Dr Ruwan M Jayatunge M.D. 

Moral Injury

The concept of Moral Injury was introduced by Jonathan Shay. The concept of moral injury emphasizes the psychological, cultural, and spiritual aspects of trauma. It refers to an injury to an individual’s moral conscience resulting from an act of moral transgression which produces profound emotional shame (Litz et al., 2009). Moral Injury is disruption in an individual’s confidence and expectations about his or her own moral behavior or others’ capacity to behave in a just and ethical manner (Litz,et al., 2009). Moral Injury disrupts relationship with self when inner moral core is doubted.

Moral injury happens when a person is able to reflect upon a traumatic experience after the immediate danger has passed (Simmons, 2013).  Moral injury is different from PTSD; it is possible to have only one or both. PTSD is a fear-victim reaction to danger and has identifiable trauma symptoms such as flashbacks, nightmares, hyper-vigilance, and dissociation. Moral injury is an inner conflict based on a moral evaluation of having inflicted harm, a judgment grounded in a sense of personal agency. It results from a capacity for both empathy and self-reflection.  Some experts believe that people with ethical values and are capable of empathy often sustain Moral injuries.

Shay (2014) states that moral injury impairs the capacity for trust and elevates despair, suicidality, and interpersonal violence deteriorating the victim’s character.  Moral injury entails emotional distress associated with perceived violations of one’s moral code and has been proposed to be a possible contributor to self-injurious thoughts and behaviors (SITB) among military personnel. Three dimensions of moral injury have previously been empirically derived: transgressions committed by others (Transgressions-Others), transgressions committed by oneself (Transgressions-Self), and perceived betrayal by others (Betrayal) (Bryan et al., 2014).

Moral injury is strongly related to negative consequences associated with war-zone stressors that transgress military veterans’ deeply held values/beliefs (Currier et al., 2013). Currier, Holland and Malott (2014) hypothesized that lack of meaning increase the risk for adjustment problems after warzone service. Moral Injury describes the effects of acts of commission or omission in war that result in mental, emotional, and spiritual struggle (Drescher et al., 2013).

Several narrations in the Jātaka story book concur that the protagonists suffered possible moral Injury due to psychological trauma. For instance Champeiya Jātakaya narrates the moral injury suffered by the king of Magadha. The king of Magadha was in a prolonged war with Angurata provincial kingdom. The battle went for many days causing enormous destructions to king Magdha’s forces. He was exhausted and eventually became a victim of war trauma. When he lost the war the king could not face his subjects. He felt guilty for sending his troops to the war front. He saw a large number of women who cried for their dead husbands. He saw sad faces of the orphaned children. The king firsthand experienced the horrors of war. He saw death and destruction – saluted men, destroyed villages. He felt that he was personally responsible for this manmade disaster. The war violated his moral code. The king of Magadha found no way out and he committed suicide by drowning.

The Prince Ajatashatru was a worrier who witnessed a number of bloody combats. His innocence was consumed   by the war and his bad friends. He was influenced by Devadathha. The prince was continuously poisoned by Devadathha against the king. Prince Ajatashatru was confused. He wanted to be the next ruler to his kingdom. As instructed by Devadathha he tried to assassinate his father the King Bimbisara.

Knowing the son’s motives the old king Bimbisara renounced his Throne. Ajatashatru became the new king. But his suspicion and paranoia grew day by day. Devadathha wanted to murder the king Bimbisara who was a devotee of the Buddha. He continuously pressured Ajatashatru to kill the old king. Ajatashatru killed his own father in a cruel manner.

The King Bimbisara was forced to starve and then his soles were cut open inserted salt and he was forced to walk on burning charcoal. The king suffered many days and had an agonizing death. After murdering his father Ajatashatru had severe guilty feelings and suffered a moral injury. He declined the friendship with Devadathha. He could not sleep and he was continuously thinking about his evil act – the patricide. He went to meet a number of spiritual leaders, but found no salvation. Finally he met Buddha and asked for his forgiveness. The Buddha accepted Ajatashatru who murdered one of his main devotees and one who helped Devadathha to send assassins to murder Buddha. The Buddha had no judgements over Ajatashatru and showed genuine empathy. Ajatashatru found an emotional relief after meeting with Buddha. Ajatashatru embraced Buddhism and renounced evil acts.

