In the awareness of evil and the tragedy of individual life, as well as in the awareness that life wants to be lived with dignity." I deliberately place this quote from former UN Secretary-General Dag Hammarskjöld (1905-1961) at the beginning of my speech. It is quoted from Roger Lipsey in his book Politics and Conscience. Dag Hammarskjöld on Leadership and the Art of Ethical Leadership. Admittedly, it is a bit unwieldy, but it sums up what it is ultimately about when we deal with the topic of wounded morale - moral injury: On the importance of ethical competence in everyday military life.
Introduction
It is not only since 24 February 2022, which Chancellor Olaf Scholz described as a turning point in German security policy, that we have been aware of the threat to human existence posed by war. For a long time, we could not or did not want to imagine such a war on European soil. Today, the daily images and news from Ukraine document the suffering of countless people caused by such a war. This reveals what I believe to be the central characteristic of moral evil. It is not a mythically glorified personified power.
Rather, it is about an interpersonal event in which the solidarity of man with man is abandoned, so that physical, mental and moral destruction is not only accepted, but also intended. The consequences are disastrous in the truest sense of the word; the lives of individuals and their communities are at stake.
In this context, the phenomenon of moral injury, which is the subject of today's discussion, emphasises the importance of dealing with moral and ethical issues. It reminds us again and again of the dignity of the human being and the need to make ourselves subservient to this dignity. This is a phenomenon at the interface of psychiatry and ethics that is increasingly occupying scientists from various disciplines in research and teaching.
Following my introductory thoughts, I would like to start by focussing on some central concepts; concepts that are essential tools for dealing with our topic. Building on this, we will address the question of ethical challenges in everyday military life. Why is it necessary for us in the Bundeswehr to deal with ethics? Is such an occupation even necessary? Or is it a soft skill that can be neglected?
The phenomenon of moral injury in particular seems to prove all those in favour of the question of negligible soft skills wrong. In addition to physical and psychological injuries, moral injury is becoming increasingly important, with important consequences for the training of soldiers. The Moral Fitness Model on Coping with Moral Harm gives an impression of the importance of acquiring ethical competence in dealing with morally damaging events, with which I place the phenomenon of moral injury in a larger context of ethical competence acquisition.
Ethics, morals, profession?
Ethics and morals are terms that we are confronted with in many different ways in our private and professional lives. We all know them. Everyone uses them. But quite a few of us flounder when it comes to explaining what exactly is meant by ethics and morals. To make matters worse, even ethicists do not always agree on what they mean.
Let us first take a look at the term ethics. It refers to the scientific-critical reflection of moral actions and the moral values, principles and norms on which these actions are based. Ethics as an academic discipline can be further subdivided. In addition to fundamental ethics, which is dedicated to the fundamental questions of the subject, a large number of area ethics can be identified, such as medical ethics, military ethics, environmental ethics and cyber ethics.
Ethics is part of the so-called human sciences, i.e. those sciences that study people and their characteristics. This includes not least their ability to distinguish between good and evil and to act accordingly; something that can be described by the terms morality or morality. In fact, it is worth thinking about what morality or morality means. Ethical thinking is closely linked to the realisation of being a moral or morally gifted being! When was the last time you recognised yourself as such?
Our lives are characterised by countless actions that we perform on a daily basis. We do not always think about whether an action is right or wrong. If this question becomes an issue when we decide to act, we can speak of a moral action that is an expression of our moral values, principles and norms.
Talking about moral values, principles and standards is an expression of our moral orientation. They play an important role as a guide when deciding on a course of action. Life, for example, can be named as a significant value and the principle of protecting life can be derived from this. This principle, in turn, is reflected in a series of norms, such as "Save drowning people!" or "Feed the starving!"
We humans have a multitude of shared, but also individual values, principles and norms. They are communicated and adopted in different contexts, for example in the family, at school or in the armed forces. The sum of the values, principles and norms of an individual or a community can be summarised by the term morality.
Moral competence is needed to be able to judge a situation morally and act accordingly. Alternatively, one could also speak of moral fitness, a term that I personally like to use in this context. The analogy with the concept of fitness in sport is entirely intentional! If you decide to run a marathon once in your life, this decision does not make you a marathon runner. It takes a lot of, often arduous, preparation before you get there. Perhaps you will read a book on the subject or talk to someone who has done it before. You will think about your diet. Above all, however, you will start running training. It is very similar with the decision to be a moral person. Just deciding that it is desirable to be righteous does not make you a righteous person. You need to get to work and start training, both theoretically and practically.
