The mutual shaping of life insurance and medicine in Finland

Abstract

This article examines the mutual shaping of medicine and private life insurance in Finland before the Second World War. Based on historical texts and archival material, it shows the important effects that the involvement of medicine in client selection for life insurance companies had on medical knowledge and practice. The analysis focuses on the tensions between the main actors in life insurance underwriting – candidates, insurance agents, examining physicians and the central office – as well as the medical examination as the key site of these tensions. The article shows how the introduction of a set of procedural and technical innovations reshaped the medical examination and helped to stabilize the fraught network of life insurance underwriting. These innovations re-scripted medical work. They stressed objective measurable knowledge over the personal skill and clinical acumen of the examining physician, propagated the physical examination and the use of diagnostic technologies and vital standards, multiplied medicine’s administrative tasks, and contributed to the introduction of a risk factor approach to medicine. Moreover, the social organization of life insurance promoted the spread of these objects, practices and tasks to other fields of medicine. The case displays how medical innovations are developed through the situated interplay of multiple actors that cuts across the science–society boundary.

Keywords

actor network life insurance medical practice mutual shaping physical examination

Introduction

Standard histories place the rise of modern medicine in the 19th century, with the beginning of the 20th century being a key period of activity (e.g. Porter, 1997). According to this account, rapid advances in scientific research and technological development produced novel insights into various diseases, with new medical instruments, cures and diagnostic methods paving the way for contemporary bio- or techno-medicine (e.g. Bynum, 1994). The status of medical expertise increased as it became bureaucratized, adopted administrative functions, and formed powerful professional groups (e.g. Starr, 1982). Health became a public problem and responsibility, manifested in the emergence of a comprehensive system of institutions and extended measures of public hygiene and prevention that encompassed almost all aspects of life (e.g. Porter, 1999). This rise of modern medicine is usually discussed in relation to such factors as the increasing deployment of natural sciences in medical research, the reorganization of medical education, and the growing role of the state in health policy and in coordinating service provision (Bynum, 1994; Porter, 1997). This article examines another context for the transformation of medicine in the late 19th and early 20th centuries, namely the selection of clients for the life insurance business.

Private life insurance transformed modern medicine in several ways. First, it was instrumental in the propagation of the clinical examination, as well as a number of diagnostic technologies and vital standards in medical practice (Davis, 1981; Dupree, 1997; Horstman, 1997, 2000, 2001; Jureidini and White, 2000: 191; Lengwiler, 2009; Porter, 2000), such as height and weight tables (Czerniawski, 2007; Weigley, 1984). Second, it multiplied administrative tasks in medicine, raising the status of physicians in the doctor–patient relationship (cf. Dupree, 1997: 100–101), while also subjecting physicians to increasing bureaucratic control (Horstman, 2000, 2001: 93–103). Third, it introduced into medicine a novel ‘risk culture’ (Horstman, 2001) or ‘risk factor approach’ (Rothstein, 2003). Importantly, all of these developments took place in the subfield of life insurance medicine, outside mainstream medicine, and were driven by the needs of business institutions not usually associated with medical practice.

This article shows how transformations in medical practice resulted from a set of structural problems in the way underwriting was organized. Life insurance companies employed a technical solution from medicine, the medical examination, to solve these problems, but the relationship between insurance and medicine was not straightforward. Rather, mutual adjustment took place and the medical examination was reformed, changing the client-selection practices of life insurance companies while also introducing novel phenomena into medical practice. My primary interest in this article is on medicine, in which the objects and practices emerging through its association with the insurance industry include (1) a set of risk factors,¹ such as blood pressure or ratios of height to weight and their normal values; (2) various methods to measure these factors, such as the sphygmomanometer popularized by life insurance; (3) a medical practice in which these methods were embedded, that is, the health examination as reshaped by life insurance medicine; and (4) a new role for examining physicians as providers of expert knowledge for administrative tasks. In addition to the primary focus on medicine, I also address how medically informed client-selection practices first enabled the expansion of the life insurance business, yet ultimately led to medicine’s relative demise in client selection.

This relationship of life insurance and medicine is addressed in this article as a special case of mutual shaping.² A major aim of science and technology studies (STS) is to challenge the common assumption that nature and society are clearly separated domains. They show how the demarcation is in fact artificial and difficult to sustain, often by following closely the construction of a particular scientific truth or technological object. The number of concepts denoting this approach, such as co-construction, co-creation, co-design, coproduction, and social shaping, attests to its centrality to STS. This article is organized differently. It highlights the mutual shaping of two socio-technological domains, life insurance and medicine. Instead of describing how a particular technological solution, the medical examination, emerges as a result of the interplay of natural and social elements, the article shows how a technological solution from one socio-technological domain is taken up and reshaped in order to solve a problem in another, which in turn introduces changes in both domains. Thus, the approach in this article is at the same time more restricted and perhaps more complex than in the STS approaches mentioned above: more restricted, since the focus is strictly on medicine and life insurance and no other contexts in the development of the medical examination are addressed; more complex, because not only is the shaping of a particular technology followed but also the relationship of two socio-technological domains into which the technology is inserted.

This case study focuses on Finland before the Second World War and provides empirical material for a fresh interpretation of the development of medicine and life insurance (for large-scale international comparisons of the development of insurance, see Borscheid and Haueter, 2012). I approach life insurance underwriting as a socio-technical actor network that is stabilized through technologies and practices that have material agency (e.g. Law, 2007). The key actors in the Finnish life insurance underwriting industry from its origin up to the Second World War were candidates, agents, physicians and the central office, all of which had conflicting aspirations and interests. I show how the expansion of life insurance business at the start of the 19th century created tensions in the network, and how they were resolved through the reshaping of the medical examination practice. This reshaping involved various methods and devices to measure the vitality of the prospective clients, procedural rules pertaining to the ‘doctor-candidate interaction’, and examination forms for recording the information, which together ‘re-scripted’ the examination practice (Akrich, 1994). This re-scripting carried lasting repercussions both for life insurance underwriting and medicine.

