A call for structured heterodoxy in medicine and public health

Can we have the discipline to create space for productive disagreement?

The past few years have underscored the consequences of rigid orthodoxies in medicine and public health. The COVID-19 pandemic was followed by a deep erosion of trust in medicine and public health, fueled in part by shifting guidance during the pandemic and the enforcement of policies (e.g., lockdowns) that were seen in retrospect as heavy-handed.

Vaccination, one of the sentinel achievements of public health, has become a flashpoint, with hesitancy growing in part because community concerns about ever-growing vaccine schedules and about potential (even if unfounded) side effects, seemed to be unheard. Dietary guidelines, long promoted as settled science, later proved partly misguided, helping to energize movements like “Make America Healthy Again” that thrive on challenging expert authority. And in areas such as addiction, where abstinence-only orthodoxy dominated for decades, people were pushed away from services that could have saved lives until harm-reduction strategies forced a course correction. Taken together, these experiences have fueled challenges of orthodoxy in medicine and public health and have led to alienation from the very people we aim to serve. This should make us pause and ask: How can medicine and public health preserve the value of consensus while creating space for dissent that builds trust and advances knowledge?

Medicine and public health depend in no small part on our orthodoxies, our dominant frameworks, paradigms and guidelines that are widely accepted as best practices. In many ways we do not want much deviation from this. We hope that our doctor knows exactly the best practice to deal with a particular condition and that they follow well-established protocols to deliver the best (hopefully evidence-based) care. Similarly, we expect that public health authorities are recommending vaccination based on the best available data; we do not expect that the evidence for core public health efforts will vary much by jurisdiction and that the experts in charge are able to apply a standard framework to guide our actions. That may be all to the good. Orthodox frameworks such as evidence-based clinical guidelines and public health protocols provide consistency, reliability, and a shared knowledge base. They help navigate complexity by offering “gold-standard care,” so much so that deviating from the evidence can be considered unscientific or potentially expose clinicians to liability. In public health, agencies such as the World Health Organization (WHO) establish orthodox recommendations (e.g., vaccination schedules, sanitation standards) and coordinate efforts across jurisdictions.

At the same time, it is not hard to realize that constructive heterodox thinking must also be part of progress. No less than Thomas Kuhn observed that scientific progress often involves questioning established “normal science.” Not all health challenges can be solved within existing paradigms, and throughout history transformative breakthroughs — from hand-washing to germ theory to the understanding of H. pylori as a determinant of peptic ulcers — began as heterodox ideas. This is, after all, how science renews itself. The question then becomes: How do we harness diverse perspectives constructively and encourage questioning that leads to improvements rather than mere disruption?

Let us start with why we need orthodoxy to begin with. Modern medical practice is anchored in orthodox clinical guidelines, often established by professional bodies (e.g., hypertension or diabetes management guidelines) that physicians are expected to follow. This orthodoxy, encoded in doctors from the earliest days of medical education, protects patients by basing treatment on the best available evidence rather than idiosyncratic individual physician opinion. Standard orthodoxy has facilitated, for example, the near-universal adoption of sterile techniques in surgery and the use of antibiotics for infections, practices once considered novel but now unquestioned tenets of medicine.

In public health, institutional orthodoxy emerges from the work of normative organizations and national and regional health organizations. These bodies develop guidelines that help guide coordinated response to health threats, including, for example, consistent approaches to infectious disease outbreaks. In addition, organizations such as WHO’s guideline review committees and bodies such as the Cochrane Collaboration ensure that public health directives (e.g., on tobacco control or obesity prevention) reflect the best available evidence that then becomes orthodox public health practice. At the national level, public health orthodoxies are backed by law or broad consensus. The Western public health model in particular leans heavily on such centralized guidelines even as there may be variation in acceptance globally.

The benefits of these approaches are clear: We have made enormous progress on reducing the burden of noncommunicable disease worldwide, controlled previously devastating childhood infections through immunization, and in a world of declining trust in all experts, trust in scientists remains substantially higher than trust in essentially all other groups.

