In answer to this question, Noor Siddiqui, founder of the embryo screening company Orchid, recently explained in a video on X that, “Sex is for fun, and embryo screening is for babies. It’s going to become insane not to screen for these things.”

Later in the video, which introduces baby Japhy, the first person born using Orchid’s genetic screening technology, Siddiqui, makes a telling remark about her relationship as company CEO to the newborn baby: “I mean, I don’t know how to explain it—it’s Leah’s baby, but it feels like my baby too. Like it’s been the culmination of an incredible amount of work of not just mine, but an entire team.”

While Sidiqqui highlights her role in bringing this child into the world (for a $50,000 fee, of course), I could not help but notice that the baby’s father is nowhere featured or mentioned in the video. After all, providing the sperm seems almost incidental, compared to the massive technical resources deployed in the genetic screening and selection process. The video also fails to mention the fate of those embryos deemed “not good enough” to be brought to birth. The discarded ones simply disappear from view. At one point in the interview, Baby Japhy’s mom, Leah, holds a picture of Japhy as an embryo, and tells her bouncing baby boy: “this is you—this was you at five days old.” She neglected to mention, or show him pictures of, his embryonic siblings.

I’ll be exploring these, and even more astonishing projects in manufacturing human life which are quickly coming down the pike, having just signed a contract for a forthcoming book, Braver New World: Reproduction in a Posthuman Society. The book will explore the ethical and societal implications of artificial gametes, artificial wombs, gene editing, human-animal chimeras, bodyoids (human bodies designed to be without brains), and whatever else we dream up between now and the book’s publication. As I dig into the research, stay tuned here at Human Flourishing for more dispatches from the frontiers of our braver new world…

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Here is my deep dive on an important question in medical research. This article was originally published in Tablet magazine and is reprinted here with permission.

In 1924, biochemist Otto Warburg observed that cancer cells “feed” differently than normal cells, preferring an unusual energy-generating mechanism where glucose is fermented to lactate. This sugar-driven process of cancer formation is linked to insulin resistance, inflammation, and the formation of new blood vessels that fuel rapid tumor growth. Known for his ascetic lifestyle and his holistic view of biology, Warburg believed that diet profoundly influenced health, and so he avoided alcohol, tobacco, and meat. Even after he won the Nobel Prize for a different discovery, Warburg continued to live a frugal life of solitary laboratory research, despite family wealth and Nobel earnings.

For almost a century, his pioneering discovery of the “Warburg effect” in cancer metabolism has been mostly ignored. Had we grasped its implications, the resultant advice to lower the risk of various cancers would probably have boiled down to: “Don’t eat sugar.” But that public health message was never promoted.

Then in the 1940s, pediatric pathologist Sidney Farber, for whom the Dana-Farber Cancer Institute is named, pioneered the first use of chemotherapy to treat cancer, specifically, childhood leukemia. Dr. Farber collaborated with philanthropist and savvy lobbyist Mary Lasker, of the American Cancer Society, to mobilize public and political support for cancer research. His focus on treatments for childhood cancer put a human face on this tragic disease and helped set the stage for the nation to go all-in on battling cancer a few decades later. Hopes were high that this scourge could eventually be overcome.

President Nixon officially launched the “war on cancer” 54 years ago. It was 1971 and jungle conflict had dissevered the nation. Nixon needed a unifying cause and America needed a cure. So he declared a cancer “moonshot.” Multiply funding tenfold. At last understand the disease’s biology. Target treatments properly. Vanquish an enemy worse than communism—even more powerful, even more pitiless.

A great hope, but what would be the reality?

The reality would be scant successes, billions wasted, dreams dashed. The reality would be meaningful victories in very few battles—most notably in public education to snuff out smoking—instead of a successful campaign to win the whole war.

Financing the War

We don’t really know how much money the war on cancer has cost. One study in the Lancet found that in the year 2020, the U.S. invested $14 billion on cancer research, which amounted to 57% of the total funding globally. Almost 80% of these research grants ($11.1 billion) came from the taxpayer-funded National Institutes of Health (NIH). This total number is surely a low estimate, however, as it does not include the considerable money spent by pharmaceutical companies on research and development of new cancer therapeutics—numbers which are even harder to come by.

Resource allocation for various types of cancer is a real problem. Funding is not allocated proportionately with disease burden. Thyroid cancer is underfunded, while brain and breast cancers receive relatively high funding. Plus, even though we still rely heavily on them for cures, surgery and radiation receive, respectively, only 1.4% and 2.8% of the research funding pie. Instead, a disproportionate amount of public and private funding goes to immunotherapies which, despite their hype and sheen, typically provide only modest benefits for a small subset of patients. Nor do we invest much in prevention and early detection, the key to cancer control globally. Instead of Warburg’s preventive measures, we’ve favored Farber’s interventions to treat, with 70% of NIH’s funding going to the latter.

There are two kinds of medical research: foundational scientific research and then applied research. The first aims to understand the causes and progression of a disease—vital work, but not always having an immediate payout in terms of treatment. The second builds on the first to find clinical methods to cure or ameliorate that disease. We need both.

Investment-wise, it pays to think long term. Yet here’s the challenge: Usually, medical breakthroughs first require getting to grips with a disease’s underlying biological mechanisms. The intricate and complex reasons why particular cancers arise and what sustains them, can provide clues regarding potential targets for treatment. When exploring foundational questions, we need to keep multiple hypotheses in play. What is the role of genetic versus environmental factors, and how do they interact? Does cancer represent a failure of the immune system to kill and clear cells that go haywire before they proliferate? Or is cancer driven primarily by metabolic dysfunction? Or some combination of both—entirely plausible since, as Warburg’s research suggested, metabolic dysregulation contributes to inflammation? Or is there some other explanation entirely?

If the NIH sidelines metabolism in favor of immunotherapies, as it has done in recent decades, despite evidence for both theories, this signals to researchers and regulators that the latter is considered “gold standard” science while the former is marginal, if not fringe. But as anyone familiar with the history of science knows, prevailing theories favored by the scientific establishment are often proved wrong, and frequently hard to dislodge even when they are wrong.

Teasing out answers to these basic questions is painstaking work, with plenty of dead ends, a high failure rate, and lag-times of up to 17 years. Which is why the NIH tends to focus on it, leaving the development of immediately applicable, patentable treatments to pharmaceutical companies. But with cancer proving such an elusive enemy, is it time to question the strategy of relying on public funds to move the ball down the field, leaving the industry to run the plays that put the ball in the end zone?

The Copycat Industry

A major breakthrough in cancer treatment should prove enormously profitable, and Big Pharma can afford the best scientists. Why, then, do pharmaceutical companies tend to focus on lower risk, short-term investment returns through “copycat” drugs? Why would companies seek only marginal gains in cancer treatment, when they could focus their R & D on a game changer? Why shy away from a strategy that aims to throw a 50-yard touchdown pass? The answer lies in the dynamics of publicly owned pharmaceutical firms.

Like any company, pharmaceuticals are legally required to focus on maximizing shareholder value. Which means, as far as cancer is concerned, developing products with the greatest profit potential and the least risk. Inventing an approved drug that is truly different from those already on the market requires enormous investments, estimated between $1.2 billion and $1.8 billion.But if there is already a treatment the FDA has approved for one cancer, there are strong incentives for companies simply to get the FDA to grant “supplemental approvals”—i.e., licenses to use the same drug to treat different cancers. And even if this will bring only marginal clinical benefits. (Enroll enough patients in a clinical trial, even if those patients only survive a few more months, the aggregate achievement might be statistically significant even if it is not clinically significant.) Of course, faced with imminent death, a patient will gladly accept two more months of life. But writ large, the sector/market is eschewing the possibility of more transformative treatments for everyone else. Again, we’re aiming at 1-yard gains, not 50-yard touchdowns.

Only 42% of newly approved therapies can be considered “clinically meaningful improvements” according to modest criteria set by practicing oncologists. The rest offer perhaps a few more months of life. Novel immunotherapies, for example, may only be applicable to only 2% or 3% of patients with a particular type of cancer, perhaps a few thousand patients in the U.S. But if a company develops a successful drug for one of those targets, other companies often develop similar copycat compounds to compete in the market. Compared to existing drugs, these products are tweaked just enough to secure a separate patent, but remain functionally the same in terms of their mechanism of action. These therapies nevertheless frequently cost $15,000 or more per month. While this approach may be profitable, it is not an effective overall anticancer strategy.

Pharmaceutical companies take safe bets in other ways too. All too often their R & D strategies are geared toward market competition, not the best treatments. Consider, for example, the billions of dollars spent on one potential therapeutic strategy, which involved attempts to starve tumors by choking off their blood supply with molecules that target blood vessels. In recent years, more than 50 tyrosine kinase inhibitors which operate on this principle entered clinical trials—most of these before a single one had been approved or even demonstrated proof of concept. Billions of dollars later, only five of these drugs have received approval, and they show extremely modest results in overall survival. The four agents approved for renal cell carcinoma were clearly redundant.

Billions of dollars were also wasted disproving the mitosis hypothesis. (Many researchers mistakenly thought that microtubule-targeting drugs like Taxol might inhibit the process of cell division known as mitosis.) Twenty-five drugs targeting mitosis entered clinical trials before any of them were proved to work. Companies spent billions testing these drugs on 2,000 different cancers, with results showing only a 1% response rate. A properly coordinated war on cancer, with adequate data-sharing across the private sector, could have disproved the hypothesis for a lot less money, time, and effort.

The copycat approach to drug development has become the industry rule rather than the exception. One analysis of drugs in the pharmaceutical company pipeline found that three-quarters of them had overlapping mechanisms of action—that is, they were not substantially different from competitor products. There is not necessarily a single nefarious villain to point to here—no rapacious executive or unimaginative board member who intentionally places profits over patients. No doubt, most company executives, employees, and scientists sincerely want to make real progress in cancer and the other diseases they target. But structural incentives tend to discourage ambitious efforts aimed at meaningful advances achieved by truly groundbreaking therapeutics.

Firms are pushed in less-than-productive directions by the internal dynamics of publicly traded companies. The wolves of Wall Street often act more like sheep. Stock price depends on investors’ trading behavior, not merely the company’s profitability. Investors naturally want higher returns, but they also strongly favor lower risks. A company’s decision to invest in a radically new breakthrough treatment may promise considerable rewards in terms of long-term earnings, but at the cost of significant short-term risks. Even if the basic science is promising, investors are easily spooked into selling shares when such ambitious ventures are announced, with the result that stock prices drop and shareholder value diminishes.

Like politicians aiming only at the next election cycle, companies concerned about quarterly earnings and stock prices are thus disincentivized to invest in longer-term, riskier ventures—precisely the kinds of research and development efforts that sometimes yield substantial overall gains for medicine. In short, nobody calling the plays in industry is attempting to throw a Hail Mary pass.

Disincentive Structures

Added to this market failure is a regulatory one. Rules around reimbursement of insurers distort supply and demand.

Due to legal mandates, Medicare—the largest purchaser of insurance, of course—is legally required to reimburse for any chemotherapeutic drug, regardless of its relative benefit over other drugs, so long as it is given for a “medically approved indication” (commonly interpreted as FDA approval). Until very recently, the government had little ability to negotiate drug prices. For drugs covered under Part B, Medicare will pay 106% of the average sales price. Many states impose similar rules on private insurance companies. Thus, Medicare tends to set the standards for all medical billing and reimbursements.

This, in part, guarantees profits for approved drugs, regardless of their degree of clinical benefit. So long as the pharmaceutical company successfully markets these products to physicians, and oncologists choose to include them in chemo regimens, the drugs are guaranteed to make money, even when their clinical benefits are marginal. If a new, expensive drug still appears to be the best that can be done under bad circumstances, an oncologist will naturally be inclined to prescribe it, even if it only extends the patient’s life by a month or two.

With these market and regulatory dynamics at work, like the trench warfare battle lines in World War I, taxpayers and industry expend massive resources only to move the battle front in the war on cancer a few meager yards.

Sometimes we face the opposite problem. Rather than expensive but largely ineffective cancer drugs flooding an already crowded market, effective but cheap treatments end up in beguilingly short supply. After the 20-year patent expires and a drug becomes available in generic form, the price usually drops significantly due to market competition from several suppliers. At first this is good, lowering the cost of treatments. But at a certain point these lower-priced drugs don’t make enough money, even though they have proven efficacy and might work just as well, or even better, than more expensive patented options. In these circumstances, a company may stop producing a generic drug altogether, creating sudden supply shortages and pushing doctors toward costlier, though not necessarily more clinically efficacious, alternatives. Imagine being a front-line soldier and fighting a war where cheaper yet more effective weapons were not being produced and shipped to the front, and you’ll know how clinical oncologists sometimes feel.

In one survey, four out of five oncologists reported that they were unable to prescribe a preferred chemotherapy regimen in the last six months due to supply shortages. Three-quarters of these reported having to settle for an alternative (and often costlier) regimen they believed was less effective. This is how optimal treatments, which should theoretically be available, are not finding their way to the bedside. Devising policies that incentivize solutions for this fixable problem seems like low-hanging fruit.

Sometimes the problem doesn’t have anything to do with economics; it’s basic psychology that’s at issue. In the life-and-death context of cancer, access to new therapies becomes a fraught issue for patients. Facing the ordeal of failed treatments, many patients become understandably desperate and strongly inclined to try experimental options in the hopes of landing on something—anything—better than the dismal status quo. Patients facing death are not disposed to limit costs or forgo drugs that promise even marginal potential benefits (especially when those costs are not coming out of their own pockets). And if policymakers complain about the $15,000-per-month price tag for a new cancer drug that only extends life by a month or two, they risk appearing heartless—for “what is a human life worth,” after all? Any proposal that might limit a dying patient’s options becomes a political hot potato.

Given these problems, would we fare better if more clinical research was done by academic institutions rather than pharmaceutical companies? There are pros and cons to both approaches. Starting in the 1990s, clinical research for cancer shifted strongly in the direction of pharmaceutical companies, who typically have more resources and the ability to move nimbly and pivot quickly compared to academic research centers. As compared to industry studies, clinical research in academia moves slowly, with less available funding and more bureaucratic hurdles. However, in contrast to industry standards, academic research findings are typically published and therefore accessible to other researchers, facilitating efforts at rational coordination and collaboration across institutions, and reducing wasteful redundancy.

The overall consequences described here of the shift from academia to industry for applied clinical research have doubtless been unintended, though they are no less concerning, even if there is no “greed is good” corporate or Wall Street oligarch toward whom we can point an accusing finger. The regulatory and market dynamics for cancer drugs differ profoundly from other consumer products like cars or smartphones. Even though it would be extremely profitable if they could achieve it, paradoxically, the current pharmaceutical company ecosystem is not likely to produce breakthrough products that significantly advance the overall treatment of cancer.

Cancer research is not the only division within the war on cancer where money is often wasted or misallocated. Cancer treatment centers are often guilty of the same, in ways that mislead patients and promote false hopes. The 1,200 cancer centers around the country, all competing for the same patients, have massively escalated their spending on marketing—more than tripling their marketing budgets (from $54 million to $173 million) between 2005 and 2014, according to the most recent industry study. A yearlong investigation by Truth in Advertising showed 43 of 48 cancer centers studied “were deceptively promoting atypical patient experiences through the use of powerful testimonials.”