The data considered in this article consist of archival materials such as insurance application forms, minutes of general meetings of medical associations and insurance organizations, company board records, and circulars for company employees. The data also includes historical texts such as textbooks, pamphlets presenting the subject to the public, articles in medical journals and trade magazines, and guidebooks for insurance agents and physicians that detail the practical aspects of risk selection. Judging by publication frequency in both the life insurance and medical literature, the medical aspects of life insurance were somewhat marginal: the topic is addressed only occasionally in articles scattered on the pages of the three national medical journals and in the publications of the Finnish Insurance Association, which was founded in 1911 (Pesonen, 1961); the Finnish Society for Insurance Physicians was founded only in 1943, and it did not have a special publication (Pellinen, 1993).

The structure of this article follows the cycles of historical development that defines the two domains under study. The first section sets the scene by describing the life insurance network and the role of medicine in it, which became more pronounced with the gradual expansion of the life insurance industry. The following section focuses on a key aspect of the dynamics of the network, namely, the tensions between the diverse actors involved in selling life insurance. The third section describes the reshaping of the medical examination, which consisted of three aspects: specific rules of conduct, examination forms, and medical technology. The common thrust of these reforms was towards a standardized and objective examination practice. Together they solved many of the tensions between the actors in the underwriting process as well as contributing to the transformation of life insurance practice and medicine, which are discussed in the penultimate section. The concluding section provides a short summary of the argument.

Medical expertise in the emerging network

Medical expertise was deployed differently throughout the history of the coupling of medicine and life insurance. The key task to which medical knowledge was put was risk selection, but it also served other purposes. According to Horstman (2001: 35–36), the companies turned to medicine in order to create public trust in an emerging and sometimes controversial field of business. Life insurance was accused of speculating with human lives and violating Christian principles of fate (Zelizer, 1983), accusations that could be countered by enlisting trusted local physicians. In addition, medico-scientific risk selection was also presented as a way to improve the financial robustness of the life insurance business amid news that mismanagement was leading to insolvency. Thus, medical expertise was adopted to stabilize the network in multiple ways.

Initially, medical expertise had a subordinate role in underwriting. For example, English life insurance societies in the 18th century preferred testimonies ‘from gentlefolk rather than from medical experts’ to counter adverse selection (Clark, 1999: 128). Later they relied on a system that supported the information in the insurance proposal with a combination of a personal interview of the candidate by the company board and written testimonies from both friends and the medical attendant. Medical expertise was represented by medical advisers employed by board of directors, or by medical directors who sat on the board itself (Alborn, 2009: 220–249). At this point in history, medical advisers acted more as consultants than gatekeepers. Client selection relied on technologies of trust that assessed information on the basis of the perceived credibility of the source and the personal experience and judgment of the assessor (Porter, 1995: 38–41, 2000). This system was used by international life insurance businesses in the middle of 19th century when they first came to Finland, which at that time was an autonomous part of the Russian empire. The small market was controlled by Russian and foreign firms until the founding of the first Finnish life insurance company, Kaleva, in 1874, as part of a nation-building exercise. Capital was accumulated through nationally owned banks and insurance companies, benefiting the economy of the nascent Finnish nation (Kuusterä, 1994). The political motive of nation-building was reflected in the social background of Kaleva’s owners and customers, who were mainly from the small Swedish-speaking but nationalistic urban elite. The company quickly gained a strong foothold in the expanding market for life insurance in Finland (Eskelinen, 1978).

Kaleva organized its business in the following way. Policies were offered only at the central office and by a few agents in the largest cities. Physicians endorsed by the company examined the health status of potential candidates. The examination reports were structured freely and focused on the present health condition of the candidate. The proposals were assessed at the central office by the entire company board, which included a medical director. These were typically senior members of the medical profession, often university professors (Pellinen, 1993). Applications were either accepted or declined, and all accepted applications were placed in the same pool. Despite the medical examination on entry, Kaleva’s initial system still rested largely on elements of the arrangement described above, namely the personal reputation and signs of respectability of the applicant. The selection process at the central office emphasized the collective assessment of individual candidates with a similar social background rather than medical facts established by expert physicians. This is reflected in the grounds for rejection at Kaleva at the turn of the century: while almost 25 percent of all proposals were rejected by the company board, less than half of those were based on the verdict of the examining physician (Mäkelä, 2002: 33).

When the life insurance business expanded to the whole country and new population strata, the role of medicine grew in importance. New companies targeted populations with social, cultural, linguistic and political characteristics that were different from those of Kaleva clientele. The first national rival to Kaleva, Suomi, was established in 1890. It addressed itself to the Finnish-speaking countryside, and life insurance started to spread into the lower classes. Due to internal strife in the Finnish party that was close to Suomi, a group split from the company to found another, Salama, in 1910 (Lyytinen, 1991). These three firms dominated the life insurance business in Finland before the Second World War, although there were a number of smaller players on the market, some short-lived (Rinne, 1966). After Finnish independence in 1917, the three central companies all made efforts to transcend the particular social and political demographics they had traditionally served and to offer policies to the whole population.

The expansion of the industry was driven by fierce competition at the turn of the century. The companies built networks of local insurance agents in order to better reach potential customers. The companies recruited well-respected citizens of local communities – notably teachers and religious officials – for the work, which was usually carried out as a secondary occupation. Agents collected a commission for each new finalized contract, although some worked without charge because of idealistic goals (Lyytinen, 1991: 5258). Insurance agents promoted the companies locally and maintained connections between the central office and the clients. They were also expected to assess the character and habits of the candidate for selection purposes, to decide when a medical examination was necessary, and record the medical data for those types of insurance policy that were granted without an examination. The agent networks expanded rapidly. For example, in 1889 Kaleva had 65 agents, at the turn of the century 341, and at the outbreak of the First World War the number had risen to over 1400 (Eskelinen, 1978: 65, 68).

The activities were fuelled by a nationalistically tinged insurance doctrine (vakuutusaate), that the companies adopted and promoted. Following Yates (2005: 13–30), vakuutusaate can be seen as an amalgamation of two ideologies. On the one hand, there was a public service ideology that stressed the social value of life insurance to the populace. Insurance provided security for old age and other risks of life and taught the working people the virtues of thrift and self-sufficiency. On the other hand, a business ideology developed, focusing on growth and efficiency. Life insurance was advertised as an investment, which was made safe and profitable by strong corporate structures and practices. The two ideologies mutually reinforced each other. For example, the introduction of new products specifically targeted at low-income customers, such as warranty insurance, both expanded the reach of life insurance and made business sense.