This is all the more important as there are a large number of situations in which there is no simple solution in terms of right or wrong. These moral dilemmas are characterised by the fact that two or more equally important moral values, principles or norms clash. In these cases, your decision has both positive and negative consequences, which can be very stressful, sometimes traumatising. In a military context, a moral dilemma can often take on the character of a dual loyalty conflict. This is a conflict situation that arises, for example, from dual medical and military deployment. Here, the values, principles and standards of members of a medical profession collide with military values, principles and standards. This may be the case during deployment, for example, if care for the civilian population is not possible for operational reasons and must be subordinated to military objectives.
Ethical challenges in everyday military life
Dealing with the concept of the dual conflict of loyalty has already led us right into the next part of my presentation, which will deal with the ethical challenges in everyday military life. The question "Why should I concern myself with ethical issues at all?" is the starting point for a purposeful examination of ethical and moral issues. It will come as no surprise to you when I answer this initial question: Because there is an important and central competence to be acquired here! And we only need to take a quick look at the Bundeswehr's current advertising campaign to realise that ethics and morals play an important role here. Slogans such as "Here you fight for your patients. Not for profit." or "Here you learn the difference between leading and demonstrating.", which appear in large letters on the campaign posters, convey a concrete image of the military profession and its values, standards and principles.
The question "What kind of soldiers do we want to be?" is inextricably linked to a number of other questions that arise from the roles we take on in our lives. We can also ask: "What kind of parents do we want to be?" or "What kind of doctors?" or "What kind of citizens?" These questions ultimately lead to the overarching question "What kind of people do we want to be?" And this question stands and falls with the acceptance of the ethical and moral challenges in everyday military or private life. Both areas are inextricably linked. The ethical decisions I make in the service have an impact on my private life and vice versa. The different roles that characterise me and my life can only be realised integratively, never in isolation from each other, let alone in opposition to each other. This is a task that should not be underestimated.
Ethics therefore plays an important role when it comes to the different spheres of soldierly competence. In a modification of the US Army's Comprehensive Soldier Fitness Model, the Teaching and Research Centre for Military Medical Ethics developed a tripartite model a few years ago that works with three areas of soldierly competence. I have described this in detail in my text Medizinische Ethik im militärischen Kontext. A challenge for research and teaching, in the journal Ethik und Militär, issue 02/2019, on pages 50-56. In addition to physical fitness and mental fitness, this model also recognises moral fitness.
Of physical, emotional and moral injuries
This seems necessary, not least in view of the significance of possible moral trauma. In addition to physical and psychological injuries, moral injuries are playing an increasingly important role. Even if they have always existed, they are now increasingly being recognised by the public as a result of the interdisciplinary moral injury research already mentioned. Moral injuries occur in the context of psychological trauma disorders.
I would therefore like to briefly address the dimensions of psychological injuries, which are usually the result of strong emotional shocks due to (life-)threatening events and are accompanied by a strong experience of fear, helplessness and horror. In this context, the World Health Organisation's International Definition of Diseases (ICD 11) formulates it relatively succinctly: "The person affected was exposed to a brief or prolonged event or occurrence of exceptional threat or catastrophic proportions."
A closer look at the causes allows us to differentiate between accidental and interpersonal trauma. While accidental trauma primarily has the character of natural or technological disasters, interpersonal trauma (we also speak here of "man-made" in the sense of "man-made") is characterised by an interpersonal act. Examples include criminal violence, sexual abuse, armed robbery, domestic violence, war, combat, torture, hostage-taking or imprisonment in a concentration camp. Julia Schellong et al. describe this in detail in the practical book Psychotraumatology in 2018.
These interpersonal traumas all indicate that, unlike accidental traumas, they involve serious moral issues. This difference is also reflected in the traditional philosophical distinction between possible evils that can befall people: In addition to the natural disasters labelled malum physicum, man-made evil is designated malum morale. It is interesting to note that both talk of interpersonal trauma and malum morale have always indirectly referred to the phenomenon known today as moral injury.