If a particular cancer has a 5% five-year survival rate, once you treat enough people you can always find a patient in that fortunate minority, whose rare outlier story then becomes part of your marketing campaign. Such marketing strategies take advantage of vulnerable patients who could get similar treatment elsewhere—often closer to home and at lower cost. But few watchdogs hold these institutions to account when they overpromise and underdeliver. After all, prestigious cancer centers are staffed by accomplished doctors and nurses just trying their best to treat a deadly illness—a hard group to publicly criticize.

Assessing Our Progress

More than 50 years later, the news regarding the war on cancer’s overall progress is sobering.

The most significant victory in this war has not been a breakthrough cancer treatment, but a public education effort aimed squarely at prevention. In 1964, the U.S. Surgeon General Luther Terry issued the landmark report linking smoking to lung cancer. (In an ironic twist, like many physicians of his day, Dr. Terry was himself a smoker but quit prior to his work on the report.) As every American knows, the report concluded that cigarette smoking is a major cause of lung cancer and other diseases. This turning point in public health reshaped attitudes toward tobacco use and paved the way for modern antismoking campaigns. Its findings led to immediate policy changes, including mandatory warning labels on cigarette packs and restrictions on tobacco advertising.

With anticipated pressure from tobacco companies, the 10 scientists working on the report had labored in complete secrecy and under tight security, with meetings held in a locked room at the National Library of Medicine. The final report was so sensitive that it was hand-delivered to President Johnson. In an unusual twist, Terry received support from some tobacco industry scientists who privately acknowledged the health risks of smoking and surreptitiously provided data to the committee. Publicly, however, the tobacco industry continued to dispute the report’s findings for decades. Nevertheless, the report catalyzed a decline in smoking rates in the U.S., from 42% of adults in 1965 to under 20% by the 2000s.

In the wake of the public health victory against (smoking-related) lung cancer, precious few subsequent battles in the war have been decisively won. The next most notable victory has been against childhood leukemia. Building upon Sidney Farber’s pioneering work, newer chemotherapies have led to significant advances in treating this cancer of white blood cells. Another blood cancer, chronic myeloid leukemia (CML), which primarily afflicts adults, has similarly seen major advances in survivability. Drugs like imatinib now cure most CML patients, compared to earlier treatments like interferon, which extended life only minimally. Also in the victory ledger, testicular cancer now has a 90% cure rate with cisplatin, surely a significant gain. We’ve also seen significant progress in treating melanoma.

Besides these select victories, and smoking cessation’s beneficial effects on the incidence of lung cancer, there’s surprisingly little to report in terms of good news. Even when we include these advancements in treating some cancers, overall cancer mortality rates declined by only 5% in the more than half-century from 1950 to 2005. While cancer death rates have shown additional improvement during the most recent two decades, this is attributable largely to declines in both incidence and death rates for lung cancer and several other smoking-related cancers. In short, after we won the public opinion battle against cigarette smoking, the rest of the war on cancer is not going so well.

During this same period, the incidence of cancers associated with obesity and insulin resistance has been rising—including breast, uterus, colorectal, pancreas, kidney, and liver cancers. At least 13 types of cancer representing 40% of the total cases in the U.S. have been linked to obesity, hyperglycemia, and inflammation—in other words, metabolic dysregulation driven by dietary and environmental factors. The hundred-year-old ghost of Otto Warburg, whom we met in the opening paragraph, continues to haunt us. The public health success story in reducing smoking has not translated to widely adopted lifestyle modifications for other modifiable cancer risk factors. And for most other cancers, the promised miracle cures have not materialized.

By comparison, during that same half century the number of deaths adjusted for age and the size of the population plummeted for other leading killers like heart disease, stroke, influenza, and pneumonia. By contrast, cancer remains the second leading cause of death in the United States. Data from the CDC suggest that, with improvements in cardiovascular disease and the treatment of aging-related ailments, cancer may soon become the No. 1 cause of death for Americans. The cost of cancer therapies has also risen sharply, with many new treatments costing upward of $10,000 to $15,000 per month. As already mentioned, many of these novel and costly therapies yield, at best, only marginal benefits.

Perhaps there are alternative explanations for this apparent failure? Some have proposed the “competing cause-of-death” hypothesis: In days past you might die of a heart attack, but with medical advances in that domain, people now live long enough to later die of cancer. This would make cancer rates appear higher, even if we enjoyed simultaneous advances in cancer treatment. Unfortunately, however, this hypothesis is not borne out by age-adjusted statistics, which calculate death rates within discrete age groups.

Another potential rejoinder is that, with increased screening, we diagnose more cancers by catching those that would otherwise have been missed. Thus, it might appear that cancer rates are rising, but this is merely due to better detection, which should lead to earlier interventions and thus better overall outcomes. But this hypothesis likewise does not hold up under scrutiny. While cancer is diagnosed more frequently today, this does not account for the increased death rates from cancer. Improved screening means there are more “cancer survivors” counted in the general population. But if treatments do not improve for lethal cancers, the age-adjusted death rate remains more or less constant, as we have seen for most cancers. Thus, more survivors do not necessarily correlate with fewer deaths.

Let’s examine a few of the key battles. While advocates of universal HPV vaccination promised to virtually eliminate the most common types of cervical cancer, actual gains since the introduction of the vaccine in 2006 have been modest at best. From 2006 to 2023, age-adjusted mortality in the U.S. for this cancer only declined from 2.4 to 2.2 per 100,000. Meanwhile, in some regions globally, rates of cervical cancer have risen during this same period due to poor screening and changes in sexual behavior.

Surgical treatments for breast cancer have shifted from more-invasive mastectomies to less-invasive lumpectomies—a modest victory—though overall rates of breast cancer have been rising, and death rates remain steady. Naturally, cancer researchers and physicians are not responsible for the increased risk factors, from obesity to delayed pregnancy among women, which contribute to this rise. Giving birth to multiple children is among the strongest protective factors against breast cancer, though it’s hard to imagine a public health campaign today aimed at that goal. We remain dismayingly far from claiming victory, or even much by way of advancing the front lines, against the most common cancer that afflicts women (breast cancer accounts for 31% of cancer diagnoses in females).

In a battle where we have lost ground, more young people are developing colorectal cancer. Over the past decade, colorectal cancer cases rose 2.4% annually in those under 50. Over the last quarter century, the proportion of cases in those under 55 doubled from 11% to 20%, with death rates among the young rising 1% per year for the last couple of decades. Colorectal cancer has thus become the leading cause of cancer death in men under 50, and the second leading cause in women under 50 (after breast cancer), up from the fourth leading cause two decades ago.

Again, this scourge—along with a dozen other cancers—is linked to dietary, environmental, and metabolic factors, which the cancer establishment has tended to overlook. Changes to our food supply and diet, with judicious help from pharmacological agents like metformin and GLP-1 agonists, could very well put a bigger dent in cancer deaths than dozens of pricey immunotherapies. We need the equivalent of the antismoking campaign—don’t eat sugar and processed foods—for the rising rates of metabolic cancers.

Meanwhile, other types from pancreatic cancer to glioblastoma (a highly invasive brain cancer) remain virtually incurable using our current approaches. Overhyped “breakthroughs” for the deadliest cancers, periodically announced by scientists and research centers hungry for more funding, have fueled increased public skepticism by repeatedly raising false hopes that fail to deliver.

In summary, a sober assessment of overall progress in the war on cancer can only conclude that the war effort has sunk massive expenditures for only very modest results.

Renewing the War Efforts

Undeterred by this slow progress, champions of the war on cancer have periodically reappeared on the political scene to renew the war effort and stir up public support. Andrew von Eschenbach had a passion for science but struggled academically—his college dean bluntly told him his grades would never get him into medical school. A stern intervention from his father and a Jesuit priest who enrolled him in summer school turned things around, propelling him to Georgetown University School of Medicine, a stellar career in oncology, and eventually, a 2021 Pontifical Hero Award from the Vatican for blending science, faith, and public service.

In what might be interpreted as an enormous act of faith in science, in 2003, von Eschenbach, by then director of the National Cancer Institute, the oncology division of the National Institutes of Health, set an ambitious goal to eliminate cancer-related suffering and death by 2015—a target also supported by the American Association for Cancer Research. Dr. von Eschenbach drew inspiration from successes like testicular cancer treatments, which he believed could be replicated using genomics to discover why a small percentage of patients respond to drugs while others do not. Like many in cancer research whose personal grief drives their professional ambitions, he founded MD Anderson’s Prostate Cancer Research Program in 1996 partly because his own father battled the disease.

By von Eschenbach’s target date of 2015, overall cancer death rates had declined about 20% compared to 1991. But as noted above, most of these gains were due to declines in smoking, not primarily to NCI-funded research on cancer treatment. While the battle front has moved modestly in recent decades, we are obviously very far from declaring victory in this war.

With its $7.2 billion budget this year, the NCI remains the largest funder of cancer research in the world by a long shot. The latest report of the NCI is brimming with information on prevention, early detection, diagnosis, treatment, life after diagnoses, and end-of-life care plans. But there is nothing in the report to indicate what we really need to know: whether any of the treatments have actually worked. Similarly, the blitz of statistics about screening obfuscates the real metric we need: death rates. While these reports are chock full of statistics, they lose the forest for the trees. One could read all the NCI reports from the last 20 years and still not gain a clear understanding of whether we are making progress or moving the major battle lines in the war on cancer.

The NCI’s wildly ambitious goal of eliminating cancer by 2015 was not the only occasion in recent memory for publicly renewing the war on cancer. The 21st Century Cancer ALERT Act, passed in 2009, aimed to overhaul the original 1971 act by funding early detection research, providing screening grants, and increasing clinical trial access. That same year, Obama’s stimulus package allocated $10 billion to the NIH, with $1 billion earmarked specifically for genetic cancer research and targeted therapies. But these laudable efforts have had little overall impact 16 years later.

Undeterred, the war on cancer was once again revivified in 2016 and again renewed in 2022 when President Biden launched a “cancer moonshot 2.0,” which sought to reduce cancer deaths by 50% over the next 25 years. Citing the loss of his son Beau to brain cancer, Biden’s plan included a “cancer cabinet” with representation from over 20 federal agencies, billions more in funding, and a focus on public-private partnerships in cancer research.

These periodic public renewals of the war effort are entirely understandable. One would be hard-pressed to find a single politician who does not want to cure cancer. As most Americans have lost loved ones to this terrible affliction, few voters would object to increased funding for cancer research. As was true in Nixon’s day when the war on cancer commenced, in our divisive and polarized political climate, support for cancer research seems like a rare issue everyone can agree on.

In medicine, an appropriate treatment plan always follows an accurate diagnosis. To move us closer to victory in the war on cancer, we must accurately and honestly assess our losses and casualties, admit our stalled progress relative to other diseases, and examine the complicated reasons for our failure to advance the front lines very far despite massive expenditures and many noble efforts. Without this sober assessment of the war’s half-century record of (mostly) disappointing results, it’s not clear that an updated 2.0 version of the war on cancer will fare any better than the original. Surprisingly, there is little published evidence that this critical self-assessment by the established cancer enterprise has yet happened.

Public Research Troubles

We also need to reckon with a set of serious problems plaguing biomedical research as a whole.

It’s not just industry pursuing “safe bet,” incrementalist approaches; academia is also settling for less. Once again, it’s not that scientists are stupid; the impasse owes to major structural problems besetting higher education.

For decades, NIH funding has been funneled to the largest universities on the coasts. The consequence is an insulated monoculture, one that tends to police in-group thinking as researchers mostly interact with other scientists who already agree with their theories. In this system, insiders protect their turf by dismissing or excluding upstarts with new ideas.

The review process for NIH grants also tends to embed a risk-averse conservatism, as the new director of the NIH, Jay Bhattacharya, has acknowledged. Reviewers will push for a portfolio where the maximum number of grants succeed, often funding only the safe projects most likely to pan out. The current configuration of grant-reviewing by established researchers disincentivizes research that potentially challenges the current consensus—which is what we desperately need. (And even if an intrepid researcher manages to get their innovative study funded, an anachronistic peer-review process, whereby a handful of reviewers with established interests tend to act as gatekeepers, often ensures the research never sees the light of day.)

For years the NIH had a policy that anyone sitting on a study section, the prestigious panels which review grant requests, was required to have an active, large NIH grant themselves. Being on a study section could help an academic researcher obtain their own NIH grants, permitting them, for example, to suggest names for who might review their grant proposals. Thus, only already accomplished scientists, with vested interests in protecting their own research results and perhaps increasing their lab’s funding, were responsible for deciding which young investigators are allowed into the club through the gateway mechanism of NIH funding.

These institutional dynamics may help us understand the decadeslong disinterest at the NIH in the metabolic theory of cancer, even though Warburg’s foundational research goes back a hundred years. A groupthink skew toward the immunological theory led to generations of complex immunotherapies that had very little impact on overall cancer mortality, while overlooking the likely enormous impact of sugars in initiating cancers and fueling tumor growth. Why are we only beginning to rigorously study this issue now, even though the basic research is a century old? Like smoking-cessation campaigns, public health efforts to reduce sugar intake just might have prevented more cancers than anything else the NIH has funded (not to mention reducing a host of other obesity-related diseases like diabetes).

Then there is the replication crisis in science. The hallmark of a reliable scientific study is that another researcher can use the same methods, run the same experiment, and get the same result. The replication crisis refers to the widespread concern that an astonishing number of published research findings cannot be reproduced or verified with a repeat study. This lack of reproducibility undermines the reliability of supposed scientific knowledge. A landmark 2005 paper by the eminent Stanford professor John Ioannidis, provocatively titled, “Why Most Published Research Findings Are False,” drew attention to this elephant standing in the room of science. He argued that systemic flaws in research design, analysis, and publication practices lead to a high rate of false findings in published studies. This rather dismal assessment of the state of contemporary science unfortunately includes cancer research.

Since Ioannidis’ groundbreaking paper, additional work has confirmed that many studies, when repeated by other scientists, do not yield similar findings. Starting in the early 2010s, several papers estimated that 50%-90% of published findings in fields ranging from preclinical research to cancer biology may not be replicable. One survey of scientists in Nature found that more than 70% of researchers have tried and failed to reproduce another scientist’s experiments, and more than half have failed to reproduce their own experiments. A 2015 study estimated that $28 billion in U.S. preclinical research alone is spent on irreproducible studies.

Outright fraud turns out to be more common in published scientific papers than we would like to think, and without efforts at replication, frankly fraudulent results often go uncorrected. To mention just one staggering cautionary tale from the world of Alzheimer’s research: In 2022, a whistleblower revealed that a landmark 2006 paper published in Nature contained manipulated images and deliberately falsified data. This paper, which supported the so-called amyloid hypothesis for the etiology of this disease, helped set the course for Alzheimer’s research over the next decade and a half. This resulted in an estimated $1.6 billion of wasted NIH funding in a failed attempt to build upon a line of inquiry which rested upon an entirely fraudulent foundation.

The war on cancer intersects with political battles waged for the control of public opinion. This can influence the kinds of hypotheses that can be entertained, and those which the establishment attempts to prohibit. Some scientific questions are hard to ask. For example, the latest neuralgic flashpoint among skeptics of the scientific establishment relates to worries that the novel mRNA COVID shots may be triggering new cancers or causing old cancers to relapse that had long been in remission. Even some insiders are quietly asking this unmentionable question: The director of a leukemia/lymphoma program at a leading cancer hospital reached out to me early in the vaccine rollout expressing precisely this concern, as he was seeing a sudden explosion of new cancers and inexplicable relapses in his patients following the injections. Early published observational studies as well as papers proposing potential mechanisms lend plausibility to this extremely worrisome hypothesis, with other analyses disputing the link.