Poorly developed social insurance increased the demand for private forms of insurance. A comprehensive accident and disability insurance system was launched by the national government in 1897, but after that there was a long hiatus before national pension, unemployment, and sickness benefit schemes followed in 1937, 1960 and 1964, respectively. Before these dates, only some population segments were covered. An insurance policy was also a form of investment, which could be sold on, or could act as a security when raising credit – a sales argument to some groups, such as university students (Anonymous, 1917a: 143–145).

Growing purchasing power, forceful marketing, rising life expectancy, the need to seek protection from social risks, and other developments made life insurance a mass product in the early decades of the 20th century. Eskelinen (1978: 127) estimates that in the early 1920s, one in four Finns had some form of life insurance policy, albeit usually modest. The number of policies sold rose steadily, except during the recession periods during and after the First World War and in the 1930s (Rinne, 1966).

The expansion of the business affected how clients were selected and how medical expertise was deployed both in the field and at the central office. To begin with, a significant part of the medical profession became involved in life insurance examinations. There were no specialized life insurance physicians in Finland, so general practitioners took care of the examinations (Louhivuori, 1937: 281). In 1912, the Finnish Medical Association and the national life insurance companies made a contract that regulated examination fees and effectively prohibited a physician from serving exclusively a single company (Von Bonsdorff, 1919). The number of physicians in the country was rather low, and a substantial number of them worked in the capital. For example, in 1910, there were 511 practising physicians in the whole of Finland (1 per 6096 inhabitants) (Nyström, 2010: 160). In the same year, a total of 36,959 new life insurance policies were issued; this number does not include rejected applications (Rinne, 1966: 179–180). Although some of the policies were granted without examination, the proportion of policies per physician was still quite high, especially if the unequal geographical distribution of practitioners is considered. It is also known that examination fees were an important part of physician earnings, at least until the 1920s (Palmén, 1937: 180; Savonen, 1919: 51; Finska Läkaresällskapet, 1913: 129–130). Thus, it is likely that the examination practice involved many, if not most, of the physicians in Finland.

Another change occurred in the central office, where the processing of proposals was streamlined and medical expertise strengthened. Medical tasks were divided between the medical director, who remained included on the company boards, and a new position, the head physician, who took care of the more day-to-day medical activities in the office. Like medical directors, head physicians were typically leading lights of the profession. Both positions were often part-time, so university teachers and high state officials could also be involved. The role of the board in selecting clients diminished. For example, at Suomi, cases were decided by the head physician, the medical director and one other board member. Only controversial cases were submitted to the whole board (Pellinen, 1993: 17).

The medical experts at the central office selected the lives to be insured and, in the light of the actuarial data available, set premiums for individual policies. They evaluated the information provided by the proposal form, the examination report and the statement from the local agent and, when needed, asked for additions from the examining doctor, the family physician or an outside expert.

In addition to the examination of new candidates, medical knowledge was deployed to assess the health condition of clients who wanted to renew lapsed contracts or be exempted from insurance charges because of disability. Medical knowledge was also used, of course, to determine the cause of death before paying out a policy. Selection at the start and assessment at the end were equally important to the business, since the selection criteria and premiums were checked and adjusted by the companies against the mortality data of the insured (e.g. Karvonen, 1923).

The 1919 founding of a national re-insurance company, Varma, further streamlined the selection process. It was owned collectively by Finnish life insurance providers, indicating increasing co-operation between them. The establishment of Varma changed the Finnish life insurance industry in several key ways. Besides providing re-insurance, it served as an information exchange and offered policies to what the insurance industry referred to as ‘substandard’ lives, lives that could not be insured in normal terms by member firms. In addition, Varma collected statistical information from member companies that was processed into nationwide mortality tables; the company standardized decision-making procedures, and it kept registers of dismissed agents and of people that had been denied a policy in a member company. The aims were to expand the insurable population, to spread the risk of insuring substandard lives, and to put a stop to ‘shopping around’ for policies (Keinänen, 1944).

Important changes occurred in the examination and selection practices. First, reflecting on the mortality of accepted candidates, the companies realized that focusing on present health status was not sufficient. According to insurance experts, ‘a person who at the examination is free of disease still cannot be regarded as a normal risk’ (von Bonsdorff, 1919: 47), since she might potentially carry seeds of future illness. This insight shifted the emphasis in selection to prognosis. The primary aim of the examination was no longer to establish the candidate’s current health status, but to assess all things affecting life expectancy (Karvonen, 1926: 319). This expanded the concept of prognosis: whereas therapeutics gave only short-term predictions about the progress of various conditions, ‘life insurance needs a prognosis for many years and decades’ (Karvonen, 1915: 4). Second, candidates were put into different classes with varying premiums. As the founding of Varma demonstrates, even substandard lives could be insured, albeit on restricted terms. Since all proposals required processing, rejected candidates were a cost factor; offering them limited insurance could recover those costs. The focus on prognosis and life expectancy, combined with the placing of candidates into different (price) categories, initiated risk assessment proper in life insurance.

Why did life insurance turn to medicine? Why did medicine’s role become more pronounced as the business expanded? The case of Finland prior to the Second World War suggests additional factors to those already documented by international studies. For example, Horstman (2001) points out how ‘the scientific determination of life expectancy’ (p. 36) based on medical criteria was in line with the new, democratic and liberal ethos of life insurance, which could no longer rely on social class and reputation. And according to Porter (2000), mass participation in the life insurance industry, complex and hierarchical organizations, and longer lines of communication created a situation where selection could no longer be based on informal expertise and trust. The personal interview became an increasingly impractical way of selecting clients, and the reliability of proposals as well as testimonies from friends and medical attendants who were close to the candidate was questioned (Alborn, 2009: 220–249). In addition to these factors, I highlight another aspect in the push for scientific expertise and objectivity in life insurance in the next section, namely the tensions among the actors in the life insurance underwriting network brought to the fore by its expansion. These tensions are crucial to understanding the mutual shaping of life insurance and medicine and the subsequent dynamics of the two domains. The tensions provided a major impetus for the reformation of the examination practice, which rearranged the relations not only among the various actors in the life insurance network but also within life insurance and medicine.

