In Part I we talked about a new managerial revolution that is taking place in medicine today.

Aaron Kheriaty, writing in The Epoch Times, tells us the managerialist ideology consists of several core tenets, according to Washington-based writer and analyst N.S. Lyons. The first is technocratic scientism, or 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 society.

This ideology manifests itself in medicine 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 based on hitting certain metrics. In 1990, the number of available guidelines was 70; by 2012, there were more than 7,500. In this metastatic managerial regime, the physician’s clinical discretion goes out the window, sacrificed on the altar of unthinking checklists. As every physician knows from clinical experience, each patient is sui generis, unrepeatably unique.

Dr. Kheriaty says, “Real patients cannot be adequately managed by a diagnostic-based algorithm or treated by an iPad. Checklists are useful only once the problem has been understood. For the practitioner to be able to make sense of problems in the first place requires intuition and imagination—both attributes in which humans still have the edge over the computer. Problem-solving in a complex environment involves cognitive processes analogous to creative endeavors, but medical education as currently configured does not cultivate these capabilities.”

Technocratic scientism has likewise driven the campaign for so-called “evidence-based medicine” (EBM)—the application of rationalized expert knowledge, gleaned typically from controlled clinical trials, to individual clinical cases. At first glance, evidence-based medicine seems hard to argue with—after all, shouldn’t medical interventions be based on the best available evidence? But this model has serious flaws, which have been exploited by Big Pharma. Studies yield statistical averages, which apply to populations but say nothing about individuals. No two human bodies are exactly alike, but technocratic scientism treats bodies as fungible and interchangeable.

By this way of thinking, treating patients might just as easily be done by robots – plug in the symptoms, out comes a diagnosis and treatment. No need for any human intervention. I’m sure there are those who would agree with this approach, but doctors know better. Medicine is both science and art – a unique blend of scientific knowledge and human experience that only can be applied by humans.

EBM proponents claim we should only use the “best available evidence” to make clinical judgments. But this sleight-of-hand is deceptive and wrong: We should use all available evidence, not just that deemed “best” by self-appointed “experts.” The term “evidence-based” functions to smuggle in the claim that double-blinded, randomized, placebo-controlled trials (RCTs) are the best form of evidence and therefore the gold standard for medical knowledge.

Dr. Kheriaty says, “This results in, among other things, the scrapping of the entire discipline of epidemiology. EBM’s criteria constitute Big Pharma propaganda masquerading as the “best” expert scientific and technical knowledge.”

(Note: More on managerial ideology and its impact on medicine next post.)

There is a revolution taking place in medicine and it forebodes poorly for the future of patient healthcare. I’ve written about changes in healthcare in the past and have even published a book, Changing Healthcare, to discuss some of what is happening.

When I began my practice in 1984, most doctors were self-employed or employed by other doctors. The only doctors who weren’t were mostly pathologists and radiologists who worked for hospitals. Today, about 70% of all doctors are employed by hospitals, large healthcare systems, or the government.

What is the impact of this change?

Simply put, doctors are no longer in control of their decisions about treating patients. They are pressured by the employers they work for to save money by limiting costly expenses or make money by performing costly procedures. Money has become the driving influence in healthcare whereas before the patient’s welfare generally came first. Doctors are trained to do what’s best for their patients, but when others have the final say, the patient’s best usually gets forgotten.

To add to this mess, patients are losing trust in their doctors, and in scientists in general. According to Pew Research, the number of U.S. adults who place confidence in medical scientists to act in the best interests of the public declined from 40 percent in 2020 to 29 percent in 2022. You can thank the Covid pandemic for this decline in trust. However, even 40 percent is much lower than the confidence people had in their doctors fifty years ago.

All of this is driving doctors to retire early or leave the profession for greener pastures. I’ve written about the doctor shortage before (Physician Shortage Getting Worse – 2024) so I’ll not belabor that issue here. But there is new information that further explains this decline.

There is a new revolution taking place in medicine that some have called the managerial revolution. Aaron Kheriaty, a physician and fellow at The Ethics and Public Policy Center, writing in The Epoch Times tells us that medicine, like many other contemporary institutions since WWII, has succumbed to managerialism – the unfounded belief that everything can and should be deliberately engineered and managed from the top down. He says, “Managerialism is destroying good medicine.”

The managerialist ideology consists of several core tenets, according to Washington-based writer and analyst N.S. Lyons. The first is technocratic scientism, or 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 society.

This is a new concept in medicine, but one that has been prevalent in politics for some time. Angelo Codevilla, professor at Boston University, wrote about this in 2010 in a book entitled The Ruling Class. In it he warns us there is an elite group of individuals from both political parties who see themselves as the only ones fit to make decisions for the people “for the good of the country.” This antidemocratic ideology has infiltrated our political system and is a real threat to our democracy.

