Air University

Steven L. Kwast, Lieutenant General, Commander and President

Air Command and Staff College

Thomas H. Deale, Brigadier General, Commandant

Bart R. Kessler, PhD, Dean of Distance Learning

Robert J. Smith, Jr., Colonel, PhD, Dean of Resident Programs

Michelle E. Ewy, Lieutenant Colonel, PhD, Director of Research

Liza D. Dillard, Major, Series Editor

Dr. Gregory F. Intoccia, Essay Advisor

Selection Committee

Kristopher J. Kripchak, Major

Michael K. Hills, Lieutenant Colonel, PhD

Barbara Salera, PhD

Jonathan K. Zartman, PhD

Please send inquiries or comments to

Editor

The Wright Flyer Papers

Department of Research and Publications (ACSC/DER)

Air Command and Staff College

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AIR UNIVERSITY

AIR COMMAND AND STAFF COLLEGE

Guilt-Free War

Post-Traumatic Stress and an Ethical Framework 

for Battlefield Decisions

John G. Sackett

Major, USAF

Wright Flyer No. 56

Air University Press

Air Force Research Institute

Maxwell Air Force Base, Alabama
ii

Project Editor

Ernest Allan Rockwell, PhD

Published by Air University Press in December 2015

Disclaimer

Opinions, conclusions, and recommendations expressed 

or implied within are solely those of the author and do 

not necessarily represent views of the Air Command 

and Staff College, the Air Force Research Institute, Air 

University, the United States Air Force, the Department of Defense, or any other US government agency. 

Cleared for public release: distribution unlimited.

This Wright Flyer Paper and others in the series are 

available electronically at the AU Press website: 

http://aupress.au.af.mil/

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iii

Contents

Foreword v

About the Author vii

Preface/Acknowledgments ix

Abstract xi

Introduction 1

Background Discussion of Post-Traumatic Stress Disorder 3

Analysis of Recent Studies 5

Discussion of Various Approaches to Addressing

Moral Injuries 7

Recommendations 17

Conclusion 19

Abbreviations 25

Bibliography 27

v

Foreword

It is my great pleasure to present another issue of The Wright Flyer 

Papers. Through this series, Air Command and Staff College presents a 

sampling of exemplary research produced by our residence and distancelearning students. This series has long showcased the kind of visionary 

thinking that drove the aspirations and activities of the earliest aviation 

pioneers. This year’s selection of essays admirably extends that tradition. 

As the series title indicates, these papers aim to present cutting-edge, actionable knowledge—research that addresses some of the most complex 

security and defense challenges facing us today.

Recently, The Wright Flyer Papers transitioned to an exclusively electronic publication format. It is our hope that our migration from print 

editions to an electronic-only format will fire even greater intellectual 

debate among Airmen and fellow members of the profession of arms as 

the series reaches a growing global audience. By publishing these papers 

via the Air University Press website, ACSC hopes not only to reach more 

readers, but also to support Air Force–wide efforts to conserve resources. 

In this spirit, we invite you to peruse past and current issues of The Wright 

Flyer Papers at http://aupress.maxwell.af.mil/papers_all.asp?cat=wright.

Thank you for supporting The Wright Flyer Papers and our efforts to 

disseminate outstanding ACSC student research for the benefit of our Air 

Force and war fighters everywhere. We trust that what follows will stimulate thinking, invite debate, and further encourage today’s air, space, and 

cyber war fighters in their continuing search for innovative and improved 

ways to defend our nation and way of life.

THOMAS H. DEALE

Brigadier General, USAF

Commandant

vii

About the Author

Chaplain Maj John Sackett is the deputy wing chaplain assigned to 

the 71st Flying Training Wing, Vance Air Force Base (AFB), Oklahoma. 

He advises on matters related to religious, spiritual, ethical, moral, and 

morale concerns and provides policies toward meeting the diverse spiritual needs of the base’s personnel. His previous assignments include 

Edwards AFB, California; Misawa Air Base, Japan; F. E. Warren AFB, 

Wyoming; Cannon AFB, New Mexico; and an Air Force Institute of 

Technology civilian institution selection to the Iliff School of Theology 

in Denver, Colorado. He has deployed with the Air Force three times to 

Afghanistan and once to the United Arab Emirates.

Chaplain Sackett originally served six years in the United States 

Navy as a reactor mechanical operator. Upon graduating from seminary, he served as pastor to a civilian parish in Abingdon, Maryland, 

while concurrently serving in the United States Air Force Reserve as 

the Protestant chaplain for the 512th Air Wing at Dover AFB, Delaware. He accessioned onto active duty in 2001. He is ordained and endorsed by the Presbyterian Church in America.

ix

Preface/Acknowledgments

The topic of moral injury continues to surprise me. When originally 

researching to write a paper on post-traumatic stress disorder, I was surprised that the topics of guilt, shame, and anger kept surfacing and not 

the emotions of fear and shock that I had expected. I was further surprised that my paper was well received and actually thought my buddies 

were playing a practical joke on me. I was surprised when a proposed 

luncheon to discuss moral injury at our base sold out in three hours a full 

month before the luncheon was to be held and surprised again when the 

crowd showed up. I was further astonished when our operational psychologist and the operations group chaplain teamed up to take this topic 

into our operations group.

However, as I have reflected more on this topic, its warm reception 

should not have surprised me. The men and women of the United States 

military are determined to serve both sacrificially and with honor, and at 

times, some feel the only way to accomplish that is to sacrifice their own 

sense of honor.

War has always been complex, and as our strike capability changes with 

remotely piloted aircraft, and in light of the reality that the desired end state 

of our recent conflicts has been fuzzy at best, some of our nation’s warriors 

are struggling with guilt and confusion about why they did (or were not 

allowed to) take that last shot. They are serving with honor without knowing why they are serving, and as such they are ripe to sustain moral injury.

I addition to my gratitude to those who received my research so warmly, 

I am deeply grateful to my wife, who graciously encouraged me to push 

through this paper even though it meant working on it through weekends 

and during our family vacation. Secondly, I am thankful to all the Airmen 

I have had the privilege to listen to and learn from. Finally, I am obliged to 

my advisor Dr. Gregory F. Intoccia, who wisely guided me to narrow my 

focus and work for more clarity.

xi

Abstract

Post-traumatic stress disorder (PTSD) affects roughly 15 percent of all 

combat veterans. In a combat situation, when a warrior experiences a 

moral dilemma that violates a deeply held conviction, he or she suffers a 

moral injury. These moral injuries and the combat guilt that accompanies 

such injuries are a leading cause in the development of PTSD. Today’s 

warriors are even more vulnerable to moral injuries, given the ambivalence surrounding morality in general. Compounding this situation are 

increasingly restrictive rules of engagement against an unseen enemy 

who does not appear to follow any rules at all. These dynamics increase 

the vulnerability of US warriors to moral injuries. Given the connections 

between moral injury, guilt, and post-traumatic stress, this paper seeks to 

open a dialogue on the need for the development of an ethical framework 

that can guide warriors in making battlefield decisions, providing possible armor against moral injury and assisting warriors in their reflection 

on previous involvement.

