Purple Hearts And PTSD

by hilzoy

Via Michael Cohen at Democracy Arsenal, the NYT:

"The Pentagon has decided that it will not award the Purple Heart, the hallowed medal given to those wounded or killed by enemy action, to war veterans who suffer from post-traumatic stress disorder because it is not a physical wound.

The decision, made public on Tuesday, for now ends the hope of Iraq and Afghanistan veterans who have the condition and believed that the Purple Hearts could honor their sacrifice and help remove some of the stigma associated with the condition.

The disorder, which may go unrecognized for months or years, can include recurring nightmares, uncontrolled rage and, sometimes, severe depression and suicide. Soldiers grappling with PTSD are often unable to hold down jobs.

In May, Defense Secretary Robert M. Gates said awarding Purple Hearts to such service members was "clearly something that needs to be looked at," after he toured a mental health center at Fort Bliss, Tex.

But a Pentagon advisory group decided against the award because, it said, the condition had not been intentionally caused by enemy action, like a bomb or bullet, and because it remained difficult to diagnose and quantify."

Let's parse this. You can only get a Purple Heart for something that is "intentionally caused by enemy action, like a bomb or bullet". How specifically does an enemy have to intend the consequences of his or her action in order for those consequences to warrant giving someone a Purple Heart? One might say that if the enemy intends something very broad, like "harm", then any soldier who suffers harm (or: harm of sufficient magnitude) as a result of what the enemy does is eligible for a Purple Heart. In that case, someone who got PTSD as a result of enemy actions aimed at causing harm would qualify.

Alternately, you could say that the harm someone suffers has to match the enemy's intentions more narrowly. For instance, it seems unlikely that people who plant IEDs want (in particular) to blow a soldier's arm or leg off, or to cause PTSD. More likely, the enemy wants to kill soldiers. Suppose that's right: then a soldier who got PTSD as a result of an IED would not be eligible for a Purple Heart, since s/he did not suffer a harm that was "intentionally caused by enemy action" (on this construction). But a soldier whose arm or leg was blown off by an IED would not count as suffering a such a harm either, nor would s/he be eligible for a Purple Heart. 

I don't see any way to argue that when an enemy intends to kill a soldier and that soldier is not killed but wounded, the enemy has "intentionally" caused the soldier's harm, but that if that same soldier got PTSD, that would not count as a harm the enemy "intentionally" caused.

The idea that PTSD is more "difficult to diagnose or quantify" than other things for which purple hearts are awarded is wrong as well. As Cohen points out, PTSD has clear criteria. I'm not sure what it means to "quantify" PTSD, but then I'm not sure what it means to quantify serious back pain or recurring headaches either.

Later in the story, someone tries a different rationale:

"There have been recent changes in awarding Purple Hearts. The criteria was expanded in 2008 to include all prisoners of war who died in captivity, including those who were tortured. "There were wounds there," Mr. Bircher said.

"You have to had shed blood by an instrument of war at the hands of the enemy of the United States,” he said. "Shedding blood is the objective.""

But shedding blood is not a condition of eligibility for a Purple Heart: "A physical lesion is not required". That's a good thing: if shedding blood were a necessary condition for being eligible for a Purple Heart, then soldiers would not be eligible if their bones were broken in combat, or if they suffered internal organ damage, or if their lungs were destroyed by chemical weapons, so long as they did not actually bleed. And that would be insane. I really can't see any reason for this decision other than the idea that mental illness somehow isn't real, or isn't a real consequence of enemy action, or wouldn't have happened if only the soldier who got it had been tough enough. That's wrong, and it's needlessly cruel. Moreover, holding onto these false ideas about mental illness will not help the military to deal more effectively with the psychiatric problems of its members. And that harms everyone.

Comments

[hilzoy]

And if anyone can figure out how to get the last 2 paras out of single space, I'd be grateful. Grr.

[hilzoy]

Ha! I did it! And by editing the raw html through guesswork!

Take that, evil TypePad! You try letting your poltergeists alter my text in random ways for which the editor provides no apparent remedy. But you can't stop me!

(Sigh.)

[JayS]

Now if you can just get the italics tags in your byline to render correctly for me, I'll grant you html genius points. Typepad seems particularly hinky tonight. Hopefully things will be better tomorrow.

[JayS]

And as soon as I comment the italics work. Good night all.

[hilzoy]

JayS: two more of its delightful glitches: (1) It has just started using a rich text editor, which displays tags as text. It gives the option of editing in html, but even if I knew html in any serious sense, which I don't, its html seems to be much more than usually complicated. I suspect, for instance, that it is preserving every stupid thing I did while I was trying to get it to render better.

And (2): for some reason, it decided that the opening 'hilzoy' was not, you know, part of the post. 'Command-A' selected everything but that line.

Which is why I only spotted it much too late.

I hate TypePad. I just wrote them a long frustrated note.

[hilzoy]

And fwiw, I have no idea at all why it is double-spacing the whole post. None.

[DCA]

OTOH, from reading Ben Shepard's history of military psychiatry from WW I on (A War of Nerves), I got the strong impression that PTSD, and battle-related mental illnesses in general, partake of the mutability that seems to be present in other diagnoses of mental illness--as, for example, neurasthenia, which nobody gets anymore. (In fact, if I remember Shepard's account, PTSD was actually developed around the aftereffects of being in concentration camps). This makes PTSD seem less "real", as a phenomenon, than, say, shrapnel wounds; none of which is to deny the experience of those who have it, but to show the difficulty of fitting it into the kind of rule-based system that governs the giving of medals.

[sonia]

It seems to me like a great big missed opportunity by the military here to begin to de-stigmatize mental health. And it looks like no one is much interested in doing that. Which is sad.

As Andrew Sullivan over at Dish suggested, it need not be a Purple Heart, but somethingg that symbolizes bravery and courage and pain suffered for one's country.

[Jesurgislac]

One strong motivation behind refusing to allow Purple Hearts to be awarded for PTSD, is that this would entail making sure veterans suffering PTSD were properly supported so that they caused no harm to others because of their disorder. And this would be expensive, and difficult, and absolutely worth doing, but did I say expensive?

Much easier and cheaper to let veterans with PTSD go unhelped and refuse to give them medals because that would mean taking responsibility for what happened to them and what they did to themselves (or to others) afterwards.

