Medical Ethics in the Military Context – a Challenge for Research and Teaching

Medicine and the military have always gone hand in hand. This is not really surprising, given that war represents a danger to life and limb for the parties involved.

Among the prominent authors in modern times who have discussed the relevance of medical care in war is Henry Dunant (1828–1910), in his book Un souvenir de Solférino (English: A Memory of Solferino).¹ Still considered one of the most fundamental documents of the modern age, this report triggered the development of international humanitarian law. In the book, Dunant not only calls for the consistent provision of medical aid in war, but also demands protection for the medical service, which must be observed by the warring parties. Efforts to save lives require special safeguards in an environment where lives are being taken. A short time later, his demands found expression in the Geneva Red Cross Convention of 1864. This first Geneva Convention is extremely important. From the point of view of medical ethics, the Convention and the documents that followed are one of humanity’s greatest achievements.

After the Second World War, the world community finally managed to formulate the current Geneva Conventions and their Additional Protocols. This subsequently appears as an event that stands out in the history of mankind. The importance of the principles set out in these documents becomes especially clear in light of the asymmetrical conflicts of the 21st century. It seems doubtful whether it would be possible to agree on a similar body of rules again today. Safeguarding the acti­vities of the medical services is an on­going special challenge, with the aim of helping humanity to prevail even in times of war. This was impressively demonstrated during the International Security Assistance Force (ISAF) mission.² Military training should take this aim into account.³

Military medical ethics as a new field

In the military, moral problems arise that medical ethics does not have to face in the civilian context. To deal with them requires knowledge of military ethics as well as medical ethics, resulting in an overlapping zone of ethical reflection. To describe this field, the use of the term “military medical ethics” (in German: Wehrmedizinethik or Militärmedizinethik) has now become established. The term used in the Bundeswehr – Wehrmedizinethik – is derived from the term Wehrmedizin (military medicine), a special medical field that deals with the prevention, diagnosis and treatment of diseases and injuries in the military. The use of the term Wehrmedizinethik reflects an effort to be terminologically stringent.⁴

A systematized and institutionalized examination of questions of military medical ethics has been ongoing since 2016 at the Teaching and Research Unit for Military Medical Ethics (Lehr- und Forschungsstelle für Wehrmedi­zi­nische Ethik, LFWME). The unit was set up as a cooperative project between the Bundes­wehr medical service and the Catholic military chaplaincy as an externally funded project, funded by the latter, at the Bundes­wehr ­Medical Academy (Sanitätsakademie der Bun­deswehr) in Munich. In particular, the project aims to carry out basic research on military medical ethics, which the medical service’s various educational programs will then build on.

A further aim is to contribute fruitfully to national and international discourse on military medical ethics. In this context, the various philosophical approaches in ethics have to be considered. The question of whether medical ethics is motivated by an ethics of duty, of utilitarianism, or of virtue, plays a considerable role. While an ethics of duty starts by declaring recognized binding precepts to be the basis of moral action, a utility-oriented view derives the moral value of an action from its consequences. The virtue-ethics approaches which are increasingly gaining attention today develop appropriate plans of action from the virtuous attitude of the actor. If these distinctions are ignored, then it is not uncommon for discourse to be seriously distorted, making it difficult to reach an agreement on the formulation of internationally binding ethical standards. For example, consider the discussion about military and medical necessity associated with the dual role as doctor and soldier. Opinions differ internationally on whether medical service activities should primarily serve military or medical purposes. This also explains the difficulty of taking up the predominantly utility-oriented publications on military medical ethics from the English-speaking world without a dedicated reflection in the German context. A critical reading of such texts requires knowledge of the respective author’s underlying philosophical point of view. These texts should be discussed in light of alternative approaches such as the principles of biomedical ethics formulated by Tom L. Beauchamp and James F. Childress.⁵

