What Have We Done

CHAPTER 1

It's Wrong, but You Have No Choice

Broad shouldered and lean at six foot two, Nikki Rudolph, an affable sandy-haired Californian, was twenty-two years old when he was sent as a marine infantryman to Afghanistan, where he shot and killed a young boy. This was not uncommon in the murderous confusion of our recent wars, where farmers and mothers and young kids might seize a weapon and shape-shift in a moment into a combatant and back again to an innocent civilian, and young Americans peering into the murk would have a moment to decide: kill or not. This time, an exhausting firefight with Taliban insurgents had dragged on for hours across the superheated desert wastes and tree-lined irrigation canals of Helmand Province. Late that afternoon, Nik saw from the corner of his eye someone darting around the corner of an adobe wall, spraying bullets from an assault rifle held against his small hips. Nik swiveled his M4 carbine, tightened his finger on the trigger, and saw that it was a boy of maybe twelve or thirteen. Then he fired.

According to the military's exacting legal principles and rules, it was a justifiable kill, even laudable, an action taken against an enemy combatant in defense of Nik himself and his fellow marines. But now Nik is back home in civilian life, where killing a child violates the bedrock moral ideals we all hold. His action that day, righteous in combat, nonetheless is a bruise on his soul, a painful violation of the simple understanding of right and wrong that he and all of us carry subconsciously through life.

Those two emotions, pride in having prevailed in a firefight and the dark shadow of wrongdoing, together illustrate the baffling and sometimes cruel paradox that so often dominates the lives of those we send into war. Duty and honor, and self-preservation, define Nik's decision to pull the trigger. At home, strangers thank him for his service, and politicians celebrate him and other combat veterans as heroes. And Nik carries on his conscience a child's death.

Americans who have served in Iraq and Afghanistan are coming to understand Nik's lingering pain as a moral injury, a trauma as real as a flesh wound. In its most simple and profound sense, moral injury is a jagged disconnect from our understanding of who we are and what we and others ought to do and ought not to do. Experiences that are common in war—inflicting purposeful violence, witnessing the sudden violent maiming of a loved buddy, the suffering of civilians—challenge and often shatter our understanding of the world as a good place where good things should happen to us, the foundational beliefs we learn as infants. The broader loss of trust, loss of faith, loss of innocence, can have enduring psychological, spiritual, social, and behavioral impact.

Each of us, of course, has experienced at least a twinge of moral regret and sometimes deeper and lasting moral injury. History is marked by immense human calamities and periods of unspeakable moral violation. Yet the moral jeopardy of war, especially in the wars the United States began and fought in Iraq and Afghanistan, is different. These wars demanded the intense and prolonged participation of a tiny fraction of the nation's youth in sustained campaigns built on the intentional violation of the ancient sanctions against killing. Those who returned did so without the healing rituals of cleansing and forgiveness practiced by past generations. Threads of anger and betrayal run through their stories: violations of their sense of "what's right" by the Afghan and Iraqi civilians who turned violently against them, by an American public that turned its back on the war, and by the lack of clear victories in Iraq and Afghanistan that might have justified their sacrifices.

In my experience, to be in war is to be exposed to moral injury. Almost all return with some sense of unease about what we've seen and done, about how well we and others have lived up to our own standards. Most of us are unprepared to disentangle the emotions of anger, sorrow, shame, or remorse that can result. It is common, researchers say, for those who have experienced a moral wound to react with cynicism or bitterness; to distrust authority; to be more prone to anxiety, depression; perhaps to seek comfort in isolation or the self-medication of drugs, alcohol, or overwork. Most common, to never talk about the war.

Trauma experts such as Brett Litz, a psychologist who is pioneering moral injury research at Boston University and the U.S. Department of Veterans Affairs (VA) Boston Healthcare System, also reference as symptoms of moral injury terms with which I was unfamiliar—dysphoria (severe distress), for one, and anhedonia (the inability to experience pleasure). But despite impressive advances in the understanding of moral injury and some breakthrough therapies that hold the promise of helping those most afflicted, my sense is that many veterans, like Nik, carry their regret and sorrow and heartache on into life and rarely speak of it. In that sense, moral injury is the enduring if hidden signature wound of our most recent, and longest, wars.

It is important to understand that while some veterans cannot find peace after a moral injury, most of those who have felt morally injured are not disabled, are not broken or dangerous, do not fit the insulting stereotype of combat vets as lunatic unemployed, homeless, drug-addled criminals.