[woody]

The military brass, no matter what noises they might make to the contrary, ALWAYS regard "PTSD," "combat fatigue," etc., to be forms of malingering.

THey may fake a certain sympathy for the victims, but behind it is scorn: "Tough Guys" don't break down like little girls at the sight of a dead body. And anyone who is so delicate as to be unable to continue is unworthy of the trust of their buddies, because they might collapse.

So there will be no Purple Heart for the PTSD victims. It would be too much like honoring what those who award the medal regard as borderline cowardice...

[Brett Bellmore]

"or wouldn't have happened if only the soldier who got it had been tough enough. "

There's at least a little truth in that, we must admit; Hit ten soldiers with shrapnel, ten get wounds. Put ten through identical combat, not all ten get PTSD. Whether you want to call it "toughness" or "variant dopamine receptors", it's real, for all that we can argue about the implications.

[John Ballard]

As I read I had a flashback of that scene in Patton where George C. Scott slaps and insults a soldier with battle fatigue, calling him a coward.
Obscene.

[bedtimeforbonzo]

"The Pentagon has decided that it will not award the Purple Heart, the hallowed medal given to those wounded or killed by enemy action, to war veterans who suffer from post-traumatic stress disorder because it is not a physical wound."

And we all know there is no way a mental wound could make one suffer as much as a physical wound.

Terrible decision.

Having never been in the military, I nevertheless tend to think there is a great deal of validity in woody's point: "The military brass, no matter what noises they might make to the contrary, ALWAYS regard 'PTSD,' 'combat fatigue,' etc., to be forms of malingering."

It is that way in society as a whole regarding attitudes toward mental illness.

I am sure there are others here who suffer from bouts of depression or what-not who -- knowing it wasn't in their or the job's best interest to work -- have called in sick with the all-encompassing "flu," rather than run the risk of being attached to the stigma of mental illness.

I disagree with Sullivan. Creating a separate award would be furthering the notion that PTSD "doesn't count" in regard to Purple Heart consideration. It is a war-time injury, plain and simple.

[J. Michael Neal]

No, Brett, there is not even a little bit of truth in it. Mental health issues are not about being tough enough. Lord knows, I've tried.

[TH]

As an OIF/OEF veteran, I'd like to shed light on why I think the DoD is reluctant to give Purple Hearts to PTSD victims. I think one of the most important things to understand about military culture is just how important awards, and the corresponding ribbons are. It truly defines one's tenure. When in uniform, you can tell ALOT about a servicemember by identifying the ribbons they wear on their chest. You can tell where they've been, their relative length of service, and if they have a few performance based awards, whether or not they're good at what they do. Like an exotic vehicle, the top-tier ribbons (Medal of Honor, Navy/Army Cross, Silver Star, Bronze Star, Purple Heart etc.) are special because they are so rare. Like currency, if you allow more into the system, the value of an individual unit depreciates. They simply don't want that to happen because in their view, it will threaten the integrity of the awards process as a whole.

I tend to agree. The fact is that being deployed sucks for everybody. Some are able to handle it, some aren't. God bless those who suffer from PTSD, and it is incumbent on the VA and DoD to provide them care. But they shouldn't be rewarded for suffering from conditions that a significant amount of people have been exposed to.

[woody]

Me? I'm a 4-year USAF vet. Non-combatant (CommInt),'Nam, 67-68. I DO know a little about how the military mind works...Which is why I am just about dead certain there won't be any PHs awarded to PTSD victims...

[bedtimeforbonzo]

Usually, I try to read the post and at least skim through all the comments before adding something, but I missed Brett's comment altogether -- which questions the toughness of some who get PTSD -- until I saw JMN's reaction.

To which I can only repeat: "No, Brett, there is not even a little bit of truth in it. Mental health issues are not about being tough enough. Lord knows, I've tried."

[bedtimeforbonzo]

On second thought, Brett, it's quite possible to be tough AND suffer from mental illness. I'd cite Abraham Lincoln as one, high-profile, example.

[Jesurgislac]

TH: But they shouldn't be rewarded for suffering from conditions that a significant amount of people have been exposed to.

"The Purple Heart differs from all other decorations in that an individual is not 'recommended' for the decoration; rather he or she is entitled to it upon meeting specific criteria. A Purple Heart is authorized for the first wound suffered under conditions indicated above, but for each subsequent award an oak leaf cluster is awarded. Not more than one award will be made for more than one wound or injury received at the same instant. A "wound" is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed above. A physical lesion is not required, however, the wound for which the award is made must have required treatment by a medical officer and records of medical treatment for wounds or injuries received in action must have been made a matter of official record." (Purple Heart: Criteria - emphasis mine)

The brain is a part of the body. A physical lesion is not required. Veterans with PTSD require treatment by a medical officer, and this treatment is a matter of official record. That some veterans do not experience PTSD as a result of being in combat is irrelevant: some veterans are not wounded.

Seems to me that veterans with PTSD as a result of being in enemy action are entitled to a Purple Heart.

[hilzoy]

Also, PTSD happens in response to trauma, not to (e.g.) generally being deployed. It's not like trench foot or frostbite or something: it's a specific response to something like nearly getting killed by an IED.

Again, if someone can tell me how this is not specifically intended, but getting your leg blown off is, assuming an enemy who intends harm generally and death (not getting a limb blown off) specifically, I'd be grateful.

[Bruce]

A major problem with the this whole bullshit is "multi-tours" in which this horrifying kind of warfare continues to make PTSD more common -- I think just about anyone who serves in those circumstances should receive it.
Support the troops is just a slogan.

[bedtimeforbonzo]

TH: I was going to say you raised some good and valid points, given your firsthand knowledge of military culture -- before I read Jes' passage.

I think you still raise some good points.

After reading what you said and what Jes said, I think it comes back to the original point hilzoy raised: Why should a severe, perhaps paralyzing, mental injury suffered in the line of duty (even if it is widespread) not count the same as a physical injury?

[Mike Schilling]

Hit ten soldiers with shrapnel, ten get wounds. Put ten through identical combat, not all ten get PTSD.

Blow up a troop transport with ten people in it: some will be badly injured, some slightly injured, some will escape with superficial wounds. Why do we reward the fragile ones with, of all things, a medal?