In any case, more rigorous research is urgently needed. But strong political and social forces mitigate against even asking a question like this one, much less attempting to answer it. Sometimes science is inconvenient, and some people would rather not know the answer if the research findings are not to their liking. Despite its elevated cultural status, science often remains a human, all too human, endeavor.

A Path Forward?

In cancer research, we desperately need more shots on goal. Only transformed systems—state and market institutions that work in a radically different way—will let us take those shots. We’ve got to take the risks necessary to move the ball farther down the field, to mix sporting metaphors—which will mean, paradoxically, living with more failure. Not every play should be a Hail Mary pass; but it’s hard to score a touchdown when the play-calling only ever includes 2-yard runs.

We need to entertain the possibility that we are overlooking or forgetting important hypotheses on foundational questions. So, we clearly can’t neglect researching the basic science. But we also need public funding to get from that research novel clinical treatments, however long they take. We need to incentivize both the state and the market to play the long game rather than cravenly settle for the next short-term, quick-hit, copycat incremental efforts.

In closing I’ll mention just a few ideas among the dozens of policy proposals that one could suggest from this analysis. In the public sector, centrally controlled top-down science should be decentralized and diversified to allow for adequate exploration of competing hypotheses. There are many ways this could be done; but perhaps we explore federal block grants to states to fund scientific research. Instead of one NIH we could have 50 SIHs—state institutes of health—all competing to attract researchers. Since there are notable regional variations in the incidence and mortality rates of different cancers across the U.S., various states could carve out specific niches within the research enterprise by focusing on cancer types that disproportionately impact their citizens. Of course, any discovery in this regard benefits everyone. This decentralization of research funding could open new possibilities for exploring relevant questions that tend to get stifled when a select few people control the purse strings.

In the private sector, we need better data sharing. After a certain duration, pharmaceutical firms should be required to publish their research. Judicious redactions of this published work can protect the companies’ proprietary interests while still informing the broader research enterprise. The war on cancer hinges ultimately on finding a better balance between private interests and the public good.

Pharmaceutical companies will only pursue patentable and profitable treatments. The NIH may therefore be able to rely on them for those clinical trials. But therapeutics like surgical innovations or advances in radiotherapy will require public funding, and may have a bigger payoff than new chemotherapeutics, for reasons already discussed. Likewise, the NIH should vigorously fund potential therapeutics using repurposed off-patent drugs, which no pharmaceutical company will invest in.

As anyone afflicted with cancer who does a Google search can attest, the internet is teeming with claims of cures from repurposed generic drugs and other nonpatentable agents, from ivermectin to various nutraceuticals. Without placebo-controlled trials—which no pharmaceutical company will pay for—these claims remain anecdotal and practically unfalsifiable. While we should be appropriately skeptical of claims of miracle cures, many of these reported cases, including some from treating physicians, seem plausible. For any of these agents with a credible mechanism of action and sufficient anecdotal evidence of efficacy, we should publicly fund clinical trials to find definitive answers. Most of these studies will not pan out, but if we find even a few diamonds in the rough the effort will be worthwhile.

Regardless of whether we do these rigorous studies, in the absence of better mainstream therapeutics, patients will continue to avail themselves of these alternative options. So we would do well to learn with more conclusive evidence whether or not they really work. Rather than merely dismissing anecdotal claims with a wave of the hand, the medical establishment can find clearer answers if we invest the resources in rigorous studies. Who knows, we may just discover a major advance that will turn out to be relatively inexpensive. Some available answers may be hiding in plain sight, only waiting for us to take a rigorous look.

Despite our stalled progress, it goes without saying that we need to keep fighting. Because whatever our differences, this is a war that all of us sincerely want to win. As Winston Churchill wrote to FDR on Feb. 9, 1941, “Give us the tools and we’ll finish the job …”

I’ve written a lot here at Human Flourishing in the last few years about freedom of speech, given my involvement in cases challenging government censorship or efforts to control the speech of physicians in the consulting room. It’s worth recalling, however, that the first freedom mentioned in the First Amendment (and therefore, the first freedom mentioned in the Constitution) is not freedom of speech but freedom of religion. The earliest settlers on our shores landed here precisely to find a place where they would not be persecuted for their publicly expressed religious convictions.

Often when American’s think about religion and the American constitution, the phrase that comes to their mind is not the free exercise of religion (which actually appears in the Constitution) but the separation of church and state (a phrase which does not appear in the constitution but in a private letter penned by Thomas Jefferson). Furthermore, many people mistakenly interpret the notion of “separation of church and state” to mean the banishment of religion from public life—also not a constitutionally defensible position, and certainly not what Jefferson meant when he penned that phrase. The non-establishment clause of the First Amendment—that “Congress shall make no law respecting an establishment of religion” exists precisely to serve “the free exercise thereof.”

Because there is so much confusion about the freedom of religion in America, I was pleased to receive an invitation back in March to testify at the President’s Religious Liberty Commission, which held a series of hearings to assist them in preparing their report, delivered to the White House this week. (My boss at the Ethics and Public Policy Center, Ryan Anderson, and my friend Bishop Robert Barron, both serve as members of the Commission.) You can find a video and the text of my testimony here:

The Commission has published a draft of their report along with a two-page summary for those who don’t want to dig into all 200-plus pages. Also, and importantly, you can submit public comments on the report between now and July 13, as explained here:

• Draft Report of the Presidential Religious Liberty Commission, June 2026
  This draft of the Religious Liberty Commission Report, based on public hearings held and public comments received, is available here and open to public comment for fifteen (15) days, with comment period closing on Monday, July 13, 2026. Comments may be emailed to RLC@usdoj.gov.

  To aid the Religious Liberty Commission in processing your comments, please format the subject line using the following:

  PUBLIC COMMENT – [TOPIC OR CHAPTER NUMBER] – [NAME].

  Please be aware that public comments are open to public inspection, not confidential. Please do not include personally identifiable information, such as personal addresses, in your comments.

  After the fifteen (15) day comment period, Commission will hold a virtual public meeting to review comments reviewed, discuss the draft, and finalize the report. Attendance information will be posted on the “Upcoming Events” page and in the Federal Register at least seven (7) days prior to the meeting.

The comment can be as simple as “thank you for addressing this issue; I applaud the work of the Commission” to detailed suggestions and policy proposals that may not have been included in the Report’s recommendations. Now, you might be asking, is it worth my time and trouble to submit a public comment as an ordinary citizen? The answer, as I have learned over the last few years from my colleagues at EPPC’s Administrative State Accountability Project, is emphatically YES. (For more on this, see their helpful document, How to Submit a Public Comment on Agency Rulemaking.) The executive branch and its various agencies are required by law to carefully review and respond to all comments submitted during the comment period.

As I have come to appreciate, public comments can slow or stop bad rulemaking and expedite good rulemaking in ways I did not fully appreciate until I started doing more work in this area (I have submitted detailed comments this year with colleagues at EPPC on a variety of federal policies). If agencies fail to respond adequately to comments, this can also set up future litigation to challenge bad rulemaking. There has been much talk in recent years on the runaway and bloated administrative state with all its 434 unaccountable three-letter agencies—a hugely important issue in American public life and governance. But many Americans are unaware of simple things we can do to nudge this apparatus in positive directions. All this is to say, consider looking at the Report’s recommendations and submitting a comment, whether brief or detailed. The support of the American people matters when folks in government are trying to advance good policies in the face of opposition from some quarters.

Even though I already testified at the Commission, and they cited my testimony in several chapters of the report, I plan to submit a detailed comment myself. These simple actions can make a difference.

I was pleased to see my testimony described in some detail in Chapter 10 (pp. 145 - 150) of the report, and cited in several other chapters as well as the appendix. Here’s the relevant section from Chapter 10, on the topic of Conscience and Coercion in Vaccine Policy:

Dr. Aaron Kheriaty

For Dr. Aaron Kheriaty, concerns about conscience rights in medicine did not begin during the COVID-19 pandemic. They began years earlier, in a hospital operating room, when he was forced to decide whether he could take part in a procedure that violated both his medical judgment and his religious beliefs.

As a medical student assisting on a labor and delivery rotation, Dr. Kheriaty was asked to participate in a procedure that conflicted with both his medical judgment and his religious beliefs. After a patient, in the midst of labor, agreed to an additional sterilization procedure, he raised concerns—not about the patient’s decision, but about his own role in carrying it out. “I informed [the resident physician] that while I was willing to assist on the cesarean section, I would need to step out of the operating room and not help with the tubal ligation as a matter of conscience,” he told the Commission onMarch 16, 2026.

The response that followed was harsh and direct.“ The resident became irate, asking: ‘How dare you impose your views on the patient?’” he recalled. “I replied that I was imposing nothing on anyone,” but “merely telling her what I was willing and not willing to assist on.”

That decision carried consequences. Dr. Kheriaty was removed from the case, faced retaliation during his rotation, and received negative evaluations that followed him into his residency applications. At the time, he was unaware that federal law protected his right to decline participation in procedures that violated his conscience. “These laws were actually in place when I went to medical school, but I had no understanding of them,” he said. “Through that whole process, I was never advised of my rights even after they were violated.”

Years later, those same questions of conscience resurfaced in a different context. As director of the Medical Ethics program at the University of California, Dr. Kheriaty became concerned about proposed COVID-19 vaccine mandates. “Troubled by the draft policy that was about to go into effect, I published a piece in The Wall Street Journal […] arguing that university vaccine mandates were unethical,” he explained.

When the university moved forward with the policy, he challenged it in court. “I made the fateful decision to try to challenge the university’s vaccine mandate in federal court,” he said. But his challenges did not end there. “They placed me on first what they called investigatory leave, then a month later on unpaid suspension. Then a month after that, they fired me,” he told the Commission.

At the time, Dr. Kheriaty had spent more than a decade at the university and had received multiple teaching awards. His dismissal, he argued, reflected a broader failure to protect conscience rights in healthcare and academic institutions. “When it comes to vaccines, laws in many states failed to protect conscience rights and religious liberty,” he said, pointing specifically to states that offer no religious exemptions for childhood vaccination requirements. “Many people have religious or moral objections, for example, to the use of cell lines derived from aborted fetuses or derived from embryos created and destroyed in the laboratory, which are very frequently used in the development and testing of many of the vaccines on the CDC’s childhood immunization schedule,”Dr. Kheriaty explained.

For Dr. Kheriaty, the issue extends beyond any single policy, but as a question of the moral foundations of medicine itself: “Medicine should always and only be aimed at health and healing,” he said. “Doctors should not force treatment on patients that patients decline for medical, moral, or religious reasons.”

He concluded by urging stronger protections and clearer enforcement, emphasizing that without them, individuals will continue to face the same choice he did:between their profession and their conscience.

As I have said many times here, unless we defend our constitutionally protected rights and help educate fellow citizens on what those rights actually entail, then the Constitution will remain merely words on a piece of paper. The American experiment in ordered liberty requires constant vigilance and the work of all citizens to maintain.

Wishing all of you readers a very happy Independence Day as we celebrate our Nation’s 250th birthday.

David Lorimer wrote a terrific review of Making the Cut: How to Heal Modern Medicine for Paradigm Explorer. I republish it here with permission.

Aaron Kheriaty is currently director of the programme in bioethics, technology and human flourishing at the Ethics and Public Policy Centre. Prior to this, he was professor of psychiatry at UCI school of medicine and director of the medical ethics programme at UCI health. He is also author of The New Abnormal, which I reviewed in Paradigm Explorer 140, p. 44. The previous book tells the story of how he felt compelled as a medical ethicist to do what he was convinced was morally right under pressure when the university banned him from working on campus and eventually sacked him for not complying with their vaccine mandate on the grounds that there was good scientific evidence that natural immunity was superior to vaccine immunity – he himself had had Covid. In the present book, he makes very little reference to this life-changing episode, which I also discussed with him on my podcast Imaginal Inspirations. However, in the final paragraph of my review, there is continuity in the author making the case for universal rationality and pursuit of truth grounded in a transcendent logos beyond mere instrumental rationality. He also advocated restoring the moral authority of values and the dignity of work, while recognising our need for roots and living from enduring principles.

The present work is informed not only by medical science, but also by Aaron’s wide literary culture, a rarity these days – Karl Jaspers, TS Eliot, Tolstoy, Illich. Much of the text recounts his own medical training and experience, illustrated with key episodes involving his patients. He is concerned that medicine has squandered public trust and abandoned its mandate to heal, especially during the Covid period. The Pew Research Centre found that the number of US adults placing confidence in medical scientists to act in the best interests of the public declined from 40% in 2020 to 29% in 2022; moreover, almost half the population do not trust public health agencies to act in our interests (p. 199). The medical model is mechanistic, reductionist, and instrumental, taking the dead body as its starting point and casting the role of the physician as an efficient mechanic or technician. The living body is seen as a machine, as Claude Bernard advocated (p. 40) and is subject to the deterministic laws of physics and chemistry, hence to the principles of control. Aaron quotes Iain McGilchrist on the shortcomings of such a biomedical model that is also underpinned by the idea of fighting disease rather than promoting health.

Language becomes objectified, and the system is one of functionalism dedicated to efficiency. The physician has to accompany patients in their experiences of loss, pain and death. Death frames our entire life, and should be approached through processes of reconciliation, acceptance, and surrender rather than the language of succumbing. This is also why a group of us has recently put together the Death is not the End website (https://deathisnotend.com) to show that there is good evidence that death is a transition rather than extinction. Aaron himself is no stranger to suffering, having himself had a serious car crash and experienced five years of debilitating pain (p. 97). Some of his encounters are intensely personal, such as with his patient Lisa and his schoolfriend Matt, who succeeds in committing suicide at the third attempt. In another moving episode, he asks for the blessing of a dying priest (p. 181).

A key influence on Aaron’s life was Dr. Edmund Pellegrino, whose integrity and insight he seeks to emulate. He quotes one of his own speeches to students (p. 30) where he reminds them that ‘it is not science, but love and devotion, that transforms the world…we physicians are not robots who treat diseases; we are people who treat other people… always follow the light of your conscience, even when your decisions are unpopular… medicine is a vocation; it’s not just a career.’ On p. 170, he lists some of the most essential virtues recommended by Dr Pellegrino including fidelity to trust, intellectual honesty, compassion, courage, and prudence. The doctor-patient relationship is the absolute fulcrum of the issue, forming ‘the core of medicine.’ This reminded me of Jacob Needleman’s classic book which I reviewed 30 years ago, The Way of the Physician. We are always human beings before we are professionals. This means that the instrumental language of clients, consumers, contractors and providers mischaracterises the nature of the doctor-patient relationship. The primary good of care and compassion is in tension with the secondary goods of money, power, prestige, honour, ranking, and competitive advantage (p. 174) reflected in the institutional structure of medicine and which threatens to undermine these primary goods.

