Ideology and Values in Healthcare: A Commentary on Baker's (2025) Medical Lysenkoism

There are many reasons why an individual will engage a physician. The individual may want to learn about the cause of the symptoms they are experiencing and what to expect if there is no intervention, and/or obtain care that gives a reasonable chance to change the course of their health state. The physician is valuable in such cases, as they will often possess expertise that is not otherwise accessible to the individual. What makes that expertise valuable is that claims physicians make in service of their patients are not arbitrary—rather, they are grounded in a system of knowing that produces reliable and valid claims. In a recent paper published in the Journal, Baker [1] raises concerns about how ideology can undermine the physician's system of knowing, potentially compromising patient care. Tensions can arise where an ideology that is imposed on the medical community (either through regulation or social pressure) conflicts with what is accepted in the medical knowledge. How physicians navigate that tension can impact both their epistemic authority and the standard of care they provide to their patients. Ideology is frequently used pejoratively to describe beliefs that one opposes. However, ideology can also be understood as a system of beliefs that guides particular actions or applications. As we will highlight in this commentary, the generation and application of medical expertise operate within social institutions, and as such, the impact of ideology is unavoidable. As such, we must be cautious in drawing sharp distinctions between social values, our ontological beliefs about nature, and our epistemic commitments to understanding it—recognizing the central role that humans play in shaping these foundational assumptions. A key question to consider is when does ideology become problematic, and who has the authority to decide?

Baker invokes the term “Medical Lysenkoism” to describe how ideological forces shape medical science, drawing a parallel to the famous case of Soviet biology in the 20th century. Trofim Lysenko was a mid-20th century Russian biologist and proponent of a theory of inheritance of acquired characteristics akin to Lamarckian inheritance, a theory itself discredited by Darwinian evolution and subsequent work in genetics [2]. Despite its lack of credibility in both the local and international biology community, Lysenko's views gained traction with the Russian government, primarily due to a perceived alignment of the theory with a Stalinist interpretation of Marxist ideology. In what would come to be known as the Lysenko Affair, the biology of Lysenko would be officially adopted by the State, leading to persecution of more than 3000 scientists who did not conform, which included dismissal from their jobs, imprisonment, and even execution [3]. Adoption of the theory was also devastating for agriculture in the country, leading to decreased crop yields and subsequent famine for many. Lysenkoism is invoked as a cautionary tale of where ideology can adversely affect scientific progress with implications for the greater public good. Just as the adoption of Lysenko's theories subordinated genetic science to a politically driven state ideology, Baker argues that current trends in medicine risk placing social and political agendas above epistemic standards, potentially compromising scientific integrity and patient care.

The inherently social nature of health care complicates the boundaries between epistemic and non-epistemic values. While the Lysenko Affair exemplifies political interference in science driven by government ideology, Baker's concerns, on the other hand, center on the influence of ideology arising from what he identifies as social movements and their potential to change clinical thinking and decision making. Baker's perspective, grounded in the belief that the world is an ordered system discoverable through empirical inquiry, emphasizes the danger of integrating non-epistemic beliefs into medicine. Such beliefs can distort the pursuit of objective knowledge, threatening the elemental goal of medicine: a reliable understanding of the natural world to improve health outcomes. Yet, clinical care is fundamentally social: shaped not only by technical knowledge but also by the values, priorities, and resources of the communities it serves. What patients will demand (and why), what the public will fund, how public resources are allocated all impact the clinical encounter and shape what the clinician can offer and to whom and for what reasons. It is reasonable that two communities with differing values can vary in how they address such issues, potentially leading to very different practice styles among clinicians, models of care, and patient outcomes and experiences. Baker's analysis does not suggest we outright reject the role of non-epistemic beliefs in clinical practice. Rather, we need to be careful that what we accept or promote in clinical practice is sensitive to the needs of the patient, and that clinical practice does not simply become a tool for social or political agendas.

Indeed, even the core scientific foundations of medical expertise, such as clinical trials and basic sciences on biological processes, are subject to the influence of social ideologies that shape both the direction of research and the practice of clinical care. For example, Canadian government grant proposals for clinical research currently require explicit statement by the investigators of how the research will incorporate diversity considerations in design and analysis or an explanation justifying any exclusions. Similarly, the National Institutes of Health (NIH) grants in the United States often stipulate the collection of racial data to ensure proportional representation and inclusivity, thus impacting how research is framed and conducted. Government granting agencies frequently call for directed research on high-profile health concerns like COVID-19 or prioritize improving care for vulnerable or marginalized populations, such as indigenous peoples and LGBTQ+ communities. These requirements could be interpreted as political interference or as incentives designed to advance a particular social agenda—one that placates constituents and incorporates policy priorities into scientific inquiry. However, this shift can also be understood as epistemic justice [4]: recognizing that health inequities may arise from overlooked biases and gaps in study design, these directives might be seen as a corrective effort to broaden the scope of what counts as scientifically rigorous and ethically sound. In this sense, efforts to include diverse populations and perspectives are not simply socio-political impositions but can be seen as integral to advancing a more comprehensive, reliable, and objective body of medical knowledge––one that more accurately reflects the reality of the world it aims to understand.