Nor does moral injury necessarily describe legal wrongdoing. Moral injury does not imply that an atrocity or a war crime has been committed, simply that an individual's ethos has been violated. "War is vile. There are some things that are more vile, and that's why we fight, but that vileness affects you down to your core," David Sutherland once told me. A soldier for thirty years, Sutherland commanded the twelve thousand men and women of the Third Brigade Combat Team task force of the First Cavalry Division. For fifteen months in 2006 and 2007 in Iraq, they fought day and night. Sutherland had vowed to personally honor every one of his badly wounded and dead troops, and he did that, visiting hospitals and morgues, putting his hand on the body bag or head of each one and praying. It nearly broke him. "Guilt, shame, sorrow, bereavement [are] normal human reactions, but as commander I couldn't shut down. I was in a battle every single day. I'd wake up to an IED [improvised explosive device] exploding and go to bed with an IED exploding."

Staff Sergeant Donnie D. Dixon was part of Sutherland's security detail as they traveled the battlefields, and on September 29, 2007, Dixon was shot and killed. He was thirty-seven and left a wife and four children. "When Sergeant Dixon was killed, that affected all seventeen members of my security detachment, and some of us more than others: we were standing right by him when it happened," Sutherland told me. "How do you not believe this is a moral injury?"

For many of us, such war-related moral injuries are invisible because we are so disconnected from the lives of the men and women who serve in the military. Almost two million of them are home from Iraq or Afghanistan, proud of their difficult and demanding service and profoundly affected by their experiences at war. Most of it was lived in vivid extremes far removed from the ordinary: there were dazzling highs and depressing, boring, and sometimes despairing lows; the burning devotion of small-unit brotherhood, the adrenaline rush of danger. The pride of service, the thrill of raw power. The brutal ecstasy of life on the edge and the deep grief of loss. Nik Rudolph thinks of it as "the worst, best experience of my life."

But war is an alternate moral universe where many of the rules and values we grew up with are revoked. Do unto others, suspended. An alien world in which complex moral puzzles, like confronting a child combatant, demand instant decisions by those who are least fit to make them, for reasons of incomplete neurological development and life experience. An environment for which the United States has trained its warriors exhaustively in physical fitness and military tactics but left them psychologically and spiritually unprepared. An environment from which they return to find their new understanding of the world and who they have become fits awkwardly or not at all into their old lives in peacetime America. They return to a civilian public whose sporadic attention to veterans largely fails to comprehend or acknowledge the experiences they have absorbed on our behalf.

This is the dark truth of war, a secret we are all complicit in keeping. We know, though we rarely acknowledge it, that war imposes terrible costs on human beings and that, while some are strengthened by the experience, others buckle. We understand at some level why combat veterans shrink from sharing their stories: we don't want to know them. In our sometimes-frenzied veneration of war heroes, we are too eager to rush past the shadowed doorway where lurks what the poet Peter Marin calls "the terrible and demanding wisdom" of war. In the lofty discussions about putting "boots on the ground" among Washington's strategists and national security experts, those in government service or awaiting their turn in the city's comfortable think tanks, there is little room for considering the inevitable cost, the well-being of those men and women we will send next.

But out there, it will get worse. The brutal new conflicts that tempt American intervention as we move deeper into the twenty-first century pose intense new moral challenges. The old signposts of morally acceptable behavior, the laws of war, the Geneva Conventions, the just war doctrine, seem increasingly irrelevant in a world of drone killings, the beheading of hostages, and the deliberate massacre of schoolchildren by Islamist extremists. Traditional ideas about "victory" over these groups are obsolete, battered relics of a bygone age, given their ability to inspire disaffected youth and the wildfire spread of weapons technology that has enabled them to armor their utter ruthlessness with the killing power once reserved for nations. Moral challenges face us as well back home as we continue to recruit, train, and dispatch a tiny number of our youth for military actions about which we are deeply skeptical and for battlefield risks we ourselves are not willing to take.

What we know of this latest generation of veterans, and what we fear of the future, demand that we finally pay urgent attention to the moral dimension of war. As we consider committing more young Americans to twenty-first-century warfare, we must do so with full knowledge and acceptance of the price they will pay on our behalf.

