Ins i u ionaliza ion and Medical
Viewpoin s in Indus ial Socie ies.
An
His o ical In oduc ion
DIETRICH MILLES
(*)
The ollowing con ibu ions we e o iginally p oduced o he In e na ional
Semina on he S udy o Occupa ional Heal h Sys ems and he P o essions
o he Wel a e S a e, held a he Uni e si y o Be gen on 2nd and 3 d
Sep embe 1991, whe e 33 pa icipan s om Be gen, Oslo, T oms, Linkoping
and B emen me a he in i a ion o he Occupa ional Heal h and P o essions
Semina SEFOS. The cons ella ion o pa icipan s ensu ed a mi ul discussion
on he in e disciplina y aspec s o he heme and especially he his o ical
and in e na ional. When dealing wi h ques ions o isk, insu ance o wel a e
socie y, hese aspec s should be aken in o accoun in e e y academic
discou se.
Du ing he con e ence he ques ion o wo k- ela ed heal h isks and
he esponsibili ies o a socially unde s ood medicine was app oached om
he poin o iew o p o essionalisa ion in he cou se o mode n socie al
de elopmen . A he same ime, he e was a s imula ing exchange o iews
be ween his o ical sociology and cu en heo ies o poli ical and social
science. F esh in e es was shown in he compa ison be ween Ge man and
Scandina ian expe iences due o he in e na ional discussions and exchange
o in o ma ion and also o he examina ion o speci ic sociopoli ical
de elopmen s. Non egian doc o s, o ins ance, we e pa icula ly in e es ed
in he discussions be ween he medical p o ession and he heal h insu ance
companies on he ques ion o being ee o choose one's own doc o in
Ge many a he u n o his cen u y. On he o he hand, he highly
(*)
Sozialpoli isches A chi . Zen um ü Sozialpoli ik. Uni e si a B emen. Pa kallee
39.
D
2800
B emen
1.
Alemania.
DYNAMIS
Ac a Hispanica ad Medicinae Scien ia umque His o ianz Zllus andam.
Vol.
13, 1993,
pp.
19-28.
ISSN:
0211-9536
20
DIETRICH MILLES
complex and dynamic p ocess o p o essionalisa ion was in many ways
dependen on he ins i u ions which expanded as na ional wel a e s a es
de eloped (see
J.
Albe , 1982).
One impo an ou come o he li ely discussions can be wo ded o he
e ec ha nei he heal h p oblems no he ac i i ies o he medical p o ession
can be success ully analysed in isola ion om one ano he . Whe he a
heal h p oblem was iden i ied as such o no has in indus ialised coun ies,
since he second hal o he 19 h cen u y a he la es , depended on
medical de ini ions. And he exempla y p o essionalisa ion o doc o s canno
.be ully explained wi hou aking in o accoun he p essu es o con empo a y
social p oblems (see D. Milles, 1989 and 1990). Bu how can his connec ion
be desc ibed in heo e ical e ms?
Fi s o all, he single componen s o he co ela ion mus be de e mined.
One impo an link be ween he p essu es o social p oblems and
p o essionalisa ion appea s o lie in a poin o iew which ound gene al
social accep ance, ha is he assessmen o heal h isks on he basis o
de e minable physical impai men s and he es ablishmen o h eshold
alues o heal h isks (see D. Milles, 1988). This posi i is ic poin o iew
shaped he a icula ion o heal h isks and de ined which isks we e no mal
and which excep ional, which we e accep able and which should be educed.
A he same ime i o med he amewo k wi hin which medical knowledge
assumed social esponsibili ies in he diagnosis and assessmen o ce ain
diseases. In pa icula , his poin o iew became mo e dominan because
i only ecognised sociopoli ically ele an ac ions on he basis o iden i iable
and e i iable condi ions. I hus adop ed impo an aspec s o libe al
ideology which subjec ed he jus i ica ion o s a e o socie al ac ion o
s ic p econdi ions, bu bound hem a he same ime o he equi emen s
o an in e en ionis s a e which was inc easingly o ced o p oduce and
main ain social condi ions. Medical assessmen s ad anced o become he
pa agon o socio-poli ical expe ise and medical expe s an example o
success ul p o essionalisa ion (see G. Gockenjan, 1985).
