Motivating biases need not be considered nefarious, only considered.
In 2019, Drs. John Mandrola, Adam Cifu, Vinay Prasad, and Andrew Foy wrote an article titled The Case for Being a Medical Conservative. In it, they stressed the importance of considering “dualities of interest” and “motivating biases”. They wrote:
The medical conservative sees benefits from the confluence of interests between profit motives of industry and progress in research; we do not oppose industry–physician collaboration. But these dualities of interest must be considered in determining the quality of evidence for or against new interventions. For instance, an incomplete evidence base due to selective publishing of “positive” studies can inhibit true knowledge of an intervention’s net benefit.
The medical conservative, therefore, is pragmatic about human nature and the prevailing business model of medical science. To wit, content experts, professional societies, or journal editors who too harshly criticize an industry product jeopardize future funding. Motivating biases need not be considered nefarious, only considered.
Fair enough. I also wrote extensively about the risks of these motivating biases in my book on cognitive errors in medicine. I made many similar points.
In their must-read article, Subscription Science: How Crowdfunding Has Become a Conflict of Interest, Drs. Benjamin L Mazer and Michael R Rose similarly warned about these “dualities of interest” and “motivating biases.” They said:
For example, Substack, an online newsletter platform, is increasingly used by physicians to write medical commentary, with some newsletters reaching 10s of thousands of subscribers. Substack estimates that 5-10% of readers will upgrade to a paid tier, and paid subscriptions on the service cost a minimum of $5 per month. Although $5 sounds negligible, consider a newsletter with 10 000 total subscribers, 1000 of whom pay a $5 monthly fee. After subtracting Substack’s 10% cut, a doctor could expect $54 000 in annual payments. If physicians accrue 5000 backers, they can expect $270 000 in revenue. This is greater than the $265 000 average salary of primary care physicians in the US.
Not bad.
Why Doctors Should Learn to Stop Worrying and Love MAHA.
In spirit of considering “motivating biases”, we can turn to Sensible Medicine, a monetized Substack founded by these same “medical conservatives”. Sensible Medicine has over 100,000 subscribers and multiple subscription plans.
In return for their money, Sensible Medicine readers were treated to absurd and dangerous articles, such as Why Doctors Should Learn to Stop Worrying and Love MAHA, which was written by Dr. Joseph Marine in November 2024. Though you should read the entire article, it said:
I argue that we should embrace the Make America Healthy Again (MAHA) agenda and try to convince our medical leaders to work for major changes in our dysfunctional health agencies and deteriorating health care system.
RFK Jr has tapped into a strong sense among the public that government health agencies, and the health system at large, have been corrupted by corporate interests that have become increasingly misaligned with the public interest, a fact that was exposed by the disastrous authoritarian covid response.
The raw, histrionic appeals to anger and emotion- disastrous authoritarian covid response– are standard fare on Sensible Medicine, as are attempts to numb people to risks that are both grave and obvious. Dr. Marine’s article did not mention RFK Jr.’s anti-vaccine disinformation, and on social media he said:
MAHA is more than RFK and has little to do with vaccines.
This is the wisdom and insights that Sensible Medicine offers to its paid subscribers, and this was not an isolated article. Dr. Frederik Schaltz-Buchholzer published an article there titled The Nomination of Robert F. Kennedy Jr. as Secretary of the Department of Health and Human Services: A New Beginning? He wrote:
My prediction? RFK Jr. will be a net positive for public health in the US. The mainstream media – who were the most important enablers of the destructive COVID-19 policies – are falling over themselves and screaming wolf, oblivious to the fact that current US public health is a complete failure.
According to Dr. Schaltz-Buchholzer, RFK Jr.’s critics- enablers of the destructive COVID-19 policies– were just “screaming wolf.”
In the introduction to that article, Dr. Prasad said Sensible Medicine offered a “refined view of evidence based medicine” and begged more people to subscribe to it. Dr. Prasad wrote:
Today’s guest column is by Dr. Frederik Schaltz-Buchholzer. He is Danish expert in vaccine science, who is supportive of US reforms. How can he possibly be enthusiastic about RFK Jr? And enthusiastic despite writing, “[Mr Kennedy] focuses on topics that are potentially important/relevant, and then unfortunately often exaggerates or distorts the facts.” So what are the facts, and what are the distortions? Why is this expert in vaccine science largely in agreement with RFK Jr’s skepticism? In my opinion, this is why Sensible Medicine exists. To take you, the reader, out of your comfort zone, and towards a more refined view of evidence based medicine. If you believe in what we are doing, subscribe.
Sensible Medicine published at least one honest article, RFK Jr is NOT the Contrarian We Need, but the paid subscribers hated it. “More recycled arguments from a Big Pharma shill,” said one typical commentator. “The use of the term ‘anti-vaxx’ is polarising and unhelpful…. The proper term should be ‘pro-health’, not ‘anti-vaxx’,” said another. This is the audience Sensible Medicine cultivated. This is who paid for their content.
I Was Inside CDC During the Shooting. I Can Still Hear the Bullets.