[John Thullen]

We are told Christ was crucified, but at first, no none believed. Why? Because, human beings are literalists and require physical "show me" proof.

What, he was suffering from mental anguish and trauma? That wasn't good enough. Maybe he was just faking to collect unemployment benefits and disability. Jesus can't hold down a job now because he's a little sensitive to the effing meaningless violence and beastiality of the human race?

Get a job! I see here you have carpentry skills!

Ipso fatso: consult the special effects department and come up with stigmata. See, nail wounds. Now do you believe?

Purple hearts? It's obvious that giving purple hearts to soldiers suffering from combat-related mental illness would incentivize yet more combat-related mental illness. People would be falling all over themselves to get in the way of shrapnel.

Well, not too much in the way. Maybe just close enough to witness another guy getting cut to ribbons by shrapnel. Then, you get to go home AND get your purple heart.

I know how peole think. You can't let anyone out of the sight of American judgement. They'll rob ya blind!

t's like free universal health insurance. People would be breaking down the doors of every hospital in the country clamoring for that free spinal tap or maybe an exploratory needle through the eye sans anaesthesia.

It's all about incentives, people. When everyone gets a purple heart, what's the use in butchering each other in the first place?

That's right. There will no free anaesthesia. Especially for oozing shrapnel wounds. To provide free painkillers would weaken the essential moral fiber of America's youth and sever the ties between ends and means.

Especially the latter --- we want America to be lean and mean, especially mean, and understand the difference between the lentil pate and the basic lentil in a burlap sack.

You folks with physical wounds want anaesthesia? What ever happened to booze and heroin, like the sensitive guy with the mental tics sitting down at the corner of the bar at the local VFW or on the street corner, who'd just as soon kill you as look at you, because he can't the difference between death in war or death during peacetime, because we're all dead anyway.

And what's with the color purple for these battle medals? That seems a girly sort of color for such an award. That might be good enough for Oprah or Whoopi, but, by God, those medals should be fashioned of shrapnel, sinew, and bone and should smell like rotting flesh, and be a sort of gangrenous green and black.

[bedtimeforbonzo]

Bruce: I do not disagree with the spirit in which you are arguing.

". . . I think just about anyone who serves in those circumstances should receive it."

But as TH said, "They simply don't want that to happen because in their view, it will threaten the integrity of the awards process as a whole."

Explaining before that: "Like an exotic vehicle, the top-tier ribbons (Medal of Honor, Navy/Army Cross, Silver Star, Bronze Star, Purple Heart etc.) are special because they are so rare. Like currency, if you allow more into the system, the value of an individual unit depreciates."

These arguments have merit. But so does the idea that PTSD is a legitimate in-the-line-of-duty injury.

I think it goes back to woody's argument that military culture holds PTSD victims as not being tough enough.

[Brett Bellmore]

I think I've been misunderstood: As a determinist, I don't think there's any useful distinction to be drawn between "toughness", and neurological factors. So I don't think there's any blame which can sensibly be assigned to suffering from PTSD, or moral fault. But that's not how the military views these things.

Ideally the military should be screening volunteers for susceptibility to PTSD just as it screens for hemophilia.

[wonkie]

Well from the catagory of idle and uninformed speculation: to give Purple Hearts to people who got PTSD from combat reveals too much about the nature of the job of a soldier. Kind of like giving an award to a miner with emphasemia makes it a little too obvious that black lung comes with the job.

But my interpetation is colored by my assumption that emotional trauma is a more healthy reaction to the horrors of war than a failure to be traumatized. In other words to award people with PTSD is to acknowledge that war is horrifying and that emotional distress as a result is a foreseeable consequence.

Not quite what you want to put in your recruitment literature.

Better to promote the idea that people who suffer enotionally from exposure to war are in some way deficient. The problem can't be the war itself!

[Jesurgislac]

Brett: Ideally the military should be screening volunteers for susceptibility to PTSD just as it screens for hemophilia.

Ideally, the military should ensure that none of its soldiers ever get wounded in the line of duty.

[John Thullen]

Wonkie:

"But my interpretation is colored by my assumption that emotional trauma is a more healthy reaction to the horrors of war than a failure to be traumatized."

On the one hand we have Yossarian, whose mental state was as pristine and brilliantly reflective as the spit-shine on a five-star General's shoes, but who was so crazy as to be deemed fit for slaughter by his perfectly sane military superiors ....

... and on the other we have the behavior noted by Walker Percy, whereby the combat veteran, traumatized or not, sits in his barcalounger decades later, and looks back on his "moment" of combat traumatization as the first, only, and last moment he was ever truly alive.

[von]

Hilzoy, I don't think that you've correctly parsed the reasoning of the Pentagon Advisory Group ("PAG"). Accordingly to the NYT, the PAG declined to award a Purple Heart for PTSD "because ... [1] the condition had not been intentionally caused by enemy action, like a bomb or bullet, and [2] because it remained difficult to diagnose and quantify."

We'll assume that the NYT accurately conveyed the PAG's complete reasoning -- an assumption that, for reasons of the NYT's space constraints, doesn't strike me as plausible. But, even if true:

You're analysis of "[1]" is flawed because you fail to consider at least one additional alternative reading of the phrase. Indeed, the most likely reading -- to me, at least -- is that PTSD does not qualify for the purple heart because there is no evidence that the enemy intended a particular act to cause that particular harm.

For instance, you can assume that an enemy plants an IED with the intent that it cause physical harm to -- or kill -- soldiers. It's not clear at will the that enemy planted an IED with the intent that it cause emotional harm to the soldier substantial enough to result in PTSD. Moreover, although the enemy could reasonably foresee that planting an IED would cause vaious types of physical harm,* it would have no way of knowing whether the IED would cause some sort of emotional harm.

This is because PTSD can be caused by a combination of stress factors, including factors that are not directed at the individual soldier (nearby attacks, fear of attack, death/injury of comrades, etc.) PTSD can also be caused merely by the stress of being in a war zone, without any direct action by the enemy against the soldier in question. Some soldiers may suffer from PTSD without having faced a single direct attack; others may face multiple attacks without suffering from PTSD.

