Medicine, Health and the Public Sphere in Britain, 1600-2000

Steve Sturdy

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134467914
• Edition: 1
• Topic: History
• Subtopic: British History
• Index: History

Medicine is concerned with the most intimate aspects of private life. Yet it is also a focus for diverse forms of public organization and action. In this volume, an international team of scholars use the techniques of medical history to analyse the changing boundaries and constitution of the public sphere from early modernity to the present day.
In a series of detailed historical case studies, contributors examine the role of various public institutions - both formal and informal, voluntary and statutory - in organizing and coordinating collective action on medical matters. In so doing, they challenge the determinism and fatalism of Habermas's overarching and functionalist account of the rise and fall of the public sphere.
Of essential interest to historians and sociologists of medicine, this book will also be of value to historians of modern Britain, historical sociologists, and those engaged in studying the work of Jürgen Habermas.

Part I Public-private interactions

1 Public and private dilemmas

The College of Physicians in early modern London

Margaret Pelling

DOI: 10.4324/9780203520178-2

We have only to conjure up such epithets as ‘public health’, ‘private practice’ and ‘secret remedies’ to begin to realize how intimate is the relationship between medicine and concepts of privacy and the public. Moreover, medicine, with its apparently unique ethical responsibilities focusing on human survival on the one hand, and confidentiality and the human mind and body on the other, seems to have a major influence on the value attached to these concepts. As this chapter will try to illustrate, value and meaning are interdependent. A shift in values causes one or the other concept to become better defined. In what follows, the aim is to use an early modern case study to reveal the decidedly ambivalent antecedents of what professionalized societies in general, and Habermas in particular, take for granted as being valued positively. The subject of the case study is a small, isolated, homosocial medical institution in London, the College of Physicians, in the period before the English civil wars. My concern is with something like a ‘history of interiority’ for a select group of highly educated males as expressed in an account of themselves – the College’s Annals – which was at least semi-public. The College’s attempts at defining both itself, and its opponents, in the wider world of London medicine involved a complex of meanings for public and private in which we can perhaps see the germs of the modern stress on privacy, itself an aspect of the hegemony of the middle class.

We can also discern in the College something like the literate, self-regulating detachment that Habermas idealized as essential to the authentic public sphere. However, this too calls for close inspection, and, as a result, proves to be a peculiarly constructed phenomenon indicative as much of weakness as of strength. If the College achieved detachment, it was as a side-effect of dependency. Further, the medical role itself can be shown to entail status and gender disadvantages that are intrinsic to the style and content of the physician’s connection with the political process, and to his influence on the demarcation of the public and private realms. Privacy in the relationship between patient and practitioner emerges as contingent, compromised and at odds with the contemporary ideal in which the relationship was one necessarily involving other people. In general, the case study of the London physicians demonstrates how the closest possible proximity to the project of professionalization – and, it may be argued, a prominent role in defining it – can nonetheless be associated with a movement not from the proto-private towards the proto-public, as Habermas postulated, but of something like its opposite.

Privacy and individualism

In terms of basic demarcations, the early modern period contrasts with our own. Our own era appears convinced that the private realm is now of greater interest than the public. The latter concept is, at best, in the process of redefinition. Modern opinion has disengaged itself fairly thoroughly from such concepts as public service and public life; scrutiny in the public interest is only valued if it is individualistic. For many, the significance of ‘public’ is in its meaning for the individual, and what duties the individual is owed by the state, including such liberal preoccupations as freedom of information and whether a ‘right to privacy’ can safely be the subject of legislation. In the context of medical services, analysis is dominated by the single instance, or the definitive personal experience. Any deviation within the patient–practitioner relationship from the ideals of privacy and personal autonomy is resisted and deplored, even in the context of calls for greater accountability. In an article published in 1989 on ‘unconscious aspects of health and the public sphere’, Karl Figlio reflected current opinion by characterizing ‘public’ as a bland word, desexualized and lacking in energy, which did not even have the status of being the polar opposite of ‘private’. ‘Health’, he claimed, was itself a public word, and both ‘health’ and ‘public’ stood apart by providing ‘reservoirs of non-conflictual phantasy’. The complacency so attributed may be an aspect of the ‘culture of contentment’, although Figlio does not say so. ‘Disease’, on the other hand, was personal.¹ Recent calls for an insurance-based system to replace the National Health Service (NHS) reinforce these impressions. It is less clear how far this analysis can be reconciled with the revival of public health concerns and public health historiography.² An illustration of recent shifts is the renaming of the linear descendant of the first British department of social medicine, founded by a Nuffield benefaction in Oxford in 1942. What in the 1970s was a department of ‘community medicine’ is now one of public health within a division of public health and primary care. It might be argued, however, that such changes reflect in a purely pragmatic way the return of infectious diseases as a subject of professional concern, and, with that, some of the freight of meaning of earlier decades, rather than a new phase of redefinition. In spite of the trend towards globalism, it would be difficult to argue that the notion of public health has regained anything like the currency and substance it enjoyed in this country before the Second World War.³

