The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as “knights,” “knaves,” or “pawns.” Human beings are motivated by virtue ( knights) or rigid self-interest ( knaves) or are passive victims of their circumstances ( pawns). A society's view of human motivation influences whether it builds public policies that are permissive, punitive, or prescriptive.
Le Grand's observations were drawn from his studies of British social welfare policy and civil servants but could aptly be applied to physicians and their role in the US health care system. Many health care debates—especially those relating to health care financing, quality, and education—implicitly prescribe a view of physicians and their underlying motivations. Depending on the perspective, physicians are either in practice for the betterment of society or their own selfish gain; or they are automatons whose actions are defined more by external rules and regulations.
In a Commentary published in JAMA Vol. 304 (9) 1009-1010, Sachin Jain and Christine Cassel explore the ways in which physicians are variously represented as knights, knaves, and pawns in public discourse and relate the importance of de- signing policies that match the true motivations of physicians—whatever they may be.
Jain and Cassel suggest that their views are grounded in evidence of unwarranted variation in care, clear evidence of waste and even fraud, and decline in knowledge over time. The modern US physician they conclude is regarded as either a knave or a pawn and is seldom regarded as a knight.
But they also suggest that evidence that has led to distrust of physicians does not apply universally and many physicians still are the knights in the health care system.