The same way of thinking threatens our healthcare system as doctors are forced into a one-size-fits-all mentality that may be good for business but not so much for patients. As any physician knows, every patient is an individual and decisions based on the population as a whole rarely are best for that patient.

How does this way of thinking manifest itself in medicine?

(Note: I’ll discuss the answer to this question in the next post.)

In Part I of this series, we discussed the fact that physicians are taught to “first do no harm.” To assist someone in committing suicide is a violation of that training and neither noble nor natural. It is actually playing God, since God is the creator of all life and only He should have the last word on when life ends. All those who live by the values of Judeo-Christian teaching and the Bible would agree.

But some disagree. Assisted suicide is now available in ten states plus the District of Columbia. The late great Washington Post columnist, Charles Krauthammer wrote in 1997, “When you see someone on a high ledge ready to jump, you are enjoined by every norm in our society to tackle him and pull him back from the abyss.” “We are being asked to become a society where, when the tormented soul on the ledge asks for our help in granting him relief, we oblige him with a push,” wrote Krauthammer when reflecting on the oral arguments of Vacco v. Quill, in which the Supreme Court eventually ruled the Constitution doesn’t create a right to that procedure.

But Canada has pushed even farther down this slippery slope than the United States. Nicholas Tomaino, writing in The Wall Street Journal, tells us the Canadian Parliament has made it easier than ever to obtain assisted suicide, dropping safeguards such as the minimum 10-day assessment period between request and provision. It also proposed mental illness as an eligible condition, the implementation of which the government has delayed until 2027. It seems their message is “If you want to die, you needn’t wait.”

But there are consequences to this policy. The consequence, Ethics and Public Policy Center fellow Alexander Raikin notes in a new study, is that what was meant to be exceptional has become routine. Using two government data sets, he estimates the program is at least the fifth-leading cause of death in Canada, claiming a reported 13,241 lives in 2022, up from 1,018 in 2016.

Mr. Raikin notes the government believed doctors wouldn’t merely rubber-stamp applications. Yet in 2022 more than 81% of petitions resulted in death, including for “vision/hearing loss” and “diabetes.” He documents that the percentage of denied written requests has been falling for years, from 8% in 2019 to 3.5% in 2022, even as the number of applications has increased. The upshot has been that 44,958 people have been put to death between 2016-22. One estimate, published in the New England Journal of Medicine in 2020, predicted that “approximately 2,000 euthanasia” cases could be expected annually. The MAID toll that year was 7,611. Thus “either in absolute numbers or when weighed as a percentage of deaths,” Canada has the “fastest-growing assisted-dying program” in the world.

Roger Foley, who suffers from a degenerative neurological disorder, cerebellar ataxia, has witnessed MAID since its infancy. In 2009, as Mr. Foley’s condition worsened, he resigned from his job at the Royal Bank of Canada. After several years in home care, in which he claims he was mistreated, he was placed in a mental-health ward.

“I became extremely suicidal,” Mr. Foley, 48, says in a Zoom interview from his bed in the hospital, where he’s lived since 2016. After he shared those thoughts with staff, he says they began to float the idea of euthanasia. That alarmed him, so he began to record conversations secretly. He later shared them with Canadian journalists.

In one, a hospital ethicist threatens Mr. Foley with denial of insurance coverage and says it would cost him “north of $1,500 a day” to stay in the hospital. When Mr. Foley protested, the ethicist retorted: “Roger, this is not my show. My piece of this was to talk to you about if you had interest in assisted dying.” He didn’t. “I have a passion to live,” Mr. Foley says. He wants to volunteer and write songs. Many people like to “use the term ‘end suffering,’ ” he says. In practice, that means “Don’t help the sufferer, end the sufferer. “ ”I deal with a lot of pain every day,” he says, “but you can’t give up at the point of any problem—you’re still of value, your life has value.”

Mr. Tomaino says, “Mr. Foley isn’t religious, but to my Catholic ear, it sounds as if he’s saying life is sacred. Canada’s healthcare system wants not only to give up on him, but to compel him to give up on himself.”

Congratulations to Mr. Foley for standing up against those who would push him into assisted suicide – for their own misguided agenda. Yet as he rejects MAID, others seek to open its doors wider still. On August 19, an organization called Dying With Dignity filed suit in Ontario Superior Court, claiming that preventing assisted dying for mental illness is discriminatory. Tomaino warns, “That may not sound dignified – but, as Krauthammer saw, it is logical.”

The plain truth is when man decides to play God, there is no limit to what evil he can do.