Questions of our time in ­military medical ethics

One of the central problems of our time in military medical ethics is certainly the question of dual loyalty. This results, for example, from the simultaneous role of doctor and soldier. In particular, the International Security Assistance Force (ISAF) mission from 2001 until 2014 raised a series of military medical ethics issues that have been the subject of sometimes controversial national and international debate. They include, for example, the use of weapons by medical personnel. There was heated debate in the context of the Afghanistan mission, and not only in the Bundeswehr, on whether the agreements in the Geneva Convention are actually sufficient to protect activities by medical personnel. The question of medical care for the population in the country of deployment should also be mentioned. The associated allocation problems create serious medical ethical challenges for the decision-makers concerned. Internationally, the handling of torture has occupied military medical ethicists no less than the question of whether care of the sick and wounded should be geared more to military or to medical necessities.⁶

The closeness of military medical ethics to the ethics of technology becomes obvious in the field of human enhancement. The question of how to deal in the military context with the capability to technologically enhance human beings will become increasingly relevant in the future.

Moral psychology takes special account of the fact that ethical questions play an important role with regard to our self-realization as moral beings. Moral conflicts do not leave the soul and body unaffected, and the phenomenon of moral injury is increasingly attracting the attention of psychologists, ethicists and pastoral caregivers.

Physical Mental Moral Fitness (PMM) model

Generally speaking, the teaching of ethical skills is centrally important when it comes to successfully coping with the requirements of a soldier’s role at home or overseas. Following the U.S. Comprehensive Soldier Fitness (CSF) model, which contains many elements (including family fitness, social fitness, spiritual fitness), a reduction to three central core competence areas seems advisable from an application-oriented point of view.

The PMM model proposed by the Teaching and Research Unit for Military Medical Ethics consists of physical, mental and moral fitness (see fig. 1). The term “fitness” has proven particularly useful in emphasizing individual responsibility and the capacity for personal development. In analogy to the idea of fitness in sport, the need for soldiers to train to acquire skills can be extended to physical as well as mental and moral abilities. The importance of soldiers’ physical fitness is obvious. Mental fitness proves to be particularly relevant with regard to potential post-traumatic disorders. Furthermore, moral fitness is important with regard to the moral challenges associated with overseas deployments, which require ethical reflection.

Teaching and learning medical ethics

Knowledge of medical ethics is one prerequisite for successful activities in the medical service, but a corresponding basic level of knowledge is also essential in the other branches of the armed forces. The requirements arising from different roles both in the medical service and in the other parts of the armed forces have to be taken into account. The Joint Service Regulation (Zentrale Dienst­vorschrift) on ethical education in the Bundeswehr that was drafted in 2019 underlines this point emphatically in the field of general ethics, and makes some references to medical ethics.

As well as imparting fundamental ethical knowledge, ethical education in the Bundes­wehr also has to take into account various fields of applied ethics. Along with military ethics and peace ethics, the various branches of the armed forces should pay attention to questions of leadership ethics, cyber ethics, political ethics, the ethics of technology and medical ethics, for example, with a view to today’s real situations. Here the character of ethics as a cross-sectional subject is clearly evident, as it requires detailed knowledge in various academic disciplines as well as moral philosophical knowledge. This fact must be taken into account in the selection of suitable teaching staff. It is important to realize that it is almost impossible nowadays for the complexity and breadth of topics in the fields of applied ethics to be covered by just one teacher. For example, let us just consider the question of when human life begins. Without relevant knowledge in human genetics, embryology, anthropology, reproductive medicine, gynecology and perinatal medicine, this question cannot be mastered. Interdisciplinarity is therefore not only an advantage, but a pre­requisite. Similar examples can be found for all of the areas of applied ethics mentioned above. It should be pointed out that this is not in any way about preventing individuals from engaging with ethics by overloading them with requirements. What is important, however, is that teachers have an appropriate level of competence so that they can be accountable for the teaching they provide with respect to their employer, to their learners, and to themselves.

With regard to the imparting and acquisition of ethical knowledge, a distinction can be drawn between an ethics of teaching and an ethics of learning, with medical ethics serving as an underlying paradigm. An ethics of teaching focuses for example on the academic expertise of the teaching staff, which they are to be accountable for, and on the design of a course offering for learners that is capable of imparting both general ethical skills and skills in fields of applied ethics. An ethics of learning is based on the insight that engaging with ethical questions is an expression of morally accountable action in itself. To sensitize military personnel to this distinction and motivate them accordingly is a requirement that should not be underestimated.

