Objectifying Uncertainty: History of Risk Concepts in Medicine

Abstract

The issue of risk has become so common in contemporary medicine that social scientists speak of a veritable ‘‘risk epidemic’’ in the medical literature since the 1960s (Skolbekken, 1995). The use of the term ‘‘risk’’ implies a specific strategy of dealing with uncertainty based on calculations of probabilities (Short and Clarke, 1992a,b: 317–318). Probabilitybased logic helps medicine ‘‘to approach the uncertainties of diagnosis, therapy, and prognosis, and the clinical judgment that lies at their heart’’, as medical sociologist Renee Fox (2000: 410–411) points out. This strategy of objectification can be traced back to the Enlightenment period, and by the end of the 18th century, mathematical and quantitative methods were being applied quite frequently in order to create certainty in medicine (Magnello and Hardy 2002: iv). Historically, however, the idea of risk has emerged in an economic context. It referred to the danger of losing money in business, especially on loans, in gambling and in insurance (Gigerenzer et al., 1989: 20–26). The earliest link to health issues can be seen in life insurance companies that needed to decide on the conditions under which they would accept applicants for a policy. Already the first life insurance company, the Equitable in England, charged extra premiums in 1762 for applicants with gout, hernia and no history of smallpox (Rothstein, 2003: 61–62). As a basis for their policy, the companies used mortality tables. The technique of drawing up mortality tables goes back to vital statistics, which used records of births and deaths in a locality or country to provide knowledge about the statistical regularity of health conditions within populations. This tradition started with the bills of mortality that were published in 1562 by the city of London to keep track of plague deaths as a warning of a major outbreak (Gigerenzer et al., 1989: 20–21). In the 16th century, the London merchant John Gaunt began to apply his commercial accounting practices to mortality lists. The resulting tables were published in 1662 under the title ‘‘Natural and Political Observations Made Upon the Bills of Mortality’’. They enabled a systematic comparison between past and present mortality numbers, parishes and city quarters, as well as death causes and gender specificities. This type of argumentation was found persuasive by British physicians and subsequently applied to medical questions (Rusnock, 2002: 40–50). Within the emergent commercial and consumer culture of the period, counting and accounting came to be the preferred method of assessment in many different areas, among them medicine. The British hospital and dispensary movement, for example, induced doctors and lay sponsors to count recovery and death rates within these institutions and to calculate success rates of specific cures. Broadening their perspective beyond the traditional individualistic approach of medicine, doctors and administrators now focused on the well-being of the whole population or specific groups within it – such as the laboring poor, soldiers, women, children, rather than on individual patients. This applies to the evaluation of clinical experience too: An analysis of British medical journals from 1733 to 1829 shows the gradual reduction in dependence on single case reports and a growth in the publication of larger series, some of which were even analyzed by what can be called proto-statistical methods. In 1747, the British Navy physician James Lind (1736–1812) conducted his famous experiment on the treatment of scurvy amongst sailors, a procedure that can be interpreted as an early type of