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Tuesday, March 19, 2013

"physicians as stewards of society's medical resources" is not just bogus but is a dangerous concept

The "physician as a steward" idea is implicit in Medical Professionalism as defined and promoted by a number of physicians who I label medical progressives and notably by the ABIM Foundation. In their own words they are advocates for " a just and cost effective distribution of finite resources." See here for source of quote.

 I argue that the physician-steward is a bogus and dangerous concept.
To consider physicians as stewards is to consider the medical care resources as a collective entity.
This is to say that  Individually possessed  resources or assets should be considered as part of a collective pool owned by everyone and that all have an equal right to some share of the pool.That is the core concept implicit in the physician as a steward phrase.

In regard to a private property system the rights of the owner in general terms are clear. He has the right to use his property,exclude others from use of the property and dispose of the property through sale,gift or inheritance.

 In contrast , the rights are in a common ownership system are vague and indeterminate. It is  not clear how one can be said to "own" something if no one in principle is excluded from making a claim .

 Once the common ownership idea is accepted it then seems to make sense to talk about allocating resources and to consider some one or some group or groups as the appropriate allocators. With common ownership it simply would not work for all of society to willy-nilly feed on the medical commons as soon the resources would be depleted Rather there needs to be a rational plan so that just and cost effective distribution can take place.

The first thing wrong with considering  medical resources as collectively owned is that they are not collectively owned in any real ,literal or legal sense in a free or even semi free society. U.S.medical resources are not like a grassy field in which all of the town folks sheep can come to graze.

While a grassy field for the villager's sheep to graze can be defined by a specific surveyor description, the "medical commons" is a extremely large,always changing, amorphous array,the elements of which defy enumeration. Various entities own various elements of this array-society owns none even though various government entities own some but the government is not society.It is an amorphous abstraction.

The skills,and knowledge of thousands of physicians and others involved in health care are aggregated and then allocate. Further, to speak of allocation means some one or some elite group will do the allocating not individual physician patient units.You know the "dyads" that Drs.Berwick and Brennan wanted to eliminate as the decision making unit in matters of health care.(See here for what Berwick and Brennan has to say about that.)

The dangerous element of the concept is that when medical decisions are made on the basis of cost effectiveness as judged by some third party the individual is at risk of being harmed in the name of some aggregate benefit allegedly exceeding the aggregated cost. It is the utilitarian enterprise -the greatest good for the greatest number. there will be winners and losers and as long as the "utility" of the winners exceeds the utility lost by the losers we have a cost effective outcome. As since society as a whole is better off  it must be fair by definition. Never mind that individuals may be sacrificed to some abstract aggregate benefit .

 This utilitarian approach is not just opposed by libertarians but the egalitarian thinker, John Rawls says of utilitarianism that individual rights may be breached in its effort to bring about the happiness or utility of the greatest number and objects to utilitarian decisions because it ignores the separateness and distinctness of individuals.

The ABIM foundation and committees of the ACP both  are  promoting cost effectiveness analysis. Note this is not comparative effectiveness analysis but recommending the technique to determine  for example if two treatments are both effective that the one with a more favorable cost effective ratio be used.

The idea that medical data analysis technocrats  should be the allocators or at least advisers to the actual allocators is what one would expect from the medical progressives whose major tenet appears to be that medical decisions and too complex to be made by the individual physician patient dyads and is also a  died-and- gone- to- heaven moment for the third party payers who could not be more pleased that is the medical profession itself ( or certain elements of it) who are advocating cost effectiveness .

Social justice was the Trojan horse on which cost effectiveness allocation of finite resources and guideline adherence rode. Operationally it seems that to the ABIM Foundation social justice is mainly all about fair and cost effective allocation of resources. In that scheme there will be two tiers of physicians.

There will be the highly trained cost effectiveness analysts who will determine what is just and cost effective and the worker bee physicians who by adhering to the allocators' guidelines will be promoting social justice in their stewardship role. 

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