As Iran prepares for the funeral ceremonies of Ayatollah Seyyed Ali Khamenei, the former Supreme Leader of the Islamic Republic, the scale of anticipated public participation indicates that they are set to become one of the most significant mass gatherings in contemporary Iranian history. Reports indicate that vast crowds are expected to arrive from across the country, alongside official delegations from numerous states. This moment offers a clear opportunity to assess the U.S. and Israeli decision to assassinate him in February 2026. The operation rested on a flawed assessment of Khamenei’s real role and standing within Iran’s social and political structure. In this regard, the United States was shaped largely by Israeli media narratives and intelligence assessments—accounts that substantially underestimated Ayatollah Khamenei’s popularity, institutional influence, and capacity for social mobilization. The preparations already underway and the expected scale of the turnout make this analytical failure harder to ignore. They show how far American policymakers relied on an incomplete and one-sided picture of Iranian reality.
To understand this miscalculation, it is necessary to return to the framework that had cast a long shadow over analyses of Iran before the attack. For years, Israeli media outlets and a number of research institutions close to Israel’s political and security establishment portrayed Khamenei as a leader with limited social backing, governing a society marked by deep divisions, economic discontent, and generational distance. These narratives repeatedly suggested that removing him could trigger serious instability, or even a fundamental transformation of Iran’s political system. Such an image aligned with the stated purpose of the joint U.S.-Israeli operation: weakening and destabilizing Iran’s political order. Yet this analysis ignored the more complex realities of Iranian society and politics. In assessing Khamenei’s structural position and the attachment of significant parts of society to ideas such as independence, security, and resistance to external pressure, Washington effectively accepted a narrative that minimized decisive factors. The result was an expectation that his removal would rapidly expose internal fractures. Developments since then—including a relatively orderly leadership transition and the continued functioning of core institutions—have pointed in the opposite direction.
Khamenei’s position in Iran went far beyond that of a conventional head of government. For more than three decades, he stressed national self-reliance, scientific and technological development despite external constraints, and sustained resistance in foreign policy against outside pressure.
These priorities helped produce a measure of institutional resilience and measurable progress in certain sectors. Iran has, of course, faced genuine social discontent, economic pressure, and political divisions. But that did not mean Khamenei’s role had been reduced to personal isolation, nor that his removal would necessarily paralyze the country’s political machinery. Israeli media coverage generally emphasized critical currents and visible signs of dissatisfaction while downplaying evidence of broader attachment to ideas such as independence, national sovereignty, and security. This selective emphasis produced an image of fragility and isolation that did not correspond to the durability of Iranian structures after his assassination. America’s acceptance of that image represented a serious intelligence and analytical failure in understanding the depth of Khamenei’s place within Iran’s political structure.
The February attack was accompanied by public statements from American and Israeli officials describing it as a decisive blow. The initial expectation appears to have rested on the assumption that the vacuum created by eliminating the leader would intensify internal divisions or create opportunities for greater outside leverage.
In practice, Iran preserved the functional continuity of its core institutions and its broad policy direction. This outcome showed that Khamenei’s influence was not merely personal. It had taken root in institutions, political networks, security structures, and the political culture of the Islamic Republic.
Washington’s error was to imagine that the base of support around him was narrower and more brittle than events ultimately showed it to be. The upcoming funeral ceremonies, scheduled to unfold over several days and across major cities, are set to draw exceptionally large crowds and will provide further tangible evidence against those earlier assumptions. The anticipated presence of mourners and foreign delegations will demonstrate a degree of recognition, respect, and social connection that earlier reporting and assessments had treated as marginal.
From a broader policy perspective, this episode reveals the dangers of excessive reliance on particular intelligence and media sources. In Iran’s case, cultural, religious, and historical forces shape political loyalties and behavior in ways that demand a more precise understanding of the country’s internal realities—not broad, externally produced narratives. Analyses that overlook these factors are vulnerable to strategic error. What was supposed to weaken Iran’s political structure instead reinforced commitment to established principles, heightened sensitivity to foreign intervention, and underscored the perceived necessity of institutional continuity. The forthcoming ceremonies, with their extensive organization, will serve as a visible corrective to assessments shaped by one-sided reporting.
By relying on Israeli media narratives and intelligence assessments of Khamenei’s position and the level of support surrounding him, American decision-makers arrived at a conclusion that developments since the assassination have not borne out.