Du ing he discussions in Be gen i also became appa en ha he
posi i is ic medical iew was he speci ic p oduc o wel a e s a e de elopmen s
he cha ac e is ics o which a ied om one coun y o he nex , bu which
can al1 be unde s ood as social secu i y ins i u ions. I was only wi hin his
amewo k ha he p o essional oles o doc o s, ce ain medical knowledge
and p o essional s anda ds o examina ion and assessmen we e able o
ake shape.
Ins i u ionaliza ion and Medical Viewpoin s in Indus ial Socie ies.
21
These poin s o in e es and he esul s o he discussions in Be gen
coincide wi h a ecen g owing in e es in he his o y o ins i u ions. The
ins i u ional de elopmen o indus ial socie ies also appea s o be o cen-
al impo ance o he his o y o medical iewpoin s and medical
p o essionalisa ion.
One may ask whe he a his o y o s a e s uc u es is su icien o unde s and
he wel a e s a e ins i u ions which al1 ha e di e en o e y gene al objec i es.
Whils social and poli ical scien is s inc easingly end o e lec on he
his o ical dimensions, one mus concu wi h
P.
Baldwin ha in gene al
his o ians s ill do no ha e a ully de eloped de ini ion o he e m ((wel a e
s a e~ (P. Baldwin, 1990, p. 1). Baldwin himsel discusses he in e es s and
ambi ions o ce ain g oups, and especially he wo ke s mo emen , in
e ms o causal mo i es o poli ical ac ion. This ((socialdemoc a ic in e p e a ion
o he wel a e s a e,,, which a ose ou o he pos -wa e o m mo emen ,
nei he co esponds wi h he his o ical o igins o social e o m no wi h he
ambi ions o e o men. Baldwin inally asks whe he i eally was classes,
occupa ional g oups o o he in e es g oups which we e he his o ical
ac o s. He concludes ha he social insu ance sys em, among o he s, c ea ed
and de ined i s own ac o s. Beyond he classi ica ion o class and social
s a a, Baldwin sugges s he applica ion o he e ms x isk communi y,, o
(( isk ca ego iesn o g oups wi h simila in e es s in eia ion o he social
insu ance sys em. «The s uggles o social insu ance e o m ha e in gene-
al aken place be ween di e en isk ca ego ies, be ween hose who hoped
o gain and hose who ea ed o 1ose.n Baldwin hus calls o a e ision o
ou concep ion o his o ical ac o s in his espec (P. Baldwin, 1990).
He e
he add esses a poli ical and social eali y which was c ea ed by sociopoli ical
ins i u ions and hen ook on a momen um o i s own, and has only begun
o be discussed in poli ical and his o ical esea ch, bu no ye examined in
ela ion o indus ial diseases and occupa ional heal h ca e.
The ques ion o his o ical ac o s and hei ac ions is also essen ially
conce ned wi h ((social medicine., i.e. unc ions which do no de i e om
he di ec , indi idual ela ionship be ween doc o and pa ien . Does his o ically
ele an ac ion a ise ou o an agg ega e o indi idual needs o p oblems,
o does a socio-poli ical ac o ha e o be assumed, wi h which o e iding
objec i es a e b ough o bea on indi idual ac ions?
Up un il now he ques ion o his o ical concep ions o ((social medici-
ne» has (in Ge many) mainly been app oached om he angle o he
his o y o de ini ions (see
E.
Lesky, 1977). Only a ew s udies ha e looked
22
DIETRICH MILLES
a socio-his o ical connec ions (Michael Hubens o has aken up his app oach
in his disse a ion which will be published sho ly; a ecen wo k modelled
on old concep s is
S.
Hahn; A. Thom, 1991). S ic ly speaking, he endea ou
is s ill being made, as wi h he epidemic pa adigm, o de e mine he
his o ical and sociopoli ical quali y in he diseases hemsel es. Media ing
be ween concep ual his o y and social his o y a e s udies which do no
e e o he eal sociopoli ical con en o heal h o illness, bu o he
sociopoli ical con en o he medical de ini ion o heal h and illness. Mo e
ecen discussions a e p o i ing mo e and mo e om impulses a ising ou
o discussions be ween a ious disciplines. He e, concep ual ques ions a e
necessa ily he ini ial oca1 poin o a en ion.
