Are Patients Knights, Knaves, or Pawns?

British sociologist Julian Le Grand has noted that public policy is grounded in a conception of humans as “knights,” “knaves,” or “pawns.”¹ Human beings are motivated by virtue (knights) or self-interest (knaves) or are passive respondents to their circumstances (pawns). A society's view influences whether it builds public policies that are permissive, punitive, or prescriptive.

Le Grand's original analysis applied to British citizens affected by the postwar social welfare state in Britain, and it has previously been applied to the role of physicians in the US health care system.² In this Commentary, we describe ways in which patients might be considered knights, knaves, and pawns in public discourse and the importance of policies that match actual motivations.

If a society conceives of patients as well-intentioned knights, it assumes that the will and values of patients should drive the structure and organization of health care, called patient centered by the Institute of Medicine and extolled by leaders and consumer advocates.³ Patients are trusted to wisely use health care services when necessary and to take responsibility for actions they can take and behaviors they can learn to promote their own well-being. Individual patient decision making and autonomy are the center of the system⁴ with patients striving for health and following expert medical recommendations. The role of policy and payment is mainly to empower patients and physicians working together toward shared aims; insurance coverage should make these interactions as facile as possible.

If a society conceives of patients as knaves, policy, management, and education efforts are designed to work against patients, not with them. Waste and even fraud are the behaviors that come most naturally to the knave—and it is the role of physicians and health insurance companies to monitor for this behavior and impose stiff financial penalties to deter it. In this scenario, patients engage in risky habits because they are in denial, confident that few personal consequences will follow, and they are passive regarding consequences because others will subsidize the costs of the medical consequences. They use health care—office visits, hospitalizations, procedures, and diagnostic studies—because they do not want to take responsibility for themselves. Policies and regulation must guard against malfeasance, including high co-payments and high-deductible insurance policies as mechanisms to ensure against knavish patient behavior.

If societies conceive of patients as pawns, efforts are applied to building systems that ensure patients do what is right for themselves and for the health care system, because patients cannot be trusted to do so on their own accord. In this scenario, patients are considered uninformed or generally misguided, with unpredictable and unscientific behaviors. The pawn patient is merely a function of the environment and incentives he or she is given; accordingly, physicians and health insurance companies must be benevolently paternalistic and prescriptively decide on clinical priorities. Shared decision making is irrelevant because the physician is responsible for making sure the patient makes the right decision. The role of health policy and regulation for the pawn patient is to guide every behavior because patients lack judgment to do what is right.

Le Grand's work on post–World War II British social policy found that perceptions of human motivations gradually transformed, with the prevailing view of the typical British citizen morphing from knight into knave as the costs of maintaining a welfare state increased.

The United States has never had the extensive British safety net, yet in many ways, the same attitudinal changes that emerged from the British experience exist. As patient behavior is tied to rising costs, and increasing scrutiny is applied to the volume of health care services consumed, policy discourse often reflects the perspective that patients are an obstacle to, not an enabler of, a functioning health care system. Rather than counting on patients to exercise good judgment in managing health care problems, this view holds that patients should be guided with an increasing menu of behavioral or financial devices and strict regulations. Because it is assumed that patients will not undertake healthy behaviors on their own, they are increasingly subject to directive health and wellness programs by their employers, health plans, clinicians, or communities.

As with physicians, the patient in the United States today is seen either as a knave or a pawn and is seldom viewed as the knight. Patient centeredness is lost in a tangle of insurance arrangements. Nonetheless, most patients do not abuse the health care delivery system or actively injure their own personal health. Many are struggling with access to basic services, and others defer needed treatment because of the high deductible amounts health plans put in place.⁵ Many patients seek more information on the internet because they perceive they cannot get needed information from trusted clinicians. How can society avoid inflicting harm on the patients whose needs remain great and genuine while guarding against abuses by the few whose needs are not?

The success of innovations in care that seek to improve coordination and reduce unnecessary and harmful overuse will rely on effective connections to the motivations of patients toward better health. For the vast majority of patients, these motives are consistent with their behaviors. Psychological theory suggests that health plans that create a “gaming” mentality by clearly establishing a distrustful relationship with patients and families may backfire. Unless patients trust that clinicians have their best interests first and foremost, any barriers to seeking service will be seen simply as money-saving measures and create the impression that these services are something the patient ought to be able to get and therefore ought to want.

As better outcomes and lower costs are sought by innovative delivery models and new communication technologies, patients must be engaged as trusted partners, not as passive subjects or manipulative knaves. Coordination of care requires communication with patients, their families, and other members of the health care team, often including community resources. Optimal outcomes are not possible without the patient at the center expressing his or her personal values and goals for treatment, trusting that clinicians share that focus.⁶

There are a small number of patients who abuse the system by habit or by pathology (ie, Munchausen syndrome or hypochondriasis). Still, Le Grand offers an important warning that warrants repetition: it is critically important to understand and get true motivations right. Best intentions will fail if persons largely of a knavish quality are treated as knights, but the same may be true for “policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses.”¹ Le Grand further warns that policies that “treat people as pawns may result in individuals making mistakes that damage their own or others' welfare.”¹

The medical profession, policy makers and analysts, health plans, and other key stakeholders would be wise to heed Le Grand's advice and carefully consider whether their perceptions of and approach to patients match reality. For their part, patients and consumer groups can thoughtfully consider how they may be contributing to the perception that they are either altruistic knights, self-interested knaves, or hapless pawns.