Machines in our hearts: the cardiac pacemaker, the implantable difibrillator, and American health care

The book begins by charting the rise of the Dutch life insurance industry and the early debates about the necessity of medical selection. Horstman shows convincingly how an advisory role distinct from family practice emerged, due both to the industry's desire for objective risk assessment, and to the NMG's concern that medical assessment by family practitioners breached patient confidentiality. The central sections deal with the broader implications of insurance work for medical practice. In her account of medical examination she shows that company worries about the reliability of doctors' assessments led to an increasing standardization of the examination code and recourse to "objective" procedures such as urine analysis. Here she echoes the argument of Marguerite Dupree, whose study of Scottish life examinations pointed to a transition from diagnosis founded upon the patient's narrative to dependence on scientific measurement. The destructive effect of life work on the traditional relationship between doctor and patient was also evident in the demise of professional secrecy, when the NMG resolved, in 1910, that practitioners could inform companies of cause of death. Doctors' expectations that this cooperation would have public benefits, in the form of mortality statistics or industry sponsorship of periodical medical examinations, went unfulfilled. Indeed Horstman's closing sections indict the companies for abandoning the ethical principles they initially espoused, and for fostering a culture in which health risk was understood as an individual rather than a collective responsibility. There are two areas in which fuller contextualization would be helpful. First, despite the importance to the analysis of the life companies' strategic decisions, little is said about their business history. Matters such as their membership statistics, their range of policies and their fluctuating profitability are consigned to footnotes (p. 63), while the mortality and morbidity regimes in which they operated are dealt with only cursorily (p. 31). Second, it is surely difficult to consider the impact of life insurance in isolation from mutual health insurance. Scholars estimate that by 1920 some 23 per cent of the Dutch population had sickness cover, including, for many, medical assistance. It would therefore be interesting to know whether this played an equally significant part in transforming the public role of medicine in the Netherlands.