In conclusion, the assassination of Ayatollah Khamenei and the domestic and international response to it expose the limits of policymaking built on incomplete information and politically shaped interpretations. The forthcoming funeral ceremonies and the anticipated exceptional public turnout will offer a vivid illustration of social cohesion in Iran—one that stands in clear contrast to earlier predictions of rapid collapse or internal rupture. This expected turnout suggests that America’s assessment of Iran’s Supreme Leader and the degree of public support he commanded was significantly influenced by Israeli media and intelligence narratives, and ultimately proved mistaken. Rather than producing the disruption that had been anticipated, the process has highlighted Iran’s institutional continuity and social resilience.
Senator John Kennedy, the Democrat turned Republican from Louisiana, came up with a whopper during an interview with a comedian slash podcaster. It is a take on Netanyahu’s perennial claim Iran is five minutes away from having nuclear weapons that maniacal mullahs will use to bomb New York, London, Berlin, Brussels, in addition to all Arabs and Muslims in West Asia.
Kennedy told Theodor Capitani von Kurnatowski III, aka Theo Von, US intelligence informed him Iran is “stacking ballistic missiles and killer drones like never before” and will rain them down on London, Paris, and Germany. The culprit here is Iran’s Khorramshahr medium-range ballistic missile with a range of 2,000 kilometers, said to be derived from the North Korean Musudan (BM-25) missile. London is over 5,000 kilometers from Iran, while Paris is over 4,000 kilometers, and Berlin 3,000 kilometers.
Trump to the rescue, according to Kennedy. The president faced a “nightmare decision: Let them arm up until they could rain fire on our allies and threaten the homeland… or strike first and save the world? He chose to bomb their nuclear sites and stop the madness.”
I thought the illegal sneak attack on Iran, including the assassination the Supreme Leader of Iran, the 86-year old Ali Khamenei, eliminated Iran’s supposed nuclear threat, or that’s what Trump told us, ad nauseam. Iran has never possessed nuclear weapons and remains a non-nuclear-weapon state under international treaties, specifically the Treaty on the Non-Proliferation of Nuclear Weapons (NPT). US intelligence agencies have assessed that Iran is not currently building a nuclear weapon.
Trump’s former (now persona non grata) Director of National Intelligence (DNI), Tulsi Gabbard, told a Senate Intelligence Committee hearing in March Operation Midnight Hammer had “obliterated” Iran’s nuclear enrichment capability. No mention on the obliteration of the Shajareh Tayyebeh Elementary School in Minab, Iran, murdering 156 civilians, 120 of them school girls. That collateral damage is 1,200 kilometers from the Fordow Uranium Enrichment Plant.
Anyway, anything Mr. Kennedy says should be taken with a boulder of salt and a fistful of antacid. He has benefited from $113,680 donated by the Israel lobby. He co-sponsored the Taylor Force Act (legislation prohibits American funds from being given to Palestinian entities), the Israel Anti-Boycott Act (making “economic speech” illegal), the Combating BDS Act of 2017 (making Boycott, Divestment, and Sanctions illegal), and the United States-Israel Security Assistance Authorization Act (providing and additional $3.3 billion to Israel for “self-defense,” that is to say abducting, torturing, raping, and murdering thousands of Palestinians).
Slovenian President Nataša Pirc Musar has called for an international investigation into Israeli interference in Slovenia’s parliamentary elections, escalating a diplomatic row that has also exposed deep internal political divisions over the country’s stance on the Middle East, VINnews reported.
President Musar, who previously accused “Israel” of committing genocide in Gaza, appealed for the release of intelligence findings that reportedly point to a coordinated disinformation campaign targeting the then-ruling liberal party during the March 2026 elections.
According to Slovenian intelligence investigations, the operation involved an electronic disinformation network that leveraged deepfake technology and artificial intelligence to undermine the liberal camp. The probe allegedly attributed the campaign to a private Israeli intelligence firm operating in coordination with elements of Slovenia’s right-wing opposition.
Right-wing takes over Slovenia, strives to repair ties with the occupation
While the liberal party ultimately won the highest share of the vote, it failed to secure a governing coalition. That deadlock paved the way for right-wing leader Janez Janša, who successfully formed a government and took office as Prime Minister in May 2026.
In a sharp reversal of his predecessor’s foreign policy, Prime Minister Janša has announced plans to repair bilateral ties with “Israel”. In an exclusive interview for the Israeli daily Israel Hayom over the weekend, Janša confirmed his intention to relocate the Slovenian embassy from Tel Aviv to al-Quds, a move that aligns with the policies of several right-wing Israeli governments but has drawn international criticism in the past.