1

Introduction

There’s an old adage that “war is hell.” For many, though, war is simply 

the beginning of hell. Historically, approximately 15 percent of returning 

warriors struggle with the long-term effects of the unseen wound of posttraumatic stress disorder (PTSD).1

 Current fiscal estimates show that 

warriors suffering from PTSD received during tours in the last 20 years 

will cost the US government more than $6 billion. Cost considerations 

alone should prompt us to work to understand and minimize causes of 

PTSD.2

Throughout the history of warfare, the names or terms used to describe what is currently called PTSD have changed: shell shock, combat 

fatigue, or PTSD. Most researchers have traditionally felt that the condition’s principal causes were prolonged exposure to threat, fear, and the 

bloody aspects of war. Because these are generally unavoidable aspects of 

warfare, little was done to prevent the onset of PTSD; however, new research is showing that a leading cause for PTSD is the feelings of guilt.3

Combat-related guilt, which is being categorized as a “moral injury,” is 

also being recognized as a leading cause of suicide among veterans.4

Moral injury occurs when a warrior faces what he or she perceives to 

be a moral dilemma on the battlefield.5

 To further compound this challenge, today’s warrior is more likely to face these dilemmas for several 

reasons. For instance, warriors often now find themselves burdened with 

increasingly complicated rules of engagements (ROE)—often fighting an 

unseen enemy who appears to follow no rules at all. This dichotomy is 

especially challenging to service members with an inherently ambivalent 

moral framework. The moral and ethical training that military members 

presently receive is varied, unsystematic, and, in large part, completely 

unregulated. This ambiguity puts the warrior in a precarious situation 

when confronted with a moral decision and increases the likelihood of 

sustaining a moral injury.

To address this cluster of important issues, this paper seeks an answer 

to the following question: To what extent, if at all, may having ethical 

frameworks enable warriors to process battlefield decisions and minimize or heal long-term moral injuries? 

This paper proposes to answer that question by showing that to survive in a battlefield environment, warriors need an ethical framework 

that will enable them to process moral challenges and navigate the complex decisions they face on the battlefield. An ethical framework is a system of criteria that individuals could use to process experiences and perceptions from a moral and ethical perspective. 
2

This ethical framework could serve as moral armor that protects warriors in two ways. First, it could provide them with a framework for realtime decision making. Second, it can provide them a process for healthy 

reflection regarding previous moral challenges on the battlefield. In both 

cases, an ethical framework could reduce the number of warriors receiving moral injuries on the battlefields and therefore reduce the number of 

warriors suffering from PTSD.

Warriors within the battlefield environment need an ethical framework for decision making in today’s complex environment because without such a framework, those warriors are more susceptible to the longterm effects of PTSD. As recent and ongoing studies show, there is a high 

correlation between a warrior’s feeling of guilt and the development of 

PTSD. Admittedly, the construction of an ethical framework highlighting universally recognized standards of moral behavior is a lofty goal, 

especially in a culture that exhibits a wide range of perspectives on morality. However, it is not an impossible task because cultures agree to a 

similar set of universal truths about morality. Furthermore, the construction of a working ethical framework or key criteria for models of ethical 

frameworks would be a worthy endeavor if such could reduce the number of moral injuries on the battlefield—thereby reducing the number of 

warriors suffering from PTSD.

This paper will utilize aspects from the problem/solution framework 

approach, employing a few case studies. The paper begins with the storytelling format of the case study framework to introduce at a personal level 

the possible connection between guilt resulting from a battlefield decision and the onset of PTSD. This story will explore to what degree an 

ethical framework could equip today’s warriors against moral injuries. 

The narrative will then shift toward the problem/solution approach, 

where the foundational ideas of “moral injury,” “guilt,” “ethical framework,” and PTSD will be discussed. The paper will then give a brief historical look at the previous understandings of PTSD. Elements of the case 

study approach are utilized to identify PTSD causation, particularly focusing on several studies within the last two decades, including a recent 

US Marine Corps study. The paper will then move toward a discussion of 

ethical frameworks: a decision-making system that allows an individual 

to judge an action as morally acceptable or not. Further discussion will 

follow showing how various models or approaches, historical and modern, affect a warrior’s vulnerability to moral injuries and likelihood of 

PTSD. Finally, based on the analysis, a recommendation for an ethical 

framework—or key criteria to be included in ethical frameworks—will 

be given to further equip warriors against moral injuries and therefore 

lessen the likelihood of PTSD.
3

Background Discussion of Post-Traumatic

Stress Disorder

The Marines of Fox Company, 2nd Battalion, 23rd Marine Regiment 

were warriors who called themselves “the Saints and the Sinners.”6

 They 

had recently entered into Baghdad and were enjoying cheers, flowers, 

and accolades from the gathering crowd, when the sound of gunfire and 

the visible trauma of their radioman falling backward from a gunshot to 

the head sent them into action. They executed their ambush drills as they 

had been trained and—5,000 rounds of ammunition and dozens of 

rocket-propelled grenades later—emerged from their intense firefight. 

Amazingly, all the Marines from Fox Company made it home to Salt Lake 

City, Utah, alive—even the radioman that had been shot in the head. 

However, since those days, 25 percent of those Marines have been diagnosed with PTSD. One of them is serving a life sentence, convicted of 

drowning the mother of his twin daughters in a warm bath he had drawn 

for her after they had made love.7

This story of warriors returning home, only to find that their minds 

and emotions are still at war, is all too common. Data collected from a 

series of conflicts spanning from World War II to the present show that 

between 10 to 30 percent of veterans will develop PTSD.8

 The likelihood 

of warriors developing PTSD varies with the conflict. Those percentages 

translate into hundreds of thousands of warriors returning home victorious but unable to live with the damage they inflicted, the violence they 

witnessed, or the senselessness perceived of their combat experience. For 

instance, over 61,000 or 21.8 percent of veterans who served in Iraq and 

Afghanistan have been diagnosed with PTSD.9

 Additionally, a Department of Veterans Affairs (VA) report released in March 2013 indicated 

that over 286,134 combat veterans have been seen by the VA for PTSDrelated symptoms they received since 2001.10 Clearly the prevalence of 

PTSD as well as the costs incurred, in terms of dollars spent and lives 

damaged, warrants a look into the causes of and potential ways to minimize the effects of PTSD.

PTSD is a condition defined by the Diagnostics and Statistical Manual

of Mental Disorders (DSM) as occurring when an individual has experienced, witnessed, or been confronted with an event or events that involve 

“actual or threatened death or serious injury, or a threat to the physical 

integrity of another person . . . [and responded to that event with] intense 

fear, helplessness or horror.”11 In general, PTSD has traditionally been 

considered the result of prolonged exposure to the bloody or dangerous 

aspects of war. When one looks at the DSM definition, it is easy to understand why combat experience would increase an individual’s propensity 
4

to suffer from PTSD. Furthermore, the more frequently or more intensely 

an individual experiences combat, the more likely that warrior is to develop PTSD. This correlation further reinforces the traditional understanding that fear, combat, killing, and the threat of death were the principal factors in causing PTSD.12

However, newer research is beginning to challenge that traditional 

model and suggests that a leading cause of PTSD may actually be the 

emotional feelings and moral attitudes that a warrior has regarding the 

combat experience. In other words, it may not be the killing itself but the 

warrior’s attitude regarding the killing that causes PTSD. This causality 

would be particularly true if a warrior experiences intense feelings of 

guilt resulting from his or her involvement in killing.13

Feelings of guilt from a battlefield environment typically come from 

two factors. First, warriors can feel guilty over something that they did 

not do. Survivor’s guilt is a prime example: a warrior experiences feelings 

of guilt over his or her inability to save a comrade, to warn a buddy, or to 

react fast enough. Feelings of guilt can also be caused by what the warrior 

did. For instance, warriors who engage in killing often find emotional 

conflict, shame, and profound guilt regarding their actions that may burden them for a lifetime.14 Because of the potentially devastating effects of 

these feelings of guilt, mental health professionals are beginning to use 

the descriptive term moral injury.