An unstable network

Life insurance underwriting was organized as a network of actors – candidates, insurance agents, examining physicians and the central office – each with specific roles and relationships.³ The diverging interests of actors introduced tensions in the network that made it unstable, precipitating a crisis in the established practice of selecting clients for life insurance that was resolved through the subsequent reshaping of the examination practice.

Although life insurance companies wanted to maximize their sales, they worried about the propensity of agents to push any life for insurance. Expansion and competition were key maxims of the companies throughout the period, and they constantly urged their agents to break records in sales. In order to encourage them, companies paid agents a commission for each new policy sold, which introduced the moral hazard of agents promoting unfit candidates (Louhivuori, 1937: 278–279; Anonymous, 1904). Therefore, the 1915 meeting of the district inspectors of Suomi deemed it necessary to issue a resolution prohibiting agents to ‘invite to insurance individuals with dubious lifestyles or economic habits’.⁴ Not all seem to have complied with this principle, since there is information on cases in which a negligent agent was expelled from company service (Koskimies and Ingman, 1926: 353–354).

Medical examiners were designated by the companies as gatekeepers for accepting new policyholders. However, the companies worried about their loyalty. A family physician might be more dedicated to the interests of the client than to the company, reporting, for example, a tuberculosis death of a close relative as ‘pneumonia’, ‘pleurisy’ or ‘chronic bronchitis’ out of courtesy for the long-term client (Karvonen, 1923: 147, footnote). One solution was to use outside examiners: ‘The physician employed by the company has an entirely different position in relation to both the company and the candidate than the family physician [in life insurance]. The former serves one master, the latter two’ (Finska Läkaresällskapet, 1889: 98). However, this approach was not without problems. Unlike the family physician, the outside examiner could not draw on previous medical history and had to rely solely on the account of the candidate, who might withhold vital information in the hope of gaining an advantageous insurance contract (Maaseutulääkäri, 1916: 109).

Physicians framed the situation as a threat to the confidentiality of the doctor–patient relationship. Implicated especially were family doctors, who were still an important sub-group among the medical profession at the beginning of the century. They often had long-running associations with patients and their families that gave them access to potentially sensitive information. Moreover, their income and social standing was conditional on good relations with their client families. Hence, they were reluctant to compromise their position for the benefit of the companies either by personally examining their own patients or giving additional information about them to the central office. In the countryside and small localities, the problem was exacerbated by the fact that the family doctor was often the only medical expert available for examinations (Ryömä, 1912; Finska Läkaresällskapet, 1889: 98–99; 1891: 113–114; Anonymous, 1906).

The financial stakes involved in different forms of insurance introduced a new element of mistrust between the physicians and the patients. Physicians were compelled to suspect that candidates were withholding information for the sake of insurance benefits. The issue of fraud and dishonesty (or moral hazard in contemporary terms) runs through insurance literature (e.g. Koskimies and Ingman, 1926). Depending on the type of insurance, the problem was presented differently; with life insurance the issue was misinformation, whereas with disability insurance it was simulation. However, especially in relation to social insurance, the patient’s point of view was not forgotten; some experts stressed that physicians were expected to find the cheats, but also to safeguard the rights of the candidate in obtaining compensation or a policy (Koskimies, 1915: 563; ReijoWaara, 1908).

The relationship between physicians and agents was overshadowed by financial issues. The former looked for job opportunities, the latter for co-operative examiners who could help them to maximize their sales. Life insurance examinations were a convenient source of additional income for physicians. Before the First World War, there were two types of examinations used in different situations, the broad and the brief. The fee for the broad examination (20 FIM) was twice that for a normal medical consultation (10 FIM). For the brief examination, the ratio was even better compared to short medical consultations (10 to 1–5 FIM) (Saltzman, 1933). Since there were no specialists in life insurance medicine, in principle all physicians could benefit from the lucrative practice.

The collegial rules issued by the medical profession in year 1917 attest to the financial importance of the examinations for the physicians. The rules stipulated, first, that no physician was allowed to make examinations in another’s district unless there was ‘an acceptable reason’ to do so (e.g. the primary physician was not available or was boycotted by or otherwise not on good terms with the company). Second, secret contracts with agents to gain a monopoly on examinations in an area were prohibited (Anonymous, 1917b).

Despite these rules, there were reports of suspected co-operation between agents and examiners. Life insurance experts lamented how ‘some agents, in areas where there are several physicians available, often prefer to consult the less conscientious or less discerning’ (Saltzman, 1933: 301). An agent might recommend for examination a certain physician whose practice was situated far from the candidate’s place of residence, or tour large areas with a particular physician who made examinations en masse (Maaseutulääkäri, 1916).

As seen above, there were a number of tensions among the different actors in the underwriting process, which set candidates, agents, physicians and companies against each other. As Porter (2000) notes, the issues share a focus on trust. The parties questioned each other’s motives, whether they were following the rules or pursuing personal gain. The established methods of producing, circulating and assessing information in life insurance were based on informal expertise, where the perceived credibility of the person was central. With the expansion of the business, this mode of regulating underwriting became untenable. New ways of ordering the relationships between the various actors had to be found that could address the tensions and configure underwriting into a relatively stable network.

As I will show in the following section, a key development in relieving these tensions was the reshaping of the medical examination. There were a number of additional developments, but reshaping the examination practice had the most profound effect on the practical work of physicians and the transformation of medicine.

Re-scripting medical work, stabilizing the network

Life insurance companies made efforts to improve the examination practice. The companies promoted uniform examination procedures to make the results more reliable and comparable. Following Horstman (2000, 2001: 81–103), three aspects of this standardization of the examination practice can be distinguished: the creation of rules of conduct, the designing of forms and the adoption of medical technology and measurements. Together they re-scripted the actions of the physicians performing the examination, modifying the material conditions of examination work to channel the behaviour of physicians and open it for better outside control. In the process, part of the competencies previously expected from the physicians were delegated to the forms and measuring technologies introduced with the reform.

