In the United States and elsewhere, the concepts of stress, trauma, and mental health provide an authoritative language for articulating the psychological impact of violence. This medicalized language is insufficient if we are to grapple with the moral and political dimensions of trauma, what experts now call “moral injury.” Drawing on interviews with influential experts in the US military, this chapter explores how the post-9/11 wars led psychologists to rediscover the moral dimension of trauma. Psychology has the potential to address the moral and political sources of trauma and alleviate some of war’s painful consequences, but this effort requires a complex understanding of what violence does to those who experience it, including those who perpetrate it. The challenge for psychology is to tackle the ethical complexities of war and trauma without reducing the issue of moral responsibility to a question of moral or psychological injury.

The First World War confirmed combat operations as the ultimate test and practical justification for Army chaplaincy, inspiring G. A. Studdert Kennedy’s famous admonition to ‘Live with the men, go where they go … share all their risks, and more, if you can do any good.’ This, however, was constrained by circumstance. Chaplaincy’s standard expression was garrison or station ministry, increasingly among a sizeable population of soldiers’ families. This was not a milieu in which the wisdom of Studdert Kennedy (aka ‘Woodbine Willie’) could be easily followed, and chaplains generally became familiar with their soldiers through exercises (the longer the better) or on operations. However, the latter varied enormously. In Cyprus, chaplains were targets for EOKA; in Northern Ireland, they went largely unmolested. Both were a far cry from battlefield ministry in the Falklands, the Gulf War or the 2003 invasion of Iraq. While the War on Terror, especially in Afghanistan, highlighted the controversial question of chaplains bearing arms, its nature and longevity enhanced the role and stature of the chaplain, enabling the wisdom of Studdert Kennedy to be applied to striking effect.

A patient at a Catholic hospital wants medical assistance in dying (MAiD). Fulfilling her end-of-life wish by facilitating her transfer to a hospital willing to provide MAiD seems like the right thing to do. But unforeseen challenges arise that force the ethicist to reckon with her dual leadership roles, the moral weight of her title, the psychological sequelae of bearing witness to suffering and death, and the moral distress that arises when law and ethics clash. Although the patient gets her wish, the case feels unfinished; the injustice that caused her unnecessary suffering remains a spiritual wound for her children. Through partnership with the patient’s family, the ethicist works with hospital leadership to devise a systemic remedy to mitigate the harms of forced transfers for similar patients in the future. By reckoning with the challenge of juggling multiple roles, and the impacts of workplace trauma exposure and moral injury, the ethicist creates resources and relationships to provide greater psychological safety and mutual support, ensuring the sustainability of her work in ethics consultation for years to come.

This chapter explores the concepts of self-compassion and moral injury, and ways of navigating complex healthcare roles with self-awareness, kindness, and greater compassion. Self-compassion involves recognising our suffering, being moved by it, and offering kindness and understanding towards ourselves. Human beings can be our own worst enemies and toughest critics. Cultivating self-compassion helps to address this tendency, increase resilience, and empower us to show greater compassion towards others. Moral injury stems from situations in which a person must make choices that go against their core values and can corrode compassion. There are many kinds of moral injury, ranging from a single large, conflictual decision to a sustained pattern of smaller but still conflictual decisions that arise on a day-to-day basis. The latter is common in large healthcare systems owing to rapid decision-making, inadequate resources, outsized expectations of healthcare providers, and working conditions that are often not conducive to clear thought: long hours, sleep deprivation, inadequate personal support, and lack of compassion for staff. This chapter examines how to manage the risk of moral injury in these situations, how to boost self-care for staff, and the importance of self-compassion when managing or living with difficult experiences or situations, especially on a recurring basis.

This chapter of the handbook tackles a frequently discussed topic in moral psychology: moral dilemmas. The authors offer a normative characterization of moral dilemmas as a situation in which every available course of action involves a difficult moral trade-off and it is morally appropriate for the agent to feel conflicted about the choices available. The authors then explore different empirical accounts of why some moral trade-offs are experienced as difficult or impossible to resolve. Among the most influential of these accounts is dual-process theory, which traces the experience of moral dilemmas to a conflict between a value backed by automatic emotional processes and a value backed by reflection. The authors argue against the dual-process account, and review empirical research bearing on the psychological mechanisms underpinning a person’s experience and resolution of moral dilemmas, as well as the phenomenon of “moral residue.” They argue that further empirical work is needed to understand how people weigh competing values against one another and that such understanding requires expanding the range of moral dilemmas to include cases beyond those targeted in recent research.

