White coats, green jackets: Physicians and nurses in the Dutch armed forces, professional identity & agency, 1990-2010

Deployed on military operations with the armed forces, physicians and nurses have been confronted with multiple problems. Battle casualties, scarcity of supplies and personnel, danger, and civilians requesting medical aid were amongst the factors that could compromise medical professional standards. Meanwhile, military hierarchy and the deployment context potentially threatened healthcare professionals’ autonomy and aspirations. Physicians and nurses in the armed forces had to continuously navigate between the different expectations, priorities, and moral codes that came with membership of both the medical and the military profession and identity. This dissertation firstly traces the developments in the deployment of medical personnel with the Dutch armed forces between 1990 and 2010 from both a personal and an organisational perspective. Different peacekeeping, stabilisation/combat, and humanitarian missions all confronted military medical personnel with different circumstances, leading to different problems concerning the amount and nature of casualties, local natural hazards, the reliability of logistics, scarcity in personnel and equipment, civilian demand for healthcare, and military tactical use of medical resources. All factors had the potential to impede medical professional and ethical standards and harm medical personnel’s autonomy and agency. Secondly, this dissertation analyses the importance of professional identity and the meaning of professional autonomy and agency within decision-making processes. Most academic literature and debates focus on the question whether medical personnel can consciously serve in the military from a philosophical perspective. This dissertation makes an empirical and theoretical contribution by analysing military medical personnel’s actual experiences of dual-loyalty and dilemmas while deployed. Oral history reveals the nature of dilemmas and the factors contributing to their origin and solubility. Moreover, it reveals the salience of professional identity when making sense of complex situations, when making decisions, when acting on those decisions, and when justifying them in hindsight. Three different patterns of coping with dilemmas were identified through the analysis of discourse and emotions, reflecting the medical, military or – as discovered in this dissertation – hybrid professional identity. Furthermore, although situational factors remained influential, these different expressions of professional identity influenced the meaning and extent of autonomy physicians and nurses were willing and able to claim in complex situations. This dissertation demonstrates that instead of considering both professions and related identities as static and conflicting, and defining the problem as choosing between identities or loyalties, analysis needs to move beyond the obvious tension between professions. By taking a closer look at how identity is shaped and continuously reshaped and how it affected military medical personnel’s cognition and emotions in different phases of decision-making, it is demonstrated how medical personnel coped with military service in reality and dealt with the tension between professions and identities. It offers a new perspective on the paradox of the medical-military identity.