This very substantial and well-structured anthology, by former Anglican Bishop Tom Frame (Australia), is a collection of essays from Australian military historians, ex-soldiers, ethicists, psychologists and chaplains, who attempt to identify and explain something of the ‘unseen wounds’ or ‘soul wounds’ that may be attributed to ‘moral injury’. Moral injury is gaining increasing societal awareness. This is due to greater recognition that trauma (in its various forms) can cause much deeper inflictions than just biological or even psychological damage—for there may also be wounds affecting the ‘soul’ that are far more difficult to heal, if at all.

It is important to note at the outset that no single review could do this book justice; it is a substantial text containing a great deal of controversy and challenge. To assist the reader to comprehend the depth of this book, it is nicely structured into six major sections supposedly reflecting the key disciplines or perspectives relevant to moral injury, namely (1) historical perspectives, (2) personal perspectives, (3) ethical perspectives, (4) psychological perspectives, (5) practical perspectives and lastly, (6) religious perspectives. Each section is further divided into chapters, not all of which seem particularly passionate or focussed upon moral injury per se. Rather each chapter reflects the author’s own idiosyncratic area of expertise, which they have attempted to reshape to consider moral injury. Indeed as revealed in the introduction, the whole purpose of the text seems to be motivated not so much by an investigation into moral injury but rather ‘…the focus of this book is [about] the descent into barbarism that has drawn into its wake mainly young men and women from stable and prosperous Western democracies who have been tasked with preventing anarchy, restoring order and offering hope’ (p. 6). Nevertheless, all of the chapters are invaluable for understanding something about the effects of barbarism—one of which, it can be argued, is moral injury.

What is Moral Injury?

While the book is a very insightful text, one difficulty for the reader is simply that the term ‘moral injury’ is not clearly defined (or even attempted to be defined) in the early chapters of the book, leaving the reader somewhat bewildered. This is quite surprising given that the term has progressively been used over more than a decade for both clinical and research purposes. It is not until the reader progresses to Section 3, Chapter 7, by Matthew Beard, that two fundamental definitions of moral injury are offered. While it can be argued that ‘there is, as yet, no agreed definition of moral injury’ (Phelps et al., chapter 10, p. 152), nevertheless for the benefit of readers we present three definitions upfront to at least provide some background. Firstly moral injury is, ‘…a soul wound inflicted by doing something that violates one’s own ethics, ideals or attachments’ (Shay 2012), or more broadly moral injury means, ‘…perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et al. 2009). Beard then constructs his own working definition: ‘moral injury involves the difficulties an individual faces when forced to integrate the wrongdoing of moral authority into their broader conception of the world as a morally reliable place’ (Beard, chapter 7, p. 115). No doubt similar to the necessity of having a consensus conference to define the vague term ‘spirituality’ (e.g. Puchalski et al. 2009), there will also need to be a conference to achieve a consensus definition about ‘moral injury’. Nevertheless, the above definitions are at least a start.

The historical section of the book commences with military historian Michael Tyquin (chapter 1) examining WWI records to indicate the extent of ‘unseen wounds’. The chapter does not define ‘moral injury’. It does, however, present a clear picture of the effects of early twentieth century military barbarism upon surviving soldiers and the perspectives of those who tried to ‘treat’ them. In the subsequent paper (chapter 2), Robertson does not define ‘moral injury’ either, but considers the military propaganda utilised for recruitment. It was highly manipulative to counter any individual or community views that may discourage recruits from enlisting for war due to the potential damage to their physical, psychological and moral well-being. This chapter makes it pretty clear that even before going to war, recruitment advertising may have been the first level of ‘moral atrocity’.