Medical knowledge has always been shaped by changing philosophical and cultural frameworks, complicating the role of ideology in the standards by which we justify accepted truths. One important criterion for evaluating medical knowledge, raised by Baker, is “falsifiability”—the principle that scientific claims must be empirically refutable, ensuring that medical knowledge remains open to dissent and protected from the distorting influence of ideology [5]. Yet, the history of medicine is a history of changing ontological, epistemological, and ethical commitments about the nature of the world, our understanding of the human body, and the principles that define effective care. Many practices stemming from earlier belief systems would not stand up to empirical justification through rigorous study and the standard of “falsifiability,” and yet, they were not considered problematic when they were practiced. Humoral theory, advanced by Hippocrates and Galen and practiced in Europe for almost two millennia, was grounded in a belief system about the elements of nature (earth, wind, fire, air) and the elements of “man” (i.e., the four humors: blood, yellow bile, black bile, phlegm). The interaction of these humors led to disease, and their balance was necessary for good health. Ayurvedic and Traditional Chinese Medicine (TCM), originating in India and China respectively, have been practiced for 3000 years and are deeply rooted in belief systems centered on the balance of energy—whether through the Doshas in Ayurveda or Qi in TCM. While Baker holds the received view that science has since progressed toward an objective understanding of the natural world, with increasingly stringent standards for justifying our claims, a finer distinction must be made between “incomplete knowledge” and “ideological contamination.”

The application of the above-mentioned belief systems in clinical practice differs from the Lysenkoism discussed prior in that they were not impositions by governments adhering to an ideology. Rather, these belief systems were reflections of the accepted ontology about nature and health established by epistemic communities of the time [6], where shared commitments guided medical practice and informed the way that medical knowledge was understood and applied. Although these systems would mostly be replaced—we say mostly because many practices have persisted, for example, the wisdom of our grandmothers had us dressing appropriately to avoid “catching a cold” in cold weather, eating soup when we are sick with a “cold,” and striving for “everything in moderation,” and some communities embrace pluralism by practicing these traditions alongside “modern medicine”—these systems also differ from Baker's concerns in that they were seen by both practitioners and the community as positively serving the interests of the patient. Furthermore, they did not create a conflict for the physician, where they would need to decide between what is implied from the medical knowledge and what is asked of them by adherents of the ideology.

“Scientific medicine” was born out of a change in how we saw the world, with an emphasis on empirical observation over speculative or deductive reasoning, paving the way for more ostensibly rigorous methods of evaluating medical knowledge. This led to the rejection of many traditional practices and theories in medicine, including humoral theory, miasma theory, and views on contagion, and likely emerged in part as a response to the growing prevalence of dubious medical practices, such as homeopathy, that lacked empirical support and were thus of questionable value. Claude Bernard, a 19th century French physiologist, advanced the idea that medicine should strive to be grounded in clear understanding of empirically demonstrated mechanical processes. He asserted that “in a word, if based on statistics, medicine can never be anything but a conjectural science; only by basing itself on experimental determinism can it become a true science, that is, a sure science,” [7]. The advent of Evidence-Based Medicine (EBM) arose from similar recognition that many medical practices at the time lacked rigorous systematic corroboration, leaving their true effect uncertain [8]. Proponents of EBM “have identified randomization as a necessary condition to establish the relationship between cause and effect,” suggesting that the randomized controlled trial (which yields an estimate of average effect)—the favoured design in the EBM hierarchy of evidence—is the best way to determine the effect of interventions [9]. The difference between Bernard's mechanistic determinism and EBM's evidence hierarchy lies in the contrasting ways each assigns significance to statistical data, both underpinned by differing commitments about causation. Yet, both approaches reflect their respective attempts to ground medical practice in empirical reality.

