbot and Dean describe the resultant routine of “incessant betrayals of patient care and trust” as examples of “death by a thousand cuts.” Delivered alone, any one of them might heal, they point out, but when repeated on a daily basis, “they coalesce into the moral injury of health care.”

Some healthcare workers will take their own lives, having been crushed by the decisions they had to make, swamped by unrelenting grief, and consumed by fury and humiliation at the authorities who failed them.

Nöel Lipana was left with a moral injury from his 2008 Air Force tour in Afghanistan and now works as a social worker while promoting better understanding of moral injuries both in the military and beyond. These efforts include staging art performances and a forthcoming documentary film, Quiet Summons.

“A trauma surgeon has their hands on a chest until the very end, and then we ask that person just to take the gloves off, scrub, and go and do the paperwork as if that loss for them isn’t going to affect their moral fiber,” Lipana says. “They came into the profession to help people, so what do you do when there is that sense of helplessness, when you are a great surgeon and physician given the best equipment in the world, and you still can’t save someone?”

In comparison, Lipana says that those in the military have it “better in a way, as we get this break between deployments, whereas healthcare workers and first responders like the police and firefighters have to reset themselves every twelve hours and go back out on their next shift.”

Another moral injury parallel between military personnel and healthcare workers is the potentially damaging role played by a sense of having been betrayed by authorities and those in charge. For many veterans, the Christian Science Monitor article notes, the pride in once wearing their uniform collides with a feeling of futility about what their service achieved—with the ongoing turmoil in Iraq and Afghanistan acting as further repudiation of the war efforts—and a belief that military leaders failed or deceived them and their fallen comrades. The resulting sense of violation can further fuel the lingering crisis of conscience and spirit—deepening the moral injury.

“Betrayal wrecks trust, profoundly disrupts identity, and destroys relationships,” Brock says. “It’s also suspected of causing or aggravating post-traumatic stress symptoms—nightmares, intrusive memories, hypervigilance, irrational angers, and depression. Our healthcare workers are working to save people, but they’ve been betrayed by the government’s inadequate response.”

While healthcare workers can be confident that they’re doing the right thing helping people fight COVID-19, this self-knowledge that they are involved in a virtuous endeavor—as opposed to how many veterans view the wars in Iraq and Afghanistan—can “actually make it even worse,” Brock explains. “You know you are on a life-saving mission, and so you can’t fathom how the president doesn’t seem to get it in the same way.”

An estimated 11 to 20 percent of the 2.7 million American men and women who deployed to Iraq and Afghanistan have received a diagnosis of PTSD linked to their service. The percentage of former service members coping with moral injury appears comparable, though experts warn that the prevailing emphasis on PTSD means moral injury can often go unrecognized and ignored. The potentially destructive and lethal impact of this complex mix is illustrated by the numbers of veterans who kill themselves. Between 2005 and 2017, a staggering 78,875 veterans took their own lives, according to the Department of Veterans Affairs, which estimates that seventeen US veterans commit suicide each day.

The National Institute of Mental Health estimates about 7.9 million civilians suffer from some form of PTSD. Both Brock and Palmer fear some healthcare workers will take their own lives because of moral injuries experienced during the pandemic, having been crushed by the decisions they had to make, swamped by unrelenting grief, and consumed by fury and humiliation at the authorities who failed them. According to Talbot and Dean, physicians have long been the “canaries in the healthcare coal mine, and they are killing themselves at alarming rates—twice that of active duty military.”

Reports on Lorna Breen’s death noted that she was a deeply committed Christian. Amid the increasing recognition of and understanding about moral injury, military veterans with a religious background are speaking out more about the clash between their war experiences and their faith.

“As a Marine veteran who served in Afghanistan and a Catholic, it’s been hard for me to reconcile the stories senior US government officials have told with the war I experienced and the faith that helped bring me home,” Peter Lucie, who deployed to Afghanistan in 2011, wrote in a 2019 Washington Post article.

Lucie describes how the release last year of the so-called Afghanistan Papers showed that the US government deliberately misled Americans about the progress of the war in Afghanistan and proffered misleading and dishonest claims that senior officials knew were untrue. This has cast profound doubt on whether Afghanistan was a just war according to the tenets of the just-war theory promulgated by church authorities and theologians as a means of discerning whether engaging in a war is morally justifiable.

Given such historical links between religion and morality, might those with religious faith be more susceptible to a moral injury?

“There is no good science on the issue, and it is a good question,” says Brett Litz, a clinical psychologist and director of the Mental Health Core of the Massachusetts Veterans Epidemiological Research and Information Center at the VA Boston Healthcare System. “I have always thought that it is a potential double-edged sword,” adds Litz, who counts himself as a Jewish atheist. “Overly moralistic and faith-driven self- and other judgments, like what I have learned is called ‘bad theology,’ can promote condemnation. Then there is the love and forgiveness that comes with faith, which can be mitigating.”

Ultimately, Litz says, it’s important to recognize that religious faith and practice aren’t prerequisites for experiencing war-related moral injury or an essential vehicle to address these psychic wounds and achieve moral repair. At the same time, he says clinicians need to appreciate the degree to which faith informs morality and whether transgressions are tacitly or explicitly faith-determined in the service members and veterans they treat.

“Clinically, if faith is someone’s bag, more power to them if it can be a helpful resource,” Litz says. “If it’s not, thank goodness we have developed secular tools and methods.”

