Tom Frame, ed., Moral Injury: Unseen Wounds in an Age of Barbarism. Kensington, NSW: University of New South Wales Press Ltd., 2015. 278 pp. (Pbk). 978-1-74223-465-6, £19.99.

Reviewed by: Chris Swift, MHA, Derby, UK

Email: [email protected]

In 2014 a keynote lecture at a professional chaplains’ conference in the USA addressed the topic of “moral injury”. It is an emerging field and one still mapping out its territory. This creates some uncertainty about its definition, a fact reflected in this book which contains both glimpses of clarity as well as evidence of academic and practice-based disagreement. For health care chaplains the relevance of this debate is twofold. First, in that we provide care for many veterans of military campaigns and second, because some facets of moral injury may well appear among the civilians in our hospitals. Not least in the frontline of health care, our A&E (ED) departments’ staff witness injuries and behaviours which can challenge their moral convictions. Reading this collection of chapters provides both insight and evidence of an active and growing debate focussing on the “unseen wounds to the mind and spirit”.

The book is based on a conference held in Australia to test two questions. Whether a category of “moral injury” exists and, if so, how the Australian experience of this compares with evidence from other countries. While non-physical wounds often fall into the category of psychology it is noted that moral injury has generated the involvement of a wider range of disciplines. This is reflected in the structure of the book which groups contributions under six “perspectives”: historical, personal, ethical, psychological, practical and religious. The 15 chapters are not evenly distributed across the sections, with ethical perspectives containing four of them and three other sections with two chapters apiece.

The history of moral injury is traced back to the first modern war and the Australian experience fighting in Gallipoli. The First World War became synonymous with the widespread description of “shell shock”. For the first time war became a 24 hour experience protracted over months and years. Yet the diagnosis of shell shock was linked to a belief in the natural susceptibility of some troops to experience it – an idea linked to concepts of class. In other words a sign of personal weakness.

Emily Robertson’s chapter on atrocity propaganda identifies the link between the publicity of (enemy) atrocities and the morality of conflict. The impact on moral injury of war propaganda associated with atrocities was to lower a willingness to believe such events (because they were used for strategic purpose) and to leave returning troops with a sense that they hadn’t participated in anything noble. War led to savagery on all sides and drew out the worst aspects of human beings.

A section of personal perspectives takes the book into the heart of what combatants experience. This is a vital ingredient in a book where the experience of war is seen as something unique. For a commander moral injury may be avoided if the conflict is just; the objectives are clear; and lastly that the conduct of the campaign retains moral purpose and the rule of law. Recent conflicts are used to illustrate these points. An officer’s perspective on time spent in Afghanistan provides a sober account of what it means to witness evil, and by implication, be a party to it. The nightmares and long-term consequences of conflict are described in detail as well as the effects on returning home, with binge drinking and withdrawal from friends and family. The subsequent toll on relationships, work and health is set out with candour. A chaplain’s account echoes similar themes and the effects of trauma in hollowing out the inner person leading to an almost zombie-like state of behaviour.

Opening the ethical perspectives section, Deane-Peter Baker examines the complexities of modern conflict and their accompanying moral ambiguities. Matthew Beard’s chapter tackles the conceptual issues around moral injury and as such it is a seminal contribution to the book as a whole. A potential problem with the field of study is the range of disciplines that have contributed perspectives. Inevitably, each discipline has brought its own particular framework to the examination of moral injury and this has influenced their findings. Beard opts to take two of these perspectives, philosophical and therapeutic, as the focus of his exploration. He argues that it is only by approaching moral injury through both these lenses that inter-disciplinary engagement will be successful. A chapter by Ned Dobos provides a further (brief) consideration of how moral injury is conceptualized, including a discussion of the potential for remote operations (e.g. drone) to simultaneously remove the moral injury of witnessing casual violence whilst degrading the general moral sensitivity of the operators (warfare resembles a video game rather than reality). If nothing else this illustrates the complexities of moral injury in an age of technological warfare, including reference to drugs which can be used to numb soldiers’ emotions.

Rhiannon Neilson defines moral injury as an act, or omission, on behalf of the perpetrator of a morally unacceptable action. This allows a distinction to be drawn with PTSD, where the sufferer could be a victim of the actions of others. The concept of “moral affront” is introduced to describe the moral impact of witnessing an intolerable act. This can be a grey area as those experiencing an injury from perpetrating an act may also feel compelled or coerced by their leaders into committing the act: so they are both injured and affronted. Neilson argues that understanding the element of agency is a vital first step in determining how the moral injury; affront; or PTSD should be treated.