Moral injury can be defined as an injury that occurs as a result of a 

warrior “perpetrating, failing to prevent, bearing witness to, or learning 

about acts that transgress deeply held moral beliefs and expectations.”15

Moral injury occurs when warriors are faced with what they perceive to 

be a moral dilemma on the battlefield and they are unable to respond in 

what they understand to be the moral or ethical manner.16 Moral injury 

can also develop as warriors reflect on their combat involvement and 

sense profound regret for the senselessness of their actions.

PTSD is a relatively new category as a disorder, and as such, the data 

pool or knowledge base used to understand and hopefully work to treat 

or prevent it continues to grow. For instance, in the definition of PTSD 

cited above, which came from the revised fourth edition of DSM (DSMIV-TR), the wording makes no mention of guilt as one of the causes of 

PTSD. However, the latest edition of DSM (DSM-5), released in May 

2013, includes the language “persistent and distorted cognition about the 

cause or consequences of the traumatic event(s) that lead the individual 

to blame himself/herself or others” as one of the new criteria.17 What is 

significant about this definition is that DSM-5 appears to recognize feelings of guilt or, in clinical diagnostic language, “distorted blame of self ” 

as one of a list of criteria associated with PTSD.
5

This recent change to the definition and criteria of PTSD is a result of 

some contemporary studies that will be reviewed in the following sections. While an exhaustive study of the growing body of research and 

literature surrounding PTSD would be impractical, several studies have 

been selected to show the steady and strengthening realization among 

mental health professionals that feelings of guilt are linked to the development of PTSD.

Analysis of Recent Studies

An analysis of studies in the last two decades shows a shift in understanding of the causal factors of PTSD—initially thought to result principally from prolonged exposure to the threat or fear of danger. The studies 

which follow now point to a correlation between feelings of guilt and 

development of PTSD.

1991—Guilt and Suicide among Vietnam Veterans

One of the earliest studies to suggest a correlation between guilt and 

PTSD was a 1991 American Journal of Psychiatry article that noted that 

feelings of guilt were predictive of suicidal ideation. In this study, a small 

sample of 100 Vietnam veterans with combat experience and diagnosed 

with PTSD was evaluated. Following the war, 19 of the veterans had attempted suicide, and another 15 were significantly preoccupied with suicide. Of the five factors determined to be indicators of suicidal ideation, 

guilt about combat actions ranked first among this cohort while survivor 

guilt ranked second.These indicators were significantly higher than depression, anxiety, and severe PTSD as factors predicting suicide. While 

the purpose of the study was to determine if there was a reliable method 

of suicide prediction, the results pointed toward the need for increased 

clinical attention to “the role of guilt . . . with PTSD.”18

1997—Combat Guilt and Post-Traumatic Stress Disorder

In 1997 another key study took up the challenge of taking a deeper 

look into the relationship between combat guilt and PTSD symptoms. 

This study noted that while it has been understood for quite some time 

that involvement in military and combat operations has been a source of 

guilt, not much is known about the consequences of that guilt. This study 

attempted to determine if guilt was more of a “mechanism in the development and/or maintenance” of PTSD.” One finding of the study was the 

realization that feelings of guilt often accompanied a traumatic event, 

which “produces aversive emotional responses.” Then when the warrior 
6

recalls or is reminded of the traumatic event, these negative thoughts 

continually recharge and reinforce those initial feelings of guilt. The 

study concluded that “guilt plays a more prominent role in PTSD than is 

currently recognized.”19

2009—Killing and Post-Traumatic Stress Disorder

Shira Maguen is one of the current leading researchers working to 

discover just how prominent a role guilt plays in PTSD. Early in her research career, she conducted multiple studies which revealed that the act 

of killing is the single most significant factor in determining the probability of a warrior developing PTSD. Her groundbreaking work drew the 

conclusion that “killing in and of itself may be a causal ingredient in the 

development of combat-related PTSD. [Moreover, killing ought to be 

considered] as a separate component of the PTSD theoretical models.”20

While at face value this study appears to support a more traditional 

understanding of PTSD causation, in her personal interviews with warriors, Dr. Maguen observed that warriors repeatedly told her that “nothing can prepare you for what it is really like. . . . It feels like I’ve lost my 

soul.”21 She noted that soldiers were remarking that their feelings surrounding the killing—feelings of guilt and self-blame—were a more vivid 

memory than the killing itself.

This revelation represented another shift in understanding PTSD causation. PTSD was initially thought to occur when individuals experienced prolonged exposure to a threat. Then PTSD was thought to emerge 

when soldiers engaged in the action of killing. Now, however, there is a 

growing recognition that it may actually be the feelings and emotions 

that surround “the killing” that can increase the likelihood of the onset of 

PTSD. In this new theory, those feelings can cause a moral dilemma in 

the warrior’s conscience. If this dilemma remains unresolved, the warrior 

suffers a moral injury and, as such, becomes vulnerable to PTSD.

2013—Marine Corps and Moral Injury Study

The preliminary report from the ongoing Marine Resiliency Survey 

(MRS) gives new evidence of the connection between guilt and PTSD. 

This report surveys over 2,600 Marines and notes that feelings of guilt are 

proving to be the top cause of developing PTSD.22 PTSD was diagnosed 

in 7 percent of the 208 Marines who saw the most intense combat, yet 

researchers determined that their PTSD resulted from “inner conflict 

rather than threat to their lives, the sight of bodies or blood and family 

problems.”23 While it may be too early to definitively declare that guilt is 

the leading cause of PTSD, many researchers are taking note of these 
7

findings and pushing for more research and some preliminary approaches to treatment and prevention.

The MRS researchers also used an “inner conflict” scale as one measurement that was intended to capture the moral tension or inner conflict 

that Marines felt on the battlefield. Results from participating Marines 

helped researchers term certain intensity levels of “feelings of guilt” as a 

moral injury.24

Discussion of Various Approaches to

Addressing Moral Injuries

Actually, since the country’s founding, the United States has been 

dealing with the idea of the moral dilemma of combat and moral injury. 

As these issues surface, warriors have been met with varied reactions by 

American society, ranging from shunning or rejection—as Vietnam veterans commonly experienced—to a hero’s welcome, as was common for 

veterans of World War II and the Persian Gulf War. Some individuals 

have been able to look ahead to how war would affect their conscience 

and opted to object to warfare entirely. Others served honorably and then 

have been told to grow up or “act like an adult” after expressing feelings 

of guilt over their actions and having shared their challenges of conscience.25

In the past, medical institutions and the VA have attempted to meet 

the challenge of combat fatigue, shell shock, and combat stress through 

various preventive strategies and a wide range of inpatient and outpatient 

postcombat treatment options. Ironically, however, since World War I the 

military has been using a largely “demedicalized” model to promote psychological health and to combat operational stress.26 In this model, warriors who were suffering from operational and/or combat stress were not 

allowed to see themselves as sick.27 An Army psychiatry and neurological 

consultant to the Army surgeon general summed up the military’s mindset regarding these struggling warriors when he said, “You are neither 

sick nor a coward. You are just tired and will recover when rested.”28

However, such approaches have failed to prevent or significantly lower 

the rates of postcombat PTSD in veterans from conflicts from Vietnam to 

the present.29

This inability to lower PTSD rates is particularly troubling as the ethical challenges of warfare continue, leaving US military members unprepared for the ethical challenges they will experience on the battlefield. 