This chapter explores the moral dimensions of work in emergency and pre-hospital medicine, with an emphasis on protecting the workforce and maintaining optimal functioning of teams. It explores the concepts of moral distress and moral injury from the literature and as they apply to emergency and pre-hospital medicine, but also in the light of the COVID-19 pandemic. It includes reference to the experience of one helicopter emergency medical service (HEMS) organisation attempting to make changes to its culture.

The London Nightingale was designed to be the largest field hospital in UK peacetime history. It was built in a matter of weeks on the site of an existing exhibition centre, with a final capacity planned for 4,000 intubated patients who had COVID-19, and 16,000 clinical staff. Supporting the mental health of its staff was a key element from its inception, with a specialist team engaged to create and implement an evidence-based, tiered, occupational health model. The emphasis was on minimising distress and moral injury, and maximising post-traumatic growth through a rapid, de-medicalised, forward psychiatry model that encouraged return to work where possible. The London Nightingale was fortunately never required at anything near its capacity, but the mental health team was operational throughout its life, and openly disseminated its standard operating policy and learning to other UK hospitals, many of which used it as a template to design their own.

The aim of this chapter is to provide an overview of the challenges that have affected healthcare staff in the UK through the COVID-19 pandemic, and to illustrate a selection of the responses of the UK’s National Health Service in establishing support systems and services to help to mitigate the psychosocial and mental health impacts on staff. The topics covered include the context of the NHS at the start of the pandemic and the framework on which the NHS response was based, the impact of the pandemic on staff members and teams, the initiatives put in place to support staff, and challenges for the future.

In our concluding chapter, we refocus our attention on the individual SOF operator. A career, or even a deployment, in special operations exposes operators to an exceptionally high risk of post-traumatic stress and moral injury. We argue that states, therefore, have an obligation to ’ethically armour’ their special operators against moral injury, a battlefield hazard that is just as deadly as a sniper’s bullet. Leaders at every level must ensure that SOF are educated and trained in the moral complexity of their profession. Given the emergence of SOF power as an essential instrument of statecraft, the political sensitivity that is often a feature of special operations, and the independent and improvisational decision-making that is necessary for special operations to succeed, a casual acquaintance with the ethics of their craft is insufficient. As with other skillsets that SOF are required to master, mastery in the ethics of special ops must be the standard.

Incidents involving violence and aggression are unfortunately common on mental health wards and in community settings. These incidents can lead to emotional distress, mental health issues and, in certain circumstances, moral injury. Serious incidents of aggression are, however, critical learning junctures from which improvements in clinical care should be driven. Yet if staff feel under threat or unsupported by leaders, they may not engage in the process. Clinical leaders should therefore create clinical teams which are psychologically safe, so that learning can take place as a core component of team activity. How to create such cultures is described, wherein leaders play a critical role. Staff support, after an incident, must be part of the learning process, for no traumatised team can learn effectively. Post-incident reviews should form a key component in this learning process. A team-based seven-step process of incident review is outlined, which does require skillful delivery. In some instances, a formal investigatory review might be needed, as well as prosecution of perpetrators, and brief guidance is given on this.

The end of a war is not just about a societys making peace with its former enemy. It is also about the societys making peace with itself. This begins with welcoming back those who have gone to war, those who must be at peace with themselves and at peace with others over what they have done. My title, The Lament of the Demobilized, is from Vera Brittain, a leading pacifist voice of the twentieth century whose pacifism – I call it soldier pacifism – was grounded in her first-hand experience of war. Such soldier pacifism holds that the grief of knowing war means the soldier can never fully return home, and that this constitutes an indictment of all war. I explore this theme through memoirs, literature, poetry, as well as recent topics in just war theory.