Understandably issues of psychology weave through many of the chapters to this point. However, the dedicated psychology section in the heart of the book gives a thorough focus to the insights from this field of study and practice. Once again there is discussion about the stand-alone nature of moral injury or whether it is simply a facet of PTSD. The chapter by Phelps, Kartal, Lau and Forbes sets out to test this distinction and conclude that moral injury is an element of PTSD. They also argue for the need to recognize certain events as potentially morally injurious. In other words, different people may respond differently to the same event within a military operation. They discuss screening tools for assessing the presence of moral injury. The chapter goes on to consider the role of meaning-making as a key aspect of moral injury, noting that if a veteran feels their suffering is warranted (i.e. they perpetrated an immoral act) they may decide to avoid therapy and support, including religious participation, which would be of help.

Steel and Hilbrink explore the impact of horror, as distinct from trauma and fear. They do not believe that moral injury does full justice to the effects it seeks to describe, and argue that “horror” is often a necessary addition to encompass unseen wounds in a way that chimes with the experiences of those affected. In this view witnessing horror can also be a pathway to PTSD and moral injury, and there is recognition that this may apply not only to service personnel but to civilian staff who face horrors perpetrated in the community (e.g. police and medics).

In a section on practical perspectives Rob Sutherland notes that the failure of PTSD to account for all the negative effects of deployment has led to interest in areas such as moral injury. Sutherland suggests that national differences in attitudes to war, and the legitimacy of operational methods, set a context for moral injury. Those which see the ends justifying any means are more likely to produce service personnel who suffer. However, Sutherland recognizes that a lack of research means that it is impossible to substantiate this speculation. Nikki Coleman’s chapter makes an important distinction between legal absolution for killing in a conflict and moral exoneration. Without an outlet for moral culpability (or even ambiguity) destructive self-doubt can overtake the veteran. Lauded as heroes, or ignored as combatants in an ignominious campaign, returning soldiers have to contend with differing accounts of their involvement which can be equally beguiling. For the sake of both soldiers and civilians Coleman argues that new rituals of forgiveness are needed.

Sarah Gibson develops the debate with a question about whose responsibility it is to handle the unseen wounds of returning combatants. Her argument develops to make the case for religious and spiritual specialists handling those aspects of injury which have an existential dimension: they should be part of the care package. A very positive picture of the military chaplain is described and here I would have some questions about the need for more balance and critical engagement with the role. Nevertheless, Gibson’s plea for chaplains to be part of the multi-disciplinary response to moral injury requires consideration.

The final chapter is by Tom Frame, the book’s editor, and concerns the influence of religious conviction. Here it is argued that despite secularization there is a place for theology in addressing the unseen wounds of combat. Frame skilfully charts the sea changes of attitudes in the Australian churches towards military intervention in the twentieth-century, from total support to active opposition. Psychology and related disciplines are not sources of moral direction but must look to other institutions to generate a sense of collective values. Frame sets out weighty moral claims about the factors which impinge on positive values and virtues. These are theological in nature and sit less comfortably with the idea of an evidence-based approach to moral injury. It is unclear how these relate to the shifting sands of religious opinion about conflict he cited earlier in the chapter. Equally I am not persuaded by the argument that an historic consensus about moral values was always as homogenous as it is presented. Perhaps the veneer has been lifted rather than the spiritual compass irrevocably altered.

The book as a whole is a stimulating and enlightening read. However, I was left wondering throughout about the silent counterparts to the morally injured troops of Western powers. What about the civilians left in war-torn countries once the forces have withdrawn? What do we do to assist the moral injury of people who have witnessed things no one should ever see and who feel betrayed by those who came to help but left behind a situation worse than the one they found. These are also the unseen injuries we hear about in our hospitals as we minister to refugees and asylum seekers.

Tom Frame’s book provides multiple lenses to an experience of injury increasingly recognized in the lives of returning troops. It offers an invaluable collection of perspectives which will enlighten the reader and aid those who seek to care for such wounds. As the authors’ recognize, it is still early days for this field of enquiry and one whose parameters are not yet fully defined. Frame’s Postscript contains an understandable call for research and he helpfully outlines the areas where it is thought this will be most beneficial.