It seems to me that the commission is rightly noting that, at the present time, it is difficult-to-impossible to trace most PTSD to a particular enemy action in the same way that other injuries might be traced to a particular enemy action. That makes sense. We don't award everyone injured during a war a purple heart -- only those injured by a specific enemy action.

As for item 2, it seems that you misstate the concern. The concern is not that there is no way to identify PTSD; of course there's a way to identify PTSD. The problem is that it can be very difficult and costly to identify PTSD (a point that Jes alludes to) and, at the end of the day, you will frequently not know the precise cause (per 1).

By the way, I'm not suggesting that we not treat PTSD. Indeed, I echo many of Jes's implied concerns regarding our treatment of soldiers with PTSD. Much more money should be spent. I just don't think that your criticism of the PAG's reasoning fairly addresses the issues.

von

*Your assumption that the enemy intends to kill our soldiers via IEDs is also almost certainly wrong. More likely, the enemy wants to injure soldiers. An injured soldier is far more costly to us than a dead one -- a point that virtually every modern military commander acknowledges. (IIRC, that's one reason why NATO switched to a smaller round: It wanted to injure rather than kill the enemy, because an injured enemy saps more enemy power than a dead one.)

[Phil]

Brett: Ideally the military should be screening volunteers for susceptibility to PTSD just as it screens for hemophilia.

Can you let me know what the standard medical test for PTSD susceptibility is? Thanks in advance!

Jesurgislac: Ideally, the military should ensure that none of its soldiers ever get wounded in the line of duty.

You don't believe this for a single second, any more than you believe police should prioritize their own lives over those of innocent citizens.

[John Thullen]

Ideally, hemophilia should be handled under a don't ask --- don't tell policy.

On the other hand, since bleeding seems the point of war, why not recruit those who are really good at it?

It's a little like the rule regarding undescended testicles.

How?

I don't know. But I'll come up with something.

The enemy would be required to aim higher, thus giving the rest of us a little extra time to run away.

[Phil]

Actually, does the military specifically screen for hemophilia? I'd like a cite for that, please.

[Slartibartfast]

Ideally, the military should ensure that none of its soldiers ever get wounded in the line of duty.

I can't even keep from getting injured in my own kitchen, so I think this claim errs on the side of extravagancy.

[Jesurgislac]

Phil: You don't believe this for a single second, any more than you believe police should prioritize their own lives over those of innocent citizens.

Nope. It was a sarcastic response to Brett's comment.

[Phil]

Got it, Jes. Been clearing snow and need to re-adjust my detector following exposure to the elements.

[RogueDem]

After perusing the Purple Heart regs, I would have to say that they do exhibit some degree of consistency, if you get frostbite or trenchfoot, you know lose a few toes, no purple heart, if you parachute into position and break a leg or your spine, no purple heart. Those are just the bad things that happen in war but the enemy did not ‘directly’ cause them. I mean you are in the trench or doing a parachute drop to fight the enemy but the enemy did cause the injury.

I do think this a somewhat complicated issue, at first I thought Sullivan’s idea of a separate award was wrong for the reason stated earlier about further stigmatization but maybe the award should cover all ‘indirect’ injuries. It seems like either that or just give them all Purple Hearts, and I do not mean to be flip, I would think all those soldiers have been scarred in one way or another.

[bedtimeforbonzo]

"Can you let me know what the standard medical test for PTSD susceptibility is?"

Phil you beat me to asking Brett that very same question.

Good comments, wonkie and JT.

P.S. Phil: We've been missing the season's snows altogehter here in Newark, Del., even after today's no-show was fairly hyped up (I came to work all dressed and ready to clear snow off cars. Not that I'm complaining, but I wouldn't mind a good snow on a Sunday, so the boy could use the snowboard he got for his birthday.)

[von]

Also, PTSD happens in response to trauma, not to (e.g.) generally being deployed. It's not like trench foot or frostbite or something: it's a specific response to something like nearly getting killed by an IED.

Is that true? PTSD is certainly in response to trauma, but is it in response to specific trauma? (And can you easily tell what specific trauma it responds to?)

[Slartibartfast]

I think I fixed the formatting, but how it got that way in the first place remains a mystery.

[John Thullen]

btfb:

The depth of my shallowness knows no bounds.

[J. Michael Neal]

I think I've been misunderstood: As a determinist, I don't think there's any useful distinction to be drawn between "toughness", and neurological factors. So I don't think there's any blame which can sensibly be assigned to suffering from PTSD, or moral fault. But that's not how the military views these things.

I'm not talking about blame, either. I'm saying that "toughness" is entirely the wrong prism through which to be viewing mental illness.

[efgoldman]

Someone upthread had a sarcastic response which contains the truth: its all about the benjamins.

Its the same (wrong) reasoning which has kept health insurers from covering mental health treatment equally until forced to do so by legislation.

It costs money. It costs private insurers, and it costs the VA.

And of course, since the GOP mindset is still running the Pentagon, and to some extent the services, money is much more important than people.

Or haven't you noticed all the spiffy new multi-billion-dollar weapons systems, while GI families are getting food stamps. (No cite, sorry, but it has been widely reported).

[russell]

To hell with the medals. These people need emotional and psychiatric counseling, and plain, pragmatic help integrating back into civilian life.

The medals are great, but they don't do much for you when you're hallucinating, or can't sleep, or are plagued with angry or violent thoughts, or can't hold a job or maintain a relationship.

Thanks -

[triangular gutters]

I'm not sure the PH is intended as personal compensation for suffering. It seems to me that it is designed to valorize behavior: putting yourself in obvious harm's way. Nobody wants to get one, but it may affect your future behavior if you see that somebody else is rewarded for not seeking personal safety at all costs. It needs to be externally visible and immediately causal for others to draw the proper conclusion in the short term.

Mocking REMFs and fobbits only goes so far. The medal isn't really for you, it's for the interests of the military service as an institution.

I guess I've talked myself into totally disagreeing that there should be a connection between PH criteria and proper health care--which really is owed by the society for PTSD regardless of the internal cultural issues of the military.

[Gary Farber]

"...putting yourself in obvious harm's way."

Anyone who was deployed in Iraq post-invasion did that. IEDs and mortars don't discriminate, and there are no front lines. (There are more dangerous jobs, and less, but none that aren't dangerous at all.)