This lack of ethical preparedness occurs largely because “formal ethics 

training [is] a rarity” in the armed forces. Ethical training is simply done 

by “osmosis.”30 Rarely are Soldiers prepared for the emotional and ethical 
8

dilemma of returning fire on a group of hostiles through a crowd of civilians. Soldiers may react swiftly to their physical training to return fire on 

this group wearing civilian clothes, even while they realize they have no 

clear understanding of their combatant standing.

Another new area of ethical challenges is arising among officers who 

fly remote piloted aircraft (RPA), whose mission may require pilots who 

just left their homes and families a few minutes earlier to drop precisionguided munitions on someone halfway around the world. These pilots 

must routinely process the reality of rapidly changing their emotional 

outlook between killing bad guys while on the clock and then kissing 

spouses and children when they come off shift a few hours later. At times 

these RPA pilots function as extreme long-range snipers, without the additional vetting of emotional and physical toughness that designated 

snipers receive.

Today, warriors also struggle with issues surrounding making sense of 

their involvement in helping to restore order in a country that has little 

regard for the freedoms Americans enjoy. For instance, US service members wrestle with sacrificing their lives to defend the interests of nations 

that do not respect the free exercise of religion and speech and do not 

honor diversity or promote equality in ways Americans understand. If 

these service members are unable to reconcile this struggle, they may feel 

a sense of betrayal by their nation.31 Currently, the US military has no 

formal method or framework for understanding how to help service 

members process all these ethical struggles.

This lack of structure is in stark contrast to every other aspect of training that a service member receives, which is uniform and consistent. 

Warriors may come away from training having learned that there are no 

absolutes. However, many philosophers and sociologists argue that 

throughout the ages, humanity has essentially adopted the same ethical 

standards of right and wrong.32 The resulting situation creates a disparity 

between what warriors know instinctively and the message they have 

been receiving. When they are confronted with a moral decision, this 

disparity puts them in a precarious situation.

Just War Theory

Throughout its history, humanity has deliberated the morality of war 

and combat. Writings on just war theory, also called jus ad bellum, flow 

from philosophers and military thinkers, including Aristotle, Cicero, Augustine, Locke, Kant, and Clausewitz—just to name a few. Each of these 

thinkers wrestled to articulate the reasons why a state was morally able to 

engage in warfare. Even though they wrote to different audiences in dif-
9

fering times, their lists of required criteria for armed conflict to be 

deemed morally acceptable are remarkably similar. Those principles include last resort, just cause (self-defense), right intention, proper authority, probability of success, and proportionality.33 A brief description of 

these terms will follow.

Last resort is simply the conditions under which all other instruments 

of power that a state possesses have failed to prevent war. Just cause is 

usually understood to mean that the state has a right to self-defense. 

Right intention ensures that the state’s reasons for entering the conflict are 

proper and that the state is not simply using combat to achieve some ulterior end. Proper authority ensures that those declaring war for the state 

possess the legal authority to do so. Probability of success is a criterion to 

caution a state from engaging in what may be suicidal actions. Finally, 

proportionality is a principle similar to the US military’s law of armed 

conflict (LOAC), which seeks to limit a state to using only that force necessary to defend its interests.

Another point of commonality between just-war thinkers is that for a 

war to be morally just, all of the principles listed above must be met. In 

other words, even when their particular lists vary slightly, in terms of 

order or wording, they still all agree that every principle must be met in 

order for the war to be considered morally just.34 Although not universally accepted, this commonality shows that throughout the history of 

humanity, there has long been a general understanding that if certain 

conditions exist, a nation or state was morally able to declare war on another entity and that such military action, including the killing of combatants, could be a morally justifiable action.

The Impact of Religion

Theologians have joined military ethicists and philosophers in the discussion of what makes warfare justifiable. In the past, some Christian 

theologians have fortified the morality of warfare by stating that in war, 

when fighting evil enemies, one actually does those individuals an act of 

kindness by killing them. This killing is an act of mercy because it prevents enemies from committing further sins, thus sparing them from a 

heavier divine judgment.35 Warriors from these religious traditions 

would plausibly have a lighter conscience for two reasons. First, they 

would believe that they were morally allowed to kill in order to defend 

their nation’s interests and protect the rights of innocent civilians. Second, they would believe that in killing the evil enemy, they would actually 

be engaged in an act of mercy.
10

This idea of warfare as an act of mercy on the souls of one’s enemy has 

been largely absent in recent discussions although religious organizations 

do continue to speak to the morality of particular wars. For instance on 

the eve of the 2003 invasion of Iraq, Pope John Paul II declared that a 

preemptive strike against Iraq could not be justified, either legally or 

morally.36 In his letter to Pres. George W. Bush, which was delivered by 

papal envoy, Cardinal Pio Laghi, condemned a preemptive strike, declaring the war “immoral” and “a defeat for humanity.”37 The impact of this 

statement was significant and caused complications on the consciences of 

Catholic service members.38

These concerns have not been limited to the Catholic Church as many 

denominations have spoken out either in favor of or opposition to the US 

military’s involvement in various conflicts. This response is to be expected as 78 percent of the United States population consider themselves 

Christian while another 4.7 percent claim strong adherence to other religious beliefs.39 While it could be argued that many individuals who claim 

a religious affiliation are not necessarily influenced by religious beliefs, 

over 56 percent of Americans still claim that religion is very important to 

them and affects their ideology.40 Religious leaders’ declarations do affect 

the conscience of American Soldiers. The effect of such religious influence is compounded if a warrior is already experiencing a burden of conscience prior to entering a combat environment. In that condition, warriors are more vulnerable to sustaining a moral injury, which in turn 

increases their likelihood of developing PTSD.

If, on the other hand, religious and political leaders are in agreement 

that a war is just, then the religiously affiliated warrior may have a stronger resistance to feelings of guilt, or, to use the DSM-5 language, the warrior may have a stronger resistance to “persistent self-blame.”41 In this 

case, the warrior’s conscience is armor against sustaining a moral injury. 

Clearly, this armor would not protect against every possibility of moral 

injury, just as body armor has its limitations, but an armored conscience 

could help to minimize moral injuries.42

Law of Armed Conflict and Rules of Engagement

Currently, the US military uses several means to declare whether actions and operations are legally acceptable. One of these means is the 

LOAC, which is used to help determine the legal guidelines regarding a 

particular conflict. Most often, these laws will parallel and complement 

the individual warrior’s ethical and moral beliefs. In these cases, the 

LOAC could serve as additional protection against moral injuries in that 
11

warriors have the assurance that, assuming they follow the LOAC, their 

involvement will be legal.

A second means currently used is ROEs, which serve to give specific 

guidance and are tailored to meet unique conflicts, scenarios, and circumstances. Great attention is given to the development of ROEs to minimize collateral damage and sustain—or improve—US relations with the 

host nation. While ROEs are extremely useful tools for a nation-state to 

ensure that broader political goals are being achieved through the managed use of force, such rules can cause personal conflict for the warrior.

