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

Think for a moment about the most worrisome aspects of the practice of medicine. As a social scientist living in the United States, my list includes the expansion of the concept of risk (to the point where everything we do is risky and life is fraught with fear), the blurring of the line between therapy and enhancement, and the persistent notion that access to health care is a private matter, not a public issue. It never occurred to me—until I read Klasien Horstman's excellent book—that these problems might be related to the history of life insurance. I am familiar with histories of life insurance in the United States that chronicle religious resistance to the idea, but Horstman's work breaks new ground. In this well-researched and well-organized study of the relation between insurance companies, the medical profession, and the public she shows how modern conceptions of our selves and our bodies were shaped by the business of life insurance.

Horstman begins her short book with what appear to be the mundane sort of questions often pursued in a doctoral dissertation: How did late nineteenth-century Dutch physicians become associated with the life insurance companies? What were the implications of medical advising for the professional and social identity of physicians, for the development of their skills and expertise, and for the relationships between physicians, patients, and third parties? But in answering these questions, Horstman challenges shibboleths of critical histories of medicine and provides fresh insights into the current state of affairs in health care.

For example—contrary to the oft-accepted view that the epistemic and political power of medicine gave it unchallenged authority in matters of the body—Horstman explains how a series of decisions made by the Dutch medical association and the insurance companies limited the power of medicine. Her history suggests that the medical profession was, in fact, used by insurance companies to gain the trust of the public. She points out that early in their relationship with insurance companies, medical advisors did shape policy, but "gradually this more active role evolved into a more technical role; it was no longer their task to come up with new definitions and interpretations of problems, but to supply the means to solve the problems formulated by their companies" (p. 188).

Horstman's work also helps us understand the emergence of a culture of risk, where science and technology "do not so much assess and map risks as produce them" (p. 190). The need for medical examinations to assess the insurability of an individual changed the nature of the encounter between a doctor and a client. The traditional encounter was one where a sick person worked together with the doctor to diagnose and treat the cause of ill health; with the advent of life insurance, doctors and patients became adversaries of a sort. Now a healthy person was required to submit to a physical examination, and it was in that person's interest to thwart the work of finding signs of disease. At first this incursion was justified in the name of improving the lives of individuals—through the recommendation of healthier habits—and of the public—by using aggregated statistics to develop public health interventions. But eventually insurance companies realized there was little commercial value in promoting public health: "the much celebrated cooperation between medicine and the life insurance business was headed into a single direction: medicine only served the commercial interests of the business, while the business increasingly lost its concern for the interests of medicine as well as for the health of the public" (pp. 172-73). The cultural residue of this transaction was that "everyone's life became defined in terms of risk" (p. 172).

In Horstman's view, medicine provided an ethical "bridge" between the commercial interests...