The final chapters chart a way forward for institutional medicine with a thoroughgoing critique of (left hemisphere) depersonalised managerialist ideology (pp. 200 ff.) The tenets include technocratic scientism, an emphasis on metrics and checklists, utopian progressivism, liberationism, homogenising universalism (one size fits all), interventionism, efficiency and throughput, pressure to conform through administrative control – and the failed reaction is interpreted as a call for further managerialism, in the same way that elite institutions call for ratcheting up centralisation and power. Aaron concludes that, paradoxically, ‘the cure for our epidemic of (chronic) ill-health will require less, not more, professionalised healthcare – the US system is Exhibit A (p. 110), where ‘hospitals and clinics have become factories with processed patients as the product.’

Aaron suggests that the way forward is small scale, decentralised initiatives, as the current totalising institutional juggernaut is too systemically controlled by corporate industry interests, where reform is fiercely resisted. To this end, he and other physicians have founded the Hippocratic Society (https://hippsoc.org) in the hope that every major academic medical centre will have a chapter by 2035. Individual physicians can strive to embody humanistic as well as biomedical principles, as suggested in a key essay by Karl Jaspers (p. 192), The Idea of the Physician and summarised by Aaron himself on his final page, p. 244: ‘to be a physician means to accompany patients through the enigma of human life, death, suffering, and healing without having the power to resolve these enigmas’ - combining professional skill, human kindness, and compassion. This bold book is essential reading for all health professionals and others concerned with rehumanising healthcare.

Freedom of speech is an integral aspect of authentic freedom, grounded in the distinctively human capacity to adhere to truth through persuasion rather than imposition. While truth is objective and independent of the knowing subject, it can only be received by the subject freely. We can contrast this with a thinly grounded notion of freedom as merely a pragmatic expedient to “get along” in a pluralistic society in which we assume that truth is more or less unattainable. In this thin form of liberalism, when it no longer appears the optimal empirical solution to maintain social comity or stability, freedom of speech will be easily abandoned. We have seen this dynamic play out in Western societies in the past decade, where elites now frequently insist that censorship is necessary to “protect democracy” from the populist rabble.

Principled freedom that encourages the shared discovery of truth must always exclude violence against ideas. Such force reduces individuals to mere means and undermines the possibility of honest persuasion. Instead, public authorities should only intervene to prevent persecution or the propaganda of “truncheon arguments”—that is, various forms of coercion or incitement to violence—while permitting the open expression of opposing views, however controversial.

The late Italian Catholic philosopher Augusto Del Noce illustrates this by insisting that even ideological adversaries, such as Fascists, should be permitted to voice their bad ideas (which they were not permitted to do in Italy immediately following World War II): “Let the Fascists also support their idea of violence if they so wish; we will fight them with arguments, and the task will not really be too difficult,” Del Noce confidently asserted. He warned that forcefully suppressing false speech only breeds underground myths and perpetuates defeated ideologies, as seen in the posthumous “Mussolini legend” that arose in the climate of postwar Italian censorship. Among the central problems with censorship is this: the prohibition on pronouncing certain things often makes them seem true even when they are not. Better to allow falsehoods to be voiced and refute them with arguments than to forcefully silence them before they can be spoken.

Recovery of enduring principles on which to ground freedom of speech is essential as we face new challenges from the advent of enormously powerful digital technologies and global platforms of communication. Discovery in our Missouri v. Biden case revealed extensive coercion of digital platforms by the White House, the Surgeon General, the CDC, and other federal agencies to flag, suppress, deboost, or remove online content and accounts—via direct pressure, algorithmic changes affecting thousands of posts, or the actions of suborned third parties. This “censorship-industrial complex” targeted critics of the government’s preferred covid policies, election integrity, abortion, gender ideology, foreign policy, and other issues of public importance.

As the appellate court noted in our case, given the vast reach of new digital technologies, the scope and scale of this censorship had no precedent in prior free speech cases in the U.S. In the words of the district court judge, what our case uncovered was arguably the “worst violation of free speech in United States history.” Previous cases of censorship by overzealous government officials typically dealt with one-time offenses: a single article suppressed, a few paragraphs struck from a book, a journalistic story killed before it saw the light of day. But what we saw in our age of social media was entirely new, facilitated by the powerful reach of advanced digital technologies: government action censoring tens of thousands of ordinary Americans hundreds of thousands of times.

For many Americans like me who were on the receiving end of this, such actions felt very personal: every citizen with a Twitter or Facebook account became a potential “newspaper editor” or “journalist” targeted for suppression by government speech police. Often this censorship was done by identifiable political actors, as when the White House’s director of digital communications Rob Flaherty browbeat a senior executive at Facebook into submission, as I described in detail in a Wall Street Journal piece co-authored with one of our lawyers in the case. In that instance, documents we obtained on discovery implicated an identifiable government official who could be held accountable and brought before the bar of justice.

However, much of the government censorship was far more subtle and indirect. More often, it did not require a detectable person flagging a specific post or account for censure. In the U.S., the First Amendment bars government from engaging in viewpoint-based censorship, while he state-action doctrine bars government from circumventing constitutional strictures by suborning private companies to accomplish forbidden ends indirectly, which also occurred. Our case revealed that in some circumstances, government pressure resulted in social media platform’s changing their algorithms and terms of service in order to automate and conceal the process of government-sponsored censorship.

In this regime, those silenced may not even realize that they are being censored, as the algorithm simply limits the reach of their posts such that it is impossible for them to spread organically or “go viral” and accrue influence. In the new context of digitally mediated censorship, subtle algorithmic manipulation can create an illusion of free speech while effectively controlling the reach and impact of communications online.

If an investigator or journalist asks X or Facebook to see its algorithm, the company will not be able to produce it, for the coding has been outsourced to thousands of programming consultants, each of whom are responsible for only one small piece of the entire puzzle. This produces opaque means of information control with no clear locus of moral agency or accountability. Censorship goes underground, where it is governed by machines, which, unlike human officials, cannot be challenged in court or held to account.

The future of censorship will involve outsourcing most of this work to AI. With large language models now capable of digesting and synthesizing enormous swathes of online speech, our ability to communicate in the digital realm will soon be controlled by invisible yet immensely powerful bots. Even if government actors are prevented from censoring online, and even if we beat back the egregious EU Digital Services Act and other authoritarian mechanisms of state-sponsored censorship, private companies with vested ideological interests, armed with the tools of advanced AI, will remain a serious hazard to free speech. This global threat from powerful private actors may prove to be every bit as severe, and considerably more powerful, than government-sponsored censorship. (For reasons that go beyond the scope of this article, my own view is that under U.S. law these platforms should be treated as common carriers rather than editors of content, which would mean that private companies or their algorithms could not suppress constitutionally protected forms of speech.)

We are witnessing emerge in real time this pervasive and tenacious machinery of power, propaganda, and technological control. The response will require vigilance, legal precedents, and structural reforms to allow for open online discourse in our digital future.

This piece is adapted from my Foreword to the forthcoming volume, Truth, Freedom of Speech and Modern-day Censorship (En Route Books, 2026).

The National Institute of Health (NIH) recently requested public comments on whether federal funding should continue to support embryo-destructive research. Along with my colleague at EPPC, law professor Carter Snead, I submitted the following comment arguing that federal funds should instead go toward ethically acceptable stem cell research that has proven to lead to effective clinical applications. The comment begins with a historical overview of the tangled path of federal funding for research on human embryos, then proceeds to the ethical arguments.

History of federal funding for embryonic stem cell research

In 1998 scientists at the University of Wisconsin derived human embryonic stem cells from a procedure that results in the death of a living human being at the embryonic stage of development. Since then, public controversy has centered on whether taxpayer dollars should support research that requires the destruction of living human embryos to obtain stem cells. These embryos are typically surplus products of in vitro fertilization (IVF) treatments, but it is also possible that embryos could be created solely for the purpose of embryo-destructive research (though stem cell lines derived from these sources would not be eligible for federal funding).

From the late 1970s until the early 1990s, federal policy was a de facto moratorium. In the late 1970s, the National Commission on Protection of Human Subjects recommended that Congress establish a permanent Ethics Advisory Board (EAB) to review any federally funded research involving in vitro embryos. This requirement became federal regulation. The EAB’s 1979 report endorsed such research in principle, but its charter expired before it approved any specific proposals. The board was never reconstituted, yet the legal mandate for EAB approval remained, effectively blocking funding until 1993. That year, Congress—urged by newly elected President Bill Clinton—repealed the EAB requirement.

Clinton then tasked the NIH with developing guidelines. The NIH Human Embryo Research Panel’s 1994 report recommended federal funding for embryo research. Clinton accepted most of the Panel’s recommendations but rejected funding for embryos made exclusively for research. Preparations to implement funding were underway when Republicans gained control of Congress in 1994. In 1996, lawmakers attached the Dickey Amendment to the annual Labor-HHS appropriations bill. This rider prohibited federal funds for (1) creating human embryos for research or (2) research in which embryos are destroyed, discarded, or subjected to greater risk than allowed under relevant federal guidelines governing research involving human subjects. Reauthorized annually ever since, the amendment appeared to end Clinton-era efforts to open the door to federally funded embryo-destructive research.

The 1998 scientific breakthrough in deriving embryonic stem cells prompted a pivotal “creative” reinterpretation of the law. HHS’s General Counsel under Clinton ruled that the Dickey Amendment barred only the use of federal money to destroy embryos. Once embryos were destroyed with private or state funds, subsequent research on the resulting stem cell lines was permissible. This narrow reading would have allowed funding to proceed, but the 2000 election intervened.

President George W. Bush, upon taking office in 2001, suspended pending initiatives for review. His August 9, 2001, policy balanced scientific opportunity with a robust ethical commitment. Legally, Bush agreed that the Dickey Amendment permitted funding for research on already-derived lines. His policy therefore authorized federal support only for (1) non-embryonic (“adult”) stem cell research and (2) embryonic stem cell lines derived before August 9, 2001, using nonfederal funds. Initially, more than sixty genetically diverse lines qualified; the number later reached seventy-eight, though only twenty-one proved usable due to scientific and intellectual-property barriers. By July 2007, the administration had allocated over $3.7 billion for eligible stem cell research, including $170 million specifically for embryonic lines, with nearly 1,000 shipments distributed to researchers. Later, the discovery of induced pluripotent stem (iPS) cells—reprogrammed from adult cells without embryos or eggs—prompted Bush to prioritize NIH funding for the most promising research on pluripotent cells, maximizing scientific progress while honoring ethical limits.

Congress twice passed bills to override Bush’s restrictions and expand funding to new embryonic lines. He vetoed both. A separate measure supporting alternative (non-embryonic) sources passed the Senate overwhelmingly but stalled in the House. The President’s Council on Bioethics issued balanced reports examining the policy and related issues, while the FDA assured stakeholders of its readiness to regulate resulting therapies.

On March 9, 2009, President Barack Obama rescinded Bush’s executive actions and directed the NIH to fund embryonic stem cell research “to the extent permitted by law.” Within 120 days, NIH guidelines limited eligibility to cell lines derived from IVF embryos originally created for reproduction but later donated because they were no longer needed. The rules excluded funding for embryos created solely for research due to lack of social consensus on this issue. Notably, neither Obama nor the NIH guidelines addressed the moral status of the human embryo.

This history illustrates how divergent presidential visions have produced a legislative stalemate punctuated by executive action, appropriations riders, and administrative reinterpretations. The Dickey Amendment remains in force, but successive administrations have interpreted and implemented it according to fundamentally different normative frameworks. The result is a policy landscape that continues to reflect the nation’s debates over the moral standing of the human embryo and the proper limits of government-supported science in a pluralistic democracy.

Ethical Considerations

Drawing on modern embryology, we can say with certainty that an embryo is a complete, living, self-directing human organism—genetically distinct, integrated, and on a developmental trajectory toward maturity. The classical liberal principle of human equality at the heart of America’s founding must apply without discrimination based on age, size, developmental stage, degree of dependency, or utility. The intentional destruction of human embryos for research violates this principle; creating embryos solely for destruction (by IVF or cloning) is even more objectionable.

In its policy considerations, the NIH should reject “contingent personhood” theories that would grant or withhold moral status according to others’ judgments about capacities or usefulness. Such an approach subverts equality by empowering the strong to decide the fate of the weak. This undermines our inalienable rights and risks adopting a sliding scale of legal protections based on cognitive ability or societal value. The NIH should also reject utilitarian arguments that would sacrifice embryos for potential therapies, even if personhood were granted, and refused to treat “spare” IVF embryos as mere raw materials simply because others had deemed them unwanted.

Practical Considerations

As of April 2026—28 years after their first derivation and 25 years after federal funding was authorized—there are no fully approved or marketed therapeutic applications derived from human embryonic stem cells (hESCs) anywhere in the world. In contrast, stem-cell based therapies based on sources that do not require the use and destruction of embryos (e.g., “adult” stem cells derived from more differentiated tissues such as bone marrow, placenta, and adipose cells, and “induced pluripotent state cells” derived from “reprogramming” adult cells to behave like embryonic stem cells) have shown great therapeutic promise.

Applications for adult stem cells include, for example, cardiomyocyte sheets/patches for severe heart failure due to ischemic cardiomyopathy^[1], dopaminergic neural progenitor cells for Parkinson’s disease^[2], and ovarian support cells for ex vivo oocyte maturation to treat infertility.^[3] Approved stem cell therapies globally are exclusively from adult sources (e.g., hematopoietic stem cells from bone marrow/cord blood for blood cancers, or certain mesenchymal stem cell products), not embryonic cells. Adult stem cells offer several clinical advantages, including easier generation of patient-specific (autologous) or HLA-matched allogeneic lines, reducing immune rejection and immunosuppression problems. Most importantly, they do not require embryo destruction, thereby avoiding the ethical problems that historically plagued research on embryonic stem cells.

In light of this, and given NIH’s responsibility to carefully steward its limited resources, respect ethical boundaries, and to protect the consciences of American taxpayers in a pluralistic society, federal funding should focus on the kinds of stem cells that have been proven therapeutically beneficial (e.g., adult stem cells) and ethically acceptable (e.g., iPSCs), and eschew those (embryonic stem cells) that have failed to live up to previous promises and pose serious ethical problems.

Aaron Kheriaty, MD
Director, Bioethics, Technology, & Human Flourishing Program

Ethics and Public Policy Center

O. Carter Snead, JD

Charles E. Rice Professor of Law
Concurrent Professor of Political Science

University of Notre Dame

Fellow, Ethics & Public Policy Center

^[1] “World’s First iPSC-Derived Cardiomyocyte Therapy for Heart Failure Receives Conditional Approval in Japan,” CUORiPS, March 6, 2026. https://cuorips.co.jp/en/news/2026/03/06/512/

^[2] “iPSC Therapies Make History: Japan Authorizes World’s First Two iPSC-based Cell Therapies,” BioInformant, April 3, 2026, https://bioinformant.com/ipsc-therapies-make-history-japan-authorizes-worlds-first-two-ipsc-based-cell-therapies/

^[3] “Gameto Presents Data Supporting Manufacturing Process for its In Vitro Maturation Solution for Fertility Care at 2024 International Society for Stem Cell Research Annual Meeting,” Gameto, July 10, 2024. https://www.gametogen.com/news/gameto-presents-data-supporting-manufacturing-process-for-its-in-vitro-maturation-solution-for-fertility-care-at-2024-international-society-for-stem-cell-research-annual-meeting/

You can now order Making the Cut on audiobook. I’ve included an excerpt of the book here to whet your appetite. This is from Chapter 2, “A Patient Corpse,” which describes some formative experiences dissecting cadavers in gross anatomy lab.