Chulla Dhanuddara Jātakaya describes a betrayal. When Prince Maname and his bride were confronted by a savage in the forest the princess immediately felt for the attacker. His rough body and aggressive look attracted to her and she wanted to be with the savage. Her erotic desires increaseed and during the duel she gave the sward to the savage to kill her own husband. The savage killed the Prince Maname with one blow. Then the Princess Maname expressed her lust for the savage. The savage was surprised by her betrayal. He refused the Princess‘s offer and left her alone in the jungle. The Princess Maname was disappointed. She felt guilty for her backstabbing action. She was crying alone in the jungle and finally committed suicide.

Posttraumatic Growth

In the past 10 years, the literature on disasters and mental health has shifted from a focus on psychopathology, to an interest in documenting manifestations of resilience in the face of mass trauma (Cerdá, 2014). Positive psychology has provided a new forum for discussion about how we construe mental health issues. Each generation and each culture faces basic questions about the meaning of birth, suffering, and dying. Each has its own social constructions and ways of managing these very basic human experiences (Joseph, 2009).

Term, post-traumatic growth,” was coined in 1995 by Dr. Richard Tedeschi, a psychology professor at the University of North Carolina in Charlotte, and co-author of the Handbook of Post-traumatic Growth” (Garlington). According to Tedeschi and Calhoun (1996), posttraumatic growth can be facilitated by the process of self-disclosure in the context of a supportive social environment.

Post-traumatic Growth is the positive psychological change experienced as a result of a struggle with challenging life circumstances that represent significant challenges to the adaptive resources of the individual and/or an individual’s way of understanding the world and one’s their place in it. Post-traumatic growth is manifested in several clearly defined behaviors and thought patterns not necessarily present prior to exposure (Turner & Cox, 2004). Posttraumatic growth is thought to involve positive change in five major domains: greater appreciation of life and a change in sense of priorities, warmer and more intimate relationship with others, greater sense of personal strength, recognition of new possibilities or paths for one’s life, and spiritual development (Tedeschi &Calhoun, 1996).

Posttraumatic Growth had been vibrantly described in the Jātaka storybook disclosing a number of case studies. The protagonists of these stories face major life traumas and become overwhelmed.  However they find meaning in their suffering and experience posttraumatic growth.

Patachara was a young girl who was very pretty and naïve. Her father was a wealthy merchant and treasurer in the city of Savatthi. She had one brother and both of them grew up in comforts.

Patachara had a secret love affair with a servant in her household. When the affair was exposed both ran away from home. They lived near jungle and lived very poorly.  When Patachara was pregnant with her first child she wanted to visit her parents and ask for their forgiveness. But her husband prevented her. When she was pregnant with the second child she made her mind to visit the parents despite her husband’s advice. When her husband was away she left home with the child. But she could not go further she had labor pains and she delivered her baby on the way.

It was raining heavily and her husband came in search of her. When he saw his wife with the newborn baby and the elder son he immediately went to cut some wood to make a temporary shelter for them. But the husband never returned. Patachara was anxious and went in search of her husband. She found him dead beaten by a poisonous snake. She wept relentlessly. Finally she made her mind to visit her parents.

While on her way to the city she came near a river. Patachara kept the newborn baby on the river bank and crossed the river with her elder son. After crossing the river she requested her one year old elder son to wait for her and again she crossed the river to bring the newborn. When she was halfway crossing the river she saw an eagle was coming to grab her baby.  The bird mistook the new born baby as a piece of meat. She shouted at eagle. Then her elder son thought his mother was calling him. He jumped to the river and the river current took him downstream.  By that moment the eagle grabbed the baby and flew away. Hence she lost two of her babies.

Patachara was in severe grief. She cried and went to her parental home. But the house was not there. She could see only the rubble. A neighbor approached her and delivered a sad message. He said that her parents and the brother died when their house collapsed due to severe rain on the previous day. He further said that their bodies are burning in the funeral pyre at this very moment.

Patachara went in to severe shock following the loss of her loved ones. She lost her awareness and proper sensors. She ran to the town crying. Her clothes were torn and dirty. She was half naked. Then people thought she was an insane woman and chased her wherever she went.

Finally she came to Buddha. When some of the devotees saw a mad looking woman approaching Buddha they tried to prevent her coming. But Buddha allowed her to come near him. The Buddha realized her state of mind and allowed her to come to proper sensors. When she became calm Patachara told her sad story. The Buddha gave her a sermon reveling the universal truth about death and separation of loved ones. Patachara was able to realize the meaning of death. She achieved posttraumatic growth and she became a Bhikkuni.

Suffering means an individual’s report of his or her  awareness of one or more changes in normal function,  sensation, or appearance that cause him or her some degree of  physical discomfort, mental anguish, or distress (Kyung-Ah et al., 2009). When people suffer they always suffer as a whole human being. The emotional, cognitive and spiritual suffering of human beings cannot be completely separated from all other kinds of suffering, such as from harmful natural, ecological, political, economic and social conditions (Diehl, 2009).  There can be no more profound struggle than to understand the meaning of suffering (McGinley, 2008).

