Controversies in Military Ethics & Security Policy
"Soldiers need to be prepared to endure deep inner conflicts"
Hauptmann Alexander Schäbler is a district youth officer (Jugendoffizier) in Potsdam. Previously, he served with the Joint Medical Service (Zentraler Sanitätsdienst) on missions in Mali and Afghanistan. In Kunduz, his responsibilities included organizing military medical care in a small, locally deployed multinational team. Due to health issues, he requested a transfer to his current post. He has reflected on his experiences and the associated moral conflicts as part of a Master’s degree in Strategic Studies.
Mr. Schäbler, what dilemmas or conflicts did you face as a member of the Joint Medical Service during your overseas deployments? The Medical Service applies the principle of maximum care – i.e. whatever is medically necessary, must be done – during its missions abroad. Essentially, treatment must be equivalent to that provided by a German district hospital. The dilemma arises in situations where you have large numbers of wounded or sick people, especially when this requirement applies not only to German citizens or soldiers and allies, but also to soldiers of the host nation and the local population. Then demand exceeds capacity, and medical care is in short supply.
Are the capacities of the Medical Service on the ground even designed to provide such comprehensive medical care? No. In the context of a military operation, our medical capabilities are not configured to address the full scope of local public health needs, like births and infant care. Occasionally, we encounter adult patients with birth defects, genetic disorders, or other conditions that are typically detected and treated early in Germany. The daily medical challenges in our areas of deployment are far more severe – orders of magnitude more intense than those found within Germany’s highly advanced healthcare system.
Let’s be specific: Does this mean you had to decide whether or not to perform an appendix operation on someone from the local population, for example? Exactly. At home, you expect bottlenecks to be absorbed by the system. There, it was a different decision – turning people away based solely on their nationality or status differences. Plus, you often need an interpreter to mediate. You find yourself in a tense situation because you are a guest and helper in these countries, not an occupying power. So, the opinion of the local population also comes into play. It almost crosses over into diplomacy and politics.
So these are different roles that are hard to reconcile? Yes. There aren’t any clear dividing lines between what you can and can’t do. Or between what you have to do and what you’re not allowed to do.
But you also had to navigate standardized treatment guidelines designed to solve this very problem. During my deployment in Afghanistan, the Medical Rules of Eligibility (MROE for short) were in force. These are issued by NATO and followed by Germany. They set out clearly defined national, military and political criteria for selecting who is eligible for treatment and who is not. Entire groups of the Afghan army, for example, were not covered by our treatment criteria. Members of these groups had to be turned away regardless of their injuries or pain.
Did you have to do that yourself? Yes. Imagine there is a major incident. Suddenly there are five people lying injured at the camp gate, all wearing different uniforms: local police force, Afghan special forces or secret service. The treatment guidelines require you to decide who will be treated and who will not. This also means having to turn away someone who needs more urgent treatment and telling them their case has to be taken care of locally – while treating a less serious case, such as a member of the secret service.
Doesn’t that contradict medical ethics? In principle, these rules are entirely incompatible with German ethical, and perhaps even legal, standards. But it is always possible to override them by saying that this is a life-threatening case: If we don’t treat that person, we could be prosecuted under German law.
In your experience, what is the impact of all these factors? The effect tends to be indirect. In the situation itself, there is always time pressure, and the information you have is often not entirely clear. Usually, you just act, including as a team. But when you have to tell the Afghan commander in a moment like that, “for reasons that can’t be explained here, I can take these two and not the other three” – then of course there is incomprehension and you find yourself struggling to explain. That has an impact. So does the question of what becomes of these people after they have received treatment. What happens to someone who has had a complicated metal structure fitted to stabilize a fracture? What happens to an Afghan soldier who has had both legs and one hand amputated? Will he perhaps die of the long-term effects, or be left behind without any means of support? In a case like that, have we really saved a life? These are questions that weigh heavily on you if you are interested in the continuum of care and not just the acute emergency treatment.
Of course, a handful of German medics cannot alleviate the suffering of northern Afghanistan. While entirely comprehensible, from a rational point of view, this is still not easy to accept
But Afghanistan in particular showed that a stabilization mission can take on completely different dimensions. Ultimately, wasn’t the task of providing medical assistance to our standards simply too extensive? Absolutely. Of course, a handful of German medics cannot alleviate the suffering of northern Afghanistan. While entirely comprehensible, from a rational point of view, this is still not easy to accept. I do think all of this made me very disillusioned. Then there is the question of what principles are guiding a mission like this. Are we making a serious effort to help the local population, or is our healthcare provision merely a fig leaf for hard-nosed political calculations? For a young and naive soldier – as I was in Mali in 2013 – it’s a difficult moment when you realize at some point that the idea of providing assistance might not be the main priority.And you can never really shake that suspicion.
How did the stress affect you after you came back? At first, I felt exhausted and numb. The levels of stress and excitement over there were so high that the world here seemed kind of unreal and a bit boring, artificial. Even though rationally it should have been the other way around, it felt more like I was on an alien planet in Germany. But behind this difficulty adjusting lies a deep sense of uncertainty about our worldview and self-image, and the question of why soldiers actually go on missions.
This became particularly relevant for many when Afghanistan collapsed in 2021. At the time, I was still serving as a soldier in a multinational team in the Bundeswehr health system. I think it was around then that my depression started. But in my case, there were other factors too that were not related to my deployment, such as the Covid-19 pandemic.
Did you see a therapist for your depression? Yes, I went to outpatient psychotherapy. I was signed off sick for about a year. After that, I was transferred at my own request. I started a completely new chapter in my career, and have been doing much better ever since. However, I still harbor a lot of resentment and mistrust toward superiors and authorities, and, to a certain extent, toward the system as a whole, though not necessarily toward individuals. I felt that in Afghanistan, the politicians, superiors and authorities did not communicate fairly.