But the challenges also have become painfully clear in recent years. The other side of the orthodoxy coin is groupthink, resistance to new evidence, and over-reliance on established dogma. In medicine, a rigid guideline might not fit an atypical patient, and in public health an official position might overlook subpopulation needs. Abundant historical examples show that prevailing orthodoxies can be wrong or incomplete: The once-standard practice of prescribers avoiding beta-blockers in heart failure, for example, was overturned by new evidence, but only after early adopters challenged the clinical orthodoxy. Clinical and policy paradigms that once seemed unassailable (e.g., low-fat diets as the universal heart-health recommendation) have faced credible dissent and evolved. Orthodoxies during the COVID-19 pandemic led to widespread loss of trust in public health and in no small part to a surge in vaccine hesitancy in many parts of the world. It is not a conceptual leap to note that while orthodoxy provides a foundation to ensure excellence in the promotion of health, it also may stifle innovation if dissenting voices and novel hypotheses are reflexively dismissed. Constructive heterodox thinking can serve as a corrective mechanism to orthodoxy’s limitations. The key is distinguishing evidence-based heterodox ideas from unfounded ones and finding ways to incorporate the former without undermining the core evidence base. How do we do that?

Structured heterodoxy can be an institutionalized approach that creates space for evidence-grounded dissent within medicine and public health through mechanisms that invite and evaluate minority views under norms of organized skepticism. Tools like adversarial collaboration and dissent-recording guideline panels, consistent with the principles of epistemic pluralism, could ensure that good challenges are integrated and weak ones are filtered out. Structured heterodoxy would rest on formal mechanisms to allow for — even encourage — dissent, i.e., forums where alternate viewpoints are evaluated on merit rather than dismissed out of hand. For example, guideline committees can seek not to find consensus, but rather, best recommendation based on the evidence, with dissent noted. This could institutionalize open dialogue and slowly shift a culture that otherwise prizes assent with the majority.

Constructive dissent can be encouraged in research and practice. This could involve dedicated funding for high-risk, high-reward studies that test novel hypotheses or revisit accepted ones, thereby giving heterodox ideas a fair examination. Medical journals and conferences also can play a role by publishing and platforming well-founded contrary findings and fostering respectful debate. Notably, pluralism in medical science can be encouraged through the publication of dissenting data or analyses in high-profile journals, giving dissenting voices a hearing.

Structured heterodoxy also means that guidelines and public health directives should be living documents rather than carving recommendations in stone for years. Regular review cycles and rapid-response teams can consider new data and well-founded objections. For example, if a subset of experts voices concern about an existing guideline (e.g., the age to begin cancer screening or the safety of a newly approved drug), a transparent review process can be triggered to evaluate the evidence. In this way, heterodox signals can be funneled into evidence appraisal rather than acrimonious antagonism. During the pandemic, we saw nascent forms of this as some health agencies convened special panels to review evolving evidence on masks and aerosols, eventually adjusting policies, albeit later than might have been desirable. Codifying such agility can normalize approaches that weaken orthodox grips on what we collectively think, while preserving mechanisms that can create standards of best-understood practice.

Ultimately, medicine and public health will benefit from a balance between the constraints of orthodoxy and the creativity of heterodoxy. Medicine and public health need orthodox structures to function; we cannot make policy out of debate alone without aligning on shared approaches, and we have come too far, with too much success, to forsake a shared reliance on evidence-based medicine and its organizing principles. Structured heterodoxy is about building a productive dialectic: orthodox policies set a baseline of evidence-based action, while heterodox contributions continually test and refine those policies. The deliberate integration of diverse perspectives (from different disciplines, cultures, and ideologies), and the intentional introduction of opportunities for those perspectives to be heard, can create the space for health institutions to evolve and avoid both the stagnation that can come from ignoring innovation and the chaos that would come if we ignored evidence and best practices. This could position medicine and public health to better adapt to new challenges — from novel diseases to emerging issues embedded in rapidly changing social contexts — and avoid some of the pitfalls that have befallen the health professions in the past few years.

In the final analysis, embracing a degree of pluralism in perspectives, under the umbrella of rigorous science, is not a threat to orthodox medicine or public health but a necessary strategy for their longevity and success. Sustained trust in medicine and public health comes from the formal acknowledgement of divergent views. A culture that honestly values both consensus and critique may be our best positioned hope to protect and improve the health of all in a time when a range of challenges to mainstream medicine and public health are pushing us to actively rethink how we do what we do — and perhaps to recover the humility that have long made medicine and public health credible.