My first patient was already dead. My only job involved painstakingly dissecting her lifeless corpse in the anatomy lab, reducing every inch of her body to tatters until there was nothing left to cut. I took her apart; I pulled her to pieces; but I never learned her name. And she never knew mine.

As far as I knew, she was an anonymous person with no social or psychological life, no family, no community, no context. Merely a lifeless body lying on a steel table. Unfortunately, medical students observe death before we observe life. I only later learned in the surgical operating room that a living body looks very little like a dead one. There is a strange historical myth, perpetuated still today, that early men of science in the late eighteenth- and early-nineteenth centuries pioneered dissection of cadavers by stealing bodies from graves to get around religious or legal prohibitions of the practice. It’s a myth because, while some scientific pioneers did rob graves for this purpose, it was entirely unnecessary. The practice of human dissection was neither legally prohibited nor frowned upon by the Church and civil authorities at the time.

Dissection had been forbidden earlier in Ancient Greece and Rome, and likewise prohibited in Islamic societies. It was the Medieval Scholastics who first permitted the practice under the theological justification that the soul, not the body, was unique to humans. Resistance to pathological anatomy in the early days of modern science came neither from the Church nor the law nor society.^[i] Ironically, resistance to dissection in those days came from medicine itself.^[ii] Dissecting clinics existed in hospitals in Vienna, Pavia, and Paris from the 1750s, but these were held in suspicion by the birth of new medical clinics.

Strange to say, there was no need for anatomists to rob graves, and yet they did. Why? The grave-robbing doctors of the early-nineteenth century wanted to see themselves as seeking a prohibited knowledge and exposing the inadequacy of the old ways of thinking for the new society,^[iii] as bioethicist Jeffrey Bishop explains in his book The Anticipatory Corpse: “The dead body became the fetish of medicine; the desired object was knowledge, and the dead body came to stand for that knowledge.”^[iv] Pioneers of modern anatomy cultivated a self-conception that science and medicine needed to venture into unseen realms to acquire secret—even “forbidden”—knowledge by penetrating deep within the previously inviolable space of the body.

Never mind that the early anatomists had no difficulty in the middle of the eighteenth century in carrying out autopsies, as Michele Foucault explained in his classic study The Birth of the Clinic. “There was no shortage of corpses in the eighteenth century, no need to rob graves or to perform anatomical black masses; one was already in the full light of dissection.”^[v]Nevertheless, the early anatomists felt the need to convince themselves and others that they were doing something forbidden to usher in this new science of the human body. Apparently, secret knowledge equated to special knowledge, available only to the few scientists daring enough to violate ancient taboos.

The practice of dissecting a dead body remains today a rite of passage for fresh medical students. The first thing I noticed when I walked into the lab was the smell of formaldehyde, which permeated everything (and everyone) that entered the room. No amount of washing could adequately rid our clothes of that smell. Even after two showers, my wife could smell it on my hair. The second thing I noticed was, of course, the body bags on the tables.

With due deference to ancient societies that looked askance at human dissection, I would question the moral sensibility of anyone who did not at least pause to wonder whether dissecting a dead body might be an irreverent act, perhaps one that should not be allowed. Respect for our mortal remains has been a permanent feature of human history from the beginning. The specific means of disposing of dead bodies differ across various cultures, but all share an innate sense that some ritual act of regard is necessary here. The human body can be desecrated in death, just as it can in life.

The penultimate lines of Homer’s Iliad describe how the indomitable Achilles drags the brave Hector’s dead body through the streets of Troy. Line after line of wanton death and destruction in the Trojan War, described in gruesome detail by the ancient bard, ends with this ultimate act of disrespect for the human body. The reader senses that amidst all the carnage of this poem, this is somehow the most brutal moment. Even more than the fear of death itself, Homer’s war heroes feared having their dead body left on the battlefield as food for the dogs. In the poignant final scene, Hector’s royal father, Priam, grasps the hand of the man who killed his son and desperately begs Achilles to return Hector’s body for a proper burial.

Consider this: Achilles did far less physical damage to Hector’s body than I did to another woman’s body in gross anatomy lab. We dissected her with painstaking detail: each structure was subjected to the knife. By the end, very little of her remains actually remained intact. Every bit of tissue had been opened, disconnected, removed, spliced. If this was not desecration, what is?

And yet, there is a difference between Achilles’s act and that of a medical student performing a dissection. Gross anatomy lab is often defended on the instrumental grounds that it produces a great good: essential knowledge for future physicians. It thus contributes to the lives of future patients who will rely on our knowledge. This is true, but such utilitarian reasoning is not enough. The two acts differ in their total meaning, in the attitude and approach to the dead body. Achilles intended to destroy; the medical student intends to discover.

The students I discussed this with were, without exception, profoundly grateful to the person who donated his or her body for this purpose. We approached the dead bodies—at least initially—with wonder and awe. Georgetown has a tradition of offering a Catholic Mass every year for the repose of the souls of deceased donors and for their families, who invariably express appreciation for this gesture.

The human body is an astonishing work of art—arguably the most beautiful thing in the natural world. The wisdom of the body, which I began to really understand only by dissecting it, consisted of a million secrets, none of which was divulged readily. Any gain in anatomic knowledge required probing, coaxing, and teasing it out with scalpel and scissors. I learned less in a week of studying anatomy books than in an hour of cadaver dissection. Pictures and diagrams are no replacement for the real thing, turned over between your fingers.

Gross anatomy lab totally absorbed my mind. At home, after a long day of many hours in gross lab, I would try to think about something other than medical school for a while, only to find myself staring at my forearm at the dinner table, flexing one finger at a time, watching tendon and muscle move underneath the skin. “Are you studying your arm again?” my wife would interrupt.

Snapping out of my trance, I would sheepishly reply, “Sorry . . . can’t help it.”

“You’re obsessed.”

“Yep.”

* * *

“There are no locker rooms. Where are we supposed to change for gross lab?”

“Most students opt to change next to the lockers in the hall. Or if you’re not comfortable with this, you can use the bathrooms.” The case for changing in the hall included the claim that it was a “bonding experience” among classmates. Failing to understand how this would further my professional solidarity with my female classmates, I made my way to the small men’s room, where a dozen other guys had crammed themselves. After donning the clothes that would be sacrificed to formaldehyde, I made my way back through the hall past the bonding bras and briefs on either side.

The first day, the atmosphere was somber. A feeling of quiet trepidation pervaded the room as we thought of what we were about to do. We uncovered the chest first. It appeared as the off-human color of life drained away: neither gray nor brown, but somewhere in between, a washed out yellow-beige. Putting scalpel to skin, we began to cut. The knife drew no blood, for no blood could flow from a corpse. Our pace gradually quickened as we went to work dissecting. In the days that followed, the atmosphere relaxed: the volume rose, laughter returned.

A few months later, the days of gross anatomy were winding down. Each group of four students was ready to be through with our cadaver, to finish the last section of the course: head and neck anatomy. One day near the end of the course, we uncovered the face, until then hidden under a plastic bag. The somber atmosphere of day one suddenly returned. It took us off guard. Had we gradually disregarded what we knew at the beginning? Had we forgotten what we had been doing for the past three months? “Man grows used to everything, the scoundrel,” said Fyodor Dostoevsky’s Raskolnikov in Crime and Punishment.^[vi] How quickly we had accustomed ourselves to dissecting the dead.

Before we cut again, we looked at the face, that mysterious place from which the human personality radiates most fully. We looked at the mouth that had smiled and the eyes that had cried, now dry and drained and stiff. This face—the seat of the senses and the window into the soul—arrested us for a few moments. The eyes gave us pause. Then, as instructed, after a few moments we picked up our scalpels and applied them to the face.

It is strange, the things you find when you carve open dead bodies. One man’s liver was rock hard, cirrhotic, probably from years of alcohol abuse. We discovered tumors, remnants of old surgeries, food still in the stomach, stool still in the colon, a spleen six times the normal size. One of the brains, not having been adequately preserved with sufficient formaldehyde, had begun to liquefy. After removing the top of the skull like a hat, we watched, disgusted, as the brain slid partially out, oozing in a semi-liquid sludge toward the floor. Eating lunch was sometimes difficult after anatomy lab.

The day we dissected the genitals—not an easy endeavor, mind you—we discovered that one cadaver had a prosthesis inside his penis. Until then, I was naïvely unaware that such devices existed. They are among the remedies for men with erectile dysfunction (in common parlance, impotence), and they come in various and sundry models: some inflate and deflate, while others remain permanently erect. (The latter type folds down when not in use, in case you were wondering.) One of our professors, a urologist, was delighted with this find. Students gathered around him as he held up the device, turned it over in the light, all the while explaining to us the year, make, and model. One could see a gleam in his eye as he admired the materials and craftsmanship. Urologists, I thought, must be a unique breed.

The early formative experience of human cadaver dissection powerfully shapes—for good or ill—the ethos and imagination of physicians. It sets the tone for the entire practice of modern medicine. Beginning with gross anatomy lab, the dead body becomes medicine’s template for understanding the living organism. The medical student constructs his knowledge of the human body on the foundation of the static, frozen-in-time, lifeless, decontextualized corpse. This “dead” knowledge is later overlayed onto the dynamic bodies of the living. The corpse serves as the normative starting point against which the dynamic flux of life is understood.

But this gets things backwards. Consequently, the living body comes to be seen as a machine—as dead matter somehow kept in motion by mysterious forces we do not understand. Consider, for example, this dubious claim from a contemporary textbook of medical physiology: “The human being is actually an automaton, and the fact that we are sensing, feeling, and knowledgeable beings is part of this automatic sequence of life.”^[vii] This reductionist view of the living body as mere dead mechanism is not new: we finds the roots of this cramped attitude in the advent of modern medical science, including physiology, which is supposed to study the dynamic processes of life. The dead/mechanistic model ails medicine to this day.

Modern medical training has embraced a mechanistic philosophy that views the living body as no more than passive matter-in-motion—a machine that is not fundamentally different in life than in death. The physician is trained to view the human body primarily in terms of dead dissected parts that can subsequently be reconstructed, rather than as a self-directed, coordinated, dynamic, living whole greater than the sum of its parts.

Biological life is an intricately choreographed dance that cannot be captured in a photograph. Trying to get at its essence by dissecting it into ever smaller parts and examining each part in isolation, as we would do with a machine, “would be like trying to account of the unique quality, the power, and yes, the life of a piece of music by examining each note, or at most a phrase, in ever greater detail, outside the flow of the whole work, in the hope that by this ‘drilling down’, as we say, there at last we will find the secret.”^[viii] The machine model of the human body persists in our imagination not because it is true, but because “it encourages the sense that we can easily understand what life is and learn to control it”^[ix]—a tempting proposition for our Faustian age. But because the mechanistic view of the body as a dead machine built up of distinct parts is not true to life, the cadaveric starting point is not necessarily the only—much less the best—approach to medical education. But it is the one we have deliberately chosen, and we now reap the fruits.

^[i] “It was the Scholastics, not the Greeks, Romans, Muslims, or Chinese, who based their studies on human dissection. In fact, during classical times, the ‘dignity of the human body forbade dissection,’ which is why Greco-Roman works on anatomy are so faulty. Aristotle’s studies were limited entirely to animal dissections, as were those of Celsius and Galen. Human dissection was also prohibited in Islam. But, with the founding of Christian universities came a new outlook on dissection. The starting assumption was that what was unique to humans was a soul, not a body. Therefore, dissections of the human body had no theological implications. To this, two justifications were added. The first was forensic. Too many murderers escaped detection because the bodies of their victims were not subjected to a careful postmortem. The second was that adequate medical knowledge required direct observation of human anatomy. Consequently, in the thirteenth century, local officials (especially in Italian university towns) began to authorize postmortems in instances when the cause of death was uncertain. Then, late in the century, Mondino de’Luzzi (1270–1326) wrote a textbook on dissection, based on his study of two female cadavers. Subsequently, in about 1315, he performed a human dissection in front of an audience of students and faculty at the University of Bologna. From there, human dissection spread quite rapidly throughout the Italian universities—given added impetus by the calamity of the Black Death. Public dissections began in Spain in 1391, and the first one in Vienna was conducted in 1404. Nor were these rare occurrences—dissection became a customary part of anatomy classes. The ‘introduction [of human dissection] in the Latin west, made without serious objection from the Church, was a momentous occurrence.’” Stark, Rodney. Bearing False Witness. Templeton Press. Kindle Edition, pp. 142-143.

^[ii] Cf. Foucault, Michel, The Birth of the Clinic: An Archeology of Medical Perception, trans A. M. Sheridan Smith, New York, Vintage Books, 1973.

^[iii] Bishop, Jeffrey P., The Anticipatory Corpse: Medicine and the Care of the Dying, Notre Dame, IN, University of Notre Dame Press, 2011, p. 51.

^[iv] Ibid.

^[v] Ibid., 125.

^[vi] Dostoyevsky, Fyodor. 2006. Crime and Punishment. Translated by Sidney Monas. New York: Signet Classic.

^[vii] Arthur C. Guyton and John E Hall, Textbook of Medical Physiology, 11^th Edition (New York: W.B. Saunders, 2006), p. 3.

^[viii] Emphasis in original, McGilchrist, Iain. 2021. The Matter with Things: Our Brains, Our Delusions, and the Unmaking of the World. London: Perspectiva Press, p. 712.

^[ix] Ibid, p. 735.

Interview on Get Free with Kristi Leigh.

Interview with Jeffrey Tucker, Mary Holland, and Michael Kane on CHD-TV discussing our case and the companion case (combined with ours for purposes of discovery) of Kennedy v. Biden filed by Robert F. Kennedy Jr. and Children’s Health Defense, which also recently reached a settlement.

On the Brownstone Podcast, Jeffery Tucker and I discuss the implications of our settlement in Missouri v. Biden and what’s next for government censorship in the age of AI.

With yesterday’s settlement agreement, we can finally declare victory in our case, Missouri v. Biden, challenging government-sponsored censorship on social media. I have reported extensively on this case on this site and elsewhere. As I will explain in more detail below, the settlement prohibits the U.S. Surgeon General, Centers for Disease Control and Prevention (CDC), and Cybersecurity and Infrastructure Security Agency (CISA) from threatening social media companies into removing or suppressing constitutionally protected speech on Facebook, Instagram, X (formerly Twitter), LinkedIn and YouTube. It also bars these government authorities from directing or vetoing the companies’ social media content moderation choices.

Discovery in our case uncovered a vast censorship operation emanating from the highest levels of government. Various federal agencies and the White House directed social media companies to censor viewpoints that conflicted with the government’s preferred policies and messaging on topics ranging from covid policy and election integrity to gender ideology and foreign policy. These egregious First Amendment violations silenced not only the plaintiffs in our case but tends of thousands of other Americans. With this settlement, the federal government now agrees that government officials, politicians, media, academics, or anyone else labeling speech “misinformation,” “disinformation,” and “malinformation” does not make it constitutionally unprotected. That we prevailed in this case will help safeguard that marketplace of ideas from the federal government.