[Ransom]

I don't think its about the money. The military is not afraid of spending money. And the arguments about the enemy intending this precise injury, difficulty of diagnosis, those are strawmen. Its about admitting the nature of war.

Imagine you give the PH to all the PTSD sufferers in the recent unpleasantnesses. Now (someone know the numbers offhand?) PH wearers who got it from a psychic injury outnumber those who got it from being hit by something by 5 to 1. Now when TH sees a PH he's going to think "PTSD" unless he sees a missing appendage.

Anyway Its a complete redefining of what the PH means. Its no longer a symbol of noble scars but of the deeply corrosive effects of man's cruelty to man.

[Ransom]

Also there's the buy-in from the would-be recipients. Many of these people are ashamed of what has happened to them. Do they want to be wearing such a badge on their chests?

[just me]

I think another issue that makes awarding a purple heart for PTSD complicated is that some people who experience PTSD may not show the diagnosable symptoms until well after the stressing situation. With a physical injury it is pretty clear when and under what circumstance treatment was required, with PTSD that may not be the case.

I know there are some Vietnam veterans who weren't diagnosed for years after they completed their service. Now I assume you could put in papers to request the award, but could you tie the PTSD to a specific event caused by the enemy?

I think at this point, while they know the symptoms and can diagnose it, we still don't know much at all about it. It is like many other mental health diagnosis-we know it's there, we know what it looks like, but we can't pin point every factor that makes those symptoms appear. and with the purple heart it appears that under the rules you do have to tie it to a specific enemy action.

[RogueDem]

In my comment above, the end of the first paragraph was supposed to read “but the enemy did not cause the injury” but here’s another point regarding the Purple Heart regs, friendly fire is counted but obviously not caused ‘directly by the enemy’. In the “heat of battle” when bullets are flying everywhere one can certainly argue that it does not matter much which gun the bullet came from but in a situation where there is no enemy present but someone mistakes you for the enemy and causes the injury (e.g. Pat Tillman incident) well that counts for a Purple Heart because they thought they were shooting at the enemy.

It seems to me that the internal logic is breaking down here and that the real key is the nature of the injury, the fact that someone tried to kill you and that you were injured but survived, the red badge of courage and all that jazz. However, considering the way modern warfare is conducted the whole concept of the Purple Heart may well have outlived its usefulness.

[MikeF]

I'm fairly certain that there's no standard test for determining vulnerability to PTSD. There's been some research indicating that mixed-handedness may be an indicator, and at least one gene has been identified as conferring some degree of protection or vulnerability depending on which variant is present.

It would probably make sense to screen along those lines, but the results would be far from conclusive. And regardless, it's absurd to not give Purple Hearts to soldiers with PTSD.

[J. Michael Neal]

Also there's the buy-in from the would-be recipients. Many of these people are ashamed of what has happened to them. Do they want to be wearing such a badge on their chests?

This shame is exactly what we are trying to fight. It shouldn't be shameful.

[Tony P.]

Is it amazing, or is it predictable, that opinion for and against the Purple Heart for PTSD seems to divide along liberal versus conservative lines?

As an unabashed civilian, I ask myself: is the Purple Heart, and the significance attached to it, mostly an intramural thing within the military? Is it something like an Oscar for Best Costume Design -- an award from professionals to professionals, significant within the professional fraternity but hardly of interest to outsiders?

I'm talking narrowly about the decoration itself, not any substantive consequences associated with it. That soldiers suffering PTSD deserve substantive help seems uncontroversial. The dispute seems to be over symbolism: what should the decoration, appearing on one military person's chest, signify to another military person? In that narrow dispute, a civilian who probably can't identify the decoration at first glance might honorably decline to take part.

On the other hand, I'm not sure military people themselves would appreciate so standoffish an attitude. I have to believe that military people care about what the decoration signifies to civilians, as well as to fellow warriors. If so, it's a bit much to expect us civilians to leave it entirely to "the Pentagon" to decide who gets a Purple Heart and who doesn't.

If I remember right, "the Pentagon" awarded a Purple Heart to John Kerry for wounds that conservatives mocked as superficial, and properly, according to conservatives, did not award a Purple Heart to Max Cleland for losing an arm and two legs. So, liberals are not unique in questioning "the Pentagon's" judgement in these matters.

And that brings us right back to the argument between liberal civilians and conservative civilians: what should the Purple Heart signify to us civilians? Surely that's not for "the Pentagon" to decide.

--TP

[DN]

But a Pentagon advisory group decided against the award because, it said, the condition had not been intentionally caused by enemy action

No, it was intentionally caused by presidential action.

[Gary Farber]

It looks like this:

And the badge is completely easy to spot: it's a plain purple bar.

[Gary Farber]

Sigh. I guess posting pictures just went away, too. Anyway, pictures here.

Maybe I did the last one wrong, since a picture showed up in preview this time.

[Gary Farber]

"If I remember right, 'the Pentagon' awarded a Purple Heart to John Kerry"

Three, actually.

[Decline and Fall]

What no one seems to remember is that a primary focus of any insurgency or terrorist organization is to amplify fear among their enemies. One of the horrors of Iraq (I spent 2+ years there) is that an attack can come from nearly any direction at nearly any time with zero regard for collateral damage. Some people get PTSD from living every moment with the knowledge that you might die. The insurgents know this, which is why they operate the way they do.

So yes, PTSD is "intentionally caused by enemy action, like a bomb or bullet."

[hilzoy]

von: "Indeed, the most likely reading -- to me, at least -- is that PTSD does not qualify for the purple heart because there is no evidence that the enemy intended a particular act to cause that particular harm.

For instance, you can assume that an enemy plants an IED with the intent that it cause physical harm to -- or kill -- soldiers. It's not clear at will the that enemy planted an IED with the intent that it cause emotional harm to the soldier substantial enough to result in PTSD. Moreover, although the enemy could reasonably foresee that planting an IED would cause vaious types of physical harm,* it would have no way of knowing whether the IED would cause some sort of emotional harm."

-- That's what I was getting at in my original post. You can construe the enemy intentions broadly -- e.g., "harm or death". In that case, PTSD, being a harm, ought to count. Or you can consider it narrowly, in which case a whole lot of stuff that currently does count would not.

