The surgeon general may be the nation’s doctor, but she’s not your doctor. At least that’s the view of Casey Means, the physician turned wellness influencer who is vying for the role. When asked during her recent Senate confirmation hearing whether she would encourage parents to vaccinate their children against measles—hardly a theoretical question, given the country’s ongoing outbreak—Means delivered an elliptical response. She supported vaccines as a public-health tool but wouldn’t necessarily encourage someone to get them. “I am not an individual’s doctor,” she said. (In fact, she is no one’s doctor at the moment, because she lacks an active medical license.) “And every individual needs to talk to their doctor before putting a medication into their body.”
Means’s nonanswer was more than a dodge. It represents a paradox in the Trump administration’s approach to public health. Means, Health Secretary Robert F. Kennedy Jr., and their allies have consistently eroded confidence in the medical establishment—even as they propose to solve the widespread mistrust of public health by encouraging Americans to talk to their doctor.
Kennedy and his subordinates have spent the past year infusing this approach into federal immunization policy. In October, the CDC announced that it would no longer encourage universal COVID boosters for either adults or children. Instead, a process known as “shared clinical decision-making,” in which doctors engage their patient in a detailed conversation about the pros and cons of the vaccine without defaulting to an endorsement, was the recommended approach. Jim O’Neill, the acting CDC director at the time, said in a press release that the previous guidance “deterred health care providers from talking about the risks and benefits of vaccination for the individual patient or parent.” In January, the CDC went one step further, striking several more vaccines—those against rotavirus, influenza, meningococcal disease, and hepatitis A and B—from the routine-childhood-immunization schedule. Shared decision making would be the preferred approach for these immunizations as well. On a podcast, Kennedy touted the move as returning “freedom of choice to American mothers.”
Who could argue against freedom of choice? The difficulty is that in medicine, shared decision making is not simply a synonym for allowing a patient to ask questions and decide for themselves. That sequence of events is covered by informed consent, a process that takes place before any medical intervention, including vaccination. Shared decision making, in contrast, is a somewhat nebulous term reserved for clinical borderlands: scenarios in which the trade-offs are nuanced or the best course of action is unclear.
Perhaps the most notable example of shared decision making in my area of medical practice is prostate-cancer screening. A handful of large, randomized studies have examined whether the prostate-specific-antigen blood test truly saves lives by detecting cancers earlier. These trials have yielded mixed results, suggesting that, at most, only a small number of men might avoid dying from cancer by getting checked. In contrast, the potential harms of treating an asymptomatic tumor that would not otherwise have been discovered—lifelong urinary and sexual problems, for example—are common. Given the intimate risks and modest benefits, prostate-cancer screening is not explicitly recommended by public-health or physician groups; instead, patients and their doctors are left to their own devices. I have heard from many urologists and primary-care doctors that this process can be baffling and unsatisfying for them and their patients alike. Patients may feel overwhelmed by the complexity of the scientific data, and doctors often feel that they are abandoning their responsibility to offer patients a clear recommendation.
Routine immunizations do not inhabit the sort of gray zone that would warrant such an elaborate discussion. Take the hepatitis-B shot. Everyone who doesn’t get it is susceptible at some point in their life to infection with the virus, which, if it becomes chronic, commonly results in serious liver damage and liver cancer. The vaccine is highly effective at preventing this infection, and its potential harms are either very mild or extremely rare. Vaccination also benefits entire communities by reducing spread of the disease. What would a shared decision even look like in this case? On one hand, a doctor might tell her patient, a very safe immunization can effectively prevent a potentially deadly disease across your child’s entire life. On the other hand, anti-vaccine activists have asserted, without convincing evidence, that vaccination comes with a host of possible dangers.
