History and Health Policy in the United States: Putting the Past Back In

By Rosemary A. Stevens; Charles E. Rosenberg et al. | Go to book overview

Amy L. Fairchild


Chapter 5
The Democratization of Privacy
Public-Health Surveillance and
Changing Conceptions of Privacy
in Twentieth-Century America

The right to privacy has never been regarded as absolute. In the late nineteenth century, health officials adopted the practice of name-based reporting for infectious diseases in order to isolate cases, quarantine the exposed, and monitor the health and behavior of the diseased and their contacts as a means of reducing morbidity and mortality. Public-health surveillance has persistently called into question the appropriate limits of privacy ever since. Despite the inherent tension between surveillance and privacy—that is, between a public and a private good—the nature of the conflict has changed, reflecting radical changes in the conception of privacy over the course of the twentieth century.

From the 1890s through the 1960s, privacy concerns were embedded in a medical and public-health culture that was both paternalistic and authoritarian. The prevailing conception of privacy yoked the patient's well-being to the physician's authority: physicians represented the gatekeepers to the patients and protected them from unwarranted interference by public-health authorities. Health officials accommodated physician demands to determine when they might intervene—a concession that privileged "respectable" middleclass or wealthy patients. The 1960s and 1970s were witness to extraordinary challenges to the authority of medicine broadly understood. The paternalistic authority of physicians was brought into question by a new culture and ethics that gave pride of place to the concept of autonomy (Rothman 1991). Privacy ceased to be instrumental to the clinical relationship and became a right that belonged exclusively to the patient. Dovetailing with the "my body, my business" ideal in the clinical setting, some patients ultimately challenged the

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