New Values for Military Medical Personnel? Medical Ethics in Military Context

In discussion rounds, I often get the sense that younger military doctors and medics sometimes hold a more radical view about certain things than the “old timers” – myself included.

Of the many different ethical dilemmas which we face in the medical service, I would first like to single out the conflict between the roles of physician and soldier. Publications by medical officers on this topic have been around for many years and in them they write from different perspectives about their understanding of their role, first as a doctor and then as an officer. I believe that particularly in light of overseas deployments, interest is increasingly focusing on the question that lies behind this, not only for the physician but generally for every member of the medical service: “What do we actually do in a combat situation – are we more medics or more combatants?”

At the moment, with the assistance of prominent ethicists, we are discussing the question of how we see ourselves as medics. Are there situations in which it is unavoidable or in which we are almost ethically obligated to take part in fighting – and what are the limits? Should we hide the Red Cross, so as not to become a target, or should we even go as far as to arm ourselves as heavily as possible?

This discussion is still a long way from being resolved. At a generals’ meeting at the end of 2014, we examined this question as one part of an overall picture – the medical service’s self-image.

Another dilemma can be seen when we act as a doctor, paramedic or medic during operations. How should we regard the relationship between ourselves and our patients in these circumstances, particularly given that we may be required to carry out a triage assessment? We can all recognize a mass casualty (MASCAL) situation, i.e. a situation in which the number of patients is too high for adequate treatment to be provided with the available resources. This means that even if the patient is one of our own soldiers, we still essentially carry out a usefulness assessment, in that we weigh up the chances for a patient who is very seriously injured against the possibility of being able to save many other patients who have lesser injuries. Thus there is a certain point when we lack personnel or material resources and we need to move away from individualized medicine as we know it in Central Europe, the United States, or Israel toward a consideration of the possibilities in such emergency situations.

But in my opinion this is not the actual dilemma. Rather, the ethical question is whether we should look after our own first, so to speak: Isn’t an injured soldier who is a member of the Bundeswehr or my coalition more important and worthy of treatment than a civilian or – even worse – an enemy? After all, we are not the German Red Cross, we are the Bundeswehr’s own medical personnel. As a military medical practitioner, I should be aware that my actions have an impact in three ways. Firstly on myself as the person providing treatment: I set ethical and medical standards for myself which I intend to meet. Then of course my actions have an effect on the potential patient – and if this is an enemy patient, whether I treat him or not has a considerable impact on the enemy. And the third group is my own soldiers – the people who I am actually there for. They put their trust in me and demand that I put them first. The good reputation of the Bundeswehr’s medical service during operations also rests on the trust troops have in one another and particularly the perception that we are there for them – whatever the conditions.

If we detract from this good reputation by treating others as well as or before our own soldiers, they might see this as a problem that needs to be confronted. I think this is something we definitely need to keep in mind, especially from the perspective of our obligations during operations.

The third dilemma, as I personally see it, lies in the fact that war and enemies have changed over the years. When I was a medical officer and a young staff surgeon, the most likely threat that I could think of was a war between NATO and the Warsaw Pact nations stemming from a possible confrontation. In this scenario, one could appeal to international humanitarian law, and there were – at least in theory – rules concerning how I would be treated as a medic or medical officer by the enemy and how I, as a medical officer, I should treat my enemy if I should encounter him as a patient. Given the mutual ethical obligations, I felt there was a certain degree of balance.

In modern conflicts and asymmetrical wars – currently we need only look at northern Iraq – we see significant differences. To be honest, what we see here and saw in the past in Afghanistan is, in my opinion, a real problem. For me, the enemy in Afghanistan and – worse still – IS, have a different quality. Somehow I had an emotional understanding of the old type of enemy. This enemy was a person from my European cultural group. In principle his task was the same as mine, only reciprocal. In the new wars – these asymmetrical conflicts – in which terrible things frequently happen, I often lack empathy, and personally I would have difficulty acknowledging some enemies as pitiable individuals if I encountered them as patients. This definitely makes a difference. And in this I see a dilemma that, in my view, creates an ever greater gap between what is legally correct and what is right. The fact that international humanitarian law is becoming less and less applicable in these kinds of intrastate conflicts is a big problem, especially for the medical service.

Therefore I firmly believe that events, discussions, publications, and lively dialog relating to these topics are extremely valuable and appropriate for adjusting our moral compass and developing our awareness of what it is that we stand for. Our Basic Law (Grundgesetz), enlightened humanism, or our religion – to name just a few – are key values for our self-understanding and which, in my view, we should bring into position against the atrocities of modern asymmetrical conflicts.

We – the older generation – should assume responsibility here in the discussion and cannot leave everything to the younger generation, even if they undeniably represent the future of the medical service. We should prepare our young people for situations which could arise in war or in such conflicts so that they can develop an intellectual concept of these dilemmas and ethical expertise for dealing with them. We really should promote dialog with the younger generation about these potential issues. In the last two years, we had a wave of conscientious objection within the medical service. A great number of those who wished to assert their right to conscientious objection were clearly financially motivated by the possibility of earning good money outside of the German armed forces. But I do not deny that there were some among them whose “eyes had been opened” by a difficult operational situation, who could not come to terms with it, and decided they could no longer carry on in such an emotional and ethical quandary. Consequently they sought a way out of the Bundeswehr. In my view, it was and is right to enable them to do this, since the right to conscientious objection should be observed in a democracy.

So let’s keep talking and hope to have many stimulating and controversial discussions on this topic. Medical ethics in military contexts will continue to create major challenges for us in the future.