By viewing some ROEs as overly restrictive, warriors put themselves 

into a personal state of conflict.43 They are forced to decide between following ROEs that they feel are inappropriate for the specific situation and 

listening to what their own instincts are telling them to do. Admittedly, 

ROEs are written exactly to limit an individual warrior’s ability to make 

battlefield decisions in situations where greater national interests are at 

stake. Appendix D, “Sample ROEs,” of US Army Field Manual 100-23, 

Peace Operations, makes the point with this telling quotation from British 

admiral Sir John Forster “Sandy” Woodward: “Meanwhile, I shall have to 

amplify the ROE so that all commanding officers can know what I am 

thinking, rather than apply their own interpretation, which might range 

from ‘ask them for lunch’ to ‘Nuke ’em for breakfast.’”44 The moral dilemma occurs when there is a mismatch between an individual warrior’s 

interpretation and the ROE. At that point, the warrior may consider the 

ROEs restrictive, thus increasing his or her vulnerability to suffering a 

moral injury.

However, the LOAC and ROEs are not enough by themselves to protect warriors from moral injury. That is because to declare something as 

legal is not the same as to declare it moral or ethical. Stated another way, 

the fact that authorities deem particular actions to be legal does not mean 

that individuals, or even a majority of people, will believe they are ethically or morally right. One quick, tangential example will drive home this 

point.

Research shows that 47 percent of the adult population in the United 

States thinks that abortions are morally wrong while only 13 percent view 

abortions as morally acceptable.45 Another 27 percent believe that abortion is not a moral issue while the remaining 13 percent chose not to 

answer. Interestingly, these numbers have remained relatively stable despite abortions being legal in various forms for more than 40 years.46

Thus, a legal decree declaring something as permissible does not necessarily change the perceptions of individuals regarding the morality of the 

issue. One could easily argue the reverse: that during the years in which 

abortion was illegal, many felt strongly that it was morally acceptable or 
12

right, even while it was legally wrong or illegal. This example utilizes a 

topic that for some people is emotionally charged to show the reader that 

in some cases there is little connection between the legality of an action 

and the perceived morality of that same action. For the warrior on the 

battlefield, this difference could be the deciding factor between whether 

or not he or she suffers a moral injury and develops PTSD.

The connection to this paper is to make the point that simply receiving a LOAC briefing or a set of ROEs does not necessarily preclude warriors from holding strong moral positions regarding the mission or the 

situations that they encounter. Instead, warriors need a moral/ethical 

framework that they can use to process the LOAC and various ROEs and 

actual scenarios they encounter. This ethical framework includes ROEs 

and the LOAC, but it must also consist of more than legal declarations.

 When the law or other governing authorities declare something to be 

good or bad, moral or immoral, legal or illegal, this situation is often described in ethical terms as malum prohibitum: wrong because it has been 

declared wrong. These rules are not explicitly moral in and of themselves 

though they may be moral or immoral based on their relationship to the 

proper governing of society—for instance, speed limits or zoning laws. 

Society follows these rules, but there are not necessarily moral implications when occasional infractions occur.

To be clear, ROEs and the LOAC are vital and need to be clearly articulated and understood. They play an invaluable role in helping to construct a moral framework, or, more accurately, they give concrete examples of how to apply a moral framework to particular situations. However, 

it is not enough to simply state that something is allowed or not allowed—ethical or unethical—to assuage the conscience of an individual. 

Warriors need to understand that the actions they are involved in are not, 

to use another ethical term, malum per se (wrong by nature). A warrior 

has to completely agree—and will struggle to agree—unless he or she 

possesses an ethical framework by which to judge and evaluate those 

rules.

ROEs can both complement and conflict with personal beliefs, but a 

clearly understood ethical framework can help a warrior understand the 

larger view of why a restrictive ROE is actually good. This understanding 

can then provide “armor” against a moral injury (as discussed below) by 

shifting the responsibility of the restrictive ROE to the state rather than 

the warrior.
13

Ethical Framework Defined

Psychologically healthy people have a type of ethical framework. In 

other words, they possess some means to evaluate whether an action is 

morally good or bad though most often this analysis is operating in the 

background, functioning similarly to one’s conscience. A question to 

consider is whether the US military should work to create an ethical 

framework or, at a minimum, teach individual warriors how to develop 

an ethical framework that would function in the foreground of one’s 

thought. Much like a mission planning tool—such as the LOAC or 

ROEs—this ethical framework would help warriors quickly evaluate the 

moral implications of a situation. This ability could be of vital importance 

as recent studies are showing that there is an emerging connection between guilt and PTSD.

The challenge is whether or not an ethical framework can be built that 

is broad enough to capture the diverse beliefs and backgrounds of the US 

military and yet be specific enough to actually do any good for particular 

service members. To be able to accomplish development, there must be a 

set of commonly held ethical or moral principles that, when drawn out 

and organized, could function as a framework by which service members 

could evaluate their actions.

In his work Healing Invisible Wounds: Paths to Hope and Recovery in a 

Violent World, Richard Mollica writes of a shared experience by survivors 

from combat trauma from around the world: “Looking up at the heavens, 

they saw something that was eternally unaffected by human actions. The 

stars helped keep them alive while they were being tortured . . . [and] 

every morning the sun reminded them that they had survived another 

day.”47 The constellations, the stars, the sun—all of these were forces that 

“could not be dimmed by human cruelty.”48 Mollica transitions to the discovery that these survivors often found that they were also united by a set 

of common values and beliefs even though they came from varying cultural and religious backgrounds.49

Mollica is joined in his belief of a common set of values and beliefs by 

many ethicists and philosophers who advocate that there is an “independently available conception of moral goodness and of good moral reasons.”50 While a discussion as to the source of these moral reasons, God 

or society, would be beyond the scope of this paper, the shared understanding of the existence of a moral code can be helpful.

Principles Common to Various Ethical Frameworks

In examining ethical and philosophical writings, one finds that a common listing of generally held beliefs begins to emerge. These commonly 
14

held beliefs fall into two categories, the first of which relates to the inherent value of life. In this category are those values which hold that human 

beings possess inherent rights and that these rights must be protected.51

In this category, one finds the commonly held values such as the inviolability of acting in self-defense. Another shared value in this area would be 

the belief that protecting individuals who are innocent in a conflict is 

important. Linked to this belief is the reality that cultures have historically believed it is important to protect women and children from armed 

conflict.52 Similar to these values is the instinctive understanding that 

there is a difference between a combatant and a noncombatant.

A second grouping of commonly held values is more difficult to label, 

principally due to its philosophical nature. Included in this group of values would be the idea that evil should be resisted. The challenge with this 

particular value is the obvious question: who gets to decide what or who 

is evil? While there is no easy answer to this question, the reality still applies that when military members view the adversary as evil, they are less 

likely to feel guilty fighting that enemy.53

Another commonly held value that fits this second category is the understanding that there is a difference between actions that are premeditated and those that are spontaneous. This distinction is commonly recognized throughout history as exemplified in Hebraic laws distinguishing 

various types of killing and current laws that compare various degrees of 

murder. These distinctions are designed to weigh motives and adjust the 

punishments accordingly. The implicit understanding here is that the 

more deliberate and planned the murder, the more morally heinous the 

crime, and, therefore, the greater the punishment.