Rules of conduct

Conducting a medical examination was minutely orchestrated. Save for very minor policies, the procedure was paid for by the company. The candidate received a cover letter from the agent, which was to be signed in the presence of the agent and shown to the examining physician. The scope of the examination depended on the size of the policy; small policies meant concise medical reports. In some types of insurance, like industrial assurance, the physical examination was replaced by a short health report made by the agent. At the end of the procedure, the examiner was expected to read aloud the answers to the candidate, obtain a signature, and compare the signatures in the cover letter and the application. Finally, the application papers were to be sent in a sealed envelope to the central office.

There was a set of simple rules devised to guide the activities of the examining physician, which Horstman (2001: 81) calls the medical examination code. The code had several functions. It dictated the interaction between the examiner and the examined. Candidates generally disliked the procedure, especially getting undressed for the physical examination (e.g. KHT, 1916: 22–23). To smooth the proceedings, the examiners were exhorted to treat the candidates with kindness, courtesy and respect (Soininen, 1942: 24). Overtly judgmental or suspicious attitudes were to be avoided. Even if the doctor suspected somebody’s sincerity, the doubts should not be voiced to the candidate, but related to the company representatives instead (Koskimies, 1915: 566; Versicherungs-Gesellschaft Rossija, 1908).

The examination had to be made promptly upon appointment in order to prevent the client from dropping out of the underwriting process. Enough time had to be reserved for each part of the procedure to ensure thoroughness and complete information.

Furthermore, the code provided instructions about the physical surroundings of the examination. The location had to be comfortable, well lit and not cold. Whenever possible, the examination was to be carried out in the physician’s office, not at the home of the candidate. Only the doctor and the candidate should be present, except when the latter was a minor (Versicherungs-Gesellschaft Rossija, 1908). The last two points were intended to enhance the trustworthiness of the information obtained by excluding any outside influences during the examination.

Finally, the code addressed two critical moments of the examination, the signature and the handling of the final statement. The former was important in several ways. It confirmed the identity of the person; stories of cases of mistaken identity are standard in life insurance folklore.⁵ It also made the information given by the candidate legally binding. The companies underlined that insurance fraud was a criminal offence, resulting in the termination of the contract and loss of premiums.⁶ In order to avoid misunderstandings, the physician was advised to compile the report in the vernacular and avoid Latin medical terms (Koskimies, 1915: 557–558; Soininen, 1942: 19–21). Restating the candidate’s answers to the questions in the examination form before signing was expected to generate amendments to the information noted (Koskimies, 1915: 561). Finally, with their signature, candidates allowed details of their medical history held by other physicians to be given to the company (Louhivuori, 1937: 281). From the physicians’ perspective, this solved the dilemma between confidentiality and company service.

The final part of the examination consisted of a statement of the insurability of the candidate, which had to remain confidential between the examiner and the central office. Confidentiality was stressed because of the information’s potential sensitivity and to prevent premature and potentially unfounded expectations of approval from the agent or candidate (Koskimies, 1915: 566–567; Louhivuori, 1937, 284–285).

Horstman (2000) suggests that the examination code produced a ‘cultural practice of decency’ that regulated the interaction between the two parties in the intimate situation of the examination. It placed a relationship of personal or subjective trust at the core of the practice, underpinning the public trust produced through more objective technologies. However, as described above, it was precisely personal trust between the physician and the candidate that was problematized in life insurance. Therefore, the code aimed to standardize their interaction to a degree, contributing to the formalization of the doctor–patient relationship. The code operated against individual idiosyncrasies of physicians, which were considered ‘noise’ that obscured the examination’s objectivity.

Examination forms

Forms were another means to standardize the medical examination and guide the actions of physicians. As mentioned above, the first examination reports were structured freely. Special forms became common in Finland in the 1890s. Companies issued their own models, but in 1926 they agreed on common forms (Soininen, 1942: 14). But even prior to agreeing on standard forms, there was no real variation between them. The forms were regulated by an examination tariff, which was negotiated between the companies and the Finnish Medical Association. After 1918, the industry settled for a dual model of a broad and a brief form (Saltzman, 1933). Common forms also meant common doctors; that is, examining physicians were expected to serve all companies equally. The use of forms was not restricted to examination reports, but included also application papers and salesman statements.

The forms dictated the content and progress of the examination. They were divided into two parts, anamnesis and status. The first part covered a set of background variables (age, occupation, gender, marital status, number of children), personal medical history (a number of conditions that could be interpreted to signify serious illnesses; accidents; former visits to doctors, hospitals and other medical institutions; conscription data for men, gynaecological problems for women), family history (illnesses of parents and children, their or other close relatives’ deaths and their causes), and aspects of lifestyle (temperance, ‘regularity’). These details were acquired by interviewing the candidate. In the second part, the doctor reported the results of the physical examination, followed by the final statement of the candidate’s health and insurability. The physical condition of the body cast additional light on the anamnestic data. Hence, the result of the examination was a kind of double exposure of the candidate, which increased the reliability of the information obtained.

Several factors were addressed in the forms. Age was the key variable because the tables and thus premiums were based on it. Determining the correct age was not always easy, and before the turn of the century it was debated which number should be preferred: the last or the closest birthday (von Engeström, 1894; see also Treas, 2009). Questions concerning past illnesses and symptoms took up a major portion of the forms. Most attention was given to tuberculosis, heart problems and syphilis. Hospital visits and other past treatments were important to record, since they pointed to sources of further information on the candidate. Personal habits, especially alcohol consumption, were inquired about in the forms. The importance of temperance can be seen through the initiatives to establish a separate insurance class with reduced fees for teetotallers (K-i, 1912; Anomymous, 1904, 1905, 1906, 1907). Risky occupations were divided into dangerous professions (e.g. pilot, policeman, diver, sailor), so-called ‘alcohol occupations’ (e.g. restaurateur, distillery or brewery worker) which were thought to predispose for alcohol abuse⁷, and those who were either doing precision work indoors (e.g. tailor, watchmaker, goldsmith) or working in dusty surroundings (e.g. baker, glass grinder), thus lacking fresh air and natural movement (e.g. Keskinäinen Vakuutusyhtiö Suomi, 1920: 3–6). Finally, family history of illness illuminated whether the candidate was ‘hereditarily tainted’, although the companies did not regard tuberculosis and other key diseases as hereditary in the strict sense. There is no evidence of the influence of degeneration theory in Finnish life insurance (cf. Lengwiler, 2009).