I will begin by highlighting and summarizing the key provisions in the Consent Decree, which the federal judge entered this morning. Keep in mind that this agreement, endorsed by the Court, functions just as a ruling from a federal judge would function. That is, it sets a precedent that can be cited for future cases with analogous findings of fact. While some commentators have understandably felt that the scope of the ruling was too narrow, as I will explain below, the Decree is valuable not only as it applies to the plaintiffs but as the precedent it sets can help future cases of this kind. The Decree opens:

Information uncovered on discovery in this case made this an issue during the 2024 presidential race. J.D. Vance explicitly mentioned it during the last vice presidential debate prior to the election, and on day 1 in office the Trump Administration issued an Executive Order designed to dismantle the federal government’s censorship machinery. The Consent Decree summarized these developments as follows:

The Decree describes the core principles at stake in this case and articulates a clear precedent for applying the First Amendment to the realm of novel digital technologies. I am pleased to report that this clear language endorses the core principles we were trying to establish with this case:

Then follows the central ruling which this Decree upholds:

Then we get the language of the Permanent Injunction which this ruling enforces. Contrary to the Defendant’s previous arguments in this case, the relief we sought does not restrict the Government’s own speech, but instead restricts the Government’s ability to suppress the speech of others:

What is the upshot of this final outcome in Missouri v. Biden?

Some early commentators have raised understandable concerns regarding the significance and scope of this injunction. I am sympathetic to those who have complained that the settlement agreement does not go far enough. You never get everything you want in a negotiated settlement, after all. We came to the conclusion that, given the difficulties establishing standing for purposes of the injunction when the case when to the Supreme Court, we did not want to run into similar difficulties regarding questions of standing to litigate the case as a whole. Since the Government was willing to concede key provisions that we were seeking, we felt this settlement was the best course of action.

Nevertheless, some commentators have expressed understandable concerns that the key provisions in the Decree are limited to the plaintiffs in this case:

Thus, it would seem that the Decree does not provide ready-made solutions for other Americans to enforce the provisions contained in the ruling, should they also be censored in the future. Does this suggest we are the only ones who can obtain injunctive relief should the government continue to censor citizens? Does this mean that Jill Hines, Jim Hoft, and yours truly—along with government officials in Missouri and Louisiana—are now the Country’s only free speech police on social media, or the only citizens whose constitutional rights are protected in this regard?

Well, no, not exactly.

While the Court’s jurisdiction to enforce this particular Consent Decree is limited to violations against the plaintiffs, others who are censored now have a clearly articulated precedent in Federal Court to press their case against the Government. Ever since the recent Supreme Court ruling in Trump v. CASA, Inc., which limited injunctions against executive orders to the parties involved, the Courts have been careful circumscribe the scope and application of their rulings to the plaintiffs in the case before the court. This is, I would argue, a positive development in most cases.

Without getting too far into the weeds, the SCOTUS ruling in Trump v. CASA found that injunctive relief must be limited to what is “necessary and appropriate to provide complete relief” to the specific plaintiffs (or parties with standing) in the case. A federal judge ruling in a specific case cannot broadly “set aside” an executive order or other policy for the entire country or non-parties unless that scope is required to fully redress the plaintiffs’ injuries. This makes it harder for a single judge to issue a broad ruling that arbitrarily strikes down entirely, let’s say, an executive order or law enacted by the legislature—something we’ve seen judges increasingly do in the last few years. This kind of “lawfare” has been a legitimate concern when it comes to the courts and activist federal judges.

To understand why SCOTUS ruled in this fashion in the above case, it’s worth keeping in mind that Courts are supposed to apply the law to specific cases, not broadly legislate (or even enforce laws) from the bench. However, even applying a specific court ruling only to the plaintiffs involved may still help other plaintiffs similarly situated by establishing precedents for federal courts to follow in analogous cases. This is, I would argue, generally how the federal courts should function, to avoid unwarranted judicial overreach and the unconstitutional usurpation of power from the Executive and Legislative branches of government.

So, would I have liked a much broader ruling in my own case to make it easier for any American citizen to seek relief from the court if censored by the Government? Yes, of course, but I also understand why the courts need to exercise an appropriate degree of restraint in this regard.

Before I conclude, it’s important to recall what else this case has accomplished. I said from the beginning that we had to win on this issue both in the legal courts and in the court of public opinion. What we have done with Missouri v. Biden in regard to public opinion is more important than what we accomplished today in the legal court. Our case, along with the Twitter Files, put this issue on the map for the American people. With our 20,000 pages of documents obtained on discovery, we were able to highlight and report on the scope and workings of the government’s Censorship-Industrial Complex. As mentioned above, in the vice presidential debate, the last question put to Vance was, Don’t you think your running mate is a threat to democracy? His response was, I think the real threat to democracy is the censorship by the government online that has been happening on an industrial scale. He was correct, and the issue was on the national agenda.

Not only did we get an Executive Order on day one of the new administration, we also saw CEO Mark Zuckerberg join Elon Musk in admitting in a letter to Congressman Jim Jordan and in an interview with Joe Rogan that what we alleged in the case was exactly what happened at Facebook. He acknowledged that it was wrong, apologized, and vowed not to do it again. That was a remarkable admission of wrongdoing for such a high-profile figure.

Of course, anyone familiar the history of free speech litigation in the U.S. knows that this fight is far from over, that you never win once-and-for all in a single case, that unless we continue to defend them in the court of law and the court of public opinion, the rights articulated in our Constitution remain merely words on a piece of paper. While far from the final word on government censorship in the digital age, our case did put a significant dent in the problem. Even if our legal victory was limited in scope, the principles articulated there are the central ones that we need to maintain. We did win in the courts and we are winning in the court of public opinion. For that, I am grateful to my intrepid co-plaintiffs and our diligent public and nonprofit lawyers who fought this good fight.

Finally, in closing, I would like to acknowledge our lawyers at the New Civil Liberties Alliance for their tireless work in representing us through four years of grueling litigation. I’ll let them have the last word here by including here their reactions to the ruling:

“This case began with a suspicion, that blossomed into fact, that led to Congressional hearings and an Executive Order that government censorship of Americans’ social media posts should end. Freedom of speech has been powerfully preserved by our clients, past and present, who initiated this suit.”
— John Vecchione, Senior Litigation Counsel, NCLA

“The United States government cannot abridge speech directly, nor by inducing intermediaries to do so at its bidding. As recognized by last year’s Executive Order, that is exactly what happened, sometimes driven by a prior administration, sometimes driven by bureaucrats, but always unlawful.”
— Zhonette Brown, General Counsel and Senior Litigation Counsel, NCLA

“Our clients joined this case to ensure there would be standing to oppose the federal government’s blatant censorship. NCLA is thrilled to vindicate Jill Hines, Dr. Aaron Kheriaty, and our former clients now in government service. Federal officials may police the line between lawful and unlawful speech, but they have no role in deciding if speech is true or false—even so-called misinformation, disinformation, or malinformation.”
— Mark Chenoweth, President, NCLA

“The federal government’s social media censorship was the most massive suppression of speech in the nation’s history, it was profoundly important to resist it.”
— Philip Hamburger, Founder and Chief Executive Officer, NCLA

My testimony begins at 2:34:00. The Q&A with the panel which follows is also worth watching. For those who prefer to read, I’ve included my remarks below.

My name is Aaron Kheriaty. I am a physician specializing in psychiatry and the Director of the Bioethics, Technology, and Human Flourishing Program at the Ethics and Public Policy Center. The first part of my talk will revisit some of the issues from our first panel (religious freedom for healthcare providers), while the second part will return to the theme of this panel (religious freedom related to vaccine consent).

When I was a medical student on my obstetrics clerkship, I was assisting my first patient on the labor and delivery service. However, this woman’s labor was not progressing well, so they decided to convert her from a vaginal delivery to a cesarean section. I was to scrub in and assist on the c-section in the operating room. I walked with the intern into the patient’s room to obtain consent for the procedure. The patient, still huffing and puffing from painful labor, said, “I just spoke with my husband, and we decided that while you’re in there you can go ahead and tie my tubes.” The intern responded, “are you sure,” and the patient replied, while still in labor, “yes.” That was the extent of the informed consent for an irreversible procedure that would render her permanently sterile.

As the intern and I walked to the scrub station I informed her that I was willing to assist on the cesarean but would need to step out of the OR and not help with the tubal ligation, as a matter of conscience. The resident became irate, asking, “How dare you impose your views on this patient?” I replied that I was imposing nothing on anyone, merely telling her what Iwas and was not willing to assist on. I did not scrub in on that case, and for the rest of the rotation that intern made my life hell. I managed a passing grade but the comments that ended up in my dean’s letter and residency application were unfairly critical—not because of my performance but because I chose to exercise my rights of conscience.

I believed that damaging a healthy organ system—in this case the patient’s reproductive system—contradicted the ends and purposes of good medicine. In addition, the procedure of permanent sterilization also violated the moral teachings of my sincerely held Catholic faith. What is more, I knew clearly that the so-called informed consent for that procedure was a sham. I mean, what women in the middle of labor wants in that moment to think about having another baby! That’s clearly not the time to hurriedly make this irreversible decision.

I did not realize it at the time, but I was also the only person in that case actually upholding the hospital’s own policy. For this was Georgetown University Hospital, which as a supposedly Catholic institution, was legally bound to abide by the Ethical and Religious Directives of the Catholic Bishops, which forbade procedures whose sole aim was permanent sterilization.

After the incident I ended up getting dragged before the obstetrics department chair, at the behest of the chief medical officer (the hospital’s head administrator), to explain what happened. As a lowly medical student, the power dynamics were intimidating, and nobody from the hospital administration or school of medicine accompanied me through that process. The chair of obstetrics made excuses for violating the hospital’s own policies and the entire meeting was a farce.

Another thing I did not realize at the time was that I was supposed to have been protected from retaliation by federal laws, such as Church, Coats-Snowe, and Weldon Amendments. These laws protect the rights of healthcare workers to decline participation in medical interventions that violate their conscience, religious beliefs, or moral convictions—such as declining to participate in an abortion or sterilization procedure. Although I did not know this, healthcare workers and trainees are also protected by these laws from retaliation should they decline to assist on these procedures.

The Department of Health and Human Services issued a New Nondiscrimination Final Rule to Protect Conscience Rights two years ago in January 2024. It encourages (but does not require) hospitals and clinics to voluntarily post a notice of rights to ensure compliance and educate the public about conscience statutes and rights. These laws were in place when I went to medical school, but I had no understanding of them or of my rights under Federal law. As a medical student interested in ethics, I was better informed on these issues that most. Yet still, I was never advised of my rights, even after they were violated and the hospital leadership was notified.

Clearly, if healthcare providers and trainees are not informed of these rights at orientation, then the laws on the books remain a dead letter. Those whose rights are violated need support not just from the HHS Office of Civil Rights, but also a right of private action in case the OCR is slow to respond to complaints, as often happened under previous administrations. Furthermore, these protections need to be extended in Federal law to include other procedures, which were not common when these laws were enacted but are now ubiquitous, such as doctor-assisted suicide, euthanasia, and sex-rejecting procedures (what advocates euphemistically term “gender affirmative care”). While euthanasia is briefly mentioned in the Affordable Care Act, this merely regulates payments to hospitals, and that law alone does not protect conscience rights of individuals.

Fast forward to 2021, when I was director of the medical ethics program at the University of California Irvine. I served on a committee at the Office of the President, which oversaw all five UC branch campuses that had hospital and medical schools. Our committee vetted all the covid policies up until the vaccine mandate policy, which came down from on high with no discussion or debate. I found this puzzling, since this would clearly be the most publicly and ethically controversial of the University’s proposed covid policies. So I published a piece in the Wall Street Journal, coauthored with a law professor, arguing that University vaccine mandates were unethical. This failed to start a conversation at the University, which enacted the policy a couple weeks later.

Because I had gone public in my opposition to the policy, I had students, nurses, and faculty from the University reaching out to me, very distressed that they would soon be fired for declining the covid shot. So I decided to not only criticize the policy but to try and change it: I challenged the University’s covid shot mandate in federal court on behalf of people like me who had natural immunity after recovering from the virus. Before the court ruled in my case the University fired me in retaliation. I had been a professor there in the school of medicine for sixteen years, where I had won the excellence in teaching award three times from the medical students.

When it comes to vaccines, laws in many states fail to protect conscience rights and religious liberty. While I am not a lawyer, I fail to see how such laws could withstand judicial scrutiny, as it seems they clearly violate the free exercise clause of the First Amendment.

For example, states like California where I live and practice medicine, do not have laws allowing religious or conscience-based exemptions for parents to opt-out of the childhood vaccination requirements. Many people have religious or moral objections to the use of cell lines derived from aborted fetuses, often used in the development and testing of vaccines. In states like California, if parents choose not to use these products, then they are not permitted to send their kids to public or even private schools. Those who cannot homeschool are left with no options.

As Commissioner Ryan Anderson noted earlier today at this hearing, one does not have to rely on doctrines of revealed religion to see that medicine has its own internal morality: that medicine should always and only be aimed at health and healing. By the light of reason alone we can see that (1) doctors should not intentionally kill their patients, (2) doctors should not intentionally destroy healthy functioning organs or organ systems, and (3) doctors should not force treatments on patients that patients decline for medial, moral, or religious reasons.

In our current confused culture, however, it is often men and women of faith, buttressed and given courage by their religious convictions, who uphold these traditional principles of Hippocratic Medicine. Some federal laws protect them in these circumstances, but these laws are neither well known nor consistently enforced. They are also too narrow to cover new threats to the integrity of medical practice.

After the excesses and authoritarian overreach by governments during covid, the people of the United States are pushing back and reasserting their rights of conscience and freedom of religion in healthcare. I pray that this committee will assist them by strengthening and enforcing the federal laws on the books, educating the public regarding their rights, and leaning on states to do the right thing when it comes to free and informed consent.

Thank you.

We discuss themes from my book, “Making the Cut: How to Heal Modern Medicine,” focusing on how financial, bureaucratic, and ideological forces have distorted the core healing mission of medicine in the United States. I explain here how managerialism, overregulation, and structural standards biased toward expensive pharmaceuticals have turned doctors into box-checking data clerks, eroded patient trust, and contributed to poor national health outcomes and a chronic disease epidemic.

The answer to these ills will involve decentralization, parallel medical institutions, and models like direct primary care and crowdsourced care to restore physician judgment, reducing bureaucratic waste, and empowering patients to take more responsibility for their own health. The conversation also covers end-of-life overmedicalization, physician burnout, COVID-era mandates and loss of trust, and the Hippocratic Society’s effort to re-anchor medical education in classical ethics and patient-centered care.​

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The following essay was originally published in The American Mind and is reprinted here with permission.

One year ago, President Trump signed an executive order directing his administration to develop policy recommendations to protect access to in vitro fertilization (IVF), expand its availability, and make it available at a lower cost to patients. Then in October, the administration announced additional measures to lower costs for IVF and common fertility drugs and explore pathways like expanded employer benefits or excepted benefit categories for assisted reproductive technologies. While this included joint efforts across federal agencies to make this costly intervention more affordable, the administration stopped short of imposing broad new federal mandates for insurance coverage or direct government funding of IVF.

The problem of below-replacement fertility rates in the U.S.—which poses serious demographic, social, and economic challenges—has gained some political attention since the last election. As of 2024, the fertility rate in the U.S. stands at a record low of 1.6 births per woman of childbearing age, well below the replacement rate of 2.1. This drop continues a downward trend that began in the early 2000s and accelerated after the 2008 recession. Trump frames his support for IVF as a way for the government to support couples who desire to start or grow families. While this administration has not yet enacted universal “free” IVF, as initially floated in Trump’s campaign rhetoric, the policies show clear support for making IVF accessible to more Americans.

