By Aaron Kheriaty, M.D.
Americans are rapidly losing trust in the medical profession.
The percentage of U.S. adults who are confident medical scientists act in the best interests of the public declined from 40 percent in 2020 to 29 percent in 2022, according to Pew research.
A 2021 survey by the American Board of Internal Medicine found one in six people—including physicians—no longer trust doctors, and one in three do not trust the health care system. Almost half the population does not trust our public health agencies to act in our interests.
Doctors are leaving the profession in droves. One in five doctors plan to leave medicine in the next two years, and one in three intend to reduce their work hours in the next year, according to the American Medical Association.
Why is medicine today failing many of its brightest students and pushing large numbers of its best-seasoned practitioners into early retirement?
The answer is complex and multifactorial, but a major contributing factor is the managerial revolution in medicine.
Technocratic Scientism
Since World War II, medicine, like many other institutions, has succumbed to managerialism, the unfounded belief that everything can and should be deliberately engineered and managed from the top down. Managerialism is destroying good medicine.
The managerialist ideology consists of several core tenets, according to social thinker N. S. Lyons. The first is Technocratic Scientism, the belief that everything, including society and human nature, can and should be fully understood and controlled through materialist scientific and technical means, and that those with superior scientific and technical knowledge are therefore best placed to govern.
In medicine, this manifests through the metastatic proliferation of top-down “guidelines” imposed on physicians to dictate the management of various illnesses. These come not just from professional medical societies but also state and federal regulatory authorities and public health agencies.
“Guidelines” is in fact a euphemism designed to obscure their actual function: they control physicians’ behavior by dictating payments and reimbursement for hitting certain metrics. In 1990, the number of available guidelines was 70; by 2012 there were more than 7,500.
Utopian Progressivism
The second tenet of our managerial ideology is Utopian Progressivism, the belief that a perfect society is possible through the application of scientific and technical knowledge and that the Arc of History bends toward utopia as more expert knowledge is acquired.
Promising to deliver miracles only sets up physicians for failure and patients for disappointment. When those promised miracles fail to materialize—an incurable cancer is every bit as incurable at Hopkins as it was at your local community hospital—patients feel betrayed, and doctors are bereft.
A humble and realistic acknowledgment of the limits of medicine is a necessary starting point for any sane and sustainable health care system. Doctors are not miracle workers, much less gods. Science cannot save us.
Liberationism
The third feature of the managerialist ideology is Liberationism, the belief that individuals and societies are held back by the rules, restraints, relationships, historical institutions, communities, and traditions of the past, all of which are necessarily inferior to the new, and which we must therefore be liberated from to move forward
At its foundation, medicine relies on a particular kind of relationship, one based on trust between a patient made vulnerable by illness and a doctor who uses his knowledge and skills always and only for health and healing.
Liberationism seeks to “free” medicine from these constraints. Why should physicians pursue only health and healing as their goals? After all, biomedical technology can be used for all kinds of other pursuits.
In addition to making the sick well, we can make the healthy “better than well.” Through hormones, gene editing, or psychopharmacology, we can make short people tall, weak people strong, and average people more intelligent. These projects of “human enhancement” will explode the boundaries of medicine and liberate man from the constraints of human nature, the story goes.
To take just one contemporary example, what proponents call “gender affirming care” is quickly crumbling under the weight of evidence showing puberty-blocking hormones, cross-sex hormones, and surgeries that destroy healthy reproductive organs have not improved the mental health outcomes of gender dysphoric youth.
Homogenizing Universalism
Homogenizing Universalism, the fourth tenet, is the belief that all human beings are fundamentally interchangeable units of a single universal group and that systemic “best practices” discovered by scientific management are universally applicable in all places and for everyone.
As with the so-called “clinical guidelines” discussed above, medicine has had a recent explosion of so-called quality metrics for medical providers and organizations. These measures, also numbering in the thousands, cost each physician at least $40,000 a year to manage—costs that get passed on to patients.
None of this improves medical outcomes. In fact, the metrics often worsen outcomes by mandating a one-size-fits-all approach to clinical care.
Homogenizing universalism has led to preventative overprescribing. In the United States, 25 percent of people in their sixties are on five or more long-term medications, rising to 46 percent of people in their seventies and 91 percent of nursing home residents.
Medicine’s Biggest Challenge
What primarily ails medicine today is not just technical problems or economic challenges, important as these are to address. Our deepest problems are philosophical, fueled by ideologies that distort the nature and purpose of medicine.
Will we recognize that the managerialist ideology undermines medicine’s goals of health, and summon the will necessary to cut through all the obstacles and cut away the excrescences that undermine the ability of physicians to heal?
Aaron Kheriaty, M.D., (akheriaty@icloud.com) is a psychiatrist, a scholar at the Ethics and Public Policy Center, and a former professor of psychiatry and director of medical ethics at the University of California-Irvine. A version of this article was published by the Brownstone Institute. Reprinted with permission.