Janša also pledged to revoke the previous administration’s formal recognition of a Palestinian state, a decision he characterized as a violation of Slovenian domestic law.
Lead was identified in five of the vaccines: Typhim Vi, Cervarix, Agrippal S1, Meningitec, and Gardasil. Tungsten appeared in eight more, distributed across products from GlaxoSmithKline, Pfizer, Wyeth, and Novartis. Twenty-five of the forty-four samples contained stainless steel. Across the full set, the elemental analysis cataloged bismuth, gold, silver, platinum, cerium, zirconium, hafnium, antimony, strontium, barium, copper, tin, and zinc in various alloy combinations. None of these materials appeared on any package insert. None had a declared role in the vaccines’ formulation.
The work was published in 2017 by Antonietta Gatti and Stefano Montanari, materials scientists at the Italian National Council of Research. They obtained the vaccines from pharmacies in Italy and France. The manufacturers included Sanofi, GlaxoSmithKline, Pfizer, Novartis, and Merck. They examined a twenty-microliter drop of each under a Field Emission Gun Environmental Scanning Electron Microscope. They identified the elemental composition of every particle they found using X-ray spectroscopy. They photographed each contaminant and compiled the catalog.¹
Forty-three of the forty-four vaccines were for human use. One was for cats. That single sample, Feligen CRP manufactured by Virbac, contained none of the heavy metals or industrial alloys cataloged in the human samples. The authors classified it as free from inorganic contamination.
The contamination is consistent across manufacturers, batches, countries, and years. The veterinary production line, examined by the same instruments at the same resolution, produced a clean vial. The human production lines did not.
This is not an argument about disease causation. It is not a contested mechanism. It is materials science applied to a drop of liquid pulled from a syringe. The instruments resolved what was there. None of it should have been in an injectable medical product. The system that produces and regulates these products has not addressed what the instruments showed.
One Particle in Agrippal
Figure 6 of the paper shows a single object, photographed at high magnification inside a drop of Agrippal S1, batch 147302A. This was Novartis’s flu vaccine for the 2014-2015 season. The object is a few microns across. It is wrapped in a darker, less atomically dense outline that Gatti and Montanari identify as organic material, a protein layer adhering to the particle’s surface. The metallic core, brighter under the backscattered-electron detector, registered four elements on the X-ray spectrum: cerium, iron, titanium, nickel.¹
Cerium is a rare earth metal. It has industrial applications in catalytic converters and glass polishing compounds. It has no medical use. It is not a declared ingredient in any flu vaccine. The four-element combination Gatti and Montanari documented does not match any recognized industrial alloy and appears in no materials engineering handbook. The authors describe it as the kind of debris produced when industrial waste is incinerated.
The protein layer around the metal was visible in the photograph. Within seconds of a metallic particle entering a protein-rich solution, the body’s serum proteins bind to the particle’s surface. The composite is no longer simply a foreign metal. It is a hybrid object: metal core, biological coat.
That vial was administered. So were the others in batch 147302A. So were the rest of the production batches Novartis manufactured that flu season. The doses are no longer in the pharmacy. They are no longer in any database. They are in people. Whoever received that batch received some quantity of cerium-iron-titanium-nickel debris, wrapped in their own unfolded proteins, deposited into deltoid muscle, and from there carried wherever the lymphatics and the blood took it.
The vial contained 429 additional detected particles in the same twenty-microliter drop.
The Pattern Across the Catalog
The cerium particle in Agrippal is one finding among thousands. The particle counts vary by orders of magnitude across the forty-four vaccines tested. The anti-tetanus products produced the lowest counts: two particles in one Anatetall sample, four in Vivotif. The childhood vaccines produced the highest. Varilrix returned 2,723 particles per twenty-microliter drop. Infanrix hexa returned 1,821. Cervarix returned 1,569. Fluarix returned 1,317. These are counts per twenty microliters. A standard injection is half a milliliter, or twenty-five drops. The arithmetic is straightforward.¹
The composition is more difficult to absorb than the counts.
The alloy combinations Gatti and Montanari cataloged include gold-copper-zinc in Repevax, platinum-silver-bismuth-iron-chromium in M-M-R vaxPro, zirconium-aluminum-hafnium compounds in Vivotif, and the cerium-iron-titanium-nickel particle in Agrippal. The paper notes that these combinations “have no technical use, cannot be found in any material handbook and look like the result of the random formation occurring, for example, when waste is burnt.”
