Dr. Ruwan M Jayatunge, M.D. PhD
Moral injury refers to the deep psychological, behavioral, and spiritual turmoil that arises when an individual either engages in, witnesses, or fails to avert actions that contradict their core moral convictions (Litz, Brett et al., 2009). The term moral injury was coined by Dr. Jonathan Shay, a clinical psychiatrist, in the 1990s, while working with Vietnam War veterans, and he connected their deep psychological trauma not to fear, but to a profound sense of institutional betrayal. However, moral injury is fundamentally an age-old phenomenon that has persisted throughout human history, rooted in the existence of moral and ethical beliefs that can be violated (Koenig et al., 2021). Čartolovni and team (2021) argue that, in some cases, moral distress may become moral residue and, over time, culminate in moral injury. According to Griffin and associates (2019), such traumatic experiences can create a clash with one's ethical beliefs, resulting in considerable distress and impairments in functioning.
Moral injury is an increasingly recognized phenomenon in mental health research, particularly relevant to current and former military personnel (Phelps et al., 2024). The trauma associated with warfare can inflict damage on various aspects of health, including physical, psychological, social, and spiritual well-being, thereby contributing to moral injury (Richardson et al., 2020). Moral injury arises when individuals in the military breach their fundamental moral convictions and values during combat situations (Koenig et al., 2021). This violation can lead to profound emotional distress, manifesting as shame, grief, a sense of meaninglessness, and remorse for transgressing core ethical beliefs (Brock & Lettini, 2012).
Moral injury, as outlined by Jones (2020), is defined by feelings of guilt, shame, and self-condemnation, which are often evident in combatants who have undergone traumatic experiences in battle. Williamson et al. (2025) characterize moral injury as a significant occupational risk, particularly prevalent among combatants, stemming from guilt and shame. In a soldier, moral injury develops through a specific cognitive transition in which the raw survival behaviours of combat collide with their peacetime moral upbringing. (Farnsworth ,2022).
Mental
health professionals have recognized the phenomenon of moral injury in Sri
Lankan soldiers who were involved in the protracted 30-year armed conflict against
the Liberation Tigers of Tamil Eelam (LTTE). This separatist militant
organization, which sought an independent Tamil state in northeastern Sri Lanka
from 1976 until its defeat in 2009, is often regarded as one of the most
advanced insurgent groups globally.
The
prolonged armed conflict in Sri Lanka, has significantly contributed to the
prevalence of moral injury among combatants (Jayatunge, 2013). Sri Lankan
combatants often faced extended deployment periods, frequently spending up to a
decade in active combat zones, which intensified the cognitive dissonance
between their military actions and their cultural or religious values. Many
soldiers grappled with deep psychological and ethical dilemmas during and after
their service, sometimes being forced to undertake actions that conflicted with
their personal moral convictions. Such experiences can evoke feelings of guilt,
shame, and betrayal, especially as they reflect on their involvement in the
conflict and the consequences of their actions.
The majority
of combatants from Sri Lanka identify as Buddhists, a faith that emphasizes the
principles of karma and the cycle of rebirth. This belief system inherently
instills a profound sense of moral responsibility and ethical conduct, which
can lead to significant psychological distress when individuals engage in acts
of violence or warfare that contradict their spiritual values. As a result,
these combatants often experience moral injury, a condition characterized by
the internal conflict arising from actions that violate their deeply held
beliefs.
During the
Eelam war in Sri Lanka, psychological support services were severely lacking
and not prioritized, resulting in inadequate treatment for the psychological
scars left by the conflict. The insufficient availability of mental health
resources, combined with the societal stigma associated with mental health
issues, exacerbated the moral injuries experienced by individuals affected by
the war. Many former combatants continue
to experience PTSD, depression, adjustment disorders, and moral injuries. These
conditions manifest not only as psychological issues but also pose substantial
barriers to their reintegration into civilian life, resulting in numerous
soldiers facing difficulties in adapting after their service.
