Friday, January 09, 2009

The Pentagon Dishonors Our Wounded Veterans

After considering the matter, the Pentagon has decided not to award the Purple Heart to veterans who suffer from Post-Traumatic Stress Disorder (PTSD) as a result of their service. The Purple Heart is a medal bestowed upon soldiers wounded or killed in enemy action, entitling its awardees to various benefits, including waiver of co-payments for medical treatment at veterans hospitals as well as high priority in scheduling medical appointments. PTSD is a psychiatric disorder that afflicts many exposed to highly traumatic events (such as war combat) and is characterized by symptoms that can include recurring nightmares, uncontrollable rage, and severe depression. Victims of PTSD often find it impossible to work or otherwise function productively in the ways they could prior to their traumatic experiences.

Those who defend the exclusion of PTSD from the injuries qualifying a veteran for the Purple Heart make some variation on four arguments: 1) it is sometimes difficult to diagnose PTSD with certainty, 2) symptoms may be faked, 3) enemies do not deliberately inflict PTSD, in the way that they deliberately kill and maim with weapons, and 4) PTSD is not a physical wound. These arguments are unpersuasive and demonstrate the continuing vitality of the mind/body fallacy that has plagued societal attitudes toward the mentally ill over the centuries.

1) On the question of ease of diagnosis, the Pentagon could have addressed this matter in a variety of ways, short of disqualifying PTSD altogether. It could, for example, have established criteria under which health professionals would decide -- just in the way that doctors reviewing disability claims decide -- who qualifies for the PTSD diagnosis for purposes of receiving a medal. Just as a person who suffers a stubbed toe as a result of an enemy assault would not thereby qualify for a Purple Heart, so would a soldier who suffers from mild, normal-range sadness after serving in the military similarly not qualify. Though I would not support doing so, moreover, the Pentagon could even require total disability as a prerequisite for the medal. By instead denying all sufferers of PTSD the Purple Heart for their injuries, the Pentagon implies that because diagnosis may be difficult, it is not worth the bother to recognize the sacrifice of afflicted service members.

2) Any time a person must meet criteria for any medal, there is room for fakery. Though it is difficult to fake the loss of a limb, it is certainly possible for a person to pretend that a physical injury suffered in a non-military context was in fact the result of enemy fire. Anyone who appears at work on crutches has had the experience of jokingly inventing heroic adventures to explain what was actually a slip on black ice. Furthermore, the assumption that people who claim to suffer from mental illness are inclined to and can easily "fake" their symptoms is a common misconception that infects lay discussions about the insanity defense as well. The reality is that because of the stigma attached to mental illness, people are much more likely to "fake" mental health than they are to fake a psychiatric disorder. And for those who do wish to engage in such fakery, most are not such talented actors that they can fool professionals who are trained to distinguish the ill from the well.

3) It is quite difficult to identify exactly what an enemy's goal was when we later assess the causal relationship between an assault and the injuries that followed. An army might intend, for example, to destroy munitions through a particular bombing operation but nonetheless know that in the process, soldiers will likely suffer and die. In such a case, no one would argue that the maimed and the dead did not earn Purple Hearts because the enemy did not "intentionally" kill or maim them. Injuries suffered as a result of an enemy assault in war are the foreseeable consequence of such an assault, and so are the mental disabilities that afflict many veterans who return from combat. PTSD, in other words, is -- in its causal connection to war -- not distinguishable from the loss of life and limb in a military campaign.

4) The notion that a psychiatric illness is not "physical" assumes that a person can have an experience in his or her mind without a corresponding physical component. If we ever believed such nonsense, our current capacity to analyze the brain -- through functional MRI studies as well as measures of various chemicals in the blood -- proves it to be false. When a person experiences psychological distress, there is a physical basis for this experience. Indeed, the etiology of PTSD lies in the impact of terrifying events on a person's neurological circuitry. Though psychiatric illness remains less well understood than much (though by no means all) physical distress, we do know that both types of suffering are experienced through an individual's brain and nervous system and -- when the trigger is war -- that both are a physical consequence of service in the armed forces.

In October, Congress passed, and the President signed, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, thus giving legal effect (in the health insurance context) to the notion that mental and physical illnesses are morally equivalent and merit equal societal consideration. It is disappointing that for those who serve in the military, such equality -- like that on the basis of sexual orientation -- remains elusive.

Posted by Sherry Colb