The realisation that moral injuries can play an important role in the context of trauma-related disorders led to the formulation of the moral-injury concept around 2010. In 2010, Peter Zimmermann from the Psychotrauma Centre in Berlin formulated the following questions: "To what extent can explicit events with a moral dimension lead to psychological impairment? Is there a risk of developing a longer-lasting disorder? Can a separate (sub-)group of deployment-related disorders be distinguished on the basis of violations of one's own moral standards? What consequences would a disorder of this specific aetiology have for therapy and prevention?"
Ten years later, most of these important questions are the subject of intensive interdisciplinary research in psychiatry, psychology, sociology, philosophy and theology. Even though moral injury is a relatively recent condition that can occur in the context of trauma-related disorders, moral injury has always existed. Interpersonal trauma (or the experience of moral evil) and the profound conflict of values and norms that it causes have always posed a particular challenge and have found expression in a variety of ways, not least in art and literature.
In view of the current state of knowledge and research, moral injury can be defined as follows: Moral Injury refers to a profound moral shock in the context of psychologically traumatising events, in which one's own or others' actions/non-actions contradict the values and norms of those affected and can no longer be reconciled with them. Three aspects can be particularly emphasised here: There is a profound moral shock in the context of psychologically traumatising events; it is a matter of one's own or another's actions/non-actions; these actions contradict the values and norms of those affected.
Those affected can therefore suffer a moral violation through their own actions/non-actions, for example by being forced to act/non-act. Or they can suffer a moral violation as a result of someone else's action/non-action; as a victim, because the action/non-action is directly directed against the person concerned, or as a witness, because one observes the corresponding action and cannot intervene.
The moral fitness model
In my view, the topic of moral injury is of considerable importance for ethics in several respects. It turns out that ethical and moral questions have direct clinical relevance with regard to diagnosis, therapy, rehabilitation and prevention of moral injuries. Consider, for example, the importance of ethical thinking with regard to therapeutic dialogue. Recognising, naming and discussing moral conflicts as such requires a considerable degree of ethical competence on the part of both the therapist and the patient.
In the following, I would like to present a model with which I place the phenomenon of moral injury in the wider context of ethical learning and ethical competence. This model was developed in the course of analysing the literature on the topic of moral injury, which sheds light on different aspects but does not usually link them together, resulting in a kind of synopsis. In the following, I will use ten individual steps to guide you through this model, as shown in the diagram, and illustrate individual aspects in more detail.
Let's start at the level of ethical training, in which the soldiers take part. Ethical training serves to develop moral fitness, which in turn plays an important role in dealing with a morally damaging event (moral harm) during deployment. What does moral fitness actually mean in concrete terms? First of all, moral fitness means recognising that we humans are moral beings. This goes hand in hand with an understanding of the importance of ethical issues and a willingness to engage with them. Ultimately, this is the prerequisite for acquiring ethical competence.
Working on and standing up for moral values, principles and standards certainly also plays an important role. Promoting the teaching of ethical education is also an expression of moral fitness, for example in the family, in the upbringing of children, but also in the service. Of course, this applies in particular to you as officers in a superior position. The example of moral fitness in military medicine can be used to concretise this once again: Here too, first and foremost is an understanding of the importance of defence medicine ethical issues and the importance of dealing with them. Added to this is the knowledge of special moral decision-making situations, which can sometimes take the form of a dual conflict of loyalties in the everyday lives of medical personnel. Knowledge of the medical ethics reference texts (Geneva Medical Profession, self-image, mission statement and motto of the medical service, etc.) is of central importance. This goes hand in hand with the advocacy of medical ethical values, especially in military contexts (key words: "Committed to humanity!" and "Service without arms"). Today, knowledge of moral injury is added to this. Knowledge of the moral fitness model could also be cited here.
If we now look at the keyword moral harm, i.e. the potentially morally injurious event from which a moral injury can result, then it should be noted that there is a difference between moral harm and moral injury. Moral harm refers to the cause, i.e. the traumatising event, while moral injury refers to the possible pathopsychological consequence.
I have already introduced you to the psychological concept of interpersonal trauma; moral harm is the ethical reference concept for this, for which I would now like to give you some examples from the military context. Above all, the following events can be identified: Experiencing violence and destruction, use of weapons, injury and wounding, death and violations of the Geneva Convention. The following aspects play an important role in connection with violence and destruction: the sight of destroyed houses and villages, witnessing brutality, violence and abuse, but also experiencing an attack or assault.