Three of the Meningitec batches in the table carry an additional notation: sequestered by Procura della Repubblica. Italian prosecutors had seized those batches before Gatti and Montanari obtained access. The samples were already evidence in a criminal investigation. The contamination Gatti and Montanari documented was present in the seized batches as well as the over-the-counter samples. Whatever the prosecutors were investigating, the physical evidence cooperated.
The pattern does not isolate to any single manufacturer or batch. It crosses Italian batches and French batches. It crosses production dates from 2004 to 2017. The pattern is structural to the industry, not anomalous to any one production run.
Feligen contained 92 particles in its twenty-microliter drop, but the elemental analysis identified only calcium and silicon-aluminum. This is the kind of low-toxicity material that could derive from saline or environmental dust. It did not contain the tungsten, lead, stainless steel, or rare earth metal compounds cataloged in the human samples. The veterinary production line, examined by the same instruments at the same resolution, produced a vial without industrial debris. The human production lines did not.
What the Instruments Show, and Why No One Looked
The instruments Gatti and Montanari used are not exotic. A Field Emission Gun Environmental Scanning Electron Microscope resolves features at the nanometer scale and accommodates wet or oily samples without the artifacts conventional electron microscopy introduces. The X-ray microprobe attached to it (Energy Dispersive Spectroscopy, or EDS) identifies the elemental composition of any particle the microscope can see. The combination produces two outputs for each foreign body: a photograph at high magnification and a spectrum showing which elements are present.¹
Sample preparation is routine. Twenty microliters of vaccine are released onto a 25-millimeter cellulose filter inside a clean cabinet. The filter is then dried, mounted on a carbon-adhesive disc, and placed into the microscope chamber. Observations are made under low vacuum at 10 to 30 kilovolts. The microscope’s two sensors distinguish organic from inorganic material by atomic density: metal cores appear bright, protein coatings appear dim. The EDS identifies what each bright region contains.
Any contract laboratory with the relevant instruments could replicate the protocol in an afternoon. The equipment cost is in the range of half a million dollars, a budget category that does not appear on any pharmaceutical manufacturer’s annual report under “material constraints.” Most major manufacturers already own instruments of this class for other purposes.
What pharmaceutical quality control for injectables actually examines is something different. Sterility testing checks for viable microorganisms. Endotoxin testing checks for bacterial cell wall fragments capable of producing fever. Potency assays confirm the declared active ingredient is present at the declared concentration. Visible particulate inspection involves a trained human holding the vial to a light and looking. Visible inspection cannot resolve particles below approximately fifty microns. Most of what Gatti and Montanari documented falls below that threshold.
The contamination went undocumented for a century because the question was not asked. The instruments existed. The samples were on the pharmacy shelf. The technique was routine in adjacent fields like materials science, semiconductor manufacturing, forensic analysis, and environmental toxicology. It had simply never been applied to vaccines. The first systematic survey produced the catalog above.
What Foreign Bodies Do in Tissue
A particle of cerium-iron-titanium-nickel is not a molecule. It is a crystal. Once injected into muscle, it does not dissolve or biodegrade in any meaningful timeframe. The body has no enzymatic machinery for breaking down rare earth metal alloys. There is no biochemical process that handles them.
The first event after injection is the protein corona. The surfaces of metallic particles bind serum proteins on contact. The proteins do not adhere in their natural folded configuration. The contact with the metal surface distorts them, exposing parts of the molecule that would normally remain tucked inside. The composite that results is a metal core wrapped in distorted protein. It is recognizable to the body’s repair networks as a problem but is not removable, because the metal at the center cannot be processed.
The body responds to the composite the way it responds to any persistent tissue injury. Inflammation builds at the site and does not resolve, because the source of the injury cannot be removed.
In the establishment’s framework, this is what gets labeled an autoimmune effect, with the body said to be “attacking itself.” Gatti and Montanari, working within that framework, note that the protein-corona composite is “capable of stimulating the immune system in an undesirable way.”¹ The accurate description does not require any framework about systems attacking themselves. The body is responding to documented tissue injury caused by an inserted foreign object it cannot remove. The inflammation is the response, not the disease. The damage is the foreign body’s biopersistence.