These differing views (i.e., mechanistic determinism vs. EBM) can be considered ideologies in the strictest sense in that they are systems of beliefs that provide a basis for practical application, such as clinical decision-making. The difference between these ideologies is not trivial—physicians that do not follow what is suggested by high quality clinical trials are at risk of having their decisions labelled “not evidence based” by adherents to a strong EBM program, even if they can claim a basis in reasoning from mechanisms (consistent with Bernard's view, and what could be implied from basic science). Such tensions exist in many clinics today and have led to concerns raised in the literature about “cookbook medicine” and reconsidering EBM [10], the role of context in decision making [11], and the patient centred care movement [12]. These evolving perspectives on medical practice represent a shift in how scientific methodology is understood and applied, with changes often originating from within the medical community itself. Despite these internal critiques, the overarching aim remains the same: to reflect the objective, knowable reality to be uncovered through careful observation and methodical inquiry. Ultimately, this dynamic reflects the tension between rigid adherence to a singular scientific methodology and the evolving recognition that medicine, like science itself, must adapt and refine its approaches to better reflect the complexities of the world it seeks to understand and intervene in. This world, however, and our understanding of it, is shaped by and for human beings, whose experiences and limitations must be recognized as contributing to the pursuit of medical knowledge and care.

Baker raises several interesting examples of where the conflict between ideologies can put the physician in a difficult position in having to choose between what will satisfy an individual or community and what is consistent with the knowledge base and ethical responsibilities of their profession. Yet, focus on the tension between medical knowledge and ideological conflicts overlooks the extent to which social values, embedded in the same sources of medical knowledge, shape the physician's deontological duties and the physician-patient relationship. Physicians have a fiduciary responsibility to the individual patients they serve, as is reflected in their professional oath and in the ethics of practice. Ultimately, views on what constitutes ethical behaviour are ideologies, and regulations are shaped by ideology about what is right and fair. These ethical frameworks are not always moral absolutes, but are culturally and historically contingent, reflecting the values, beliefs, and power dynamics of the societies that produce them. For example, the principle of respecting autonomy in medical ethics, which emphasizes the patient's right to make informed decisions about their own care [13], is deeply rooted in liberal individualism. This principle may conflict with cultural or religious views that prioritize collective decision-making or deference to authority figures, such as family members or religious leaders.

Moreover, the medical profession's ethical obligations are often codified in laws and regulations, which are themselves products of ideological influences, and can differ across countries and legal systems. Respecting autonomy is a legal obligation in many jurisdictions, which often require the physician obtain informed consent of the patient before administering care or acting on the patient's behalf [14]. Physicians also have a knowledge base that is recognized by the profession. For example, knowledge sourced from a clinical practice guideline that was produced by a medical association, a systematic review produced by Cochrane, data published in a recognized peer reviewed journal, or a lecture in an accredited medical school would likely be considered legitimate medical knowledge. Holding views or practices that are inconsistent with such sources might be considered questionable by the medical community and would undermine the credibility of the individual and potentially the profession. What can be lost in that assessment of a physician's credibility is that the system of thought that determines what is considered legitimate medical knowledge is equally informed by ideology. As a result, ethical, regulatory, and epistemic standards in medicine are not simply neutral or objective; they reflect the ideologies of the societies that create them, influencing the way doctors interact with patients and the decisions they make in the course of their practice.

Given the complex responsibilities physicians have to both their profession and individual patients, some of Baker's examples warrant closer scrutiny, particularly considering how broader societal pressures can challenge the traditional care model. Let us first consider the “framing of medicine that conveys a duty to the collective” which Baker (7) claims is “inimical to the practice of medicine in the traditional care model.” Governments and public health officials, for example, may put pressure on physicians to promote care that is in the best interest of the public at large, even if the individual patient does not consider it in their own best interests. The pressure may be implicit, such as through the allocation of funding for specific interventions and the prioritization of resources for some diseases or communities over others. The pressure may be explicit, as was the case with vaccination interventions during the COVID-19 pandemic, where healthcare professionals were encouraged to promote community wide uptake of procured vaccines. Nudging a patient to accept an intervention because it is what is best for the community—for example, the average effect estimate suggests an optimal outcome across the whole population, with some individuals directly benefiting and others less so—is difficult to justify under a model that holds dear a respect of autonomy and an oath to “do no harm.” Asking a physician to nudge those patients they know (e.g., from experience) will be reluctant to accept a vaccine—even if those patients ostensibly benefit from the intervention—can compromise the physician-patient relationship, resulting in negative consequences for the physician's ability to provide care for those patients moving forward. One challenging group of patients was those with a history Guillain–Barré Syndrome (GBS), some of whom may have been advised in the past to avoid certain vaccines for risk of reoccurrence. Indeed, there is evidence that some COVID-19 vaccines are associated with increased risk of GBS [15]. Encouraging vaccination in patients with a history of GBS to meet a public health agenda may be counterproductive to the care of those patients, and such encouragement by the physician may be interpreted as mixed messaging about vaccination, again undermining the credibility of the physician as expert. It would not be surprising that physicians in such circumstances would be wary of public health ideology that they believe impacts their capacity to deliver care consistent with the tenets of their profession.