Life insurance experts stressed the importance of clearly differentiating between subjective opinions and objective facts in the report. Information obtained from the candidate, the candidate’s interpretation, the examiner’s observations and the examiner’s conclusions should all be kept separate so that the central office or an outside expert could reach an informed independent judgment of the case (Palmén, 1933: 193). The individual idiosyncrasies of physicians (and candidates) were to be clearly demarcated to allow the objective facts emerging in the examination to be seen clearly.

Forms were intended to speed up the examination and save time, to ensure complete and precise information, and to ease the further processing of the application. Physicians were free to enter the information in any sequence, but following the structure given by the form was judged to be the most efficient way. The forms acted as memory aids, making it difficult to miss some valuable piece of information. The presentation of the data made it amenable to statistical analysis in the central office (Koskimies, 1915: 553–554). Hence, the forms acted as material agents that softly coerced medical work towards company wishes. They were important relays in the re-scripting of examination practice and redefinition of medical work.

Medical technology and measurements

A further change to the medical examination consisted of specific standardized measurements to be taken of the candidate’s body. The key measures were build (girth, weight and height), blood sugar and albumin detected through urine analysis, and blood pressure. Other medical instruments, such as the pleximeter, the spirometer, the sphygmograph, the electrocardiogram (EKG) and X-rays, were not used in regular examinations in Finland before the Second World War (cf. Davis, 1981; Porter, 2000).The companies had a keen interest in various measuring devices because they were perceived as producing objective knowledge.

Build was used to assess the health status of a candidate even before medicine became heavily involved in life insurance. It was variously inquired about in the examination forms, with weight, height, neck, chest (both while exhaling and inhaling), and abdominal circumference all playing a role at different points of time. The general trend in the forms was from qualitative descriptions to numerical values. In the brief form, exact figures were asked only for cases clearly deviating from the normal, or if there was tuberculosis in the family. It was believed that a slim frame predisposed one to tuberculosis. Slight overweight or plumpness was considered a positive sign, although being very overweight was considered a risk for such conditions as heart problems. Conceptions related to health and weight changed when insurance data on mortality in different weight classes gradually accumulated (cf. Czerniawski, 2007).

Diagnostic testing entered life insurance with urine analysis to detect signs of kidney diseases and diabetes. Albumin in the urine is a sign of the former, glucose points to the latter. Urine analysis was a standard procedure in the examination in Finland until the 1930s, when it was dropped from the brief form. The physician had to report whether the urine was cloudy or clear and if it contained albumin, glucose or pus. The weight had to be stated numerically. The fact that the candidate had to urinate in the presence of the physician to prevent fraud testifies to the importance of the test to the companies. The downside of urine analysis was insufficient standardization, and the several techniques in use varied in reliability. Therefore, the companies considered it vital to know which method was used in producing the results (Karvonen, 1925; Koskimies, 1915: 562).

The condition of the heart was initially assessed by auscultation and taking the pulse until blood pressure measurement was added to the arsenal of the medical examiner, in the 1920s in Finland. Besides cardiovascular problems, elevated blood pressure indicated kidney disease. Company physicians gave instructions in the key Finnish medical journal to rank-and-file physicians on the proper art of measuring blood pressure and interpreting the results (Becker, 1928; Karvonen, 1927). They warned against relying solely on touch, deemed an old-fashioned habit, and preferred instead the accurate measures provided by the sphygmomanometer. They explained how blood pressure varied in different types of people and, based on insurance statistics, estimated excess mortality in different age groups with various values of elevated blood pressure: the higher the value, the bigger the risk of premature death.

Such writings show how the Finnish life insurance experts embraced and promoted the measurements. They stressed that the ‘inferiority’ of a candidate was to be expressed numerically instead of ‘vague qualitative epithets’ (Karvonen, 1915: 7). The physician was asked to use a measuring tape (Koskimies, 1915: 565) or measure the blood pressure (Karvonen, 1927) when suspecting deviations from normality or latent illnesses. According to Palmén (1944), ‘information on the candidate’s build and nutritional status should be given in exact numbers rather than as individually varying estimates such as “strong,” “middling,” “weak”’ (p. 82), thus enabling the comparison of individual values with averages.

Measuring devices produced standardized and objective numerical information, which was considered reliable because it did not rest upon the veracity of the candidate or the clinical competence of the physician. The data was unequivocal, easy to transfer from the consulting room to the central office, and comparable over space and time. The obligation to produce standardized data disciplined physicians into ‘machinists’ who operated the measuring devices. The devices channelled and constrained their actions, thus re-scripting medical work.

There were at least four additional developments that contributed to the stabilization of the underwriting process: (1) the education provided by the companies to their agents in the art and ethos of selling life insurance, and the increasing supervision of their performance; (2) co-operation between the companies that was manifested, for example, in contracts regulating competition and the exchange of information; (3) the ethical codes agreed by the medical profession on disclosing confidential information to third parties or on collegiality in conducting examinations; and (4) fixed rates for medical certifications agreed between the companies and the medical profession. However, the threefold re-modelling of the medical examination described above profoundly affected the life insurance network by addressing the tensions between the actors in the underwriting network. Objective measurements with the help of diagnostic devices bypassed reliance on the candidates’ accounts of their life history and health condition. Instruments enabled the physician to obtain information that the client could not easily disguise or control. Standardizing the work of the physicians through codes of conduct and examination forms diminished the influence of examiners, put the weight of candidate assessment onto the central office, and made major parts of the work in both locations a matter of routine. The formalized examination practice cut through the question of loyalty by creating an administrative convention that was seen not to threaten the doctor–patient relationship. As the physicians became increasingly ‘standardized’, choosing the right examiner lost its influence and meaning. Consequently, chances for agents to push ‘bad lives’ into insurance were reduced. By creating a common standard to evaluate their activity, the reformed medical examination settled the score between the different actors. This standard relied on a formalized procedure rather than subjective trust. Central to the standard were a number of technological devices and procedural rules, which re-scripted medical examination work. By embracing objective medical science embodied by the devices and rules, life insurance underwriting was assembled into a relatively stable whole.

Reshaping medicine

The reshaping of the examination and the stabilization of the network had important repercussions for both life insurance and medicine. In life insurance, emphasis on client selection moved gradually from the doctor’s practice to the central office. This was made possible by the formalization of information gathering, flanked by the growth in the processing capacities of the companies (Lyytinen, 1991: 367–370; cf. Yates, 2005). The formalization developed along two axes. On the one hand, the standardization of the examination practice typically reduced the rank-and-file physicians to ‘form-fillers’ who only supplied the information to be processed at the central office. Specialized skills were relocated to the central offices or to the re-insurance company Varma, and were mostly required only when processing special or substandard cases.⁸ At the same time, an increasing number of life insurance policies were granted without examination, because health information could be filled in on the forms by the candidate or gathered by the agent. The companies deemed the examination too costly, and from 1948 onwards it was reserved only for substantial policies (Eskelinen, 1978: 213). Thus, the expansion of life insurance business, which initially involved physicians in novel ways, ultimately led to their taking on an increasingly subordinate role in client selection. The processing of applications became routinized, assisted by decision support manuals that, for example, Varma introduced in the 1940s (Kurenniemi et al., 1969: 28). This trend has continued. At the present time, expertise in life insurance is located at corporate central offices, where decisions use, depending on the size of the policy, a combination of a candidate’s past medical records, self-reported health information, extra medical tests, and investigations into lifestyle and other personal habits (Ericson and Doyle, 2004: 79–93).

In addition to life insurance, there are a number of ways in which medical practice too was reshaped through their interaction. First, this case study supports previous findings on the contribution of life insurance to the rise of measuring devices and calculative practices in medicine (see Reiser, 1978). The companies played a key role in ‘the creation of a range of scientific objects’ (Porter, 2000: 245). They employed a number of devices and techniques for measuring various bodily variables, which they developed, standardized and disseminated among physicians. Normal values for variables such as blood pressure and height-weight ratio were established based on aggregated life insurance data (Czerniawski, 2007; Davis, 1981; Horstman, 2001: 85–92; Porter, 2000: 239–242; Rothstein, 2003: 66–72; Weigley, 1984). The values were then used as reference points when assessing potential policyholders. Finnish companies were part of this movement. They expected physicians to utilize various techniques and devices when examining a candidate and employed normal values for different factors when assessing applications. Although the national companies mostly relied on imported devices and standards, they acted as a further relay in the global dissemination of the measuring devices and calculative practices.

Second, life insurance examination, through its focus on objective knowledge and consultative tasks, strengthened medicine’s administrative function. The demands of risk selection and medical advice were of a different order from those of clinical practice. Registering, explaining and justifying patient observations and medical procedures for third parties became an integral part of medical work. As Horstman (2001: 93–103) notes, the new gatekeeper role exposed physicians to increasing outside control. They became connected to the administrative apparatus of the companies, which aspired to bureaucratic control over the medical corps. One way to establish the connection between company bureaucracy and individual practitioners was the form, which dictated physicians’ work. By stating the procedures and information the examination was expected to contain, the forms not only re-scripted the work of physicians but also opened it for governing from a distance (see Miller and Rose, 1990).

Finally, life insurance problematized health as future risk (cf. Horstman, 2001; Rothstein, 2003) ushering in the focus on risks associated with chronic disease epidemiology (Armstrong, 1995). By foregrounding prognostics and projections of longevity, life insurance medicine connected such factors as body build and blood pressure to the risk of mortality. These factors were additive; their accumulation increased relative risk. Importantly, the tasks of prognosis and prediction were not confined to the ill but extended to all people who applied for insurance. Life insurance experts stressed how those examined in medical therapeutics and in insurance were not the same kind of persons: whereas in the former they were usually ill, those seeing the doctor for insurance purposes typically were, or at least were believed to be, healthy. Thus the task of early detection of signs of illness in healthy individuals was added into medical work.

Diffusion

A number of novel objects, practices and tasks became standards in medicine through, in part, the influence of life insurance. Although life insurance medicine was only one point of their origin, and a full explication is outside the scope of this article, the case points to some ways in which they were taken up and implicated in wider networks in Finland. First, as mentioned, it is likely that the majority of Finnish physicians were involved in life insurance examinations in the early 20th century. Thus, they were expected to acquaint themselves with how to measure risk factors, judge individual results against normal values and assess longevity, fill in forms, and make statements for administrative purposes. These competences were not confined to a few experts in life insurance medicine, but touched major parts of the profession.

Second, the medical experts in life insurance companies actively disseminated knowledge on various aspects of insurance medicine among members of the medical profession. They wrote articles for medical journals, held courses and published textbooks on different aspects of insurance (e.g. Karvonen, 1915; Palmén, 1944). The experts were in an ideal situation to promote life insurance medicine because they typically were leaders of their profession and occupied multiple positions. They held key posts in national medical associations, were involved in research and teaching at the University of Helsinki, did clinical work in hospitals, and worked in public health, either in the state administration or semi-private organizations such as The Finnish Society for the Prevention of Tuberculosis, in addition to their roles in life insurance companies.⁹ Thus, the experts had a wide reach not only among their peers but in Finnish society at large. Moreover, insurance medicine was included in the medical curriculum in order to improve the performance of the inspecting physicians (Pellinen, 1993: 21–22). This reform was motivated mainly by problems pertaining to social insurance, especially workers’ compensation, but it was expected to benefit life insurance as well (Karvonen, 1922). Therefore, the members of the profession were instructed in the practice of medical examination, risk assessment, and the performance of their new administrative duties both through the efforts of insurance experts and as part of their general education.

Third, insurance agents who sold policies without an obligatory medical examination assessed prospective clients themselves, collecting health information from candidates. For this reason, insurance agents were instructed in the rudiments of medical examination (e.g. Hirvisalo, 1934). As a result, agents had a working knowledge of the targets of the procedure and the principles guiding it. Thousands of agents sold life insurance during its heyday in Finland, many of whom were active members of their local communities. Thus, agents were well positioned to enlighten their peers on life insurance, medical aspects included.