Numerous
case studies highlight the moral injuries experienced by Sri Lankan combatants.
One notable incident involves Major SE, who was ambushed by LTTE militants in a
northern village, leading to a fierce firefight. Surrounded by the enemy, Major
SE desperately returned fire when an elderly civilian woman inadvertently
opened a window to observe the chaos. Mistaking her for an adversary, he shot
at the window, tragically wounding the old woman fatally. Despite successfully
repelling the enemy and returning to camp, the psychological toll of this
traumatic event lingered with Major SE for an extended period. Major SE later
recounted that his bullet shattered the old woman's jaw, resulting in
significant blood loss. Tragically, she succumbed to her injuries within hours
due to the severe bleeding. Major SE endured the profound effects of moral
injury, grappling with a range of distressing symptoms that persisted for many
years following his wartime experiences.
Another
soldier reported experiencing moral injury as a result of exposure to traumatic
combat situations. In April 2000, during the Elephant Pass debacle, troops were
compelled to retreat to the Soranpattu-Palai defense line, enduring a gruelling
16-kilometre march under the scorching sun, without water, and while facing
enemy mortar and sniper fire. Among the retreating soldiers was Corporal K, who
witnessed many of his comrades fall victim to enemy attacks and heat strokes.
In the midst of this chaos, a wounded soldier implored Corporal K for assistance,
but the dire circumstances left little room for altruism, forcing him to
decline. The wounded soldier, however, shared his name and address, requesting
that Corporal K convey his final words to his family. Although Corporal K
promised to honour this request, a few kilometres near the Sorampattu- Palali
defense line, Corporal K succumbed to heat stroke and lost consciousness.
Fortunately, he was rescued by fellow soldiers and transported to a hospital.
Upon regaining consciousness days later, Corporal K had forgotten the dying
soldier's name and address. This incident ignited deep shame and guilt in him,
which she suffered for many years.
Soldiers
can experience moral injury from killing enemy combatants, even when the
killing is entirely legal, justified, and necessary for survival (Maguen et
al., 2010). The subsequent case study illustrates such an incident.
Sergeant
Sx78 dedicated nearly a decade to service in combat zones, notably enduring
intense battles while defending the Jaffna Fort, which was besieged and
subjected to heavy enemy fire. During the critical operation known as
"Midnight Express," he played a pivotal role in rescuing trapped
troops, resulting in the death of five enemy combatants. However, in the years
that followed, he became increasingly troubled by the moral implications of
these actions, reflecting on the humanity of those he had killed. He expressed
a deep understanding of their backgrounds, recognizing that they were often
impoverished youths, manipulated by hatred and left with few choices. This
realization weighed heavily on him, as he grappled with the harsh realities of
war, where survival often necessitated lethal force. Acknowledging the conflict
between his actions and his Buddhist beliefs, he felt a profound sense of guilt,
believing that he would ultimately face karmic consequences for his deeds. This
inner turmoil has led him to seek solace in spirituality, aspiring to become a
monk upon his retirement from military service.
The
prolonged exposure to the tumultuous realities of war and chaos can
significantly alter an individual's psychological framework, leading to
profound changes in their mental and emotional state. In the aftermath of such
distressing experiences, many individuals may encounter moral injury. Research
indicates that cumulative war trauma can lead to moral injury among soldiers
(Wisco et al.,2017).
Lt. Colonel
LX is a seasoned field officer whose extensive involvement in numerous military
operations spanned the entirety of the war, concluding in 2009. Throughout this
tumultuous period, he was frequently confronted with the harrowing realities of
combat, witnessing the tragic deaths and injuries of fellow soldiers, often in
scenarios that left them vulnerable and defenseless. Moreover, his experiences
extended beyond the battlefield, as he observed the profound effects of warfare
on civilians in the northern regions, who bore the brunt of collateral damage
and suffered immensely due to the conflict. The psychological toll of these
experiences was significant, as he encountered the deep-seated human suffering
that often accompanies war trauma. In the aftermath of the conflict, Lt.