Personal Perspectives

The personal perspective within the second section is initially taken up by a former military Chief of Joint Operations, Mark Evans (chapter 3), who presents his concerns that a defence force is not just responsible for the physical and mental health of its personnel but also their moral well-being. While again, this chapter does not define moral injury, the author is clearly able to separate mental health from moral health, and argues that moral well-being is critical and hence the importance of abiding by the laws of armed conflict (LOAC) and the principles of a just war. Also within this section is an amazingly candid chapter (chapter 4), by a former soldier turned special forces officer (anonymously written) who reveals his post-traumatic stress disordered life. His testimony is perhaps the most powerful chapter within the book: ‘I was an empty shell at home. I stopped talking to my wife, had no interest in my children and would burst into tears over the smallest matter … I would regularly isolate myself to avoid detection… I was negative about everything…’ (p. 72). Again, moral injury is not actually clarified in this chapter either, but the reader is left clearly with the sense of the moral damage that can occur after multiple war zone deployments:

At times I think I have failed God. At other times I know that I [have] been less that I might have become, morally and spiritually. I know I am forgiven for my sins of commission and omission. But I still feel guilty. While God forgives, I am not so forgiving. I lack charity and mercy in dealing with the accusations I repeatedly bring against myself (p. 76).

Likewise Chaplain Haydn Swinbourn (chapter five) discusses his costly ‘compassion fatigue’ and PTSD accumulating after multiple deployments. Again, his chapter does not specifically discuss ‘moral injury’, nevertheless it is a powerfully honest account noting his personal ‘erosion of moral conviction … sense of hopelessness … inability to fix things and a loss of trust in leadership’ (p. 93); but he did not lose confidence in God - indeed his faith, it seems, was his saving grace.

Ethical Perspectives

The third section of the text, and the largest, focusses on ethical perspectives and opens with Deane-Peter Baker (chapter 6) revisiting historical evidence from WWI and comparing it to more contemporary operations (e.g. Afghanistan and Iraq). While this chapter six also does not define ‘moral injury’ per se, nevertheless it does identify three key changes facing contemporary military personnel: (1) the increased ethical complexities given modern day battling leading to moral ambiguity, (2) that the concept of evil is no longer a clear-cut notion and (3) that any generic demonising by Westerners towards others being ‘mindless fanatics’ or barbaric extremists is over-generalised and a morally false lumping. Interestingly at least one Muslim scholar may not entirely agree, recently arguing that the trouble with Islamic orthodoxy is that it has influenced entire populations by allowing ‘…all kinds of obscenities—beheading, rape, slavery, forced conversion, war’, and that Islam which was ‘once a robust intellectual tradition … is in need of a serious makeover’ (Moosa 2015). Baker makes the point, however, that, despite such issues, combatants need to evaluate each potential threat on its individual merit, as a ‘“You”, not “them”’ (p. 111).

Mathew Beard (a moral philosopher at the University of Notre Dame, Australia), noted earlier, has written a valuable chapter seven, ‘Conceptual Distinctions’, suggesting there have been/are two modes of viewing moral injury, (1) the therapeutic gaze orientated towards healing and (2) the philosophical gaze, assessing whether an individual’s emotions and responses are appropriate given the (normative) context. Using several case studies, literary and media examples (e.g. Iliad, Les Miserables, Hurt Locker), Beard distinguishes between ‘belief in the world’ (by considering PTSD and loss of trust) and ‘self-judgement’ (by considering culpable/non-culpable perpetration plus enlightened dissonance). Interestingly he suggests that moral injury is not a separate experience from PTSD—something which several authors in this text would probably want to debate. Chapter eight by Ned Dobos considers moral trauma and moral degradation as a distortion of appropriate moral emotions whereby, because of their moral injury, people become desensitised to unacceptable behaviour—something which in our opinion supports the argument of a comprehensive reintegration program for troops returning from war zones. Chapter nine, ‘Dents in the soul?’, by Rhiannon Neilson is an important chapter as it attempts, rather successfully we believe, to qualify the difference between moral injury from PTSD; however, she argues for another dimension to be considered namely ‘moral affront’:

Whereas moral injury is incurred only when the individual perceives themselves as the perpetrator or culpable bystander of the morally intolerable act (that is assigning themselves with agency and liability), moral affront is incurred when an individual has been done wrong by or witnesses a moral wrong ….that can lead to moral development when the individual either accommodates the wrongdoing into their personal sphere or morally acceptable acts or [conversely] affirms their existing moral values by finding the act fundamentally devastative and intolerable’ (p. 147).

