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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, November 27, 2015

The Medical Progressives are an influental subset of the Ruling Class

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 .

1 comment:

Troglodytum Brachiandum said...

You know, there's a perfect set of reasons for this rationale.

a)Now that we have scientific thinking, we should apply centralized, rational decision-making to all our challenges.
b)The old "free-market" principles have distributed thinking processes, each one running on its own rules.

It was called "Socialism." To be fair, it wasn't born ugly.

Over the next hundred and fifty years or so, Socialism turned out to be an unexpected bust, and Jeffersonian pessimism, a win.

Lord Acton's Principle stated that power corrupts. Lord Action was no slouch. Socialism depends on the most noble, wise and benificent to step forward to lead. Often they do - usually they go with a round in the spinal column.

The next heartbreak of Socialism, after the collapse of the politics, was the problem we're wrestling in with IT. It turns out that one centralized hierarchical decision-making process, with raw input from every direction, sucks. Evolution gave up on it back at the invertebrate stage.

Disseminated analysis is much cleaner than centralized analysis. It works on computers. That's how eyes and ears work. Even the frog uses disseminated analysis to catch flies.

The ultimate insult is that Adam Smith and Ayn Rand, proponents of free-market capitalism, were right, no matter how mad that makes the intellectuals.

But in Washington, no idea can stay buried, before it hauls up again out of the crypt, seeking brains. Centralized medical care means success 90% of the time, and failure only 10% of the time. That OK with you? Because in evolution, organisms with that sort of batting average disappear within a few dozen generations.

An' here we go again!