Well, fast forward to today and RFK Jr. is doing exactly what he said he was going to do. No one here at SBM is surprised by any of it. His tenure, which is just 6-months old, has been marked by purges, censorship, resignations, anti-vaccine disinformation, and defunded research. Scientists are wondering if they have a future in the US, and over 5,000 government workers wrote a letter calling RFK Jr. “dangerous and deceitful.” Other CDC staffers and walking out and quitting in protest. In a scathing resignation letter, Dr. Demetre C. Daskalakis noted that the fans of “natural infection”, We Want Them Infected– have won and warned of eugenics at the CDC. He wrote:
The intentional eroding of trust in low-risk vaccines favoring natural infection and unproven remedies will bring us to a pre-vaccine era where only the strong will survive and many if not all will suffer. I believe in nutrition and exercise. I believe in making our food supply healthier, and I also believe in using vaccines to prevent death and disability. Eugenics plays prominently in the rhetoric being generated and is derivative of a legacy that good medicine and science should continue to shun.
CDC staffers are rightly blaming RFK Jr. for the terrorist attack there. An article titled I Was Inside CDC During the Shooting. I Can Still Hear the Bullets said:
According to news reports, the gunman was fueled by vaccine disinformation. Convinced that the COVID-19 vaccine caused his physical ailments, he sought revenge…
This disinformation is now being amplified from the highest levels of the government. HHS Secretary Robert F. Kennedy Jr. has spent years fueling anti-vaccine sentiment. As chairman of Children’s Health Defense, he led one of the most prominent anti-vaccine organizations in the world. Even before the COVID-19 pandemic, Children’s Health Defense was identified as a leading source of misinformation on social media, and since the pandemic, Kennedy has been identified as one of the “Disinformation Dozen” a group of anti-vaxxers responsible for almost two-thirds of digital misinformation about vaccines.
In his short time since taking office, Kennedy has dismantled key pillars of public health. He unilaterally withdrew COVID-19 vaccine recommendations for pregnant women and children; fired all members of the Advisory Committee on Immunization Practices, replacing them with several people known to hold anti-vaccine views; and refused to strongly endorse measles vaccination. Just days before the gunman attacked CDC, Kennedy canceled $500 million in mRNA vaccine research, citing debunked safety concerns and expressing skepticism about efficacy
Other articles about this tragedy point the finger directly at RFK Jr.’s chosen leaders, including a founder of Sensible Medicine. An article titled The CDC Shooting Was Public Health’s Jan. 6 said:
Kennedy’s appointees have gone even further. In 2022, the National Institutes of Health’s now-Director Jay Bhattacharya appeared on a panel that inaccurately claimed Covid-19 vaccines had killed 20 times as many people as they had saved. The day after the shooting, Bhattacharya went on Steve Bannon’s podcast to criticize mRNA vaccines. A few days later, he doubled down in a Washington Post op-ed.
Just last year, Vinay Prasad, now a Food and Drug Administration official, said of the public health professionals who guided the Covid-19 response, “I don’t believe in forgiveness, because in my opinion, these pieces of shit are still lying.”
Dr. Prasad also called for mass purges at the CDC, the kind that are happening now. This is the type of rhetoric that Sensible Medicine doctors specifically defended and endorsed. I never spoke this way or called for anyone to lose their job.
Meanwhile, RFK Jr. himself is claiming he has magic powers to diagnose “mitochondrial challenges” in children by looking at their faces as he walks past them in the airport.
This is everything SBM warned about and everything Sensible Medicine enabled. We have 3.5 more years to go.
Tone is important. It is hard to engage when you feel like you’re being yelled at.
At the same time Sensible Medicine was telling doctors to “love” MAHA, myself and many others were desperately trying to warn about it. Some of us, especially Dr. David Gorksi, have been doing so for decades. We failed to stop RFK Jr., but at least there’s a record of us trying. One review of We Want Them Infected said:
One striking example of this is how strongly Robert F. Kennedy Jr. features in the book. Dr. Howard was writing before Kennedy announced his campaign for president, but he regularly uses Kennedy’s anti-vaccine and anti-science positions as a benchmark while refuting contrarian doctors.
Kennedy’s anti-science lies and anti-Semitic remarks had long kept him out of “polite society,” but he is now promoted as a serious politician by such diverse commentators as neo-Nazi Nick Fuentes and Socialist Alternative’s Briahna Joy Grey. Kennedy’s anti-vaccine non-profit Children’s Health Defense saw its funding skyrocket from just over $2 million a year in 2019 to $15.7 million in 2021.
There’s also a record of Sensible Medicine doctors openly refusing to even read our warnings and instead rolling out the red carpet to RFK Jr. It’s OK to consider their “motivating biases” and ask them how much money they made doing this. It’s also reasonable to ask them to explain why it was ethical and appropriate to publish and profit from love letters to RFK Jr.? I’d love to read all about it.
Until then, I think the doctors behind Sensible Medicine should only be known for helping to unleash RFK Jr. and his minions on us, even if they didn’t all personally support him. While we were trying to sound the alarm, they faked a concern about our “tone”, published RFK Jr. fluff pieces, and cashed checks from their paid subscribers. Nothing else about them matters to me, and they own everything that happens under RFK Jr.’s watch.
But hey, maybe I am wrong about all this. Maybe it was appropriate and ethical to publish articles like this. Maybe I am missing something. In contrast to the founders of Sensible Medicine, I do not publicly claim to be a master of critical appraisal. So, my mind is open to their glorious nuance, and I hope they share it in the comments here. They have so much to teach us all, and it won’t cost them a penny. Unlike Sensible Medicine, anyone can comment for free.