The acute response can be cleared if the irritant can be cleared. A splinter or a bee sting resolves once the offending material is processed. A foreign body that cannot be broken down provokes inflammation that does not resolve. Granulomas form at the injection site. Some particles remain there. Others travel. Gatti and Montanari note that blood circulation can carry them anywhere, “including the microbiota, in a fair quantity,” and that particles of the size observed in the vaccines can enter cell nuclei.¹
Charles Richet documented the underlying sensitization mechanism in 1901. Injection of foreign protein into an animal produced a measurable response. On second exposure, the response was more severe. On third exposure, more severe still. Richet named the phenomenon anaphylaxis and received the 1913 Nobel Prize in Physiology or Medicine for the work.² The finding has not been refuted. In clinical medicine it has been displaced. The route of administration is no longer treated as a primary variable, despite Richet’s demonstration that it is the only variable that matters. Foreign proteins encountered through digestion are processed and do not sensitize. Foreign proteins encountered through injection sensitize predictably.
Gatti and Montanari supply the physical substrate Richet’s mechanism predicted. The “foreign protein” in a contemporary injection is not a single contaminant in a controlled formulation. It is a protein corona: the recipient’s own proteins, unfolded and presented in unfamiliar configuration on the surface of a tungsten particle, a lead particle, or a stainless steel fragment. The sensitization mechanism is identical to the one Richet described. The physical agent has now been photographed.
On “Trace Amounts”
The standard defense of contamination in injectable products is that the quantities are below any toxicological threshold of concern. The defense does not survive examination.
Toxicological thresholds for these materials in injected products have not been established. Standard toxicology threshold work is conducted on oral or dermal exposure, with the intestinal lining and the skin filtering the dose. Injection bypasses these barriers. The pharmacokinetics of injected particulate metal is a separate body of work that, for the contaminants Gatti and Montanari documented, has not been performed.
Even if such thresholds existed, they would not apply to crystals. The relevant comparison for a soluble toxin is dose in micrograms per kilogram of body weight. The relevant comparison for a tungsten particle in muscle tissue is not. It is a foreign body. The mechanism of injury is not chemical toxicity at low concentration. It is the mechanical and inflammatory response at the site where the body cannot clear it. Threshold arguments built on solubility do not apply to objects.
For some of the elements cataloged, no threshold defense was ever available. Lead has no established safe exposure level in pediatric populations. The EPA, the CDC, and the AAP all state this. An argument that a small amount of lead in an injection is acceptable would require a separate regulatory framework specific to injected lead in children. No such framework has been published.
What the manufacturers have in place of threshold defense is the assertion that the contamination is not there. The Gatti and Montanari work establishes that assertion as false.
The HPV Cases
The paper’s discussion section opens with the HPV vaccines. Gardasil and Cervarix.
Cervarix contained 1,569 particles per twenty-microliter drop. The elemental analysis identified aluminum, silicon, magnesium, calcium, iron-chromium-nickel (stainless steel), zinc, copper-tin-lead bronze, and several additional combinations. Gardasil contained between 304 and 454 particles per drop, depending on the batch. The composition included calcium-aluminum-silicon, aluminum-copper-iron, lead, bismuth, titanium, and bismuth-barium-sulfur.¹ Both vaccines are administered to adolescents, predominantly girls and increasingly boys, between roughly ages eleven and fifteen, on the schedule recommended by national pediatric authorities and reinforced by school-entry requirements in many jurisdictions.
The adverse event patterns following HPV vaccination have been documented in the medical literature since shortly after global rollout. Brinth’s 2015 case series at Frederiksberg Hospital described fifty-three Danish girls presenting after Gardasil with severe headache, syncope, cognitive dysfunction, autonomic disturbance, episodic loss of consciousness, and impairment of gait.³ Kinoshita and colleagues at Shinshu University documented Japanese adolescent girls with peripheral sympathetic nerve dysfunction following Gardasil and Cervarix. Their symptoms included orthostatic intolerance, complex regional pain syndrome, severe headache, photophobia, cognitive impairment, and inability to maintain upright posture.⁴ Palmieri’s group at the University of Modena published a 2016 case series and literature review describing severe somatoform and dysautonomic syndromes after the same vaccines, including patients who had lost the ability to walk.⁵
The Japanese Ministry of Health suspended its proactive recommendation for HPV vaccination in 2013 following these cases. The Danish health authorities, after Brinth’s work, established specialty referral centers to handle girls presenting with the post-vaccination syndromes. The clinical labels the patients receive (POTS, CRPS, chronic fatigue syndrome, various dysautonomias) describe symptom clusters without explaining mechanism. They tell the patient she is sick. They do not tell her why.