I crossed paths with Lance Corporal Nik Rudolph and his fellow marines when I deployed to Afghanistan as an embedded journalist with his unit, the First Battalion, Sixth Marine Regiment, or One-Six. Nik is the kind of marine who always wanted to be a marine. His dad was a marine, an artillery spotter and a recon scout. As a toddler Nik wore the Marine Corps T-shirts his dad would bring home after being away on long field exercises. Nik graduated to playing with GI Joe action figures and building forts. After high school he studied auto mechanics, but there were no jobs in the downturn of 2008; even car dealerships were closing. So Nik did what he'd always yearned to do: he enlisted and was soon on his way to boot camp at Parris Island, South Carolina.

I spent months with the marines of One-Six on their first tour in Afghanistan. But it would be a few years before we could sit down and sort through all that had gone on during their second deployment, in 2010, and in particular on the February day when the marines of One-Six and the Taliban were locked in that firefight, a fury of reckless rage and exhaustion that went on for nine hours. The battle had erupted, as the marines later understood it, after Taliban insurgents castrated a young boy in a nearby village, knowing his family would summon marines for help and the marines would come, walking into a deadly ambush that would ignite the firefight. Then there comes that instant, an eternity Nik has replayed over and over in his mind, when he has to choose to kill or not. He squeezes the trigger, and the boy's body spasms and hits the ground. Now what? "We just collected up that weapon and kept moving," Nik explained. "Going from compound to compound, trying to find them [the insurgents]. Eventually they hopped in a car and drove off into the desert."

There was a long silence after Nik finished the story. He's lived with it for years, yet the telling still catches in his throat. Eventually, he sighed. "He was just a kid. But I'm sorry, I'm trying not to get shot and I don't want any of my brothers getting hurt, so when you are put in that kind of situation… it's shitty that you have to, like… shoot him. You know it's wrong. But… you have no choice.

"Thank God he didn't know how to fuckin' aim," he added morosely.

Nik is not crushed by this experience. He has a quick laugh and a life he enjoys. He dresses carefully and is polite and deferential. The regret, confusion, and sorrow he brought back from Afghanistan remain beneath his skin. But they break the surface now and again, at first leading him into heavy drinking and an effort to see a civilian therapist. He knows his demons are there. I asked him once if he found that moral injuries like killing a child heal over time, the bruise eventually fading. No, he said. "It will all be there."

Two years after Nik Rudolph came home from Afghanistan, Shira Maguen, a clinical psychologist at the San Francisco VA Health Care System and a professor at the University of California, San Francisco, published another in a series of research papers on the psychological impact of wartime killing. In her study of Afghanistan and Iraq veterans who had killed in combat, just over half had killed only enemy combatants; the rest had killed both enemy combatants and at least one noncombatant, a male civilian, a woman or child, or an elder. All those who had killed were twice as likely to develop frequent and severe psychological symptoms as those who had not. Those who had killed a noncombatant, she found, were the most likely to carry home the depression, anger, shame, and guilt of moral injury.

You don't have to go to war, of course, to feel depressed, anxious, or regretful. All of us carry the nicks and bruises of everyday experiences, and some, the deeper wounds of sorrow, grief, and guilt. But the raw, toxic violence of war can wound the soul more deeply, in ways that combat veterans know and rarely can describe to outsiders. Many have felt the crushing weight of helplessness as they are thrust into situations where they seem to have no moral agency, and any decision will feel wrong.

In recent years, we have begun to recognize that the psychological damage suffered in war far exceeds physical injury. That many of those who were caught up in war struggle during and after their service with the mysterious, troubling emotional storms that often afflict them. We have come to group all these psychological injuries under the label "PTSD." That's wrong.

Post-traumatic stress disorder is biology. It is the body's involuntary physical reaction as we relive the intense fear of a life-threatening event and the scalding emotional responses that follow: terror and a debilitating sense of helplessness. Our response to threats, to danger, is a primitive involuntary mechanism developed for survival by earth's earliest life forms. For us, fear triggers an alarm system set deep in the amygdala, in the oldest part of our brain. The alarm causes adrenaline and the steroid cortisol to spurt into the bloodstream, making us hyperalert, breathing hard with muscles tensed, eyes wide, pulse racing, ready for "fight or flight." That's a necessary response to danger, whether it's an imminent head-on collision or a battlefield ambush, and in war, people can experience it repeatedly. What's not appropriate is when that response is triggered by a false alarm. The amygdala picks up what it identifies as a sign of danger and goes into action, not knowing it's no longer in Afghanistan, and a veteran suddenly is cowering from fireworks or a car alarm. Understandably, he or she will try to avoid situations that might trigger those reactions, an effort that can lead to isolation. But avoidance isn't always possible. A vet may be sauntering happily into Walmart and involuntarily recoil from the sudden onrush of chaos and noise and light in the vast bustling space. Instantly and involuntarily, he is in a full-blown danger response. He flushes bright red, sweat runs down his back, and gasping for breath he runs out of Walmart and smacks his fist into a fence post and yells at his kids. He's depressed for the rest of the day—What's happening to me?—and sleepless and anxious at night lest the nightmares come. Next day he's irritable at work because he hasn't slept, then snaps at his wife because he can't explain what's wrong. Even he doesn't understand it.