With regard to the use of weapons, the order to fire on enemy forces, the aiming and shooting at enemy forces and the responsibility for the death of generic forces prove to be significant. In the case of injuries and wounds, the helpless sight of sick and injured women and children, the sight of seriously wounded comrades or being wounded or injured oneself are of great importance. Dealing with death is of course always a particular challenge in our lives, but it is exacerbated in the deployment situation by the sight and/or identification of corpses and body parts.
Also worth mentioning here are Witnessing the death of a comrade and being responsible for the death of a comrade. Violations of international humanitarian law cover a wide range of issues. With regard to moral violations, however, the following points should be mentioned in particular: Torture, disregard of the protective sign and use of weapons by medical personnel.
It goes without saying that these experiences are sometimes accompanied by considerable moral stress. This moral stress can - analogous to the classic stress model and depending on the resilience situation - be experienced either as moral dystress (moral dystress) or moral eustress (moral eustress). Moral resilience in this context refers to the individualised relationship between moral vulnerability and moral strength.
Depending on this, a moral challenge or a moral injury characterises the individual development of those affected. Accordingly, a distinction can be made between a moral challenge complex (M-C complex) and a moral injury complex (M-I complex).
If we now look at this separately, firstly for the moral challenge complex, then moral growth can occur via various intermediate stages (moral awareness, moral processing and moral adaptation). On the other side (Moral Injury Complex), the focus is on the clinical examination of moral injury. The steps to be mentioned here are diagnosis, therapy and rehabilitation, which ideally lead to moral recovery.
I would like to add a few more aspects to the clinical picture of moral injury at this point: In moral injury, we are dealing with a complex of symptoms that is superficially characterised by the experience of guilt and shame, alienation, social withdrawal and anhedonia (loss of the ability to feel pleasure in situations that used to give pleasure). This can lead to depression and aggression. In contrast to post-traumatic stress disorder without moral injury, adjustment and anxiety disorders, intrusions and flashbacks (remembering and reliving traumatic events and the associated thoughts and emotions) play a less pronounced role.
With regard to therapy, it can be said that moral issues relating to deployment are becoming increasingly important in the treatment of trauma-related disorders in the medical services. In addition to trauma-therapeutic methods such as EMDR (Eye Movement Desensitisation and Reprocessing), the group-therapeutic processing of moral conflicts and changes in the value system plays an important role. The prerequisite for this is a deployment-related mental illness (PTSD, anxiety, adjustment disorder, etc.) of active or former soldiers in a therapeutic setting. The therapeutic approach is interdisciplinary, i.e. members of psychiatry, psychology, pastoral care and specialised nursing are dedicated to the care of those affected.
An important aspect of the model that I need to talk about are the pillar-like structures that you see on the far right and left of the graphic. These are a series of supporting factors: Military Support, Spiritual Support, Mental Support and Social Support. Military Support refers to the support provided by the Bundeswehr as an institution. This ranges from comrades to military superiors who listen to the problems of the soldiers to the members of the German Bundestag. Spiritual support in this context refers to military chaplaincy. This is usually the first point of contact when conflicts arise. Psychologists also act as an important support factor in terms of mental support. Social support is of great importance. This can be summarised as support from family and friends. Supporting factors play an important role in dealing with and processing potentially traumatising events. A lack of support can lead to a morally eutstressful experience turning into moral dystress and vice versa.
Finally, it should be noted that this can lead to a re-evaluation of the event and a strengthening of moral fitness. Ideally, the experiences made and how they are processed are incorporated into the further ethical learning process (ethical training) by those affected.
Summary and outlook
Moral Injury is receiving increasing attention as a new clinical picture, which is being researched using an interdisciplinary approach in psychiatry, psychology, sociology and ethics. This shows the importance of ethical competence with regard to the prevention, diagnosis, treatment and rehabilitation of moral injury.
The importance of ethical learning for everyday military life is illustrated by the moral fitness model for dealing with potentially morally damaging events. The clinical relevance of moral injuries emphasises the importance of further developing ethical teaching formats in theory and practice as part of competence-oriented training for soldiers. It can therefore be assumed that the teaching of ethical education and competence in the Bundeswehr will receive important impetus in the coming years, not least with regard to the moral injury problem. Moral fitness will become increasingly important as a core military competence. 