Psychological and Practical Perspectives

The fourth section, psychological perspectives, considers the ‘utility of moral injury’ (chapter 10) written by several authors led by psychologist Andrea Phelps, all of whom appear to be warning readers that as ‘moral injury’ has still not been clearly defined or empirically tested, it would be premature to allow ‘moral injury’ to influence current understandings of PTSD or its treatment. Phelps et al’s paper would, it seem, share the same bed as Baker and Beard (noted earlier) with regard to maintaining the status quo concerning PTSD. Nevertheless, Phelp’s et al. helpfully distinguish between a ‘potentially morally injurious event’ (PMIE) and an actual ‘morally injurious event’ (MIE) but argue that the symptoms of moral injury can potentially be accommodated under PTSD in the DSM-5 (2013) and that there is debate as to the treatment of moral injury and an obvious need for more research. Chapter eleven, ‘Dealing with horror’, by psychiatrists Zachery Steel and Dominick Hilbrink, would seem to disagree with Beard, Baker and Phelps et al., as both Steel and Hilbrink seem confident that PTSD, or at least the current understandings of PTSD, is limited and that moral injury may well need to be reconsidered as a potentially specialist phenomenon.

The fifth section presenting practical perspectives introduces another multi-deployed chaplain, Rob Sutherland (chapter twelve). He questions whether the term moral injury is describing something new and whether American research will help other nations (i.e. Australia) to interpret their moral injury experience. The answer to both, it seems, is ‘no’, as other terms have been used in the past (e.g. ‘battle fatigue’, ‘shell shock’) and, culturally, other nations are very different from the US. One presumes therefore that any US research would have limited generalisability—a hypothesis that would need to be tested, for fundamentally we have in common our humanity and we are all susceptible to the negative effects of war—including moral injury (whichever way it is defined!). Most certainly Sutherland seems the most likely to argue that moral injury can be a separate experience from PTSD. Interestingly, while Sutherland questions the appropriateness of the term moral injury, he provides possibly the most practical explanation for how moral injury occurs by writing a summary of Litz et al. (2009) work:

… the precondition for moral injury is an act of transgression which shatters moral and ethical expectations rooted in religious or spiritual beliefs, or grounded in culture-based, organisational and group-based rules, about things like fairness and the value of life. The transgressions of believers in certain circumstances leads to guilt or shame which can lead to withdrawal and a failure to forgive (p. 198).

Nicky Coleman (chapter 13) reminds the reader that soldiers in the combat of killing have an approved status, but nevertheless this makes them particularly susceptible to repercussions such as moral injury and the need for absolution. The main thrust of her chapter is about reintegration, and one means of achieving this is through various types of rituals that encourage forgiveness and healing. Such restorative practices have long been known by clergy. While Coleman affirms a multidisciplinary approach she emphasises that chaplains are ‘ideally placed to collaborate with experienced veterans to develop a range of processes that seek to identify and address the causes and consequences of moral injury’ (p. 218).

Religious Perspectives

Lastly, within the sixth section on religious perspectives, Chaplain Sarah Gibson (chapter 14) asks, ‘Moral Injury: Whose responsibility?’ Rather than an academic or empirical approach, Gibson presents an autobiographical and experiential perspective arguing that ‘moral injury is not just a mental health issue … Moral injury is also a state of the heart and a condition of the spirit’ (p. 234) which should be a shared responsibility across all those involved in the health and well-being of military personnel. Similar to Coleman (chapter 13), Gibson argues a case for the role of chaplains: ‘While ethicists, philosophers and sociologists know about shame and guilt, religious practitioners and spiritual counsellors are experienced in dealing with its effects and alleviating its burdens’ (p. 233). What is interesting is that Gibson looks beyond military chaplaincy and acknowledges hospital chaplains and the increasing importance to their pastoral discipline of evidenced-based care. We would agree, as it can be argued that health care chaplains, more often than military chaplains, are constantly providing pastoral and spiritual care within the ‘civilian-war-zone’ of life and death in emergency departments, intensive care units, organ transplant units, oncology and palliative care, etcetera—all environments that would, at times, evidence ‘bioethical moral injury’ (in one form or another) due to unethical decisions resulting in additional trauma and even death. Health care chaplains are also the most aware that while religion and spirituality may essentially be existential, nevertheless religious, pastoral and spiritual care interventions are observable and therefore empirically measureable hence a considerable amount of descriptive evidence is collectable (Carey and Cohen 2008, 2014).