Gatti and Montanari’s analysis supplies the missing piece. The Gardasil vials contained lead. The Cervarix vials contained stainless steel and copper-tin-lead bronze. The particles entered the deltoid. The particles do not biodegrade. The particles bind protein. The composite persists at the injection site or travels through circulation to lodge in distant tissue. The body responds to persistent tissue injury with sustained inflammation. Where the particles come to rest determines what the patient experiences. A particle lodging near the nerves that regulate heart rate and blood pressure produces orthostatic intolerance, the picture clinicians label POTS. A particle near a sensory nerve root produces regional pain syndromes. The clinical picture in any given patient maps to the anatomical distribution of damage.
This is not a single-source argument. The physical contamination has been documented by Gatti and Montanari. The sensitization produced by injected foreign protein was documented by Richet at the turn of the twentieth century and recognized in his 1913 Nobel Prize. The clinical syndromes following HPV vaccination are documented in patient registries across Denmark, Japan, and Italy. The lines converge on a single conclusion: injection of biopersistent foreign bodies into tissue causes sustained inflammatory injury, and the clinical picture depends on where the foreign bodies travel.
The girls did not get sick from a virus. They got sick from what was in the vial.
What “Unintentional” Requires
In the conclusion of their paper, Gatti and Montanari propose that the contamination is unintentional. “Our hypothesis is that this contamination is unintentional, since it is probably due to polluted components or procedures of industrial processes (e.g. filtrations) used to produce vaccines, not investigated and not detected by the Producers.”¹ They are scientists. They stayed within what their instruments could establish. They did not assert intent they could not prove from a microscope image.
The hypothesis deserves examination. It requires us to believe specific things.
It requires that GlaxoSmithKline, Sanofi, Pfizer, Novartis, and Merck (corporations with annual revenues in the tens of billions of dollars, employing thousands of quality control personnel, with full access to the same materials science instruments Gatti and Montanari used) have not, as a matter of routine practice, examined their own injectable products at the resolution where contamination would be visible. The omission would persist despite the instruments being standard equipment in their other research operations. It would persist despite the cost of physical-evidence quality control being a rounding error against the revenue these products generate. It would persist despite the documented sequestration of Pfizer Meningitec batches by Italian prosecutors having already established that the contamination question was live.
It requires accepting that the regulatory bodies (the FDA, the European Medicines Agency, the various national medicines agencies) have not required physical contamination testing of injectable products at any resolution finer than visible particulate inspection. This is documented. The regulations require sterility testing, endotoxin testing, and visual examination. They do not require electron microscopy. They do not require X-ray spectroscopy. They do not require any examination capable of detecting tungsten, lead, or rare earth metal debris below the threshold of unaided human vision. Particles below approximately fifty microns fall below regulatory scrutiny. Most of what Gatti and Montanari documented falls below that threshold.
It requires accepting that the contamination has continued, in the same products from the same manufacturers, since the paper’s publication in 2017. The studies to determine where the particles travel after injection, what damage they cause over what timescale, and what cumulative effect they have on the recipient population have not been commissioned. The contamination has not been investigated by the producers. It has not been addressed by the regulators. It has not been examined in any follow-up by the same teams that produced the original work. Subsequent reporting indicates that the authors have themselves been the subject of administrative action by Italian authorities in the years since publication. The findings have not been refuted.
“Unintentional” is a word that requires consequent action to mean anything. An accidental fire that is left to burn ceases to be an accident. A contamination problem identified, published in peer-reviewed literature, and left unaddressed for nine years is no longer a quality control oversight. It is a settled equilibrium between what the manufacturers produce and what the regulators require.
The veterinary production line is clean. Feligen contains no industrial debris because Virbac’s manufacturing process for animal vaccines produces vials without it. The capability exists. The standard exists. It has been demonstrated by an adjacent product line owned by the same broad industry.
Whatever word is appropriate for the difference between the line that produces a clean injection for a cat and the lines that produce contaminated injections for children, “unintentional” is not it.
After 2017
The Gatti and Montanari paper was published before the rollout of the mRNA products. The contamination they documented was in conventional vaccines, manufactured by conventional methods. The pharmaceutical manufacturing system they examined was the system in place before 2020.
