Public Bodies, Private Lives: The Historical Construction of Life Insurance, Health Risks, and Citizenship in the Netherlands, 1880-1920 (review)

In 1973, a California man wrote his Congressman to complain about his medical examination for life insurance. Insurance companies, he fumed, "defiled and defamed" their policyholders by subjecting them to exams by company doctors and then using the results to refuse coverage.¹ In the writer's view, independent physicians protected their patients' interests, but insurance doctors thought only of the company's bottom line.

How and why did some physicians become employees of life- insurance companies? Horstman's examination of the Dutch life- insurance industry from 1880 to 1920 traces the growing role of medical doctors in selecting candidates for insurance coverage. But this book is far more than a study of professionalization. Horstman contends that the new field of insurance medicine created a modern "culture of risk," redefining individual health as a matter of public concern years before the emergence of the welfare state. In the culture of risk, medicine plays a predictive as well as a curative role, emphasizing future dangers and their prevention. With the rise of medical examination for life insurance, "individual health destinies turned into health risks" (20); both individuals and society assumed new responsibilities for addressing those risks.

Commercial insurance has always sought to present itself as a public service—an image often difficult to reconcile with profit seeking and the exclusion of poor risks. Physicians were central to insurers' attempts to build their public image, since medical examinations allowed companies to insist that risk selection rested on solid science. But the new relationship between doctors and insurers, Horstman shows, was far from harmonious. Physicians' desires to protect their patients' privacy or to present them in the most positive light for insurance coverage clashed with the companies' needs for complete disclosure. Insurance medicine led to an ethical crisis for the medical profession, which furiously debated whether doctors should defend the interests of insurance companies over those of their patients. By 1910, however, the Dutch Medical Association reached an accommodation that "left the development of medical advising ... fully in the hands of life insurance companies" rather than the medical profession (185).

This creative and fascinating study also includes a discussion of the role of medical and information technologies—from urinalysis to death certificates—in insurance medicine, which eroded traditional notions of medical secrecy and privacy. Horstman concludes that predictive and preventive medicine, from insurance examination to genetic testing, may offer great promise for the health of populations but also poses dangers to those citizens who are identified as "abnormal risks."

Public Bodies, Private Lives suffers from an unidiomatic translation, and the author provides little comparative context for readers unfamiliar with the Dutch example. Nonetheless, Horstman makes a new and exciting contribution to debates about the welfare state, medical expertise, the body, and the changing nature of public and private spheres. Those who think of insurance as a dry, technical topic will change their minds after reading this intriguing and provocative book.