In this context, it is important to avoid a serious fallacy: ethical competence must not be confused with morality. Morality means a person’s ability to perform a good act that stands in contradistinction to evil. Ethics is an academic discipline that considers precisely this human ability. Ethics is to morality as psychology is to the psyche, for example. Psychology as a science focuses on the psyche: ethics as a science focuses on morality.

Ethics has to satisfy scientific standards in research and teaching. To assume that anyone can be employed as an ethics teacher, even without an appropriate academic background, seems irresponsible with regard to both the teacher and the learner.

Stages of ethical education

Ethical education can only proceed in stages. Starting from a heterogeneous basic knowledge acquired outside the military, in the family, at school and in society, the aim is to impart a comparable fundamental knowledge that is appropriate for all. Indeed, military personnel today brings very different ideas of values and norms into the Bundeswehr. So far, instruction on critical engagement with values and norms has taken place mainly in the context of Lebenskundlicher Unterricht (or “character guidance training”), which is taught mostly by military chaplains. Their theological and philosophical training makes them especially qualified for this task. This should be distinguished from a third level consisting of content in fields of applied ethics (functional knowledge), which has to satisfy the requirements of each individual military role. For example, members of the medical service require more extensive knowledge of medical ethics than members of other military fields of activity.

Ethical Competence in Military Medicine (Ethische Kompetenz in der Wehrmedizin, EthKompWM)

In recent years, military medical ethics in medical service training programs has gained in importance both nationally and internationally. In the Bundeswehr, corresponding teaching content has been integrated into a large number of teaching formats. The Bundes­wehr Medical Academy in Munich has played a pioneering role in this regard. In addition, education and training formats have been developed at Bundeswehr hospitals. Complementing the educational offering in medical ethics, an international study day on medical ethics is held every two years in partnership between the Catholic military chaplaincy, the Center for Ethical Education in the Armed Forces (Zentrum für ethische Bildung in den Streitkräften, zebis) and the Bundes­wehr Medical Academy.

The question of how to implement a general education in applied ethics that is suitable for all rank groups, and a role-based education for medical service personnel, is a high priority for military medicine. The Teaching and Research Unit for Military Medical Ethics (LFWME) attempts to participate in this discourse in a special way. However, it is not purely an internal task for the Bundeswehr to determine which didactic and content-related requirements education in military medical ethics has to fulfill. As part of a conceptual proposal for medical professionals’ training, the following general suggestions could be formulated paradigmatically. A selective, one-part course offering does not appear to be appropriate for the purposes of lifelong learning. Training and continuing education in military medical ethics should accompany members of the medical service in all phases of their training, study and professional activities. Insight into and encouraging engagement with topics relevant to medical ethics could support a three-pronged model that starts early in the training process.

As a first step, a study day on ethics could give a first insight into moral problems and questions. This should ideally take place before the start of university studies, as part of the general basic training. This would be an opportunity to point out the importance of ethics for dealing positively with the questions and problems raised. Then, for example, the classes offered in the history, theory and ethics of medicine at the civil medical faculties within the framework of human medicine courses can be regarded as an important opportunity for in-depth study. Ethics proves to be closely connected with the history and theory of medicine. Since military physicians in training do not complete their studies at a central training facility, but are distributed across the medical faculties in the Federal Republic of Germany, the second step is to establish a uniform standard by providing guidance documents to accompany study courses. These would also offer an opportunity to ensure a common basic level of knowledge for subsequent ethics courses. Here the Teaching and Research Unit recommends one guidance document of manageable scope for each study year. A third level of ethics training could build on the ethics module already established at the Bundeswehr Medical Academy as part of post-university medical training. Since a basic medical-ethical education has already been provided in the history, theory and ethics of medicine subject in conjunction with the guidance documents accompanying the courses, it would now be possible to begin working on case studies in military medical ethics in a timely manner. These would provide an opportunity ahead of time to deal with the moral difficulties associated with the first foreign deployments.