For instance, consider light shrapnel wounds. Suppose they are not caused by a bomb specifically intended to produce shrapnel wounds, but by some other sort of explosive device intended to kill or maim. Do we exclude people with those wounds, on the grounds that the enemy did not intend to inflict light shrapnel wounds? I hope not.

The narrow construction, I think, is pretty nearly untenable -- at least, if you don't want to exclude a whole lot of people who are presently included. The broad construction, as I said, includes PTSD. Is there a good rationale for excluding mental illness alone? If so, would any argument used to support it not also apply to e.g. moderate as opposed to serious wounds, or wounds directly caused by a shell as opposed to wounds sustained when the shell blows up a building that falls on you, crushing bones? (E.g., if one wants to put weight on the 'medium breadth' intention to cause physical harm, why not on the similarly broad intention to cause serious harm?)

[Todd]

I am an emergency physician who has served two tours of duty in Baghdad as officer in the U.S. Air Force Medical Corps.

Obviously, combat-related stress, including PTSD, can be severely disabling, and its injuries are compounded when military supervisors refuse to acknowledge it or even accuse the sufferers of cowardice. However, awarding the Purple Heart for PTSD could actually make things worse, for two reasons: first, because many soldiers with PTSD would be suspected of just faking their symptoms to get a medal; and second, because some soldiers actually would feign symptoms of PTSD to get a Purple Heart.

I have seen numerous Purple Hearts awarded in field hospitals. Sometimes they were given for injuries so devastating that the atmosphere at the ceremony was almost funereal. Some were awarded for wounds that required surgery, but would almost certainly heal without significant disability or disfigurement, and at those ceremonies, you could sense the envy of many of the onlooking soldiers. And on those occasions when a Purple Heart was awarded for a superficial wound that only required a few stitches, the junior enlisted would openly talk about how lucky the recipient was.

During my second tour in Iraq, a Colonel actually shot himself with his 9 mm pistol in an attempt to fake a sniper injury. He was by all accounts an outstanding commander, well-liked and respected by both his subordinates and his superior officers, but this incident ended his military career. The crazy thing is, if he actually had been hit by a sniper while walking on base at night, as he claimed, the resulting Purple Heart, while not indicative of merit or bravery (just a case of being in the wrong place, at the wrong time), actually would have significantly enhanced his prospects for promotion and favorable assignments. The incentive that led him to shoot himself is real. Imagine if officers and enlisted personnel thought they could enhance their careers by feigning the PTSD symptoms so clearly delineated in the DSM-IV.

What victims of PTSD need is accurate diagnosis, compassionate support, effective treatment without bureaucratic hassles, and an end to stigmatization and suspicion. To our shame, we are not close to achieving those aims, and when seen from this perspective, the issue of Purple Hearts is a relatively trivial question which nevertheless has the potential to distract us from the vital work that needs to be done to help military members suffering from mental trauma.

[Ransom]

What Todd wrote is trenchant regarding soldiers' macho attitude towards battlefield injuries. But to presume that officers/soldiers would fake PTSD to get the medal and advance their careers, or have the prestige, seems far fetched to me. A history of mental illness is not something you want in your record, and however much we want that to change, its not going to anytime soon. If in people's minds these kinds of injuries were equivalent, sure, but realistically?

Anyway this is a non-starter. Giving the medal for PTSD says the wrong thing about war, and it falls outside the symbolism that the symbol and its perceivers (rank-and-file collectively) want it to mean.

Todd is most right that PTSD needs to be taken seriously and not trivialized by a polarizing debate around this medal.

[Decline and Fall]

Todd: I'll second your characterization of military culture regarding important medals. I certainly wouldn't want to cheapen the PH any more than most medals have been cheapened. But it seems to me that in the interest of ending "stigmatization and suspicion," some sort of official honoring of vets with PTSD for their struggles would be appropriate.

A new "PTSD Medal" might have the opposite effect, ingraining the stigmatization (remember that all military medals are ranked by importance), to say nothing of the "faking PTSD" problem.

[now_what]

an attack can come from nearly any direction at nearly any time with zero regard for collateral damage

Sounds like my old neighborhood. Didn't get a medal for living there, though. Just a few scars and a tolerance for the sound of gunfire. Nothing career-enhancing.

[Nancy Lebovitz]

Afaik, there's a physical injury involved in PTSD--it's to the amygdala and the hippocampus.

I'm a very civilian sort of person, but I get the impression that the Purple Heart rules are structured to make war look more heroic and less random by only rewarding injuries that look more like the result of combat.

As for frostbite, if it happens because the enemy blocks the delivery of supplies, this seems as worthy of an award as a comparable direct injury.

[Slartibartfast]

The military is not afraid of spending money.

Untrue. The VA is notoriously reluctant to spend money. The military has no problem spending money on stuff; it's the spending on pesky healthcare problems that gives them buttrash.

[Gary Farber]

"Sounds like my old neighborhood. Didn't get a medal for living there, though. Just a few scars and a tolerance for the sound of gunfire. Nothing career-enhancing."

You're very brave.

[Darkling]

Todd

The incentive that led him to shoot himself is real. Imagine if officers and enlisted personnel thought they could enhance their careers by feigning the PTSD symptoms so clearly delineated in the DSM-IV.

If the incentive to feign symptoms of PTSD to gain an award is being used as an argument agaisnt the award in the context of an example where someone inflicted injuries on themself in an attmept to acheive the award suggest that the medal itself might be problematic? I have a great deal of respect for members of the military and I don't want to belittle them (politicians on the other hand...). Additionally, I'm not American so it may well be cultural differences, but I don't "get" the purple heart medal. I understand bravery and service medals, but the purple heart medal seem to be just an award to people who were in the wrong place at the wrong time. I cannot understand how the awarding of the purple heart ot an officer would enhance his chances of promotion (on the other hand a VC...).

I suppose I'm somehwat conflicted. The purple heart (Enemy markmannship award) doesn't make to much sense to me. Whereas, given that purple hearts are awarded I don't see how they can exclude PTSD.

[now_what]

I would bet good money that the chance of violent death in that neighborhood was an order of magnitude greater than the chance of violent death of a member of the military serving in iraq. I made a choice to live there, those serving in iraq made their choices as well.

