Knights, Knaves, or Pawns?
Sachin H. Jain, MD, MBA; Christine K. Cassel, MD
I recently read this article in the Journal of the American Medical Association (JAMA) and it was quite disturbing for me. According to the authors, a British economist named Julian LeGrand suggested after World War II that public policy is grounded on the concept of humans being either knights, knaves or pawns.
Human beings motivated by virtue are knights, those who have rigid self-interest are knaves, and those that are passive victims of their circumstances, pawns.
These authors take this concept and apply it to today’s American healthcare system. The question is which one are you? According to these authors, physicians are either in practice for the betterment of society (knights) their own selfish gain (knaves), or they are automatons whose actions are defined more by external rules and regulations (pawns).
If physicians were all knights and well intentioned, the healthcare system would place the stewardship of it firmly in their hands. They would be trusted to use and deploy resources wisely, minimize waste, and look beyond their narrow, individual, and specialty interest to protect the system as a whole. Individual physician decision-making and autonomy would be given the highest priority. They would constantly study to improve themselves, they would do clinical research to advance science, and they would do their jobs as professionals.
If physicians are knaves as conceived by society; then society would develop policies, management and educational efforts to combat and work against physicians not with them. In this scenario, physicians are interested in themselves and their financial well-being first and their patients second if at all. In this system physicians must be given a reward or incentives to motivate them to do what is right by their patients and any such schemes would have to be carefully monitored for abuse, fraud, and waste. Policies and regulations must guard against their malfeasance. I worry that this is what too many of us have become.
If society views physicians as pawns, then efforts are applied to building systems that ensure that physicians do what is right for patients because physicians cannot be trusted to do so on their own accord. Left to their own devices, physician behaviors are unpredictable. The pawn physician is merely a function of the environment in which he or she practices. Thus they must be given guidelines to follow and policymakers must decide clinical priorities. The role of health policy and regulation for the pawn physician is to guide his or her every behavior because he or she lacks individual agency and judgment to reliably do what is right.
What were the implications of LeGrand according to these authors? Unfortunately the quality of care policy discourse often reflects the perspective that physicians are an obstacle, not an enabler to a functioning healthcare system. Rather than being counted on to maintain their knowledge and expertise on their own accord, they are subject to periodic examinations to demonstrate continued proficiencies, are grounded in evidence of unwanted variation in care, clear evidence of waste, and even fraud and decline in knowledge over time. The modern U.S. physician is regarded as either a knave or a pawn and is seldom regarded as a knight any longer. Marcus Welby where are you?
LeGrand offers an important lesson and warning. It is critically important to understand and get “true motivations” right. Disaster may follow a person largely over knavish quality or if treated as knights, but the same may be true for policies fashioned on the belief that people are knaves if the consequences to suppress their natural altruistic impulses and hence destroyed part of their motivation to provide a quality public service.
LeGrand further warns that policies that treat people as pawns may lead to demotivated workers… again causing adverse outcomes for the policies concerned, while policies that give too much power…may result in individuals making mistakes that damage their own or others welfare.
The public would be wise to heed LeGrand’s advice and carefully consider whether its perceptions of physicians match reality. For their part physicians must thoughtfully consider whether and how they contribute to the perceptions that they are knights, knaves or pawns.
I’d love to hear from any of you about your thoughts on this.
Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.