An “Ethics in Military Medicine” certificate awarded after successfully completing the proposed program could serve as an incentive to engage with questions of military medical ethics. It would certify that the medical doctor has a relevant qualification in medical ethics beyond their role in the Bundeswehr.

In addition to academically based training and continuing education in military medical ethics, the Teaching and Research Unit for Military Medical Ethics recommends that relevant content should also be included in practical military training, for example in procedures for tactical casualty management. Moral conflict situations can be specifically set up to give soldiers the opportunity to test their theoretical knowledge in practice. This could be a particularly effective way of increasing the acceptance of training in military medical ethics. Considerations that were previously perceived to be a theoretical thought game can thus be recognized by military personnel as being relevant to successfully coping with deployments. Allocation problems relating to military medical ethics are particularly suitable in this context, such as how to care for the civilian population in the country of deployment, or deal with large numbers of casualties.

Moral injury

The recognized importance of moral injury in the context of various post-traumatic stress disorders following an overseas deployment should be given special attention within military medical ethics research and teaching. A “moral injury” is a psychological construct connected to a traumatizing event and focused on questions of morality.⁷ In a moral injury, experienced reality can no longer be reconciled with one’s own values and norms. The role that ethical education plays in connection with prevention, therapy and rehabilitation for moral injury-associated post-traumatic stress disorders is an important subject of current and future research. Here it will be necessary to pursue an interdisciplinary approach that combines elements of psychiatry, psychology and ethics. A serious problem that has not yet been investigated is the question of whether ethical education and the associated sharpening of an awareness of values and norms increases susceptibility to moral injury.⁸ Further studies are needed in this regard to enable evidence-based statements. Answering this question should be a high priority for military medical and military medical ethics research.

Practical relevance of ethical education in everyday life

The motivation to engage with topics in military medical ethics generally grows with increasing clinical and military experience. When an ethical question becomes relevant in a person’s life, it is usually a long time distant from the challenges and problems addressed in training. In the sense of lifelong learning, continuous education and training needs to accompany people throughout their professional lives, so that the experiences and insights gained can lead to a deeper understanding of the practical relevance of ethical considerations in everyday life.

In this context, the military chaplaincy’s diverse offerings are of key importance. This is all the more true since it is here that a protected space for ethical debate is offered, in which questions and problems can be openly discussed.

In analogy to the concept of fitness in sport, the PMM model suggests that continuous training is required to retain, build up and keep developing acquired knowledge and skills.

Summary

Since the 19th century, the close connection between the military and medicine has shaped increasing efforts to afford special protection to medical service activities. Establishing this entitlement to protection in international humanitarian law is one of humanity’s greatest and most important achievements; the fact that it is increasingly coming under threat in the context of asymmetrical conflicts poses a worrying challenge.

Central questions and problems relating to medicine in the military context are discussed in the field of military medical ethics, which is undergoing increasing institutionalization and systematization, also in Germany, where it is known as Wehrmedizinethik. The Physical Mental Moral Fitness (PMM) model emphasizes the triad of fitnesses that mutually complement and depend on each other. The role moral fitness plays in successfully coping with deployments requires further, more intensive research, not least with regard to potential moral injury.

Military medical ethics proves to be a cross-sectional discipline that requires a willingness to carry out interdisciplinary research. This in turn places high demands on teaching. Teaching the relevant content requires profound expertise. Ethics teachers have to be accountable to their employer, to their learners, and to themselves for the content they teach. 

This applies to all levels of ethical education and the critical-reflective engagement with basic, deeper and functional ethical knowledge that takes place within it. The concept of Ethical Competence in Military Medicine developed and proposed paradigmatically for the licensed professions by the Teaching and Research Unit for Military Medical Ethics ­(LFWME) shows how the transfer of knowledge can take place in military medical ethics. This draft concept is informed by the insight that engagement with ethics has a practical relevance in everyday life. With regard to the good life, it points far beyond the military medical context.