I, however, didn't sign away all my rights in order to get paid cash to kill people about which I knew nothing, so no medals for me.

Which is fine. I lived in that neighborhood for a reason.

But I'm tired of america being turned into some militarized society where we must glamorize paid killers and where we are supposed to care about which ones get recognized for their efforts in killing people. Where mercenaries must never be criticized. Where we must elevate the military above all other parts of society, because if we don't, we'll be accused of being liberals.

I do not give a *&^&!$ about who gets the purple heart and who does not.

No standing armies. Do not kill. Figure it out.

[Darkling]

No standing armies. Do not kill. Figure it out.

This is a nice sentiment unfortunately reality is a little bit murkier. Should a state kill? No. Should a state defend itself. Yes. Standing armies are just a part of detterence. Not having a standing army would only work for an isolated country.

Nevertheless I think your last post contains a lot of hyperbole. I doubt that there is anywhere within the USA that has as signifacant risk of injury as service in Iraq. If that was true I believe those stats would quickly surface, eso in a blog like OW.

[John Thullen]

We could threaten to award purple hearts before any combat whatsoever occurs and then guys would shoot themselves before they shipped overseas.

The savings would be incredible but you could still have Memorial Day parades.

[ral]

Some careless souls might even earn Darwin awards.

[bedtimeforbonzo]

"PTSD is certainly in response to trauma, but is it in response to specific trauma?"

I began answering this question around 1 o'clock, got tied up with a couple of customers, sold them both trucks, and then when I finished the comment and hit the "post" button -- and kept hitting it like a knucklehead -- I kept getting a message about some kind of error, and since it was after 6 and we were locking up, I gave up.

Anyhow, since no one answered von's question, I would say that PTSD can definitely be triggered by a specific trauma.

On the day after Christmas in 2004, I severed more than two-thirds of my right thumb in a freak accident at work and, for the first several months of 2005, my mind was not right and I certainly was not productive (even though the plastic surgeon did an awesome job cosmetically; however, he was wrong when predicting I'd regain 95 percent of full use -- I'd say it's more like 65 percent).

I remember feeling particularly angry when friends and co-workers would reason "it's just a thumb."

I would have probably thought likewise -- until I lost mine.

You never realize how many little, everyday things you do with your thumbs which require dexterity until you lose one. I remember shoveling snow right after the injury, but counting dollar bills or, say, picking up a paper clip -- forget about it.

Over time, my mind and body felt whole. And maybe what I went through after the injury and the frustration in rehab -- which I gave up on -- was not PTSD, although I'd say it was.

And while my mind and body felt whole again, I can't begin to image the complexities and anguish involved in the PTSD war veterans face.

Obviously, some of them will never feel whole.

And if their PTSD was suffered in combat and it is not worthy of a Purple Heart, I don't know what is.

[wonkie]

Bedtime, I am glad that you have sold some trucks. I have been worrying about you.

An opposible thumb is a significant part of our humaness. If my dog had one he could open his own cans of dog food. Heck, I'd make him get off the couch and go get a job, lazy animal.

Thanks Todd for the very clear explanation of the attitudes behind the medals. Very helpful, if depressing.

[Mike Schilling]

Nancy, long time no see. We miss you over at rasfw.

[triangular gutters]

Gary Farber @ 2:39pm: Anyone who was deployed in Iraq post-invasion did [put themselves in harm's way]. IEDs and mortars don't discriminate, and there are no front lines. (There are more dangerous jobs, and less, but none that aren't dangerous at all.)

now_what @ 8:08pm: [I'm tired of an America] where mercenaries must never be criticized.

See, I find this hilarious because I'm a decidedly academic person who was paid to employ an odd mediating talent a few years ago in a combat zone. The one thing popular opinion seems and seemed very clear about is that non-military citizens doing a job in a combat zone are mercenary bastards. I could have just stayed at home amongst my books, and then I never would have had to worry about whether my life insurance policy would pay out had I been run over by the taxi taking me from my home to the airport. Medical care from the mortar fire would have been covered, but civilians don't get Purple Hearts. hilzoy started me thinking about this and now I think I understand why.

We could reconsider a lot of things in the context of these modern wars, but I'm not sure taking them as a pattern for future societal investment in struggle is either fruitful or constrained to simple local consequences.

[OCSteve]

I, however, didn't sign away all my rights in order to get paid cash to kill people about which I knew nothing, so no medals for me.

Wow. Post your address and I’ll mail you one of mine. (No PH, sorry.)

[Brett Bellmore]

"The purple heart (Enemy markmannship award) doesn't make to much sense to me."

It makes perfect sense: It's an encouragement for individual soldiers to risk injury engaging the enemy to advance the military's aims, rather than playing it safe. Handing out PTSD Purple Hearts does absolutely nothing to advance this aim of the medal.

[Jesurgislac]

Brett; It's an encouragement for individual soldiers to risk injury engaging the enemy to advance the military's aims, rather than playing it safe. Handing out PTSD Purple Hearts does absolutely nothing to advance this aim of the medal.

Because if the military were to publicly acknowledge that when soldiers engage the enemy to advance the military's aims, some of them will suffer invisible injuries that lead to PTSD, this would do nothing to inspire individual soldiers to acts of courage, since... knowing the military respects you even if you become mentally traumatised as a result of your service, is not inspiring?

I guess knowing that you may become mentally traumatised is not inspiring. But then, most soldiers don't want to suffer physical injuries either - a soldier who loses both her legs due to enemy action, may get a Purple Heart, but who would envy her having become permanently disabled? A soldier in a wheelchair receiving a Purple Heart may be inspiring - but part of that (surely) is the formal acknowledgement by the military, and via the military, the rest of the country, that these injuries were suffered in service to the country*?

Why is it more inspiring to have people suffering the invisible wound of PTSD shuffled aside and ignored and not regarded as worthy of acknowledgement? Because PTSD is not a respectable wound?

Soldier: What if they ask me where I got hit?
Hawkeye: Look them right in the eye and say without blinking, "I got hit in the butt." And if they keep bugging you, drop your pants and show them your scar.
Soldier: [Snort] make me laugh.
Hawkeye: Whitney, we're talking about your body. It's been invaded by a bullet and there's nothing amusing about that.
Soldier: Don't I know it.
Hawkeye: On the other hand, you should be proud. You have a very special wound - it's symbolic of this entire war. This whole thing has been one giant pain in the butt. When they wanna hand you your purple heart, you can tell them where to pin it.