Many discussions are content to take the distinction between public and private as a dichotomy firmly founded in nineteenth-century individualism. The contrast can be effectively deployed without matters of definition being of great concern.⁴ Here, however, an emphasis on intimacy, subjectivity and ‘the home’ can obscure the privacy of economic relations that is an essential aspect of the Victorian distinction.⁵ This aspect of privacy connotes a rejection of the state’s right to interfere. Medievalist and early modernist historiography, for its part, has given us a schema for the relationship between public and private in society at large that corresponds with the decline of feudalism, the impact of the Reformation and the increased prevalence – or perhaps intensity – of the values of the middling sort. In this schema, the main feature is not so much the decline of the public as the growing importance of the private, particularly as expressed by the professional classes and the urban bourgeoisie. For post-Revolutionary England, stress is also laid on the private gentleman, living modestly on his own land and of influence mainly in his own locality. Here again, issues of definition are not thought essential to discussions that focus on the contrast between private life and the rise and fall of party politics. In this context, privacy can become synonymous with the contemplative life, involving contrasts between the country and the town, and between ‘enthusiasm’ and ‘retirement’ in politics and religion.⁶ However, our current interest in subjectivity has encouraged the discovery of the private even in periods, like the Middle Ages, in which the concept was previously thought inapplicable because, under feudalism, the public and the private were deliberately conflated in the interests of the ruling class. That is, where the dichotomy between public and private is challenged for earlier periods, it is the private world that is currently attracting the interest. As an inverted reflection of this, resistance has been offered by feminist historians, who have qualified, or even abandoned, the notion of separate spheres, at least as a period-specific, comparative development in which the private realm contained the feminine, and was defined by its feminine characteristics. Instead, the trend is towards a redefinition of the public that includes female agency. For many historians, however, the distinction between public (male) and private (female) remains both evident and serviceable.⁷

Early modern public spheres: the British case

The sociologists, for example Norbert Elias, and the sociologist-philosophers, like Habermas, who problematize the distinction between public and private for historians, focus on the conjunction of absolutism and enlightenment in eighteenth-century continental Europe. Within this framework, the English versions of absolutism under the Tudors and Charles I are inconveniently early, particularly for Habermas’s adoption of England as the ‘model case’ of the emergence of a bourgeois public sphere. Much recent scholarship has reiterated the deliberate self-consciousness of humanist intellectuals in this period, and the shared activism of the reading and writing in which they engaged.⁸ However, it is difficult not to conclude that, although disappointment could breed detachment, the predominant intention of these figures was employment for themselves and their ideas in the service of the state. Moreover, although humanists were mutually supportive, constructed epistolary communities and more or less invented prosopography, this period in England almost entirely lacked the structures of sociability, the informal clubs, salons, societies and other semi-private gatherings that provide the focus for Habermas’s notion of the authentic public sphere and its detached criticism of the activities of the state. Similarly lacking before the mid-seventeenth century are the published, allegedly independent organs of opinion such as news-sheets and journals. Although recent historiography has criticized Habermas’s chronology in terms of the development of a public sphere in England in the 1640s or even earlier, participants, including writers and readers of the early newspapers, are seen as politically engaged rather than detached. For Habermas, civic society was forced into existence as a corollary of a depersonalized state power.⁹ Authority in Tudor and early Stuart England was certainly becoming more centralized, but it was not yet depersonalized, nor was it represented by standing armies or a faceless bureaucracy. Hindle describes this society as one in which ‘governmental and judicial resources were unprofessional and relatively shallow’.¹⁰ Perhaps most importantly, religious affiliation in the earlier period has to be seen as an initiating and organizing principle for intellectual activity, and as a factor more likely to influence ‘detachment’ than any secular motive.