But the notion that expanding access to IVF will measurably alleviate our fertility crisis is pure fantasy. First, the goal of achieving a significant number of additional births using government-funded IVF will prove cost-prohibitive: the procedure typically runs $15,000 per cycle plus $5,000 for medications. Second, the success rates tend to be low: a typical IVF cycle achieves pregnancy in about 20-35% for women under 35, and this low number drops further with age.

IVF is usually employed for infertile women who have been unable to conceive naturally. But infertility, while far from a trivial issue, is not a significant driver of our low birth rates. A 2013 Gallup poll found that, on average, American adults want to have between two and three children, a statistic that has remained unchanged since the 1970s. The 5% of adults who do not want to have children had not changed much since 1990. The fact that many Americans are not realizing their desire for children is, for the most part, not a result of medical problems leading to infertility. The main source of our birth dearth is not biological but economic: more than three-quarters of those who want more children but do not have them cite financial considerations as the main reason.

The $20,000+ invested in each IVF cycle, only to achieve a 25%-30% success rate, would be better spent on other economic incentives to encourage family formation for those who believe they cannot afford children. We can and should argue over the details of specific policy proposals—be they child tax credits, support for stay-at-home moms, or other measures to stimulate the economy generally. But regardless of our favored policy solutions, there is no doubt that these kinds of proposals promise to deliver far more per dollar than IVF. If you want more babies, simply creating them in a petri dish will not do: we need to make it more affordable for Americans to raise these children after they are born.

Even when it helps couples to have a child, IVF comes with serious ethical costs. Clinics compete in the market based on success rates. Because egg harvesting is an invasive and sometimes risky procedure, IVF cycles typically aim to create as many embryos as possible—usually more than the couple intends to bring to birth. Unused embryos go into frozen storage but can later be thawed and implanted. In one 2022 experiment, run by its very nature without consent, twins were born after 30 years in cold storage. Their adoptive father was 5-years-old when they were first conceived.

It is not known precisely how many embryos are now in cryopreservation, because clinics are not required to report these numbers. Estimates range from 500,000 to millions. Many of these end up abandoned by parents who stop paying the $500-$1000 yearly storage fees and fail to respond to repeated outreach from clinics. Most parents remain reluctant to allow clinics to destroy their spare embryos, suggesting at least moral ambivalence. Other available options include adopting out their embryos to another infertile couple or donating them to embryo-destructive research. Parents likewise rarely consent to these, likely out of similar moral reticence. These parents know well what happens when those “clumps of cells” are placed in a mother’s womb.

Thus, parents who do not want to raise additional children are stuck in an insoluble ethical conundrum; their embryos are left in a cryogenic nursery limbo. It’s hard to entirely blame IVF clients for this when all available choices seem morally problematic. Even when they are informed of these options before starting IVF, most couples admit that they were singularly focused on achieving a pregnancy and rarely considered what would happen to their excess embryos until they later faced the decision. In creating countless human embryos that will never be placed in a uterus—the only conducive environment for embryonic life—we have created a problem for which there is no morally just solution. This should invite us to reevaluate the practice that created this insoluble quandary in the first place.

It’s important to acknowledge the anguish of infertility for those couples trying unsuccessfully to conceive. However, there are better solutions to offer them than IVF. The egg-harvesting phase of IVF introduces nontrivial medical risks. Although we need much more longitudinal data on this, current evidence strongly suggests significant risks also for the child conceived by this procedure—including elevated risks for birthdefects, as well as chronic illness later in life, such as cardiovascular problems and metabolic dysregulation, cognitive impairment, and perhaps even cancer, possibly due to epigenetic changes introduced by the procedure. This research supports the common-sense notion that, whenever possible, it would be preferable to make babies in the bedroom rather than the laboratory (and much more fun, as most couples will attest).

Nevertheless, the focus on IVF as the solution to infertility—and often the first solution offered to infertile couples—has dampened research and clinical efforts aimed at treating the underlying causes of infertility. Instead of focusing on IVF, the Trump administration should support medical interventions that help previously infertile couples to conceive a child in the womb. As in many other areas of contemporary medicine, we reach immediately for medically invasive, lab-based procedures. We offer couples a Band-Aid—or in this case, a workaround—for the problem, instead of assessing and attempting to correct the underlying cause.

Interventions under the umbrella of restorative reproductive medicine range from dietary changes or hormone balancing to, in some cases, medications or surgery. This approach accords with the sensible and necessary push by the new administration to Make American Healthy Again by addressing the root causes of our epidemic of chronic illness, rather than just applying superficial, expensive, and suboptimal quick fixes.

There are several challenges to making these interventions available and accessible to more couples, which sensible policies can begin to address. Not only is research inadequately funded, but we also currently lack sufficient training for physicians in assessing and treating the root causes of infertility. To mention just one example, among the most common causes of infertility is endometriosis—a condition that not only makes it difficult or impossible for the affected woman to maintain a pregnancy but also, if uncorrected, causes intense pain and other troublesome symptoms. However, most physician specialists are not trained in the complex surgical approach required to adequately treat endometriosis to allow for pregnancy. Other such examples abound.

We should applaud the Trump administration’s laudable goal of helping infertile couples to bear children. But IVF is not the right solution. Instead of putting all our eggs in one basket, we need a capacious approach to supporting fertility that does more to address the root causes of infertility and, whenever possible, restore reproductive function the way nature intended. This strategy respects human life at all stages and avoids insoluble ethical quandaries. It also offers a recipe for happier parents and healthier children. Surely this is a proposal for addressing our fertility crisis that all Americans can endorse.

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I was delighted to reconnect with an old friend, Michael Dauphanais, who was a graduate student in theology at Notre Dame when I was an undergraduate student. He now teaches at Ave Maria University and hosts the Catholic Theology Show. Here are my two recent episodes from the show, which I thought were both terrific conversations. I hope you enjoy these interviews.

The following is an excerpt from chapter 5 of my latest book, Making the Cut: How to Heal Modern Medicine. Consider getting yourself, or someone you know in healthcare, a copy of the book!

My job as the medical student was to hold the leg. Until I was holding just the leg.

The electric saw was buzzing, bits of bone were flying, and a tendril of smoke wafted up from the point where saw met bone. We were performing an amputation.

It was a surprisingly quick operation, no more than half an hour. Above the knee, the resident made a circumferential cut with a scalpel, tied off the few major leg vessels, and continued cutting until he reached bone. Then it was time to pick up the saw, an instrument that did its work quickly. . . until it came off in my hands, floating free from the patient’s body. It was heavier than I expected. I handed it to a nurse, who put it in a plastic bag marked “biohazard” and carried it out of the operating room. I wondered what they did with these biohazards.

Surgeons traffic in body parts. They claim to heal with steel. Amputation was, admittedly, a strange way to heal. The operation was necessary, but no less bizarre for that. The leg was already useless to the patient: the vessels were so clogged that the foot no longer received adequate blood supply and had developed gangrenous ulcers. The patient had not walked on this leg for some time. Without amputation, the gangrene would eventually cause a deadly infection in his blood. The leg was already “dead,” and death cannot live in symbiosis with life for long; it seeks the company of other body parts and eventually, of the entire body.

I had handled other detached body parts before, and not just cadaver parts in gross anatomy lab. I thought back to the liver. Unlike the amputated leg, the liver was not dead. The situation was reversed: the “living” body part had been removed from a dead body and kept artificially “alive” to be put back into a different living body whose liver was more or less “dead.” A liver transplant—an astonishing feat.

I thought back also to the kidney, also a different situation. For that body part had not been removed from a dead body to be transferred to a living one. It had been removed from a living body and was itself very much alive. In this situation, the kidney was considered a “spare part,” since its twin would remain inside the donor and take over the function of the donated body part. Taking living body parts from the living so that another may live—another astonishing feat.

One morning, prior to transplant rounds, I received some good news.

“Go ahead. You can tell the patient,” the resident said.

Like so many others on the transplant service, Ms. Hahn had cirrhosis of the liver. Unlike the others, however, her disease was not caused by excessive alcohol consumption. She was born with a genetic disorder, alpha-1-antitrypsin deficiency. This disease involved the absence of a protein enzyme crucial for liver and lung function. The deficiency slowly destroyed her liver, until, in her fifties, Ms. Hahn had become seriously sick. It was at this point that we were taking care of her in the hospital while she awaited a replacement organ—the only thing that could save her life.

Transplant organs are distributed on an “as needed,” rather than a “first come, first served,” basis. After an extensive medical and psychiatric evaluation, a patient can be placed on a regional transplant list to wait for an organ among the other patients from nearby states. The more ill one becomes, the closer one moves toward death, the higher one moves up on the priority list. After arriving at the top of the list, the patient and doctors hope that an organ becomes available before the disease kills the patient. Ms. Hahn was now at the top of the regional list. She was getting sicker by the day.

I woke her from sleep. She looked at me, eyebrows raised, examining my expression.

“I have some good news for you, Ms. Hahn,” I said. She leaned forward. “You’re getting a liver today.” A broad smile crept over her face. She squeezed my hand.

“Really?” she asked, almost in disbelief.

“Yes.” I grinned back.

“Do I have time to call my brother?” she asked. “He wants to fly in from California.”

“Sure. Your liver won’t arrive here for a few hours. We’ll take you to the operating room early this afternoon.”

Just an hour before this, a young man had died suddenly in a motorcycle accident. While it sounds callous, sudden death is good for donated organs—it keeps them fresh. In one man’s death was another woman’s promise of life. It’s uncomfortable to acknowledge, but in transplant medicine, “the living are parasitic upon the dead.”^[i] One of the transplant attendings, Dr. Smith, was en route from a nearby hospital to Georgetown, carrying a special delivery in an ice chest. On his way, he stopped at a fast-food joint.

“I was hungry,” he later confessed during the surgery. “A cheeseburger sounded so good.” The guy at the drive-thru window probably never would have guessed what the passenger was carrying in his trunk.

Before you can remove a liver for transplant, the patient must be declared “brain dead”—the current medical criteria for death, which involves the total cessation of all brain activity. Advocates for brain death criteria argue that death is the disintegration of the unified organism, and the brain is responsible for maintaining organismic unity. But this rationale does not actually stand up to scrutiny. The brain modulates the coordinated activity of the other organs, but it does not create this coordinated activity. That is accomplished by the organic formal unity of the body as a whole—which modern science, with its reductionistic analysis of the body into component parts, cannot see.

Although a brain-dead patient has no functional electrical activity of the brain, the patient continues, with the help of machines, to breathe and to circulate blood. The organs continue functioning, keeping them fresh for transplant. The body of the brain-dead person on a ventilator maintains homeostasis and coordinated unity of functions: the kidneys make urine; the liver makes bile; the immune system continues to fight off infections; wounds heal; hair and fingernails grow; endocrine organs secrete hormones; broken bones heal, and broken skin repairs; children grow proportionately as they age. Pregnant mothers can even gestate babies after brain death, sometimes for months. Consider the inherent contradictions and manifest absurdities in this headline from the Associated Press: “Brain-dead Virginia woman dies after giving birth.”^[ii]

To all appearances, a patient in this state does not, in fact, appear dead. This has led some medical ethicists—quite sensibly—to question the validity of “brain death” as an adequate criterion for death. For example, the prominent neurologist Alan Shewmon argues that “‘Brain death as death’ began as a utilitarian legislative decree and has remained a conclusion in search of a justification ever since: a conclusion clung to at all costs for the sake of the transplantation enterprise that quickly came to depend on it.”^[iii]

The brain death criteria were developed by a Harvard Medical School committee in 1968 to free up ICU beds and promote organ transplantation—with death itself forming the foundation of the organ transplant enterprise. For organ transplantation rests upon a paradox—perhaps an outright contradiction—a “dead” donor whose body, with its precious organs, is still living.

After someone is pronounced brain dead, if the family refuses transplantation or if the organs are deemed unsuitable for transplant, the following situations emerge. Once the ventilator is turned off, the patient’s heart may continue beating for several minutes, or even for a few hours (especially if the patient is a newborn). We would not send such a “dead” patient to the morgue, cremate her, or bury her while the heart still beats. Should we then give a drug, like potassium chloride, to stop the heart of the supposedly already-dead patient? In some cases, we wait a day or two to shut off the machines of the patient pronounced brain dead to allow family to travel from a distance to be at the bedside when the ventilator is discontinued and the heart subsequently stops. Is this family witnessing the death of the patient, or simply the cessation of efforts to animate an already-dead corpse? If the latter, why would family members want to be present for that?

Considering these oddities and absurdities that stem from the legal fiction that brain death is the death of the person, “total brain failure” is a more accurate term than “brain death.” It indicates an irreversible coma, not a dead body. Perhaps such a person is “better off dead,” as many people assume. Certainly, it is justifiable in such a situation, where meaningful recovery of human functioning is impossible, to discontinue life-extending measures such as ventilators or antibiotics. Even so, such a person is not yet dead. Total brain failure is a state where medical interventions should be discontinued because they cannot achieve meaningful ends. But it is likely not yet a state where the body’s parts should be harvested at will.

The problem is, if critics of brain death are correct—and I find their critiques compelling and the responses to them unconvincing—this would spell the end of organ donation as it is currently practiced. But it would be many years after medical school that I began considering this matter in depth.

As a student, I was thrilled to scrub in on Ms. Hahn’s liver transplant operation. It lasted twelve hours. First, her hardened, nodular, gray liver had to be dissected out, separated from its bile duct and blood supply, and removed. Like the amputated leg, this body part was carried away as another piece of biohazardous waste. Before we removed the liver, however, the largest vein in the body—the inferior vena cava (IVC)—which carries all the blood from below the chest back to the heart, had to be clamped. The liver wraps over the IVC, which runs behind it; the former cannot be removed without also taking the latter.

To accomplish this, the blood that normally flowed through the IVC was pumped through a hose that ran outside the patient’s body, behind my back to a bypass machine, then back into her body and to her heart. Since this hose was much larger in volume than the IVC had been, the blood pressure would drop precipitously the moment we clamped the vein and the blood flow shifted to the hose. To counteract this effect, the anesthesiologist stood ready to administer rapid-acting medications that would raise the blood pressure at the precise moment when it otherwise would have plummeted to dangerously low levels. Each action, the clamping, bypassing, and medicating, had to occur in sync to allow continued blood perfusion to vital organs, especially the heart and brain. A mistake here could easily lead to a heart attack or stroke.

In Ms. Hahn’s case, all these steps went smoothly. I breathed a sigh of relief.

With the liver out, time was short. Once the new liver was removed from the ice, it would have to be put into the abdomen, attached, and its blood supply restored quickly. This meant that the vessels that had been tied off for removal now had to be rapidly sewn back onto the new liver’s vessels. The new IVC also had to be sewn to the old IVC stump on the posterior side of the fresh liver. Then, the bypass could be shut off, and blood flow could resume in normal fashion.

The doctors coordinated these actions in perfect sync, and this too went smoothly.

Before putting the new liver in, Dr. Smith called me over to a side table, where he was handling the life-saving body part. He turned it over in a bucket of ice, demonstrated its anatomy, and carefully dissected away any unnecessary surrounding tissue.

