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.

Military service members may perform an action – such as killing – that they realize is the best thing to do in some situation, but that nevertheless strikes them as being morally wrong or even unthinkable. Such unavoidable moral failure may involve feelings of extreme distress and self-destructive behavior, together constituting a ‘moral injury.’ Service members (or veterans) often feel an anguished sense of responsibility in these cases, while other people do not tend to think it is right to hold them responsible. I defend this mismatch of reactions against the claim that servicemembers cannot be responsible for actions that were unavoidable, arguing that this denies something important that their distress reveals. Their tendency to hold themselves responsible may be a fitting response that correctly represents how it matters subjectively to them that their own action was unthinkable. However, others cannot hold them responsible because they have not violated fair, shared, normative expectations.

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.

There is a tension in military culture between the growing acceptance of moral injury and an idealized view of Stoicism that leaves little room for the guilt and shame, mercy and forgiveness characteristic of moral injury and repair. Does that emotion-lean view do justice to ancient Stoic doctrine? I argue that it does not. The emotions of the Stoic moral aspirant, such as shame and moral distress, bear striking similarities to the negative self-reactive attitudes that P.F. Strawson famously discusses. Notions of mercy and forgiveness speak to the positive reactive attitudes. I develop my argument by turning to Seneca’s essay, On Mercy and his play, the Trojan Woman. Mercy, Seneca insists, makes good on the gentler side of Stoicism. Learning from the mercy others show us, and that we would show them, is one way that soldiers can begin to show mercy towards themselves.

This chapter investigates British sack atrocities to civilians during the Napoleonic era. It analyses how British soldiers represented this violence in their memoirs, especially through the lens of sensationalist gothic horror; and the challenges of estimating the scale of atrocities. It adopts a multi-contextual and multi-causal framework for understanding these atrocities, from situational rage and the brutalising experiences of war to the cultural and political contexts in which sack violence could operate. Whilst most British soldiers participated in the plundering of stormed towns, the murder and rape of civilians during sacks was perpetrated by only a minority. Across soldiers’ writings, we find horror, shame, and moral outrage at such acts; empathy towards the suffering civilian; and a moral duty to bear witness. And despite lamenting the inevitability of such atrocities, this did not prevent individuals, especially officers, from intervening to protect civilians, especially women, acts framed by chivalric and humanitarian ideals.

This chapter provides an overview of the process of moral development and the five domains of conscience functioning in children and adolescents. It describes how moral development and conscience functioning are affected by moral injuries and exposure to a natural disaster, specifically the 1988 Spitak earthquake. Alterations to conscience development and interference with conscience functioning resonate with the concept of moral injury, scientific studies of which have described moral injury in both combat and civilian populations. Both fields have been hampered by the fact that the current psychiatric diagnostic system for PTSD and depression in DSM-5, although identifying cognitive disturbances as symptoms, does not include specific reference to the moral domain. While symptoms of PTSD and depression may co-occur with conscience impairment, the moral injury involved requires creative methods for delineating the impact on demoralization and identifying potential treatments for re-moralization. Examples of conscience-sensitive evaluation methods for the domains of conscience – conceptualization, moral attachment, moral-emotional responsiveness, moral valuation, and moral volition – are presented. Each domain points the way to treatment possibilities.