The issue of how religion might intersect with moral injury is further complicated, notes Boston College theology professor Lisa Cahill, by the influence of other factors, such as how some people are more able to dissociate—or to lack empathy—which might enable them to avoid feeling guilt. Then there is the phenomenon illustrated by data from the Pew Forum’s Public Religion Research Institute that illustrates how Catholics often vote in ways that contradict traditional Catholic teaching on issues like the death penalty, immigration, contraception, and so on. One of the starkest illustrations of the potential disconnect between religious belief and personal conduct is the number of high-ranking Nazi officials who were Catholic, including Adolf Hitler (though he was not a practicing Catholic by adulthood).

In mitigating the psychological fallout of COVID-19 for healthcare workers, a significant factor will be how society reacts once the epidemic subsides, Brock says. As everyone is busy getting back to normal, that will be when healthcare workers start processing and reflecting on their experiences. Brock notes an advantage healthcare workers might have over combat veterans when facing any reckoning over their actions is that the majority of the populace can more easily relate to healthcare workers and empathize with the conundrums they’ve endured.

Already, around the world, healthcare workers are being applauded for their bravery and sacrifices, including many who have died after catching COVID-19. But some veterans see a parallel between this lauding of healthcare workers and the thank-you-for-your-service culture in America that can often prove so frustrating for many active duty military and veterans.

“One of the hardest things is being told you’re a hero, yet feeling anything but a hero—it creates a disconnect,” says Adam Linehan, who served as a combat medic in Afghanistan in 2010 and endured a mixture of PTSD and moral injury after he left the military. “You are perceiving me as one thing, but I know I am the opposite: that’s at the root of why so many veterans feel alienated.”

Linehan also fears that healthcare workers moving around the US to help in COVID-19 hotspots—a process not that dissimilar to a military deployment—may return home and face a dilemma familiar to those who came back from the Vietnam War (and the military generations that followed) only to find a home that seemed irretrievably lost to them.

“The COVID-19 outbreak is a traumatic event for everyone in society,” Linehan says. “Many people won’t want to hear the messy stories of healthcare workers when it all calms down. People tend to want stories that can fit into a particular narrative, so they can move on. Those stories rarely tell the truth. Healthcare workers will just have to carry their memories isolated in the truth.”

Brock describes in her book Soul Repair how one of the major hurdles preventing veterans from healing is how they feel that society hasn’t accepted any responsibility for what has happened in America’s most recent wars fought overseas.

“Afghanistan, in particular, is a lingering wound for so many who fought there, because it hasn’t ended and because no one in government speaks to what so many of us know to be true about the conflict,” Lucie says. “War is the ultimate denial of others’ humanity, and all war needs to be mourned and lamented.”

There is already ample discussion about how the impact of COVID-19, with so much tragedy and loss occurring, could shake up society in myriad ways. There’s even talk of how we may emerge as better people for our pandemic experience, with a restored sense of the importance of family and community. But whether any potential changes might include the types of transformations in the US healthcare sector Talbot and Dean were advocating for pre-pandemic remains to be seen.

“A truly free market of insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care,” Talbot and Dean write. “These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of healthcare.”

Lipana notes that the pressures first responders and healthcare workers are under are often compounded by finding themselves hindered from doing what they think is right or necessary by the likes of unions and city councils, or by the threat of being sued or investigated by internal affairs. On top of this, Lipana says, first responders often work in institutions where the majority of policies and regulations seem to be dictated by economic drivers and have more to do with protecting internal bureaucracies rather than the agency of individuals.

“We can make progress if we humanize the system a little more, and allow humans to be more human,” Lipana says.

But already that human element is coming to the fore in beneficial ways. As can happen on a military operational deployment, the enormity of the COVID-19 challenge is pulling healthcare workers together.

“We’re not running scared even though we are scared,” says a nurse working in a pediatric intensive care unit in New York City that has had to take on adult patients with COVID-19 and who wished to remain anonymous to discuss internal matters. “I am very proud of my ICU team and [that’s] everyone on all levels, from housekeeping to upper management.”

“Moral injuries are not inevitable,” Markman says.

Everyone in the profession needs to recognize that they are trying to do the least harm possible in a situation in which it is impossible to provide the highest-quality care to every patient in need. After the acute phase of the epidemic subsides, it will be important for these professionals to have an opportunity to reflect on the choices they made and to learn to accept that these decisions were the best ones that could have been made under the circumstances. That may require group discussions and counseling to help people to address any guilt they may feel about having to make decisions to prioritize some people’s lives over others.

The emotional plights of healthcare workers and other first responders, resulting from the conundrums they face, represent important lessons for all of society, Lipana emphasizes, explaining how too often the situations they find themselves in and the suffering that then ensues point to a deficit of empathy at all levels—within their organizations and among the general public—about the realities they face. “Veterans are typically the focal point of a trauma discussion that needs be much wider,” Lipana says. “We know where these injuries occur, and there is a language for it, so we can find solutions and change the norms that hold these problems in place.”

Brock’s book Soul Repair finishes by noting how the act of engaging in collective conversations about moral injury can strengthen the moral fabric of society and the connections that tie its members to the rest of the world: “Our collective engagement with moral injury will teach us more about the impact of our actions and choices on each other, enable us to see the world from other perspectives, and chart pathways for our future. If we achieve deeper and more open ways to grasp the complexities of human relationships, we’ll be able to understand power and the complex ways we can misuse our power.”