Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete who presumed to know what is best for every one and how to plan to bring that optimal state into being.
The following commentary highlights the views of some physicians who might be considered the medical men of system.
The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
"Today, this isolated relationship[ he is speaking of the physician patient relationship]
is no longer tenable or possible… Traditional medical ethics, based
on the doctor-patient dyad must be reformulated to fit the new mold
of the delivery of health care...Regulation must evolve. Regulating
for improved medical care involves designing appropriate rules with
authority...Health care is being rationalized through critical
pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making
Dr. Robert Berenson strikes a seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402. in which he promotes the health of the collective rather than the individual patient :
"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."
Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making away from the physician and his patient to a reliance of authoritarian rules.
More recently Berenson has this to say:
"we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now"
A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would be a greater good for the greatest number.
Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:
" ABIM could require candidates to achieve a perfect score on questions
related to costs and redundant care as a requirement for admission to
secure exams for initial certification or MOC."
So for candidates for certification or the Maintenance of Certification to even be allowed to take the test they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the Choosing Wisely guidelines.
This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.
The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...
But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .
This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitously , as was done the in the publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.
To close with a quote from Adam Smith's "Theory of Moral Sentiments" :
"The man of system, on the contrary, is apt to be very wise in his own
conceit; and is often so enamored with the supposed beauty of his own
ideal plan of government, that he cannot suffer the smallest deviation
from any part of it. He goes on to establish it completely and in all
its parts, without any regard either to the great interests, or to the
strong prejudices which may oppose it. He seems to imagine that he can
arrange the different members of a great society with as much ease as
the hand arranges the different pieces upon a chess-board. He does not
consider that the pieces upon the chess-board have no other principle of
motion besides that which the hand impresses upon them; but that, in
the great chess-board of human society, every single piece has a
principle of motion of its own,"