Although philosophers are in general agreement with the idea of commonly held moral values, even when they debate the source or author of 

those values, warriors live in a morally ambivalent time. Immoral actions 

such as adultery, sexual assault, blatant discrimination, and harassment 

are discouraged simply by using terms such like inappropriate and unwanted. Much of the moral language is removed from training. Warriors 

are continually told how to behave but rarely, in moral terms, why they 

should behave in this manner. This lack of moral teaching, coupled with 

a general doubting in society regarding the existence of a moral absolute, 

contributes to placing the warrior in a vulnerable position. As Paul Robinson states, “This lack of [positive] social influences makes a formal system of ethics training desirable.”54 Warriors seem to know instinctively 

that there exist clear rules of right and a wrong, but they are receiving 

subtle messages that all actions are relative. An ethical framework can 

correct this ambiguity and can help them in their decision making.
15

However, an ethical framework is more than simply a collection of 

moral statements and philosophical beliefs. Embedded in a warrior and 

combined with an understanding of just war and an acceptance of the 

ROEs, an ethical framework may provide armor against moral injury. 

This protection can occur in several ways. First, an ethical framework can 

help the warrior process the violence of war prior to actual engagement 

and therefore be better prepared to anticipate ethical dilemmas. Second, 

an ethical framework can help warriors process moral decisions in real 

time. Finally, an ethical framework can assist warriors as they reflect on 

their involvement in particular engagements.

In Henry V, Shakespeare illustrated the “moral needs” of the common 

warriors in a dialogue that occurred the night before the battle at Agincourt.55 One soldier remarks, “If the king’s cause be wrong, our obedience 

to the king wipes the crime of it out of us.”56 The other responds, “But if 

the cause be not good, the king himself hath a heavy reckoning to make.”57

In this dialogue, the soldiers require of their king what today’s warriors 

expect from their elected leaders: acceptance of the moral responsibility 

of the conflict.58

When a nation’s leaders publicly declare a conflict to be just, their declaration helps the common warrior transition the burden and the guilt 

associated with conflict to whom they believe to be its rightful owner.59

Warriors need to know that the violence they are inflicting is necessary. If 

the state’s reasons are neither good nor right, warriors may lose confidence in their nation and furthermore begin to personally own the violence they inflict.

A classic example of warriors losing confidence in their national leaders to hold sufficient reasons for engaging in conflict was the US military’s involvement in Vietnam. Studies focusing on combat veterans with 

experience in Vietnam showed a strong correlation between feeling betrayed by their country and the development of mental health disorders 

such as depression and PTSD.60

Ethical frameworks also help a warrior make real-time decisions. If 

integrated into their training, an ethical framework can be a final check 

on the morality of pulling the trigger in specific situations. This final ethical check could prevent tragic violations from occurring, averting both 

personal and international damage.

Lastly, an ethical framework acts as an aid to reaching a fuller decision 

or to reflecting more fully on a previous event. After the event, warriors 

are able to process their involvement throughout the combat experience 

by using an ethical framework that reminds them why they needed to 

take that shot. Alternately, if upon reflection they realize they are not sure 

if they should have pulled the trigger, an ethical framework will help fo-
16

cus and narrow their feelings of guilt to a specific event. This awareness 

of guilt could prompt them to seek relief more quickly and aid them in 

returning to mission-capable status.

Ethical frameworks strengthen a person’s moral conviction. Research 

has clearly shown that when violence shatters one’s world, strong beliefs 

and convictions can slow the descent into anger and despair and may 

lessen feelings of guilt.61 Additionally, religious frameworks and practices 

may have an important influence on how people interpret and cope with 

traumatic events.62

Key Criteria for a Strong Ethical Framework

For an ethical framework to be effective as moral armor for a warrior, 

several factors must be present, including a strong message of instruction 

from the national authority figures sufficient to justify the Soldier’s personal call to action in a national cause. National leaders must articulate 

that the conflict is a just war. Reasons for the Soldier’s involvement must 

be communicated in moral terms. Particularly, the national leaders need 

to explain why the enemy is evil or, at a minimum, why an adversary’s 

actions are evil. Second, national leaders must show that the victims of 

the enemy’s actions are innocent. Finally, national leaders must communicate that because of this situation the nation’s citizens have a moral obligation to consider their part in stopping that evil and protecting those 

innocents.

A second potentially significant voice in a warrior’s life is religion. 

Many US service members remain deeply affected by the teachings of 

their religious institutions.63 Individual religious leaders as well as many 

religious organizations often issue statements regarding how they view 

pending or ongoing conflict from their religious perspectives. Their 

statements are often stated emphatically using strong moral language.

Once national authorities and religious leaders have stated their reasons for national involvement in a particular conflict, warriors need some 

time to reconcile that message with their own understanding of right and 

wrong. Warriors will also undoubtedly be hearing from other voices in 

society through the media and their own social networks and family connections. During this time, an ethical framework can help warriors process all of these competing or complementary voices with their own understanding of what is ethical.

Moral instruction should be woven into current training. Clearly, the 

topic of a nation’s involvement in a conflict should be taught and communicated, but additionally local military leaders should communicate 

desired behavior across a full range of topics in terms of moral language. 
17

Wherever behavioral problems existed, military leaders could utilize the 

ethical framework to challenge their warriors in moral terms.

In these moral and ethical discussions, an ethical framework would 

benefit leaders who might otherwise feel uncomfortable with this type of 

controversy. Without an ethical framework, every warrior is left alone to 

figure out where to find national leaders’ declarations regarding a particular conflict and how to process all the opinions from society, friends, 

family, and religious leaders regarding that conflict. This practice has 

been the status quo that the US military has been operating under 

throughout its recent history. The problem is that warriors enter conflict 

lacking a firm conviction that their involvement, including the taking of 

life, is morally justifiable. For all these reasons, several recommendations 

are warranted.

Recommendations

In this section, three recommendations will be made that could aid in 

preparing the warrior for the ethical challenges of combat. These recommendations will highlight the existence of moral injury and the need for 

its further study. Additionally, they will call on national leaders to communicate more clearly the ethical basis for particular conflicts and will 

call for the development of a framework to assist warriors in their decision-making dilemmas. Adopting these recommendations will promote 

a better understanding of the relationship between guilt and PTSD and 

equip US military personnel with armor against sustaining moral injuries on the battlefield. Finally, these recommendations could serve as a 

benefit to current combat veterans suffering the effects of PTSD.

Expand the Understanding of Moral Injuries

Better understanding of the concept of moral injuries requires further 

study regarding causality of PTSD. The evidence showing a strong connection between guilt and PTSD is growing, yet many leaders within the 

Department of Defense (DOD) are reluctant to acknowledge the reality of 

battlefield moral injuries. This acknowledgment is critical for two reasons. 

First, it would serve to help remove from combat veterans the stigma 

associated with PTSD. Many combat veterans wrestle in profound ways 

with the notion that they have committed grievous and morally heinous 

actions. They are profoundly weighed down with the guilt that they experience, all the while being told they simply need to grow up. A DOD acknowledgment of the reality of a moral injury would help the healing 
18

process for these wounded warriors, encouraging them to utilize an ethical framework to specifically address the moral challenges they faced.

Additionally, this acknowledgment by the DOD would help warriors 

that have just engaged in morally questionable actions. If DOD leaders 

have admitted the existence of moral injuries, then warriors who may feel 

they have been morally grazed or come dangerously close to a moral dilemma would be more willing to seek helping agencies in a timelier manner. Using commonly accepted criteria for an ethical framework, military 

units can help warriors process their involvement and continue the fight.