Colonel LX retreated into seclusion, grappling with the weight of his memories
and developing a more cynical perspective on life, shaped by the stark
realities he had witnessed. He is experiencing a range of psychological and emotional
symptoms that are significantly impacting his overall well-being, characterized
by a profound sense of loss of meaning in his life.
Following
the Eelam war in Sri Lanka, numerous combatants were found to be suffering from
post-traumatic stress disorder (Jayatunge, 2004). It is essential to distinguish between
combat-related PTSD and moral injury, as they stem from different sources. There
are many differences between combat-related PTSD and moral injury. While PTSD
is driven by fear and threat, moral injury is driven by a collapse of a
person's ethical framework (Farnsworth et al.,2017). When a soldier experiences
moral injury, it profoundly impacts their personality, identity, and behaviour
(Litz et al., 2009). Unlike PTSD, which is primarily a fear-based response,
moral injury represents a wound to the conscience, leading to significant
psychological, relational, and behavioural challenges (Barnes et
al.,2019).
Moral
injury often results in a collapse of identity and self-worth, characterized by
aggressive self-loathing and an overwhelming sense of chronic shame and guilt
(Farnsworth et al., 2014). Furthermore,
deep cynicism and a loss of trust emerge, eroding the soldier's faith in the
military hierarchy, political leaders, and the institution as a whole, which
can extend into their civilian life (Shay, 2014). The consequences may include
a loss of faith and a descent into existential nihilism, relational
destructiveness, and isolation. Additionally, self-sabotage and self-punishment
frequently occur, often accompanied by engagement in high-risk behaviors
(Griffin et al., 2019).
Specialized
treatment for moral injury in soldiers is essential, as neglecting this issue
can result in severe consequences, including a total collapse of identity,
increased social isolation, and a heightened risk of suicide (Bryan et al.,2014).
Once moral injury occurs, evidence-based
clinical therapies become essential to address the profound shame and guilt
experienced by these individuals.
Adaptive
Disclosure (AD) is one of the premier, evidence-based treatments developed
specifically for moral injury in military personnel (Litz et al., 2016). Adaptive Disclosure (AD) integrates focused
imaginal exposure with organized, real-time dialogues to assist military
personnel in addressing and processing the unique emotional traumas associated
with combat experiences.
Another
effective intervention is Trauma-Informed Guilt Reduction (TiGR) Therapy, which
evaluates the realities of a crisis, enabling soldiers to discern what they
could control versus what was beyond their influence during chaotic situations
(Norman et al.,2019). Additionally,
spiritual therapy plays a crucial role in addressing moral injury. Spiritual
therapy heals moral injury by directly addressing the existential and
metaphysical wounds (Carey et al.,2026).
Group
therapy sessions and Peer support groups enable veterans to share their
experiences with others who have faced similar combat situations, fostering a
sense of normalcy in their reactions to trauma. Creating safe spaces for open
discussions about deeply held shame is vital for bringing these hidden memories
to light (Allbaugh, Placeres & Toor, 2023). Furthermore, mindfulness breath meditation
and loving-kindness meditation (LKM) are highly effective tools for healing
moral injury (Kelley et al., 2025).
Moral
injury among Sri Lankan combatants who took part in the Eelam War represents a
significant yet under-explored area of research that warrants immediate
attention. It is crucial to accurately
diagnose the presence of moral injury in these veterans, as it can manifest in
various ways, including feelings of guilt, shame, and a diminished sense of
self-worth. Furthermore, providing appropriate psychological support tailored
to the unique experiences of these combatants is essential for their recovery
and reintegration into society. By addressing this critical issue, we can not
only aid those who have suffered in silence but also contribute to a broader
understanding of the psychological ramifications of war, ultimately fostering a
more compassionate approach to veteran care in Sri Lanka.
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