Finally the editor frames the book (chapter fifteen) by providing the last chapter about the influence of religious convictions. He asserts that historically, Australians, while not particularly religious, nevertheless have mostly been shaped by a Christian heritage that has promoted positive life values along with democratic principles. However, when exposed to alternate toxic beliefs and antisocial behaviours during war, this can adversely challenge people’s sense of morality and ultimately affect their well-being leading to moral injury. Interestingly one can extrapolate from Frame’s chapter, that in the same way it is important to recognise the toxic environments into which we send our military personnel, that it is just as important to prevent ‘toxic ideas and poisonous imperatives’ breeding elsewhere—for if moral injury can affect military personnel who are rigorously trained, it can most certainly corrupt civilian communities, states and nations, particularly those naïve about the subtle and overt methods of what might be called ‘moral terrorism’.

Chaplaincy

There are many gems within this text. Given time and space restrictions, we are not able to discuss them all. What is rewarding to find within this text is the contribution of chaplains—albeit ecclesiastically and militarily biased, as the chaplaincy authors are all Anglican chaplains and all army (i.e. Swinbourne, Sutherland and Gibson), which is somewhat disappointing as the military (we hope) has moved away from denominationally driven chaplaincy to being more ecumenical, interfaith and more discipline specific (Carey 2012). Nevertheless, it is wise to have included a chaplaincy perspective within a text titled ‘moral injury’. So often there is agreement that a ‘holistic multi-disciplinary’ model is mandatory within any contemporary health care programme, so as to ensure total person-centred care for clients/patients. In actual fact, however, modern health care is usually not holistic but simply operates within a limited ‘bio-psycho-social model’. Fundamentally this is usually because some from medical, psychological and social work backgrounds have a personal and/or professional lack of respect for metaphysical dynamics. The editor of this text should be congratulated for the inclusion of chaplaincy perspectives thus ensuring that a truly holistic ‘bio-psycho-social-spiritual’ model is incorporated (Sulmasy 2012) and that pastoral and spiritual care is considered relevant to global bioethical issues (Carey and Cohen 2015). However, it is not just the inclusion of military chaplains within the text that affirms the role of chaplaincy. Coleman, a civilian cleric (noted earlier), also highlights the role of chaplains. While she raises issues about denominational differences and language, plus a concern for those of non-Christian and non-faith backgrounds, nevertheless she argues that: ‘Chaplains are vital because they are acquainted with confession and contrition, with forgiveness and absolution, both at a corporate and an individual level’ (p. 212).

We only have three minor criticisms of this book. The first we have already mentioned, regarding the failure to systematically explore the term moral injury earlier in the book so that the reader has a better understanding from the commencement of the text about what moral injury is, or at least what it maybe. Secondly, there needed to be more empirical evidence presented—whether it be from the USA or any other country. At times there seemed to be a retreat to classical literary texts to compensate for the lack of evidence. While some research findings were noted, mostly these were cited as secondary sources; there was no new empirical research reported in this text and, it would seem, no empirical research from Australia from whence the book originates. However, this is understandable given the paucity of research undertaken thus far, for most defence forces would be reluctant to support independent research to explore moral injury among serving members due to the findings potentially leading to societal transparency, community reaction to the findings, damage to the reputation of a defence force and/or possible costly government compensation. Nevertheless, there is clearly a need for a number of studies to take place for the sake of the current generation and those to come. Our third criticism was the simple need to have incorporated an index so that particular topics can be found easily—particularly given the complicated referencing style making it awkward to quickly search, check and access references.

Despite our critique, this book is unquestionably a valuable text as it collates together a variety of perspectives into a useful anthology from an Australian viewpoint that will serve as an initial prologue about moral injury, more of which is undoubtedly yet to come. To a certain degree, the theme of this text seems almost an extension of Frame’s previous award winning work about the ethics of armed intervention (Frame 2004). We recommend Tom Frame’s most recent anthology on moral injury, as a good primer for those wanting to explore the field of barbarism and moral injury. As we are also engaged in moral injury research, we look forward to a more advanced edition.