But you don’t question everything, do you? As a youth officer, you need to identify strongly with the “Bundeswehr system”. No. Partly thanks to my studies, I’ve gained a deeper understanding of how these things arise. It’s not that easy, but you can make your peace with it; I communicate this to the public as well now. When school students ask me what it was like in Afghanistan, I try to explain – give them the light version, so to speak – telling them what such an experience can do to you.
You can’t just escape your shared responsibility and shift it all onto others or your superiors. I worked in a key role in the emergency medical unit and was jointly responsible for everything that happened there. And I think I can be proud of the fact that we really tried to go far beyond what we were supposed to do. This annoyed our superiors, who were stricter about the treatment rules and guidelines. But we always felt that we had to be able to look at ourselves in the mirror and at the same time give the people we were working with – the Americans, the Afghans, and also the German military – the feeling that they could rely on us and trust our decisions.
Looking back on it now, didn’t you sometimes feel overwhelmed? Of course. Given our weak personnel setup, we couldn’t even work in shifts. For months on end, you’re the only one who can perform a particular role, such as a surgeon or emergency paramedic, so you do it 24/7. Even if you have to do three days straight because of the fighting in the region. For four months, I had two radios and two cell phones with me day and night, and they never stopped buzzing. There was almost no chance for any sleep or downtime.
To what extent was the multinational nature of your team a complicating factor? Regardless of whether it’s a military, medical or tactical situation, you find that in multinational operations, national laws and cultures clash with internationally standardized regulations and doctrines. The complexity and potential for conflict increase massively. Politicians need to be aware of this when they send soldiers on multinational missions.
In my case, it worked well. But I suspect that the multinational nature of such missions contributes significantly to the psychological strain, especially when the host nation is also involved. For example, the Malian army with its human rights violations, or the Afghan army, which certainly fought according to very different rules than we like to imagine.
Apart from your therapy, what else helped you deal with your experiences? It was definitely taking an abstract, academic approach to the problem, while I was studying but also in workshops. The military medical ethicist Michael Gross at the University of Haifa, for example, has clearly identified the various dilemmas: the dilemma of resources, the dilemma of dual agency – i.e. trying to meet the demands placed on you as a soldier while also being a humanistic medic. This helped me understand everything better, to clear up the jumble of feelings and impressions. But talking to fellow soldiers and good superiors afterwards was also helpful.
For your Master’s thesis, you took a critical look at the MROE guidelines mentioned earlier. Even if some of these guidelines are questionable, isn’t it better to have them than to have nothing at all? Or could they be better designed? I believe there is definitely a need for bodies of rules that anticipate situations and provide certain guidelines. However, these rules also need to be aligned with German law and German ethical standards, and adapted to the national context. At the same time, those who are subject to these rules – i.e. medical service personnel – must be well prepared in a transparent way in advance. But within the framework of mission-type tactics – which the German armed forces like to tout but rarely actually put into practice – soldiers on the ground should be given the opportunity to make decisions based on these rules, and these decisions should then be accepted and supported by third parties and superiors who are not themselves present. This was a problem for us sometimes, because decisions were questioned from 150 kilometers away based on disciplinary law or assessment results.
Are there other specific points that could be improved, even if this might not prevent all moral conflicts? Soldiers need to be specifically prepared for the fact that they will face moral dilemmas and may have to endure deep inner conflicts. Secondly, of course, efforts should be made to optimize structures and processes, minimizing dilemmas and limiting the consequences.
Open communication is essential as a way to gain different perspectives and limit the manifestation of bitterness and trauma
And people must be given the opportunity to talk about this whilst on deployment, for example with knowledgeable superiors, with military chaplains, and also with experienced medical professionals or people from other nations. I also think that open communication is essential as a way to gain different perspectives and limit the manifestation of bitterness and trauma. Trust breaks down bitterness, in my experience. Younger soldiers in particular, and perhaps also those who are indirectly affected, should not be forgotten in this process.
Did you get the opportunity to have such conversations during your deployment? Not with superiors as such, because they were hardly ever there, but certainly with the very experienced doctors and sergeants in the team. I am still in close contact with some of them today.
Did pastoral care also play a role in the process of dealing with your experiences? I had two conversations with Military Dean Adomat near the end of my deployment, which were very important to me. He wrote a letter to my superior in Germany at the time. His successor showed it to me one day. It was actually very touching and appreciative, and I felt very valued.
Is there anything else important regarding your experiences that we haven’t discussed yet? Looking to the future, under the expected national/Alliance defense scenario, moral injury will probably be the least of our concerns. On the other hand, the enduring consequences of such a war would surely inflict a profound and lasting moral injury upon an entire generation of soldiers. These psychologically injured individuals will not be able to reintegrate well into a post-war society.
A military medical research paper from the United States from 2025 points out that in large-scale combat operations, the role of prolonged care and triage will massively increase the risk of moral injury, not only for medical personnel.[1] NATO estimates put the number of casualties and deaths in Europe at 1,000 per day. In a Ukrainian frontline scenario, for example, the constant presence of attack and reconnaissance drones often means that the wounded can only be evacuated after nightfall. Sometimes, however, it can take weeks. Ordinary soldiers on the ground therefore have to try to keep their colleagues alive for much longer, and decide who receives which treatments and transport privileges. We ought to prepare ourselves for this so that we don’t stumble blindly into what might lie ahead. That feeling of powerlessness when you need to help – but can’t – has changed me.
Mr. Schäbler, thank you very much for the interview.
Questions by Rüdiger Frank. Assistance: Kristina Tonn.