Habermas did see the British case as, in outline, the model for development, and mid-seventeenth-century England as producing a sense of ‘the public’ in advance of eighteenth-century France or Germany. British historians have however been primarily concerned with whether the civil wars and the Commonwealth were necessary to bring about a participation in politics and structures of authority by those below the level of the ruling elite. This version of the public sphere does have a private dimension, as well as a local one, but it implies participation in government, not detachment from it. Critiques of Habermas in these terms, such as that of Goodman, therefore focus on nationalisms to which his formulations have appeared more applicable, such as that of eighteenth-century France.¹¹ This chapter follows suit in that it is not primarily concerned to find Habermas wanting as an analyst of England before the 1690s. Rather, it looks at relevant forms of interiority that appear to have projected themselves into future periods, and examines their ambivalence. Habermas himself implicitly singled out English interiority, attributing considerable significance to the Protestant Reformation as a factor in the evolution of privacy. Thus, England’s bourgeois revolutions were prompted in part at least by issues of freedom of conscience. Religiously and politically, English people in the seventeenth century are seen as achieving the right to think differently in private from what might be demanded of them in public.¹² Private devotions, as opposed to the whited sepulchres of the Pharisees, had always had a value in Christian theology, but this was naturally accentuated when intermediaries between God and the individual soul were removed. The early seventeenth century was still exploring the dangers for the individual and the body politic of a century of religious change in which an individual’s allegiances might be very different from those he or she appeared to espouse. Hence a degree of paranoia and resort to covert operations in which physicians and other medical practitioners played an active and sometimes central role. As is well known, Elizabethan and Jacobean literature and satire are much preoccupied by sincerity, by both the uses and abuses of techniques of persuasion, of self-presentation in person and in print, and by the differences between appearances and reality.¹³ As one reflection of this, the College of Physicians in 1599 felt obliged to communicate in English rather than its own language of Latin, to make evident the ‘truth, honesty and sincerity’ of its proceedings.¹⁴

Recent revisionism notwithstanding, in this period, by contrast with the present, it was ‘public’ that was the defining category, and ‘private’ that was the residual. This is not to deny that ‘private’ had already acquired many of the shades of meaning familiar today. Rather, the balance of usage was fairly evidently in a particular direction, which, not surprisingly, bore a direct relationship to masculine authority and male experience. In academic discourse, for example, woman could be defined as a ‘species privata’. Women were allowed to work as sextons in London in the eighteenth century because this office was regarded as both private and menial.¹⁵ Privacy signified mainly a form of deprivation, or even bereavement, referring to areas of life that lacked contact with, or were cut off from, the world of authority. Hence private traders, or private soldiers, were those who lacked an office or public position or clear allegiance. A private man was not entitled to forgive wrongs that contravened the public laws. Even towns could be described as ‘only private places’ if they were not a seat of government. This usage was evidently related to classical sources, images of republican Rome, and especially to notions of the appropriate political role, defined as public, of the adult male. Privacy at home was defined not by domesticity in the modern sense but by property rights, an aspect that is echoed, but greatly expanded, in ninet...

Table of contents

• Cover Page
• Half-title Page
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of Contributors
• Acknowledgements
• Introduction: Medicine, health and the public sphere
• PART I. Public–private interactions
• PART II. Voluntary institutions and the public sphere
• PART III. The state and the public sphere
• Index