There is a triad of closely related psychological phenomenon that arise from war trauma—PTSD, survivor’s guilt, and moral injury. The psychiatrist, Jonathon Shay, who first used the term moral injury, states that “war creates psychological and spiritual wreckage.” Indeed, it does.

Current levels of suicide amongst the U.S. veteran population amount to twenty-two per day. That is over eight thousand a year. Veterans account for seven percent of the population but twenty-five percent of the homeless. 

Broadly, PTSD relates to fear-related symptoms stemming from trauma. Survivor’s guilt is exactly what the phrase implies. Moral injury is the social, psychological, and spiritual harm that arises from a betrayal of one’s core values.

Since I am not a psychologist, I restrict my perspectives to ones that have resonated with my experiences. 

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My worst moral dilemmas in the war resulted from civilian war casualties. It was bad enough as a medic to see my fellow combatants wounded, suffering, in pain, disabled and killed during the war. Even though most of us were drafted, there was a degree of resignation to our situation. The Vietnam War had become our reality, and unless badly wounded or killed, our only alternative was to survive our tours so we could return from the war and get on with our lives.

It is probably dangerous for self-preservation to philosophize too much while in a war, but every once-in-a-while, through the fog of my fatigue the question arose: What are we doing here?

Half way around the world, in a poor country, in a remote village, the inhabitants so obviously poor, and we are unleashing the arsenal of a superpower on them in the form of artillery, air strikes, napalm, gunships and all the while spraying chemical defoliants on the landscape. All of it dropped on innocents along with combatants. Our country’s stated reason? We were bringing freedom to the Vietnamese people. Even as a nineteen-year-old, my age when I arrived in country, the cognitive dissonance became mind boggling. Leaders throughout my chain of command spoke of freedom in one breath and demanded dead bodies with the next. I was not alone in resenting risks to my life for a dubious cause, or the suffering of fellow soldiers for a suspect one. 

As a medic, I soon realized how it only took a moment to kill, maim or wound, but took enormous effort to try and piece back together and heal broken bodies. And I had no idea how the psychological consequences would dominate so many lives in the aftermath. I didn’t return from the war a pacifist, but with a strong conviction that a country should have an ironclad reason for going to war. 

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I believe we have an innate sense of compassion and empathy that connects healthy people with other human beings. Under normal circumstances we don’t like seeing the suffering of others. Abuse and trauma can bury that sense of caring deep within the psyche. War is an extreme type of trauma, and the closer the combatant is to the killing, the worse it becomes. The mind finds ways of coping with the proximity and possibility of death and with witnessing friends being wounded and killed. A certain numbing of emotions and a desire for vengeance is common. I always felt fatigue factored into the equation as well. It is easy to demonize and hate your enemy. It may even be necessary for survival. It doesn’t make it healthy, and psychic damage accumulates.

An incident comes to mind. We had captured a suspected high-ranking VC soldier in one of our rare finds from a village search. As the medic I was ordered to have a look at his infected shoulder wound. He was not the first VC I had direct contact with, but I had never experienced such a palpable degree of hatred as he exhibited in his gaze. It is difficult to explain because I have never experienced it before or since. He was wounded and without a weapon when I examined him, but his hatred penetrated and had an eerie feel that communicated a deep menace that had a strange power. 

An opposite experience to the Viet Cong soldier presented itself numerous times. Our firepower consistently hurt innocents when gunships or artillery wounded noncombatants. I found it impossible to demonize a child. The frag wound embedded in the brain of a prepubescent girl, still alive, conscious and breathing, but without any chance of surviving. Several children caught in a napalm strike and suffering. Another child with his intestines cascading out of his abdomen. I felt a deep shame that my side had done this. It became part of the “psychological and spiritual wreckage” of war, a psyche left with a deep burden to sort through.

Because of the suffering of others was so much greater than mine, I never allowed myself to drift into a perspective of self-pity. Witnessing this destruction was in no way as harmful as directly experiencing the physical pain and maiming of the wounded. Nothing in the rationale of my country’s reasons for going to war in Vietnam even put a dent in alleviating a sense of guilt and shame at the senselessness of the killing. At some deep level we were all responsible, the soldiers and society at large.

Of course, when a person feels guilt or shame in one’s actions, it is often accompanied by an attempt at self-justification. This is true for individuals and for countries. In Vietnam, that became equating our actions with bringing freedom to the Vietnamese. More than once I heard a soldier say: “We’re just here to help these people and look at how they resent us.”

Or: “Life doesn’t mean as much to the Vietnamese.”

There is no question the Viet Cong and NVA were capable of great cruelty. War brought that out in some of their soldiers just as it did in some of ours. I’m not writing this to excuse anybody’s cruelty or draw any comparisons or judge who was worse. The fact is, we can only control our own actions, not those of others. Only we can examine our own motives.

I’m not sure I will ever completely purge the sense of sadness for having witnessed and participated first-hand in the horrible consequences of war. By relating these personal experiences, I hope that I have explained one perspective on why soldiers experience what has come to be called moral injury. It is not merely the violation of an abstract moral code adopted by the conscious mind, but something that goes deep within the psyche to the core of what it is to be human. The term may be current, but the phenomenon has been around for as long as humans have been killing one another.