*Even if I don't agree with it: this is the principle on which a volunteer military is based, isn't it?

[john miller]

I am not going to get into the whole should they or shouldn't they debate here, except to say there have been so good and not so good comments on both sides.

Among the latter category is Brett's last statement which is extremely insulting og the military.

[Sapient]

john miller, agreed.

Also, despite what people think of the actions of the U.S. military (or of any military action in general), the United States military does serve the elected civilian leaders of the United States. Medals are awarded not to soldiers who serve the interests of the military. They're awarded to soldiers for serving their country.

[John]

There seem to be a number of very serious practical problems with the idea of giving out Purple Hearts for PTSD.

Firstly, how do you determine that a particular case of PTSD was brought about by a particular incident? My sense is that you'd have to connect the PTSD to some particular incident involving enemy action. But how much is that possible? Often times the PTSD doesn't appear until much later. This would be very problematic.

Secondly, it seems likely that, rather than showing that the military doesn't view PTSD as shameful, what it will do is bring about investigations to determine if people really suffer from PTSD, and thus deserve the Purple Heart, or if they're faking it. You end up doing the opposite of what you're trying to do.

Beyond that, I think Hilzoy's initial explanation has something of a false dilemma:

One might say that if the enemy intends something very broad, like "harm", then any soldier who suffers harm (or: harm of sufficient magnitude) as a result of what the enemy does is eligible for a Purple Heart. In that case, someone who got PTSD as a result of enemy actions aimed at causing harm would qualify.

Alternately, you could say that the harm someone suffers has to match the enemy's intentions more narrowly.

Are these the only two options? I'd say the definition would be that the enemy intends to inflict "physical harm" on its opponents, rather than psychological harm. And it's problematic to say that they aren't intending to cause injury - of course they are. They are trying to cause injury and/or death. The idea that it is not "intentional" when a soldier causes an injury in an attempt to cause death seems ridiculous - in order to kill someone, you have to injure them, and injuring them is a preliminary stage to killing them. Causing PTSD is just a completely unrelated result.

As far as PTSD being hard to diagnose, I'd say the issue, as I said before, is more that it's hard to determine if the PTSD came from an incident of the sort that would qualify, under this definition, for a Purple Heart.

So, anyway, I'm very skeptical of the idea of giving purple hearts for PTSD.

[von]

I have to continue preparing for a deposition tomorrow, so I'll be very brief. Hilzoy, re: this point:

For instance, consider light shrapnel wounds. Suppose they are not caused by a bomb specifically intended to produce shrapnel wounds, but by some other sort of explosive device intended to kill or maim. Do we exclude people with those wounds, on the grounds that the enemy did not intend to inflict light shrapnel wounds? I hope not.

I don't see that as establishing your case. Maybe my post wasn't clear enough, but my point was about the "foreseeability" aspect of intent, not the quantum of harm. Under this thinking, an enemy can only intend what he or she can reasonably foresee.

So: An enemy planting an IED can foresee a wide range of physical harms, up to death(s). That includes the light shrapnel wounds that you identify. But the same enemy is not likely to be able to foresee whether (or the extent of) planting an IED woudl contribute to PTSD. And more to my point, it's unlikely that we'll be able to trace a case of PTSD to any particular enemy action (there may be rare cases in which we can, and maybe those arethe exceptions that prove the rule.)

[Jesurgislac]

what it will do is bring about investigations to determine if people really suffer from PTSD, and thus deserve the Purple Heart, or if they're faking it.

The military already do this.

You don't get a Purple Heart unless you have an injury for which you needed to receive medical treatment.

PTSD is an injury for which veterans need to receive medical treatment.

The military (at least, according to the only sufferer of PTSD I know personally) will spend quite some time investigating to establish that the veteran does have PTSD, didn't have PTSD before they went into combat, couldn't have got PTSD from anything that happened since combat. Only then will the veteran receive medical treatment for PTSD. Only then, therefore, will a veteran get a Purple Heart.

So the process will be the same. The only difference is that, absent a decoration, the process currently ends only with grudging recognition "yeah, we'll treat you", whereas a Purple Heart would at least recognize that this is a wound for which the veteran is entitled to receive honor from their country. It is a wound received in service. It's just a question of whether the military wants to honor the veterans who receive this wound.

Like Hawkeye's comment about the pain in the butt...

[bedtimeforbonzo]

"Thanks Todd for the very clear explanation of the attitudes behind the medals."

I second that.

Also, I understand the desire to keep as much meaning as possible behind each award, and make awarding them special, if not rare.

However, if a soldier qualifies for a certain award -- and here we are talking about the Purple Heart -- then he or she qualifies.

And I continue to think that PTSD -- along with a review of the circumstances, just as there is a review if someone loses a limb in combat, etc -- qualifies as a combat injury eligible for a Purple Heart.

P.S. Thanks, wonkie.

[ajay]

The Purple Heart is a bit of an oddity - other nations' militaries don't tend to give out medals just for being wounded. You get campaign medals for showing up, and other medals for performing well (either in the sense of doing your job well, or in the sense of displaying courage. Not the same thing).
But why single out a wound for particular honour, when it's often a matter of blind chance who gets wounded and who doesn't?

There's also the requirement that the injury result from enemy action rather than just from being on a battlefield, which is a tricky line to draw, as this discussion shows - why single out enemy fire over the many other hazards of the battlefield, like friendly fire, vehicle accidents, frostbite, heatstroke, UXO, disease and so on?

[p mac]

I understand hilzoy's point, but I think it's mistaken here. The purple heart is not an award that is recognized as particularly meritorious. I've only heard one story about Viet Nam from my uncle, and that was about how he got his "Forgot to Duck" medal for taking a shrapnel fragment in the ass while brushing his teeth.

The combat award that really matters to people is the CIB, and the real problem is that (a) it's only for "infantry" and (b) it isnt, or wasn't, granted to MP units on patrol, because that would mean that women were in combat. (Military logic at it's best.)

[Jesurgislac]

Because I had to look it up - CIB is Combat Infantryman Badge.