The core belief of the Medical Progressives (MPs) is that medicine and health care are too important and complex to be left to decisions made by individual patients and their physicians. What is needed , in slightly paraphrased words of one of the MP's upper echelon, Dr Don Berwick: We need wise leaders with ideas.
He and another leader of the MPs, Dr. Troyen Brennan expressed their credo explicitly in their book entitled "New Rules". Here is a key quote.
"Today, this isolated relationship[ 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.
Decentralized decision making means individual people making their own individual medical decisions with the counsel of their physicians. There must be a word stronger than hubris to describe the attitude of the medical progressive elite.
The MPs advocate and promote abolition of the traditional fiduciary of the physician to his patient. Phrases like " Rules with authority" and the "constraint of individualized decision making" made it clear what they propose. Some one will be making the rules for everyone rather than the individual physician patient "dyad" and those rules need to be enforced.Advocates of individual liberty should probably thank Dr. Brennan and Berwick for their making it crystal clear what they want for medical care in this country.
Others in the MP community have approached that aim with a more opaque and convoluted game plan.
One approach in that regard has been the advocacy of the concept of social justice as a primary precept in the physician's ethics code., particularly as advocated in the new medical professionalism.Advocacy for social justice would appear on the surface to have nothing to do with destruction the medical ethical principle of the fiduciary duty to the patient. But here is how I believe it has worked out.
First the term social justice was promoted as an obligation of physicians.The Overton window of discourse has been significantly shifted. Social justice was not specifically defined but served as a general feel good, ambiguous idea that would be be unlikely to generate much opposition.It could mean many things; aid to dependent children,initiative to eliminate racial biases and generally hep the poor- social justice as a egalitarian concept-equal respect for all. As time went on social justice as a physician obligation took roots and became acceptable part of the rhetoric of health care and the various problems associated with it although it was never clear exactly how individual docs would fulfill that obligation. It was not long until the MPs made it clear how that should be done.
Certain factions of the MPs proceeded to phase two of the bate and switch strategy and quietly and without debate sneaked in the idea that the social justice obligation of the physicians was actually to be stewards of the nations finite medical resources. Implicit in this concept is the idea that individually owned assets and knowledge and skills composed an entity that was collectively owned to which everyone by virtue of their existence were entitled to their share of this medical commons.
With collective ownership everyone cannot just wade in and consume whatever and everything they want.The commons will be overgrazed .We will need leaders with ideas about how the contents of this collective owned aggregate will be distributed.
Now we can see the key role of the MPs. Someone has to oversee this collective. Someone has to have the knowledge, and skills to make the decisions as to how this collective pie will be sliced.Next we are told that the pie is best sliced with the sophisticated tools of cost effectiveness analysis so that everyone can enjoy high value care and we will eliminate low value care.Of course these slicing rules should be translated into guidelines adherence to which will demonstrate the practitioners' fidelity to a social justice quest and a measure of his delivery of quality care .