Almost everyone I know considers the American healthcare system to be a horrible mess, although some that are deeply into it are quite happy with it. It serves their interests well.

Many do have big-time power.

There are lots of candidates for the “most powerful” title.

How about Regina Benjamin, the Surgeon General of the United States Public Health Service?

Maybe Kathleen Sebelius, the Secretary of Health and Human Services?

Consider Howard Koh, the Assistant Secretary of HHS for Health.

Many would name Donald Berwick, who heads CMS, thus running Medicare.

Could it be Walter Herger, the chair of the Subcommittee on Health of the Ways and Means Committee of the U.S. House of Representatives, or maybe Max Baucus, the chairman of the U.S. Senate Finance Committee?

Or perhaps President Obama himself?

Consider Francis Collins who runs the NIH, or Margaret Hamburg who directs the FDA, or Tom Frieden who is in charge of CDC.

Outside government, how about Harvey Fineberg, President of the Institute of Medicine of the National Academy of Sciences?

Or George Halvorson, the CEO of Kaiser Permanente?

Or maybe the presidents or CEOs of the American Medical Association, the American Hospital Association, the Joint Commission, or perhaps United Healthcare or Anthem Blue Cross Blue Shield?

Consider the dean of Harvard Medical School, or the editor of the NEJM or the JAMA, or the highly visible Dr. Mehmet Oz, or the New York Times‘ Gina Kolata, CNN’s Sanjay Gupta, or Quackwatch’s Steve Barrett?

A pretty impressive list of candidates, I do believe. Which one or ones are the most powerful?

Impressive though their individual and collective clout is, it is none of these powerhouses.

The most powerful people in American medicine are every patient, empowered by the dominant ethic of patient autonomy; the authority to say Yes, or No, to anything.

And it is every American physician, empowered by the dominant ethic of physician autonomy; the authority to say Yes, or No, to anything.

When working effectively together in the professional relationship, the patient and physician must and can continue to be supremely powerful.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.