DOD acknowledgment of growing evidence showing the correlation 

among moral injury, guilt, and the development of PTSD can free additional resources to deepen further study that can result in better treatment modalities and preventive measures. Additionally, particular studies can be designed to measure the impact that ethical training has on 

protecting against moral injuries.

Clearly Communicate Just War Criteria for Conflicts

In his article “Moral Injury,” Jonathan Shay notes that a key element to 

protect the warrior mentally and emotionally in combat is “expert, ethical, and properly supported leadership.”64 Shay means that the warrior 

must hear a consistent message defending the ethical basis of a conflict 

from all levels of leadership for any given conflict. From the commander 

in chief down to the platoon sergeant, if military leaders fail to explain 

the moral significance and ethical relevance of a conflict, the warrior is 

left alone to evaluate his or her involvement in that war. Even more damaging, warriors may engage in the violence of combat with no thought of 

the potential moral consequences, only to find after the fact that they 

suffered a moral injury by engaging in actions that violated their ethics or 

ideals.65

If and when a nation’s reasons for entering into violent conflict have 

changed, then national leaders must reevaluate its involvement, and a 

new or revised message of moral necessity must be communicated. This 

open communication will keep the public in general and the warrior in 

particular more attuned to the national leaders’ motivations for continuing in the conflict and will help warriors understand that they serve as 

agents of national power.

Develop and Adopt an Ethical Framework

Finally, the US military must develop and adopt an ethical framework 

for individual warrior’s use. This development will require thoughtful 
19

navigation through various philosophical worldviews and should be part 

of both initial and ongoing training.

During initial training, by using an ethical framework, military leaders can demonstrate that their various services’ core values flow out of 

moral reasoning. While such a commitment could be demonstrated for 

each branch, one example should suffice. For instance, the United States 

Air Force’s core value of “Integrity First” can be shown as necessary on 

both moral and practical grounds. An ethical framework firmly establishes integrity on moral grounds. Integrity and all it encompasses in reporting, work ethics, and one’s personal life are the morally right approach. If, however, the Air Force insists on integrity on the basis of the 

pragmatic or practical reasons “in the best interest of the Air Force,” then 

each Airman is implicitly invited to make his or her own assessment as to 

what the best course is in each situation.

Furthermore, an ethical framework will serve as the basis for all of the 

behavioral modification training in which each service engages. Focus 

areas such as sexual assault, harassment, and drunk driving can then be 

tied to this ethical framework. Using an ethical framework to evaluate 

not only warfare but also actions at every level will enable warriors to see 

the moral connections and their moral responsibility in every area of life.

Conclusion

Today’s warriors are continually confronted with complicated decisions often involving split-second decisions with profound implications 

for themselves and their adversaries. In the current environment of moral 

ambivalence in which military leaders are hesitant to speak to the morality of actions, US service members are unprepared for the emotional and 

spiritual damage of engagement in the violence of war.

When warriors react in ways that they feel are morally improper, they 

suffer what researchers are calling a moral injury. These moral injuries, 

particularly the intense feelings of guilt, are now shown to predispose 

warriors to a higher likelihood of developing PTSD. Additionally, the 

complexities of irregular warfare against an often unseen enemy, coupled 

with necessarily restrictive ROEs, potentially compound the moral dilemma for American warriors.

However, if warriors were equipped with an ethical framework that 

brings together an understanding of just war theory and commonly held 

moral beliefs, they would possess the tools to process these complex battlefield decisions. In real time, warriors could quickly determine the 

moral challenges presented in any given scenario and act in the manner 

that best accorded with those beliefs.
20

Similarly, warriors would also possess a framework of understanding 

to process their involvement in previous combat engagements. This reflection could highlight the warriors’ need for timely intervention and 

prevent the negative experience from embedding itself in their conscience. An ethical framework could minimize guilt for warriors both by 

helping them avoid moral violations and more quickly dealing with any 

troubling events. Minimizing guilt could lessen one of the key factors 

causing PTSD, thus lowering the likelihood of those warriors developing 

PTSD.

For all these reasons, the DOD must take seriously the very real threat 

that moral injury presents to its combat forces and adopt a position of 

determined study, making every effort to minimize the likelihood of 

PTSD. These efforts include an acknowledgment of the moral dilemmas 

in war, a clearer articulation of the reasons to enter into particular conflicts, and the development of an ethical framework to assist American 

warriors in their battlefield decisions.

Much work must be done toward gaining a better understanding of 

the real relationship between moral injuries and PTSD and developing 

subsequent research study to better understand how an ethical framework can assist warriors in their battlefield decision making, thereby 

minimizing the likelihood of incurring PTSD. However, because of the 

dramatic cost in terms of damaged lives and extreme costs of long-term 

care for combat veterans suffering from PTSD, any work in these areas 

will be well worth the effort.

Notes

1. National Center for PTSD, United States Department of Veterans Affairs, “How Common Is PTSD?,” 10 November 2014, http://www.ptsd.va.gov/PTSD/public/PTSD-overview/

basics/how-common-is-ptsd.asp.

2. Katie Moisse, “Army Hospital Accused of Reversing PTSD Diagnoses to Cut Costs,” 

ABCNews.com, 22 March 2012, http://abcnews.go.com/Health/MindMoodNews/madiganarmy-medical-center-investigation-reneging-ptsd-care/story?id=15969914.

3. Gregg Zoroya, “Study Suggests Feelings of Guilt May Be a Top Factor in PTSD,” USA 

Today, 25 November 2011, http://usatoday30.usatoday.com/news/military/story/2011-11-23/

study-of-marines-ptsd/51386488/1.

4. Herbert Hendin and Ann Pollinger Haas, “Suicide and Guilt as Manifestations of 

PTSD in Vietnam Combat Veterans,” American Journal of Psychiatry 148, no. 5 (1991), 588.

5. Jonathan Shay, “Moral Injury,” Intertexts 16, no. 1 (Spring 2012): 57–66, http://muse.

jhu.edu/login?auth=0&type=summary&url=/journals/intertexts/v016/16.1.shay.html.

6. Tony Dokoupil, “A New Theory of PTSD and Veterans: Moral Injury,” Newsweek, 3 December 2012, http://www.newsweek.com/new-theory-ptsd-and-veterans-moral-injury-63539.

7. Ibid.

8. National Center for PTSD, United States Department of Veterans Affairs, “How 

Common Is PTSD?”
21

9. Karen Seal, Thomas J. Metzler, Kristian S. Gima, Daniel Bertenthal, Shira Maguen, 

and Charles R. Marmar, “Trends and Risk Factors for Mental Health Diagnoses among Iraq 

and Afghanistan Veterans Using Department of Veteran Affairs Health Care,” American 

Journal of Public Health 99, no. 9 (September 2009),1651.

10. Department of Veterans Affairs, Report on VA Specific Operation Enduring Freedom 

(OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans Coded with 

Potential PTSD (Washington, DC: Epidemiology Program, Veterans Health Administration, 

March 2013), 10, http://www.publichealth.va.gov/docs/epidemiology/ptsd-report-fy2013-

qtr1.pdf.

11. American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, rev. 4th ed. (DSM-IV-TR) (Washington, DC: APA, 2000), 424, http://www.

terapiacognitiva.eu/dwl/dsm5/DSM-IV.pdf.