A second example highlighted by Baker is related to current thinking on gender in many communities. It is believed in both progressive social movements and academic communities that gender is a social construct. Stemming from that belief is the view that gender identity is independent of assigned sex based on anatomy—that is, biological sex does not entail gender. Yet, for some individuals, biological sex impacts their ability to fully realize gender identity. In such cases, gender affirmation surgeries and hormone therapies are used to align physical characteristics with gender identity. Any success of such interventions in achieving alignment would suggest that gender is related to biological sex, or at least for some people. A physician who holds a strong belief that gender is a social construct independent of biological sex—aligned with the academic literature—may view the promotion of gender affirmation interventions as ontologically inconsistent and an imposition to them if such interventions are promoted due to pressure from social movements. Appeals to science to tease out issues of gender and gender affirming interventions can be challenging due to the impact that strong commitments about gender (which many people seem to hold) can have on the design and interpretability of studies. Nonetheless, even the tenets of EBM acknowledge that medical practice is not purely technical; patient values and preferences are integral to clinical decision-making. Regardless of the perceived value-freedom of the most rigorous methodology, social ideologies are always woven into the fabric of medical care.

Douglas' view was consistent with the first two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a key text in the practice of psychiatry [17]. Some form of homosexuality, such as paraphilia and sexual orientation disturbance, was included in the DSM as far back as 1952. Although homosexuality was removed as a mental impairment in 1973, reference to ego-dystonic homosexuality and “persistent and marked distress about one's sexual orientation” could be found in the DSM as late as 1987 [18]. Later editions of the DSM removed all reference to homosexuality as a mental disorder, recognizing the science on sexual behaviour, changes in the definition of what constitutes a mental disorder, pressure from activists, and perhaps that it was not homosexual behaviours or the presence of homosexual thoughts that caused harm to the individual, but the stigma ascribed by the public to those who are homosexual. That is, construing homosexuality as a medical diagnosis was not in the service of the patient. Ideology got homosexuality into medicine, and ideology got it out.

Medicine as a practice operates at the level of social interactions, with and by people who hold values and beliefs. Thus, as we have stated throughout, it is not surprising that ideology can shape medical understanding and clinical decisions. The question is whether this is inherently problematic, or rather, when it becomes as such. Drawing that line is a matter of perspective, as what constitutes a harmful belief may depend on what one already believes. The question of when we know we have achieved sufficient incorporation of social values, as Baker fairly raises, parallels the ambiguous pursuit of an objective grasp of nature itself. Although he frames the telos of ideology with conviction, it is unclear what justifies this endpoint, particularly when both concepts–elusive and shifting–poses a dilemma to all who labour toward progress. In the same way that scientific inquiry is a dynamic and ongoing process, characterized by the order of continual challenging and revision of established knowledge, its ideological foundations partially constitute this process. To be sure, while this foundation can be moral or political, it can also be epistemic. A more critical argument could posit that disentangling the boundary between the problematic and productive incorporation of values is neither a straightforward task, nor, perhaps, an entirely achievable one. Yet, what matters is not so much the purity of these categories as the commitment to scrutinize their overlap and the openness of our discourse. Rather than aiming for strict separation of these values, these intersections should remain spaces of ongoing examination, open to revisiting assumptions, confronting biases, and refining our understanding of medicine and its place within society.

Baker offers a timely warning about the intrusion of ideology into medicine, where unchecked beliefs can compromise patient care and undermine the physician's professional autonomy. Medicine, like many professions, is defined by its specialized knowledge and self-regulation, yet it cannot escape the social forces that shape its practice and understanding of the world. While such pressures have at times driven positive change—such as the adoption of scientific methods in clinical decisions or the removal of homosexuality from the DSM—the challenge is not ideology itself but how that can steer medicine away from its primary goals. Medicine cannot be free of values, for values underlie both the creation and application of knowledge. When one should shelter the practice of medicine from ideology may be clearer in cases where there is wholesale rejection by the medical community, akin to the Lysenko affair, but less so in moments of internal debate over the role of medicine in broader social movements. As Baker suggests, this is where epistemic humility becomes crucial. Just as we may never grasp a wholly objective understanding of the world, we many never fully achieve ideological balance in a way that satisfies every stakeholder or meets an absolute standard. Yet, what is essential is not a fixed endpoint but the continuous striving to understand, represent, and care for the world and the people within it. Science and medicine are progressive precisely because they are open to dissent, and inherently flexible. Without the capacity for revision, and growth, both disciplines would stagnate. This attitude of humility, recognizing the impermanence of knowledge and the complexity of human experience, is foundational to the advancement of both scientific and social progress. In navigating the intersection of ideology and medicine, this humility ensures that we remain open to correction, adaptation, and ultimately, better care and understanding.

Mathew Mercuri is the former Editor-in-Chief of the Journal of Evaluation in Clinical Practice and is co-authoring a book on philosophical issues in the clinical encounter with Dr Steven Baker.

The authors declare no conflicts of interest.