The medico-sociological unde s anding o heal h and disease has ex-
ended o in eg a e hese concep s in o ins i u ions and he cons uc ions
o no mali y. Cul u al, poli ical o economic in luences on he pe cep ion,
de ini ion and ea men o diseases a e weigh ed and eappea in he
concep ualisa ion o how diseases a ise and de elop. In a condensed his o ical
and sys ema ic o m, hese concep s can be ca ego ised as he s uc u al-
unc ionalis ic pa adigm (((illness as social ole and mo i a ed de iancen),
he in e ac ionis ic pa adigm (~illness as p o essional cons uc ionn), he
phenomenological pa adigm (((illness as in e subjec i ely cons uc ed eali p)
and he con lic heo y pa adigm (((illness as ailu e o esou ces and
ideological cons uc .)
(U.
Ge ha d , 1989). Acco dingly, he necessa y
sociological analysis o disease p ocesses mus be ca ied ou as an analysis
o he his o ical and social condi ions su ounding hei concep ualisa ion.
This genuinely sociological app oach was no , howe e , applied sys ema ically
o he subjec ma e o he Be gen Con e ence.
Resul s o he s udy o he social his o y o medicine, which has now
become a well-es ablished discipline
(A.
Labisch;
R.
Sp ee, 1989), ha e
unde lined ha in he analysis o p o essionalisa ion o o p oblems ela ed
o medical ac ions me hodological di icul ies can a ise i medical de ini ions
a e applied o analyse he ac ions o he medical p o ession. Al ons Labisch
has ecen ly aced he line o de elopmen o he medical poin o iew o
heal h haza ds and he comba o diseases in ci il socie y
(A.
Labisch,
1992), and poin s ou he ema kable ac ha ce ain e ms, o ins ance
((heal h se ice e o m», a e in e p e ed in apid succession ei he as he
ex ension and be e dis ibu ion o , al e na i ely, he es ic ion and
concen a ion o medical se ices. He enqui es u he in o he con as
be ween he exposu e o medicine «as a sub le ins umen o social powe »
Ins i u ionaliza ion and Medical Viewpoin s in Indus ial Socie ies.
23
(ibidem,
p.
7)
and he inc easing demand o medical assis ance which in
u n is c i icised as ~demand in la ionn. Public a i udes o heal h and
medicine can nei he oday no in he pas be unde s ood in e ms o
heal h p oblems pe se o speci ic medical skills o capabili ies alone.
A.
Labisch hus comp ehends heal h and medicine as a p oblem o social
ela ions, and he desc ibes he p ocess by which he scien i ic in e p e a ion
o heal h, which had ini ially a isen as a maxim o he middle class, became
a gene al and binding social cons uc . This cons uc p o ided a ious
o ganisa ional o ms o social secu i y in he ci ilised wo ld wi h a common goal.
The concep ual and e minological in eg a ion o he
-
os ensibly
-
scien i ically de i ed medical modes o a gumen a ion and beha iou in o
he social cons uc ion o eali y has been con incingly demons a ed wi h
in e disciplina y su eys which a emp o o e come he sepa a ion be ween
illness and social eali y
(J.
Lachmund;
G.
S ollbe g, 1992). Thus, he scope
o social his o y is b oadened o no longe only mean he addi ion o social
ac o s o he his o y o diseases, hospi als, doc o s o ields o specialisa ion,
bu also he social econs uc ion o in e ac ions, in which illness i sel is a
social phenomenon. The ques ion is hen: «how a e bodily p ocesses
expe ienced as a p oblem, and how a e hey ende ed socially signi ican ?
How is he body pe cei ed as an en i y? How do people cope wi h illness?~
(Z.C.,
p.
9)
I , howe e , i is asse ed om a cons uc ionis pe spec i e: .al1
o hese a e based on cul u ally en enched s uc u es o sensibili y, body
images, illness ocabula ies, and ela ed symbolic p ac ices
(ibidem),
hen
he his o ical explana ion is subs i u ed by he cons uc ion. One hen has
o examine he p inciples o cons uc ion and, especially, who he cons uc o s
we e. I , in eply o his, e e ence is no o be made ba~k o he dominance
o medical poin s o iew and de ini ions, hen o he his o ical answe s
mus be sough .
The e has been an ine i able social in ol emen o medical de ini ions
and medical ac ions in his o ical eali y since he beginnings o he social
insu ance sys em a he end o he 19 h cen u y. The social insu ance
ins i u ion seems o ha e le such a s ong imp ession on his o ical
de elopmen s ha h ough i ac o s and concep s, poin s o iew and
in e subjec i e aims in he con ex o wo k and heal h since he las qua e
o he 19 h cen u y can be s udied.
In e na ional compa a i e s udies o en emphasize he exempla y
signi icance o Ge man wo k nen's insu ance. «The Ge man p og am ep esen s

24
DIETRICH MILLES
a c i ica1 poin in he de elopmen o he disabili y ca ego y, no only
because i became a model, explicidy o implici y, o al1 subsequen social
insu ance p og ams. The e is ample e idence ha policymake s om se e al
coun ies consciously examined he Ge man sys em du ing he phase o
s udy and legisla i e d a ing in hei own coun ies~ (D.
A.
S one, 1984, p.
56).
The lines o de elopmen o a leas h ee ypes o wel a e s a e we e
he subjec o in e es a he con e ence, in pa icula in he ligh o he
coming sociopoli ical in eg a ion o Wes Eu ope. The di e en sociopoli ical
egimes a e ca ego ised as he Scandina ian, he Bisma ckian and he
Anglo-Saxon ypes o ((wo lds o wel a e capi alismn (D. Esping-Ande sen,
1990; see he gene al su ey in
S.
Leib ied, 1990). In his b oad discussion,
howe e , i is he po e y pa adigm which is ocussed on as a model
-
e en
o heal h insu ance
-
and no he acciden pa adigm as a model o isk
managemen . Ye he ((compensa ion s a egy*, which was emphasized in
he Ge man de elopmen , akes a well- unc ioning isk managemen , o ganised
wi hin he amewo k o acciden insu ance, o g an ed. One undamen al
esea ch hypo hesis could be ha he e y combina ion o medical iewpoin s
and he c isis managemen o an insu ance socie y explains he iumph o
medicine based on clinieal assessmen as a pa icula a ian o social
medicine.
The his o ical p o essionalisa ion o doc o s in he con ex o indus ial
and wel a e s a e de elopmen was discussed in Be gen along hese lines as,
essen ially, a o m o ins i u ionalisa ion.
While he p ocesses o p o essionalisa ion ha e o qui e some ime
been he objec o ema kable academic in e es , ins i u ionalisa ion p ocesses
ha e, in a speci ic academic adi ion, been neglec ed. This mus u gen ly
be emedied.
The p ocesses o ins i u ionalisa ion we e i s examined om a sociopoli ical
poin o iew. In his book, poli ical ins i u ions a e unde s ood as ~ egula ing
sys ems o he p oduc ion and execu ion o gene ally binding decisionsn
(G.
Kohle
e
al.,
1990,
p.
12).
A
egula i e social unc ion o ins i u ions is
hus assumed, which in u n is o p ima y signi icance o he his o y o
social medicine.
Fo he his o y o heal h isks and medical iewpoin s, he ins i u ionally
o ganised ela ionship be ween a ce ain measu e o e ec i e powe , he
se ing o legal no ms and accep ance by he pe sons a ec ed is o pa i-
cula ele ance.
Ins i u ionaliza ion and Medical Viewpoin s in Indus ial Socie ies.
25
Howe e , a ce ain amoun o cau ion is ad ised owa ds a oo simple
his o iog aphy. I , o ins ance, he objec i e is o de e mine he unc ional
equi alen o poli ical ins i u ions as hey a e unde s ood oday, in he
his o ical concep s and lines o easoning (ibidem, p. 13), hen he his o ical
analysis is educed o a po ayal o he o e unne s o oday's ins i u ions.
This ype o his o y o ideás which does no allow any u he academic
e i ica ion o co ec ion, bu is simply seeking o iden i y amode nn app oaches,
eally only deli e s a con i ma ion o he de ini ion o ins i u ions as i is
applied oday.
An
al e na i e o his app oach was de eloped some ime ago in B emen
and Kassel which in ol ed he sea ch o xbu ied al e na i esn. This pe haps
misleading e m means mo ing away om linea his o ical models o
explana ion and main aining a c i ica1 posi ion owa ds his o ical expe ience.
His o ical knowledge hus s ill emains discu si e and is no pe mi ed o
a ophy o a means o jus i ica ion o illus a ion. Fo his eason objec s o
s udy, such as he dispensa ies o he Gene al Heal h Insu ance Company
du ing he Weima Republic (see
E.
Hansen e
al.,
1981), we e selec ed o
esea ch, as hey indica e he di ec ion which subsequen deba es would
ake and do no po ay he amaking~ o his o y om he poin o iew o
he iumphan ac o s.
The e m ~bu ied al e na i es), also in ol es wo p oblema ical aspec s
inso a as i sugges s ha ce ain his o ical posi ions should be analysed
ela i ely independen o each o he and acco ded equal s a us, and ha
hese al e na i es only ha e o be ecollec ed o hem o eappea om
mo e o less unin ended isola ion. Fo his eason, in B emen, g ea impo ance
has always been a ached o unde s anding his o y as a pe pe ua1 discussion
and his o ical analysis as pa o his discussion. A en ion has he e o e
been paid o his o ical-compa a i e ques ions and me hods.
These conside a ions appea o be e y p o i able o he his o ical
analysis o wel a e s a e ins i u ions and medical concep ions. Wha essen ially
is needed is a social analysis based on he p inciple ha ~his o y is no
illogical, bu i s logic is no mechanical,,
(J.
A. Schülein, 198'7, p. 19). Fo
de eloping a concep o ins i u ionalisa ion and he signi icance o ins i u ions
in his o y, he ollowing impo an assump ions o hei basic de elopmen
ha e he e o e always been e ec i e:
-
he op imis ic assump ion o a p og essi e endency
wi h
inc easingly
imp o ing condi ions o gene al well-being; o
26
DIETRICH MILLES
-
he pessimis ic assump ion o ego is ical powe in e es s which
ha e o be es ained by s a e in e en ion.
Today, he e is some ag eemen ha he endencies o ins i u ion
heo ies o unde ined gene ali y and socio-biological in e ences which ha e
domina ed up un il now nus be coun e ed wi h a ela ional e sion.
~Ins i u ions a e no isolable uni s, bu ep esen a ela ionshipn
(Ibidem,
p.
131).
Such p ima y and seconda y ela ions can be di e en ia ed acco ding
o ecological o eleological mo i es, depending on whe he basic needs o
speci ic objec i es, a e conce ned.
This discussion appea s o be c ucial o p og essing in he unde s anding
o s a egies and ac ions in social medicine and heal h policy. The ole o
he idea o p e en ion, which is cen al o he his o y o occupa ional
diseases and occupa ional heal h ca e, has been examined wi h espec o
he his o y o public heal h ca e and social medicine aking bo h he
ecological and he eleological pe spec i es in o accoun
(D.
Milles, 1991).
The jus i ica ions o public heal h go beyond indi iduals and he ea nen
o hei own bodies and assume a gene al in e es o which he indi idual
is commi ed wi h body and souI. The di icul y o his assump ion, i.e. ha
p e en ion is undamen ally a poli ical issue and canno be de e mined
wi h exac me hods, unde lines he i npo ance o he his o ical analysis o
discou se o es ablishing whe he p e en i e needs, demands, s a egies o
p og ammes a e undamen ally an h opological in na u e ( o ins ance in
he assump ion o equali y in he solida y communi ies o social insu ance)
o based on speci ic objec i es ( o ins ance he p o ision o su icien
medical ca e). The eally impo an ask o his o ians is hen o es ablish
wha he jus i ica ions we e o he adop ion o p e en ion s a egies and
how e ec i e hey we e (see
A.
Windho -Hé i ie , 1989).
Ins i u ionaliza ion and Medical Viewpoin s in Indus ial Socie ies.
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