Clinically, this is described as "fear-circuitry dysregulation," but mental health professionals themselves disagree on the causes and precise parameters of PTSD. The official definition, written and sanctified by the American Psychiatric Association (APA) in its Diagnostic and Statistical Manual of Mental Disorders (DSM), has shifted four times since it was first adopted in 1980. PTSD is real, and I have seen it among the combat vets of Iraq and Afghanistan and previous wars. The mechanism of PTSD is well understood: perceived threat and automatic response. It's simple enough that the VA has hired IBM to set up a computerized "clinical reasoning" database to assist physicians in making faster diagnoses of PTSD and to accelerate the process of selecting the right treatment plan.

Although battlefield PTSD and moral injury can occur together, Nik Rudolph doesn't have PTSD. What Nik struggles with is not the involuntary recurrence of fear. He's okay with the crowds at Walmart. He doesn't startle at loud noises. In contrast with veterans who've experienced PTSD, Nik didn't feel the pain of his moral injury at the moment of the incident. It was only later, well after he'd pulled the trigger, that the implications of what he'd done began to weigh on him. Moral injury occurs "when a person has time to reflect on a traumatic experience," Major Paul D. Fritts wrote in a paper at Yale Divinity School, which he attended after serving two army combat tours in Iraq.

That's Nik. He is bothered with the memory of that Afghan boy and with questions about what he did that day. Like all of us, Nik had always thought of himself as a good person. But does a good person kill a child? Follow that line of thinking, and it quickly becomes No, a good person doesn't kill a child, therefore I must be a bad person. And think of all the other bad things I've done. Left unattended, a moral injury that began as a bruise on the soul can continue to disrupt life. If I killed a child, could I ever be a trustworthy father? The symptoms can be similar to those of PTSD: anxiety, depression, sleeplessness, anger. But sorrow, remorse, grief, shame, bitterness, and moral confusion—What is right?—signal moral injury, while flashbacks, loss of memory, fear, and a startle complex seem to characterize PTSD.

Most of us, like Nik, have a firm and deeply personal understanding of life's moral rules, of justice and injustice, right and wrong. That sense, our inner compass, is built on beliefs we begin to acquire as infants. Being fed and cared for and loved, the psychologist Ronnie Janoff-Bulman wrote, teaches us that the world is a benevolent and meaningful place, that we can expect good things to happen. Infants begin to develop a sense of self-worth and trust—I'm being cuddled and fed and kept warm, so I must be a good person to deserve this. That dawning awareness is what the philosopher and psychologist William James called "our more or less dumb sense of what life honestly and deeply means." These earliest learned beliefs are extremely powerful, buttressed by later experience into a sense of cautious optimism "that things will work out as well as can reasonably be expected," as psychologist Aaron Antonovsky has written. Most of us, through experience and over time, modify that sunny view. The world is not always benevolent; some people are jerks; some leaders are despicable.

Still, I think most of us like to believe that we act in good faith. We know we should follow the Golden Rule even if most of the time we don't, and we get angry when others treat us ill. Against evidence to the contrary, I still hope that our leaders are somewhat competent and honest and act in our best interest. Like most people, I want my life to go well. We all want the best for those we love, spouse or child or battle buddy. If bad things happen, we hope they won't happen to us.

But war, by its very nature, tends to suddenly and violently upend these remaining moral beliefs. Things don't go well in war, whose very purpose demands death and destruction. Innocents and those we love will suffer and die; some leaders will make bad decisions that put ourselves and our friends in peril. Thou shalt not kill hardly applies when your job is to kill people. Army Lieutenant Colonel Doug Etter says it most simply. He is a National Guard chaplain with two combat tours in Iraq. It was Etter, a Presbyterian minister, who led the ceremony of the burning of regrets in the stone baptismal font in Habbaniyah. War, Etter said, "is a sin."