Shrouding established immunizations in the confusion of shared decision making does not add nuance; it introduces only ambiguity. The Department of Health and Human Services, the Office of the Surgeon General, and public health as a whole exist in large part to offer scientifically accurate advice that doesn’t take a physician to understand. The system that Means seemed to be proposing for the measles shot during her confirmation hearing is so absurd that it left Senator Bill Cassidy—a doctor himself—apparently dumbfounded. At one point, Cassidy wondered whether Means was likening immunizations to something as risky as a bypass surgery, which does require a doctor and patient to intensively discuss the risks and benefits. (Means did not directly answer the question, and instead responded, “The constraints on doctors are monumental, and many American parents are frustrated by what they feel like is lack of transparency on the issue of vaccines.”) The comparison was clarifying. The risks of coronary-artery-bypass surgery, which involves cracking someone’s chest open and stopping their heart, are hardly in the same league as a vaccine-induced sore arm or a mild fever—or even the statistically minuscule risk of a serious side effect, such as anaphylaxis.
[Read: Well, that didn’t sound like Casey Means]
Means declined to comment for this article; the White House did not respond to a request to do so. Andrew Nixon, a spokesperson for HHS, wrote in an email that the CDC “has an established tradition of applying shared clinical decision-making when individuals may benefit from vaccination, but broad vaccination of people in that group is unlikely to have population-level impacts.” Nixon cited COVID vaccines, which provide only modest protection against infection, as appropriate candidates for shared clinical decision making. But in seeming contrast to Means’s testimony, he indicated that such an approach would not be appropriate for the measles shot.
The administration’s defenders might argue that shared clinical decision making is a way to ensure that informed-consent discussions occur reliably, or that the practice constitutes a calculated retreat from the sort of public-health paternalism that lost credibility during the coronavirus pandemic. Nixon suggested as much, writing that this story’s framing is an attempt at “reputation rehabilitation of the experts who presided over a sharp decline in public trust.”
Yet the administration is applying epistemic modesty selectively. When HHS announced the government’s new set of dietary guidelines earlier this year, the instructions were unambiguous: Americans “must prioritize whole, nutrient-dense foods—protein, dairy, vegetables, fruits, healthy fats, and whole grains—and dramatically reduce highly processed foods,” Kennedy said in an accompanying press release. President Trump and Kennedy have also confidently instructed Americans on what they say is the proper use of Tylenol. “You shouldn’t take it during pregnancy,” Kennedy told the podcaster Joe Rogan recently, due to what his administration perceives as a heightened risk of autism associated with the painkiller. At a September press conference, Trump instructed pregnant women to “fight like hell” not to take the drug. Nixon defended the administration’s definitive language, writing, “Delivering a message about a specific neurological risk for babies is another example of our commitment to telling the truth about public health.” But among scientists, the alleged connection between Tylenol and developmental disorders remains quite controversial.
Meanwhile, many leaders of the Make America Healthy Again movement have repeatedly undermined the very professionals whom they now insist patients consult before every shot. FDA Commissioner Marty Makary has accused doctors of relying on “dogma” and “groupthink.” Vinay Prasad, the FDA’s top vaccine regulator, aggressively sowed distrust in public-health authorities before becoming one himself. Kennedy has celebrated “the pediatricians who earn families’ trust every day,” but also has accused the American Academy of Pediatrics of being beholden to pharmaceutical companies; in an interview last summer, Kennedy said that “trusting the experts is not a feature of either science or democracy.” Means, too, has seemingly contradicted the advice she is now giving. A chapter of Means’s book, Good Energy, is titled “Trust Yourself, Not Your Doctor”; in a 2024 Free Press essay adapted from the book, Means wrote, “Most health advice ends with a disclaimer to ‘consult your doctor.’ I have a different conclusion: When it comes to preventing and managing chronic disease, you should not trust the medical system.”
[Read: America’s would-be surgeon general says to trust your ‘heart intelligence’]
The Medicaid and Medicare administrator, Mehmet Oz, a former cardiothoracic surgeon, seems to be one of the few federal health officials who understand the stakes of instructing Americans to embark on in-depth conversations with their doctor before getting routine vaccinations. Oz has counseled countless patients about major heart surgery, but he hasn’t felt the need to prevaricate about something as straightforward as the measles shot. “Take the vaccine, please,” he pleaded recently in an interview on CNN. It’s just the sort of clarity that was once prosaic in medicine and public health, but risks extinction under Kennedy’s leadership.