I placed my fingers in the cool ice bath and ran them over the organ’s smooth surface. Compared to the knotted greyish-hard ugliness of Ms. Hahn’s old liver, the new body part was a thing of beauty: browned from its large supply of blood, supple, and soft to the touch. Without a fresh supply of blood, it would not last long outside the ice bath.

Dr. Katz, who was still working with two other residents on the patient, preparing the empty space inside to receive its gift, called for the liver. Dr. Smith picked it up and carried it to the operating table. Carefully, he lowered the fresh body part into the patient’s open abdomen. Then, both attendings went to work sewing the new cloth into the old. I watched in wonder. What an extraordinary thing we are doing here.

“Time for a break,” Dr. Katz said after some time had elapsed. “Come on,” she said, motioning to one of the residents and me.

There were still a few hours to go before the surgery would be finished, but the most difficult part was over. Dr. Smith and a second resident continued working, while the three of us “scrubbed out,” removing our bloody gowns and gloves, and made our way to a nearby conference room. There we found cold Chinese food, left over from lunch that day, waiting for us. It was nearly midnight. Hungrily, we grabbed a plate and dug in. As I sat down, my stiff back and cramped legs thanked me. Nine hours standing is a long time to hold retractors and suction blood.

Although I had been working with her all month, I rarely conversed with Dr. Katz. She stood barely five feet tall, yet she was widely regarded as the most intimidating attending at Georgetown. I have already mentioned her propensity for profanity. From her sharp tongue, she frequently fired verbal arrows at the residents. Interns were terrified of her. Although she was much tougher on the residents than on the medical students, each of us secretly feared committing the unforgivable blunder that would bring her wrath down upon our heads.

Without warning, she struck up a conversation with me as we sat munching chow mein and kung pao chicken.

“What are you going into?” she asked.

“At this point, I’m leaning toward psychiatry. But I’m not sure yet,” I said, hoping that she had in fact been addressing me.

“I almost went into psychiatry,” she said.

“Really?” I could not picture it.

“Yeah. I loved it. Fascinating stuff. Only thing was, I couldn’t stand all the group therapy garbage. Too much fluff, you know.”

I duly nodded.

She continued, “Actually, surgery is a lot like psychiatry.” I waited for the explanation, which was forthcoming. “We surgeons manipulate people’s bodies, and you psychiatrists manipulate people’s minds.”

I suppose that’s one way to look at it, I thought, but kept my thoughts to myself.

Ms. Hahn spent many days in the intensive care unit before awakening from sleep. The surgery had gone as well as it could have, but a liver transplant is so traumatic that her body needed several days of rest before she regained consciousness. When she finally awakened, her life had changed forever. For the rest of her days, she would take drugs that suppressed her immune system so that her body would not reject the foreign body part. This made her more susceptible to infections, but this was more than a fair trade for the benefits she had received.

She was no longer a patient with a terminal illness. She would live. And she lived because another was declared dead. Or mostly dead.

^[i] Cf. Chapter 6 of Jeffrey Paul Bishop, The Anticipatory Corpse : Medicine, Power, and the Care of the Dying, Notre Dame Studies in Medical Ethics (Notre Dame, Ind.: University of Notre Dame Press, 2011).

^[ii] Associated Press, “Brain-dead Virginia woman dies after giving birth; was kept on life support as fetus developed,” August 3, 2005. Accessed at https://www.9news.com/article/news/brain-dead-virginia-woman-dies-after-giving-birth-was-kept-on-life-support-as-fetus-developed/73-344702383

^[iii] D. Alan Shewmon, “Brain Death: A Conclusion in Search of a Justification,” Hastings Center Report 48, suppl. 4 (November-December 2018): S18–S24, https://doi.org/10.1002/hast.949

The video interview above might be behind a paywall, but this audio/podcast version is not:

From the show notes…

Modern medicine is veering away from the traditional Hippocratic Oath that required physicians to do no harm and use their knowledge and skills solely for the purpose of healing the patient, says psychiatrist and bioethics expert Dr. Aaron Kheriaty.

Now, physicians are euthanizing patients, removing healthy organs in certain transgender-related surgeries, and injecting drugs for late-term abortions even when the mother’s life is not threatened.

Hippocratic principles are being superseded by utilitarian ethics that prioritize the “greater good” over the well-being and rights of individual patients, Kheriaty says. That’s fueling, for instance, the push to expand the dead-donor eligibility criteria for organ donations.

It’s also manifesting in the push to adopt technological advancements like germ-line gene editing that could be used to create “designer babies” or in vitro gametogenesis (IVG), a process that uses stem cells, such as those derived from skin cells, to create human eggs and sperm in a lab.

Earlier this year, an op-ed in the MIT Technology Review argued for the creation of “spare” human bodies called “bodyoids.” These would essentially be human bodies created in laboratories from human stem cells, but without brains or consciousness. Proponents say they would revolutionize medical research and drug testing and create an unlimited supply of organs.

It sounds like the stuff of science fiction. What are the true ethical implications? Is this really where we want medicine to go?

Kheriaty is the director of the bioethics and American democracy program at the Ethics and Public Policy Center and former director of the medical ethics program at UCI Health.

His latest book is titled “Making the Cut: How to Heal Modern Medicine.”

“The biggest advance [that] medicine needs to make is to accept the limits of medicine,” he says.

My segment starts at minute 1:03:00 following the segment with Charlie Sheen (I had a nice chat over Zoom with Charlie as we were waiting for the interview to start — was great to see that he got sober and is looking very well these days). In addition to discussing themes from Making the Cut, Drew and I also talked about the rising euthanasia regime in Canada.

And here’s a radio interview I did the same day discussing, among other topics, how to fix the skyrocketing costs in our healthcare system. Enjoy!

My colleague Stanley Kurtz at the Ethics and Public Policy Center recently published in National Review a terrific piece introducing the Hippocratic Society, which I co-founded a couple years ago with three other doctors from Harvard, Stanford, and Duke. with permission, I’m publishing an excerpt here with a link to the entire article. This may be of interest to anyone you know in medical school or residency training.

Something more should be said about the Hippocratic Society’s name. Hippocrates of Cos (ca 460–370 B.C.) was the father of ancient Greek medicine. He initiated the medical tradition ancestral to our own, grounded in meticulous empirical observation. Hippocrates is most famous, of course, for his oath, the code of medical ethics that many or most modern doctors once swore to uphold. The original Hippocratic oath forbade both abortion and physician-assisted suicide. Most medical schools therefore now either forgo the oath altogether or rewrite it to modify or eliminate those and other provisions.

Most Hippocratic Society members, by contrast, tend to remain loyal to the original oath and to the more encompassing “do no harm” morality that lies behind it. Also, as we’ve seen, HippSoc works to revive knowledge of the philosophical and religious (Jewish, Christian, and Muslim) foundations of medicine, going back as far as Aristotle. It’s a return to medicine in the great tradition.

I only recently learned about the Hippocratic Society from my EPPC colleague Aaron Kheriaty, who is on the group’s board, and immediately realized that news of a medical counterpart to the Federalist Society would be of interest to conservatives generally.

Dr. Kheriaty’s new book, Making the Cut: How to Heal Modern Medicine, explores the problem of physician burnout and the numerous other ailments besetting his profession. Toward the end of the book, Kheriaty calls for the creation of a series of alternative medical institutions to help shift the profession’s current direction. Sounds like a good idea to me. Stanley Goldfarb’s group, Do No Harm, which addresses the harmful effects of identity politics on medicine, is another excellent example of the sort of thing that is needed, I’d say.

The Hippocratic Society is growing rapidly. When Kheriaty wrote his book, published in September of this year, HippSoc chapters for premedical and medical students had been established at nine universities. I now count 28. (If you’d like to join, or start a chapter of your own, go here.)

What Kheriaty recommends for medicine applies more broadly. We need to establish a set of alternative institutions across many fields of endeavor in order to break monolithic progressive control of our institutions under the guise of “professional” consensus. The Federalist Society established the model. The Hippocratic Society, with modifications, continues it. With luck, we’ll see yet more to come.

To read the resit of the article, click here.

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Hope you enjoy this interview with Brian Hooker in which we discuss medical freedom and free speech, science vs. scientism, problems in our current healthcare system, and proposals for fixing these.

And my recent interview with bioethicist Wesley Smith on the Humanize podcast, also available here:

The following interview with Charlie Camosy recently appeared in OSV News and republished here with permission.

Has modern medicine lost its focus on the health of the patient? That’s the contention of Aaron Kheriaty, a physician specializing in psychiatry who serves as director of the Bioethics, Technology, and Human Flourishing Program at the Ethics and Public Policy Center. He spoke with OSV News’ Charles Camosy about the flawed vision of patient care pervasive in modern medicine in his new book Making the Cut: How to heal modern medicine.

Charles Camosy: Your story permeates this book. Can you give us a preview or brief overview of how you came to write a book like this?

Aaron Kheriaty: The narrative portions of Making the Cut: How to Heal Modern Medicine, which recount my four years at Georgetown University School of Medicine, were written 22 years ago, immediately upon completion of medical school.

This gives them an immediacy that would not have been possible had I written those sections today, when many of the details of these cases have since faded from memory.

Here’s a taste of the narrative, from the opening of Chapter 5, which gives you a flavour of the gritty realism that places the reader at the hospital operating room or the clinic bedside:

“My job was to hold the leg. Until I was holding just the leg. The electric saw was buzzing, bits of bone were flying, and a tendril of smoke wafted up from the point where saw met bone. We were performing an amputation. It was a surprisingly quick operation, no more than half an hour. Above the knee, the resident made a circumferential cut with a scal­pel, tied off the few major leg vessels, and continued cutting until he reached bone.

“Then it was time to pick up the saw, an instrument that did its work quickly . . . until the leg came off in my hands, floating free from the patient’s body. It was heavier than I expected. I handed it to a nurse, who put it in a plastic bag marked ‘biohazard’ and carried it out of the operating room. I wondered what they did with these biohazards.”

The more mature philosophy of medicine, the critique of contemporary health care, and my proposed solutions for reforming medicine were parts of the book I wrote more recently, after 20 years of clinical practice.

So, the book has been a couple decades in the making. Hopefully that additional experience as a physician informs my thoughts and reflections on the narrative stories I recount from training.

Camosy: If you had to boil down the central problem with the way we practice health care in the US, how would you do that?

Kheriaty: Somewhere along the way, medicine itself got sick. A recent survey of almost half a million Americans published in the Journal of the American Medical Association showed that trust in physicians and hospitals plummeted 30 points following the COVID crisis, from 72 percent to 40 percent.

Meanwhile, we’re grappling with an epidemic of chronic illness – heart disease, cancer, diabetes, obesity, metabolic syndrome, Alzheimer’s, stroke, and chronic lung and kidney disease – affecting six in ten Americans, which medicine seems powerless to fix.

Starting in 2014, the overall life expectancy of Americans has declined for the first time since the 1918 influenza pandemic.

The United States spends twice as much on health care per capita than any other country but barely ranks in the top 50 in terms of health outcomes.

As I argue in the book, like the old Soviet Union, the US health care system has evolved so that a whole bunch of vested interests can extract rents from a bloated, dysfunctional bureaucracy. And patients are left to suffer.

Sad to say, the highest aim of modern medicine is not health, but rather efficiency. Today, medicine has often become more adept at controlling bodies than curing them.

Like other fields, it has fatally succumbed to managerialism – the belief that, through the accumulation of “rational” knowledge, everything can and should be engineered and managed from the top down.

It matters little whether the management is coming from government bureaucrats or corporate conglomerates.

Managerialism ignores the fact that every patient is unique. No sick person wants to be “processed” through an industrial-scale, “turnstile” medical system that treats every patient exactly the same.

This starts with medical training, where students are conditioned, beginning in gross anatomy lab in the first year, to view the human body as nothing more than a complex machine, an assemblage of replaceable parts.

Camosy: I’m very interested in how the Catholic Church can move to address this central problem. Through its massive health care systems, yes, but also how it trains those who practice health care. Any thoughts on this?

Kheriaty: We need to recover a sound Christian anthropology, rooted in the Catholic intellectual tradition, to correct the errors of modern scientism – which is the (non-scientific) claim that science is the only valid form of knowledge.

This leads to a crass materialism, whereby the living body comes to be seen as a machine – as dead matter somehow kept in motion by mysterious forces we don’t understand.

Consider, for example, this dubious claim from a contemporary textbook of medical physiology: “The human being is actually an automaton, and the fact that we are sensing, feeling, and knowledgeable beings is part of this automatic sequence of life.”

This reductionist view of the living body as a mere dead mechanism is not new. We find the roots of this cramped attitude in the advent of modern medical science, including physiology, which is supposed to study the dynamic processes of life.

The dead/mechanistic model continues to ail medicine to this day.

Contrary to this mechanistic picture, biological life is an intricately choreographed dance that cannot be captured in a photograph.

The machine model of the human body persists in our imagination not because it is true, but because “it encourages the sense that we can easily understand what life is and learn to control it” – a tempting proposition for our Faustian age.

We need a new medicine, attentive not just to decontextualised mechanistic forces – controlling blind biological functions without purpose – but attentive to meanings, intentions, loves, hopes, fears and embodied purposes.

That is to say, we need a medicine that treats human life as always embedded within a community and a context of meaning.

The rich tradition of the Catholic Church’s understanding of what it means to be human is the best remedy to these serious deficiencies in modern medicine’s view of human life.

Camosy: Do you have advice for faithful Catholics who are navigating our current health care system with your concerns in mind?

Kheriaty: Remember that your conscience rights to recuse yourselves from immoral procedures are protected in federal law, and the HHS Office of Civil Rights as well as the lawyers at the Alliance Defending Freedom can assist if your training program attempts to force you to participate in abortions, sterilisation procedures, euthanasia or anything else that contradicts the healing goals of medicine.

It takes courage to navigate those tough situations; but do not be afraid to stand up for your rights and defend the value of human life at all stages, from conception to natural death. This courage and prudence will require a life of prayer and the grace of the sacraments.

As Our Lord instructed us, we should seek first God’s kingdom, and everything else will be given to us besides.

Trust in his providence, and do not fear suffering or hardship. Jesus made it clear: We cannot follow him unless we deny ourselves and take up our cross daily.

It’s precisely in the cross of Christ that we find freedom and peace.

Charles Camosy teaches moral theology and bioethics at The Catholic University of America in Washington.

Here’s my recent interview with Drew Mariani, which draws on themes from my book, Making the Cut: How to Heal Modern Medicine. (The book would make a great Christmas gift for any loved ones in the medical field.)

From the show notes:

Drew and Aaron Kheriaty, MD cover the broken medical system and how to fix it (1:00). Topics: how homeschooling can teach medicine (14:50), subsidiarity (23:54), issues with academia (30:55), consolidation of hospitals (35:24), standards of care (42:33), and AI in medicine (46:27).

Making the Cut Book

Chapters:

1. 04:36 Dr. Aaron Kheriaty - Healing Medicine

2. 14:50 Homeschooling analogy

3. 23:54 The Principle of Subsidarity

4. 30:55 Issues with academia

5. 35:24 Consolidation of hospitals

6. 42:33 Standards of care

7. 46:27 AI in Medicine

Also, a few weeks ago I invited you to participate in my online seminar, sponsored by the Bios Center in the U.K., titled, “What Makes a Good Doctor.” In case you missed it you can watch the video here: