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Keywords: deployed German soldiers, value orientations, moral injuries, focus groups, psychiatric disorders. Dieser Einsatz sowie auch die nachfolgenden Missionen in Somalia und Bosnien-Herzegowina stellten noch Peacekeeping-Mandate dar, in deren Auftrag der Gebrauch von Waffen nur zur Selbstverteidigung vorgesehen war.

Diese Notwendigkeit weitete sich dann ab in Afghanistan deutlich aus, vor allem in den Jahren bis im Raum Kunduz in Nordafghanistan. LITZ et al. So kann es beispielsweise zu einer Dissonanz mit internalisierten Wert- und Normvorstellungen kommen. NASH et al. Wachstums- und Entwicklungsprozesse kommen.

Die ausgewerteten Daten wurden aus zehn Fokusgruppen mit insgesamt 78 Teilnehmern je sechs bis neun Teilnehmer pro Gruppe gewonnen. Die Gruppen hatten einen im Vordergrund stehenden therapeutischen Nutzen, da die Ergebnisse neben der wissenschaftlichen Auswertung zur weiteren Behandlungsplanung genutzt wurden. Aus diesem Grunde war kein Ethikvotum einzuholen. Die Gruppendiskussionen begannen im Regelfall mit der Schilderung Werte-bezogener bedeutender oder belastender Erfahrungen im Einsatz. Das ist hier im Inland oft anders. Von etwa einem Drittel der Befragten wurde das Verhalten von Vorgesetzten kritisch dargestellt.

Zwar gab es auch immer wieder Berichte von vorbildhaftem Verhalten, es dominierten jedoch eher problematische Aspekte.

Aber auch eine Auseinandersetzung mit eigenem moralisch relevantem Fehlverhalten wurde thematisiert. Im Vordergrund standen Zweifel, in verschiedenen kritischen Situationen nicht ausreichend professionell bzw. Wir konnten das nicht verhindern. Hinterher habe ich die vielen Leichen gesehen. Zum einen bezog sich dieses auf noch nicht einsatzerfahrene Kameraden, denen man helfen wollte, gut ausgebildet und vorbereitet zu werden.

Ein Soldat berichtete, nach dem Einsatz seinem Sohn nur noch Vorschriften zu machen und ihn nichts mehr alleine unternehmen zu lassen. In fact, Freiburg is unique in Germany in being a university hospital with a clinical ethics consultation service. Being the only institution of its kind, ie one that is built within the structure of a university hospital, the Centre for Ethics and Law in Medicine ZERM , Freiburg, founded in , is particularly well placed to collaborate with clinical units on an everyday basis and to provide ethics support services according to individual needs.

Because ethics consultation is likely to be a developing area, an initiative has been started by the author together with her colleague, F J Illhardt, to set up a network of professionals active in ethics consultation or interested in becoming qualified to practise ethics consultation. In October, , the Akademie der Wissenschaften und der Literatur, Mainz hosted the first meeting of a German network in the field of ethics consultation; the second meeting was held in January Different concepts, methods and settings were presented and discussed.

The clinicians involved stated in the evaluation following the two meetings that the need for ethics consultation was obvious, particularly in the care of the critically ill or in the care of patients where different parties' interests clash. It was recognised that there was a need to formulate quality control criteria for the outcome of decisions, and also for the competence of the providers of such services.

Another concern was the availability of ethics consultation for patients themselves and for their relatives. These issues need further elaboration and will be discussed at a future meeting. There is evidence among clinicians of difficulties in everyday clinical practice which require ethical competence, particularly in the treatment of severely ill patients. There also seems to be a growing interest in, and open-mindedness towards, seeking help in making the ethical dimensions of critical decisions clear, by consulting professional medical ethicists.

What are the reasons for this recent development? One of the reasons for the increasing ethical awareness in the health sector is the plurality of values. Not only different religious values or contrasting political ideologies, but also a plethora of lifestyles and personal preferences, make it almost impossible to generalise from one individual's wishes to other patients about, for instance, how to handle the doctrine of truth-telling at the bedside, or how to live the last weeks and days at the end of life. Another reason for the need for ethical competence and advice stems from the expansion of medical interventions as such.

It is the nature of the internal dynamics of medicine that practice is continuously changing through the limitless progress of research and its application. Among the many examples of the challenges created by expansion and innovation are the possibilities of prolonging the life of critically ill patients, even beyond limits which seem reasonable from a medical or commonsense perspective. As a result, dying in hospital has become a major ethical issue which is widely debated both by the public and the medical profession. Ethical dilemmas may arise from the patient's wishes as such, from the question of whether to follow these wishes or not, or from the difficulty of discovering what the patient's wishes actually are.

Closely linked to the complex issues of terminal care is the growing involvement or influence of legal aspects in clinical decision making. Sometimes ethical awareness seems to be motivated by a certain defensiveness on the part of doctors who are trying to avoid legal risk.

This question is—among others—a matter of rational and legitimate interest for any ethical investigation. Only if self interest and self defensiveness are a doctor's sole motivation will it be difficult to stimulate ethical discourse. In such a case it is the task of the consultant to find a balance between the professional's interests and those of the patient. Economic constraints are having an increasing impact on clinical decision making in Germany as elsewhere, if not at the level of individual treatment micro allocation , certainly at the level of national health policy and hospital policy.

The economic dimension of medical practice puts pressure on individual health professionals as well as on administrators. In this domain, and also in many other respects, the experience of ethical conflict has become common to all parties involved: doctors, nurses, patients, and family. The experience of ethical conflict , however, should not be considered a negative issue.

To become aware of ethical conflict and to be capable of formulating explicitly the clash of ethical principles and values, is a crucial factor in reflective and responsible patient care. At the university hospital in Freiburg ethics consultation is practised solely at the request of clinicians in need of help, and not on the initiative of the ethics professionals themselves. The requesting clinician also has the opportunity of influencing the setting for ethics consultation, in that he can choose between an individual and a group session.

Two working groups located in Munich and Freiburg directed by Hiddemann and Reiter-Theil are carrying out a special research project. This involves documenting and analysing the conditions of treatment at the end of life in oncology, neonatology, perinatology and intensive care. In addition, the needs for assistance in the clarification of ethical problems, in the ethical reasoning about the pros and cons of different treatment options and in the decision making process are being assessed as part of this research project in order to help develop, on the basis of empirical evidence, the most effective ethics support service.

There is often more than one category involved as is made clear in the case example discussed below in section 4.

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All four categories mentioned represent the perspectives of the health professionals seeking advice, not the view of the patient directly. This is due to our limited experience of ethics consultation, which is restricted to helping colleagues. Patients in Freiburg have so far rarely made use of direct access to ethics consultation.

Although this has been discussed recently, we have little practical knowledge or documentation about patients' needs in this respect. It seems probable that patients' needs would have very different foci, since those seeking ethics consultation would obviously not be either patients at the point of death or comatose patients. Yet the treatment of both these kinds of patient often causes ethical problems for doctors and nurses.

Furthermore it may well be that patients would wish to express criticism about care or communication in the hospital rather than ethical problems to do with difficult clinical decision making. Once again, there have been few cases in which the relatives directly asked for ethics consultation. Yet it does happen routinely that relatives as well as legal representatives of patients are invited to participate in ethics consultations and to give their opinion.

One example will be given in the following case report below see section 4. Another important issue concerns the ethical principles which are used to present an ethical structure and orientation to those in need of help. It is evident that the well-known attempt to offer a framework suitable for pluralistic societies, namely the four principles approach of Beauchamp and Childress, 15 fits well with the needs of a flexible ethics consultation.

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The principles 1. From this variety of settings it becomes obvious that the procedures and methodologies of ethics consultation have to be applied somewhat flexibly in a problem-oriented and person-oriented form.

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On the other hand, the variety of settings does require the consultant to use a systematic framework to structure and lead the process of exchanging views, moral reasoning and evaluating options. The ethical principles discussed accord well with the operating logic underlying ethics consultaton, as does an approach incorporating a systematic change of perspectives in order to ensure fair consideration of the views of all the parties involved.

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The systematic change and exchange of perspectives has to cover:. The reflection of the interests of the individuals involved the patient, relatives, the doctors, nurses, therapists ;. The analysis of the relationship between the patient relatives and the professionals;. The relevant social context such as family, friends, workplace on the part of the patient, while on the part of the professionals, the team, colleagues, hierarchy and related issues must be considered;.

The societal and legal circumstances of the treatment as well as the cultural and political context;. Acknowledgement of the universal ethical principles which serve as general ethical orientation.

Besides this ethical methodology, a set of rules should be available for ethics consultation. In fact, we have been practising many forms and combinations in order to find out what functions best in a specific context. There is at least one strong argument for professional moderation from the ethics side: as far as those with different professional experience and hierarchical positions are involved, an independent moderator is more likely to guarantee a full exchange of all perspectives than a professional who is a member of the clinical team.

Clinical problems encountered in the treatment of adolescents with anorexia nervosa.

Therefore, we suggest that the ethicist be the moderator and that he or she must have adequate training in counselling and communication. This raises the question of which professional and academic qualifications are necessary for a good ethics consultant. It is evident that no expertise is possible in this domain without a deep knowledge and analytical capacity in ethics itself. This can be developed during regular philosophical or theological studies. Special academic qualification in medical ethics is another objective criterion graduate, postgraduate or postdoctoral degree.

Also of great importance is competence in one of the health professions such as medicine, nursing or clinical psychology and a considerable experience in patient care. It may well be, however that a hospital chaplain is clinically more knowledgeable and experienced than someone qualified in medicine who turned to theoretical research very early. It may also be possible that a clinical ethics curriculum prepares candidates adequately for practice.

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