PTSD has little to do with sin. It is a psychological wound caused by something done to you. Someone with PTSD is a victim. A moral injury is a self-accusation, prompted by something you did, something you failed to do, as well as something done to you. Combat veterans may feel a moral injury from being unintentionally responsible for the death of a civilian. Some may feel regret and sorrow for not having spotted the sniper who wounded a buddy. A flight medic may feel guilt and shame for failing to save a mortally wounded soldier; a young woman who enlisted to help Iraqis build a new country and found only destruction and death may feel bitter and betrayed by her leaders and may become deeply cynical about public service. Military families, too, absorb moral injury, living with loneliness and fear and perhaps emotions of anger and betrayal along with their pride of service and sacrifice.

The loss of a warrior's moral guideposts can be as devastating as a hiker losing the trail in a blizzard. Where so much is wrong, discovering and holding on to your own morally comfortable bearings can be difficult. Stress, exhaustion, loneliness, and the peer pressure of small units at war can make such reflection impossible. Guilt, the recognition that I did a bad thing or I failed, can harden into shame: I'm a bad person. Mild or severe depression and anxiety can follow, along with anger and bitterness. Alcohol and drugs can seem like an easy way to ease the pain. Shame can lead to risky acts of indiscipline, such as drunk driving, brawling, or mouthing off to superiors. That's behavior that could result in a bad-conduct discharge, which bars a veteran from receiving the services of the VA, a growing problem among Iraq and Afghanistan War veterans.

The moral pain of warfighters is reason enough for us to pay close attention, but there are practical considerations as well. Disillusioned, angry, or bitter soldiers can become a military-readiness issue by dropping out or underperforming. Once out of the service, veterans may find it difficult to reconcile their wartime actions with the moral standards and expectations of home. Unable or unwilling to share the emotions of moral injury, some veterans choose isolation, depriving their families, colleagues, and communities of their presence, their skills, and their insights—a loss for all of us.

The U.S. involvement in Vietnam was a watershed in our understanding of war trauma, and even though it took almost a decade for the mental health profession to officially recognize PTSD, tens of thousands of combat veterans eventually found some relief through psychotherapy. But because several of the indicators of PTSD—anxiety, depression, anger, isolation, insomnia, self-medication—are shared with moral injury, it took time for therapists and researchers to unbraid the two. Jonathan Shay, a former staff psychiatrist at the VA medical center in Boston, worked for years with Vietnam combat veterans diagnosed with PTSD before he could see the scope of the war trauma he described in his breakthrough 1994 book, Achilles in Vietnam. To fully capture that facet of war trauma he felt was not PTSD, Shay coined the phrase "moral injury." Cleanly differentiating it from PTSD, Shay wrote: "Moral injury is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as 'what's right' has not also been violated." Despite such leaps in understanding war trauma, the U.S. government's response to moral injury is light-years behind its ability to recruit, arm, and deploy young men and women into combat. "In the military and the VA, moral injury is a uniquely and significantly unaddressed war zone harm," says psychologist Litz.

Litz's colleague William Nash also has explored this wartime clash of moral values as his lifework. Nash is a combat psychiatrist, a groundbreaking researcher whose academic work is enriched by his battlefield experience: he was awarded a Bronze Star in combat with marines in Falluja. He holds a medical degree from the University of Illinois College of Medicine and did his residency in psychiatry at the Naval Medical Center San Diego. During thirty years' active duty in the navy, he established programs on combat stress and trauma and produced a long list of academic research papers—all aimed at understanding war trauma and moral injury and helping young warriors cope. In 2015 he was named director of mental health for the Marine Corps.

Nash is one of a growing circle of researchers and mental health practitioners who are defining the scope of moral injury and experimenting with promising new forms of therapy. Among these experts are Litz, Shira Maguen, and Amy Amidon at the Naval Medical Center San Diego, where the therapy group is the only government-sanctioned treatment for moral injury that I have found.

Over hours of conversation, Nash asserted that the moral values we learn early in life, and those that are reinforced in basic military training, represent the best of humanity's ideals. "It's these values that give you some chance of doing something good in a war and limiting collateral damage," he told me. "The problem is that war will break these values.