12. Seal et al., “Trends and Risk Factors,” 1654.

13. Shira Maguen, Thomas J. Metzler, Brett T. Litz, Karen H. Seal, Sara J. Knight, and 

Charles R. Marmar, “The Impact of Killing in War on Mental Health Symptoms and Related 

Functioning,” Journal of Traumatic Stress 22, no. 5 (October 2009), 435.

14. Ibid.

15. Brett T. Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline 

Silva, and Shira Maguen, “Moral Injury and Moral Repair in War Veterans: A Preliminary 

Model and Intervention Strategy,” Clinical Psychology Review 29, no. 8 (December 2009), 697.

16. Kris R. Henning and B. Christopher Frueh, “Combat Guilt and Its Relationship to 

PTSD Symptoms,” Journal of Clinical Psychology 53, no. 8 (December 1997), 804.

17. American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental 

Disorders, rev. 5th ed. (DSM-5) (Washington, DC: APA, 2013), 272. 

18. Hendin and Haas, “Suicide and Guilt as Manifestations,” 586–88.

19. Henning and Frueh, “Combat Guilt and Its Relationship,” 801–6.

20. Maguen et al., “Impact of Killing,” 435, 441.

21. Tony Dokoupil, “A New Theory of PTSD and Veterans: Moral Injury,” Newsweek, 

3 December 2012, http://www.newsweek.com/new-theory-ptsd-and-veterans-moral-injury-63539.

22. Dewleen G. Baker, William P. Nash, Brett T. Litz, Mark A. Geyer, Victoria B. Risbrough, Caroline M. Nievergelt, Daniel T. O’Connor, Gerald E. Larson, Nicholas J. Schork, 

Jennifer J. Vasterling, Paul S. Hammer, Jennifer A. Webb-Murphy, and the Marine Resiliency Survey Team, “Predictors of Risk and Resilience for Posttraumatic Stress Disorder 

among Ground Combat Marines: Methods of the Marine Resiliency Study,” Preventing 

Chronic Disease 9 (2012): 1–11, http://www.cdc.gov/pcd/issues/2012/pdf/11_0134.pdf.

23. Zoroya, “Study Suggests Feelings of Guilt.”

24. Baker et al., “Predictors of Risk and Resilience.”

25. Zoroya, “Study Suggests Feelings of Guilt.”

26. William P. Nash, “US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders,” in Combat and Operational Behavioral Health Manual, 

edited by Elspeth Cameron Ritchie (Fort Detrick, MD: Borden Institute, 2011), 108, https://

ke.army.mil/bordeninstitute/published_volumes/combat_operational/CBM-ch7-final.pdf.

27. Ibid.

28. Franklin D. Jones, War Psychiatry (Falls Church, VA: Office of the Surgeon General, 

United States Army, 1995), 9.

29. Ibid.

30. Paul Robinson, “Ethics Training and Development in the Military,” Parameters 37, 

no.1 (Spring 2007), 23–26, http://cape.army.mil/cgsc-ethics/repository/Ethics-Training-
22

and-Development-in-the-Military_Robinson_Parameters_Spring%202007_pages%2023-

36.pdf.

31. Hendin and Haas, “Suicide and Guilt as Manifestations,” 589.

32. Susan Wolf, “Moral Obligations and Social Command,” in Metaphysics and the 

Good: Themes from the Philosophy of Robert Merrihew Adams, edited by Samuel Newlands 

and Larry M. Jorgensen (New York: Oxford University Press, 2009), 344.

33. Brian Orend, “War,” Stanford Encyclopedia of Philosophy (website), 2005, http://

plato.stanford.edu/archives/fall2008/entries/war/.

34. Ibid.

35. Thomas Aquinas, The “Summa Theologica” of St. Thomas Aquinas, rev. 2nd ed., 

translated by Fathers of the English Dominican Province (London, UK: Burns, Oates, and 

Washburne, 1920), http://www.newadvent.org/summa/3040.htm#article1.

36. Associated Press, “Vatican Strongly Opposes Iraq War,” FoxNews.com, 12 March 

2003, http://www.foxnews.com/story/2003/03/12/vatican-strongly-opposes-iraq-war/.

37. Associated Press, “White House Rejects Vatican View That War Has No Moral Justification,” USAToday.com, 5 March 2003, http://usatoday30.usatoday.com/news/washington/2003-

03-05-bush-iraq-vatican_x.htm.

38. “Military Chaplains Coping in Iraq: Interview with Archbishop Edwin O’Brien,” Catholic 

Online (website), 2 December 2003, http://www.catholic.org/featured/headline.php?ID=548.

39. Pew Forum on Religion and Public Life, U.S. Religious Landscape Survey 2007

(Washington, DC: Pew Research Center, 2007), http://religions.pewforum.org/reports/#.

40. Ibid.

41. Froma Walsh, “Family Resilience: A Framework for Clinical Practice,” Family Process

42, no. 1 (March 2003), 8.

42. Ibid.

43. Mark David Maxwell, “Individual Self-Defense and the Rules of Engagement: Are the 

Two Mutually Exclusive?” Military Law and the Law of War Review 41, no. 1–2 (2002), 39.

44. US Army Field Manual 100-23, Peace Operations, December 1994, 90. This FM was 

superseded in 2007 by Joint Publication 3-07.3, Peace Operations, 17 October 2007, http://

www.dtic.mil/doctrine/docnet/courses/operations/peace/jp3_07_3.pdf.

45. Pew Research Center, “Roe v. Wade at 40: Most Oppose Overturning Abortion Decision,” PewForum.org, 2013, http://www.pewforum.org/2013/01/16/roe-v-wade-at-40/.

46. Ibid.

47. Richard F. Mollica, Healing Invisible Wounds: Paths to Hope and Recovery in a Violent 

World (Orlando, FL: Harcourt, 2006), 176.

48. Ibid.

49. Ibid.

50. Susan Wolf, “Moral Obligations and Social Command,” 344.

51. Martin L. Cook, “Ethical and Legal Dimensions of the Bush ‘Preemption’ Strategy,” 

Harvard Journal of Law and Public Policy 27, no. 3 (June 2004), 802.

52. Maguen et al., “Impact of Killing,” 439.

53. Ibid.

54. Robinson, “Ethics Training and Development,” 26.

55. Edward Tick, War and the Soul: Healing Our Nation’s Veterans from Post-Traumatic 

Stress Disorder (Wheaton, IL: Theosophical Publishing House, 2005), 236.

56. Ibid.

57. Ibid.

58. Ibid., 237.

59. Ibid.

60. Hendin and Haas, “Suicide and Guilt as Manifestations,” 589.
23

61. Mollica, Healing Invisible Wounds, 177.

62. Julio F. P. Peres, Alexander Moreira-Almeida, Antonia Gladys Nasello, and Harld 

G. Koenig, “Spirituality and Resilience in Trauma Victims,” Journal of Religion and Health

46, no. 3 (2007), 346.

63. Pew Forum on Religion and Public Life, U.S. Religious Landscape Survey 2007.

64. Shay, “Moral Injury,” 57.

65. Ibid., 58.

25

Abbreviations

DOD Department of Defense

DSM Diagnostics and Statistical Manual of

Mental Disorders

LOAC law of armed conflict

MRS Marine Resiliency Survey

PTSD post-traumatic stress disorder

ROE rules of engagement

RPA remotely piloted aircraft

VA Department of Veterans Affairs

27

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