Viktor Frankl believed that complicated grief could be accepted as a crisis that encourages new meaning in life.  Frankl wrote:   We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters are to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph, to turn one’s predicament into human achievement. When we are no longer able to change a situation… we are challenged to change ourselves (Frankl, 1969). As Frankl viewed post-traumatic growth provides greater appreciation of life and development of personal strengths.

There are many other Jātaka stories (eg: Jaddisa Jātakaya, Sujatha Jātakaya etc) discuss posttraumatic growth.  The processes of self-disclosure, spiritual enhancement, realization of universal maladies such as disease, aging, death and dying, concept of impermanence help these individuals to achieve posttraumatic growth.

Kisa Gothami became devastated when her infant child died due to an illness. She went to the Buddha asking medicine to bring him back to life. The Buddha told her to bring mustard seeds from a family where no one had died. Kisa Gothami went to each and every house in the county asking for mustard seeds from a family where no one had died. But she could not find any house. But she did not give-up. She went to the next county. She went house to house but she couldn’t find even one house where a death had not occurred. Death was everywhere. Finally Kisa Gothami realized that there is no house free from mortality. She laid her dead child to rest in a cemetery and went to Buddha to become a Bikkuni. In Kisa Gothami’s case she achieves posttraumatic growth by realizing the meaning of death.

When heavy rainstorm flooded and destroyed Baradvaja Brahmin’s paddy field he became severely heartbroken. Months of his efforts were wasted within one night of severe rain. Despondently he looked at the destroyed paddy field. His eyes filled with tears. He refused food and laid on the bed aimlessly. The loss has caused enormous pain in his heart. The Buddha visited him and explained the nature of desire and how it causes emotional pain. Baradvaja Brahmin saw the correlation between extreme heart desire and subsequent emotional pain. The Brahmin realized the true nature of desire and craving. He was able to come to terms with his loss. Hence he achieved posttraumatic growth and regained his functionality.

The Bikku who had a severe PTSD type reaction in Maranabheruka Jātakaya was unable to function as a monk. His traumatic memories hounded him as intrusions and flashbacks. He was frightened all the time. He was unable to meditate. Mortal fear ruined his functionality. As a part of his therapy the monk was encouraged to think of death. Little by little he practised Marananusmathi Meditation or Mindfulness of Death Meditation. Gradually he was able to desensitize his fear of death. He realized that no one cannot evade death and it is a common occurrence and a universal phenomenon. The said monk reached posttraumatic growth by desensitizing his fear of death via Mindfulness of Death Meditation.

Angulimala who killed 999 men suffered from severe guilty feelings after he became a monk. As a person who took many lives of other people he became ashamed. He was an addictive killer; however after he renounced violence he relentlessly practiced Methha or loving-kindness towards other people. Once he saw a pregnant woman who was in pain. She was about to give life to another human being. Angulimala realised the value of human life and focused his loving kindness feelings towards the pregnant woman and blessed her for safe labour. This event changed his perception about life. He realized that life ought to be treated with love and respect. These positive emotional feelings gave Angulimala mental soothing. Hence Angulimala achieved posttraumatic growth.

Samawathi lived with her wealthy parents in a populated city. Once highly contagious infectious disease hit the city and a large number of people died. Following the disease the elegant city became a ghost town.  Death was everywhere. To escape death Samawathi and her parents decided to abandon their native town. They left their property and traveled to another county. They walked days and finally came to the nearest town. They were exhausted. Exhaustion and hunger weakened her parents and they passed away as soon as they came near the city gates. Young Samawathi was left alone in a strange city where she had no friends. She was devastated. But she determined to survive. She met a kind old man and his family. They adopted orphaned Samawathi. They became her new guardians.

Once the King saw young Samawathi and invited her to his palace and made her one of his queens.  She lived comfortably, but sad memories of her native town and parents impacted her. She needed spiritual guidance and she was searching for meaning.  She came to know about the Buddha‘s teaching through her old female servant. The old woman used to go to the temple and listen to Buddha’s sermons and narrated it to Samawathi in colloquial terms.  Although the illiterate old woman missed a large portion of the sermon Samawathi was able to grasp the main themes. This became a daily practice. Gradually she was able to understand the Buddha’s core teaching. She found a meaning and was able to conquer her negative feelings about past memories. Samawathi achieved posttraumatic growth.