Finally, a significant number of Finns during the time period examined in this case study had experience with life insurance, becoming acquainted with the practice of taking medical tests, filling in forms, and declaring their health status to an outside body. Such commonplace experiences must have made the principles of insurance medicine tangible. Insurance examinations taught people that they might have a medical condition even though they felt completely fit and well. Being declined for insurance because of the potential for future health problems connected personal health to a temporal dimension that foregrounded risk factors. The act of measuring bodily parameters popularized normal values and deviations as indices of health and longevity. The company interest in the health of the insured did not end when the policy was sold; similar to foreign firms (Jureidini and White, 2000: 205–206; Rothstein, 2003: 146–178), some Finnish companies offered free or subsidized medical care and health education for their clients (Eskelinen, 1978: 85–86), which further disseminated among the population the novel principles and objects introduced by insurance medicine.

Conclusion

How did the mutual shaping of life insurance and medicine unfold? As a first step in the process of their interaction, medicine was assigned the selection of new clients. Although the network of life insurance underwriting was already in place, candidate selection relied on subjective technologies of trust that assessed information on the basis of the perceived credibility of the source, and the role of medicine was not yet formalized. This level of involvement of physicians in life insurance did not yet influence either in a significant way.

Medical expertise grew in importance when the insurance industry expanded at the start of the 20th century, inaugurating the first cycle of mutual shaping. The network became larger and more complex, which introduced tensions between the actors involved in underwriting, and it was no longer possible to control the network through trust. A reshaped medical examination, using methods ranging from an examination code to medical devices and special examination forms, provided a technical solution to the selection problem in the new set of circumstances. Trust was replaced by a focus on objectivity embodied by a formalized practice. This contributed significantly to alleviating tensions between the various actors in the life insurance network, thus stabilizing it.

In the subsequent cycle of mutual shaping, the practices adopted in the network described above modified both life insurance and medicine. In life insurance, the examining physicians were increasingly reduced to auxiliary workers, providing information to be processed by the experts at the central office. Client selection developed into a routine that was based on large bodies of aggregated information. This development was due to the increasing calculative capacities of the companies, made possible not only by technological advances and comprehensive databases on clients but also by the very standardization of the medical examination.

As regards medical practices, the physician’s new role as an intermediary between candidate and company, as well as the technical development of the vital examination practice, strengthened medicine’s administrative functions and contributed to its general transformation from an art to a science. Co-operation with life insurance facilitated the emergence of risk rationality, the rise of bureaucratic controls for doctors, and growing reliance on technological devices in diagnostics, which are key characteristics of modern medicine. The life insurance network was also in a good position to promote these phenomena in medical practice at large and the wider society.

The process was remarkable for its orderly nature. There were no competing models or major disputes on how to organize client selection. The reshaping of the medical examination did not raise professional objections. Save for some singular statements that can hardly be construed as concerted resistance, the physicians did not express vocal criticism of standardization and quantification nor did they make programmatic references to clinical judgement in life insurance practice. It seems that overall, Finnish physicians were happy to adopt the reforms promoted by the companies, especially after confidentiality and remuneration issues were settled.

It could be asked why physicians submitted to a development that constricted autonomous expert judgment, promoted quantified decision criteria, and put their work under increased outside control. Porter (1995) suggests that

the transition from expert judgement to explicit decision criteria […] emerged as a strategy of impersonality in response to their exposure to pressures from outside. While […] numbers and systems of quantification can be very powerful, the drive to supplant personal judgement by quantitative rules reflects weakness and vulnerability. (p. xi)

Hence, only professions succumbing to external pressures ‘abandoned their open reliance on expert judgment in the name of public standards and objective rules’ (Porter, 1995: 89).

Clearly, life insurance companies pressured physicians to change their ways. However, the Finnish medical profession was neither weak nor vulnerable. There are a number of other plausible reasons why the physicians were willing to accept the reforms. Life insurance examinations did not immediately affect their regular relationships with patients, which remained their core activity; the system did not introduce specialized insurance physicians working for particular companies but upheld the free choice of physician, cherished by the profession; and the examinations provided a steady source of extra income and freed the examiners from haggling with candidates for compensation. Comparing life insurance with accident and disability insurance provides a further point. In both, physicians acted as gatekeepers to benefits, and their work was standardized with the help of a formalized practice that relied on quantification. Yet the latter was problematized more intensely, because it was a state-funded system, whereas life insurance remained a matter between a branch of private industry and the profession. State supervision was restricted to the financial performance of the companies and did not cover the minutiae of client selection. Private life insurance companies, mediated by powerful members of the medical profession, pushed for objective rules, but the standards were not public in the strict sense.

Crucially, the outcomes of the foregoing process – risk rationality, bureaucratic controls for doctors, and technological devices in diagnostics – were neither a natural and inevitable outgrowth of life insurance medicine nor of medical progress at large. They were not imposed on physicians by all-powerful life insurance companies. Rather their promotion was an unintended consequence of a well-demarcated structural problem in early life insurance business, which involved both medicine and life insurance. This has repercussions for the study of network-building. From the perspective of mutual shaping that looks at the crossing over and reciprocal constitution of two socio-technological domains, as in the case presented in this article, it becomes evident that networks are not only about mobilizing allies, aligning interests, and establishing obligatory points of passage. Network-building can produce outcomes that extend beyond the immediate intentions of the network and are not actively promoted by any of its members. The consequences of the attempt to stabilize life insurance underwriting and reshape the medical examination went beyond the immediate concerns of the actors involved and had lasting effects on both domains involved in the process.

Footnotes

Acknowledgements

I want to thank the three anonymous referees and Sergio Sismondo and Mark Vardy for their great help in improving this article.

Funding

This work was supported by the Finnish Academy, grants 128334 and 258688.

Notes

Author biography

Mikko Jauho is a Sociologist and University Researcher at the Consumer Society Research Centre located in the Department of Political and Economic Studies at the University of Helsinki. His research interests cover both historical and contemporary perspectives on biopolitics of health, standardization practices, and public engagement with health risks. He is currently working on a political history of health risks, with a special focus on cardiovascular diseases and diet.

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