Subsequent work on the mRNA products has documented the same baseline. Sasha Latypova’s manufacturing analysis identifies undeclared contaminants in injected materials and regulatory frameworks that did not require the testing that would have caught them. What Gatti and Montanari cataloged in 2017 continues in new products under new labels. The 2017 findings and the post-2021 findings are not separate stories. They are the same story, told in different chemistries by an industry whose quality control standards are set by what the regulators require rather than what the instruments can detect.
The Particle Is in Someone
The cerium-iron-titanium-nickel particle photographed in Agrippal batch 147302A is in someone now.
We do not know whose arm received the dose. We do not know whether the particle remained at the injection site, traveled through lymph to regional nodes, entered circulation, or lodged in muscle, spleen, liver, brain, or microbiota. We do not know what damage it has done or is doing. The studies to determine these things have not been performed. They will not be commissioned by the entity that produced the vial.
The particle is a few microns across. It is composed of four elements, only some of which appear in any technical catalog of recognized industrial alloys. It is wrapped in protein. The protein was the recipient’s own, bound on contact, unfolded by the binding, presented in a configuration the body has no template for. The composite is biopersistent. It does not biodegrade. The response to it is the one Richet documented in 1901 and was awarded the Nobel for in 1913.
The vial it came from was administered in the 2014-2015 flu season. The batches manufactured this year are being administered now. The instruments Gatti and Montanari used are still available. The procedure they described is still routine. The contamination they documented has not been investigated by the producers, named by the regulators, or addressed in any meaningful way.
The particle is in someone now. The vial it came from is gone. The vials in production this week contain debris of similar composition in similar quantities, headed for arms that have not yet been chosen.
If You Were Six
Some scientists looked at the shots that doctors give to children. They looked very carefully, using a special microscope strong enough to see things much smaller than a speck of dust.
They found tiny pieces of metal in the liquid inside the shots. Some of the pieces were lead. Some were stainless steel. Some were other metals that nobody had told anyone were in the bottles. The pieces were too small for your eyes to see. You would need the special microscope to find them.
The scientists looked at forty-four different shots. Forty-three of them had the metal pieces inside. One shot did not. That clean shot was the one made for cats.
Once a tiny piece of metal goes into your arm, your body cannot get rid of it. Your body knows how to clean up many things, like old skin or the food you eat or the cut on your finger from yesterday. It does not know how to clean up metal. So the metal stays. It sits where it landed in your arm. Sometimes your blood carries it to other parts of your body.
When the body cannot clean something up, the place around it gets red and sore. If the metal does not leave, the redness does not leave either. Some of the children who got these shots got sick afterward and stayed sick for a long time. Some of them stopped being able to walk properly.
The companies that make the shots have special microscopes too. They could have looked inside their own bottles. They did not. The people whose job is to keep the shots safe never asked them to look. The cat company looked at the cat shots, and the cat shots are clean. The companies that make shots for children did not look, and the shots are not clean.
That is what the essay is about.
References
Gatti AM, Montanari S. New quality-control investigations on vaccines: micro- and nanocontamination. International Journal of Vaccines and Vaccination. 2017;4(1):7–14.
Richet C. Anaphylaxis. Nobel Lecture, December 11, 1913. Nobelprize.org, The Nobel Foundation.
Brinth L, Pors K, Theibel AC, Mehlsen J. Suspected side effects to the quadrivalent human papilloma vaccine. Danish Medical Journal. 2015;62(4):A5064.
Kinoshita T, Abe RT, Hineno A, Tsunekawa K, Nakane S, Ikeda S. Peripheral sympathetic nerve dysfunction in adolescent Japanese girls following immunization with the human papillomavirus vaccine. Internal Medicine. 2014;53(19):2185–2200.
Palmieri B, Poddighe D, Vadalà M, Laurino C, Carnovale C, Clementi E. Severe somatoform and dysautonomic syndromes after HPV vaccination: case series and review of literature. Immunologic Research. 2017;65(1):106–116.
Google wants a look at your hands before it lets you through. The company’s newest reCAPTCHA check, rolling out now as a test, asks you to switch on your camera and wave at it so an algorithm can decide whether you’re a human or a bot.
That wave is less casual than it looks. The system records a short video of your hand and pulls 21 hand-landmark coordinates from it, mapping your finger joints, your palm geometry, and the way you move in real time.
Google describes the purpose as liveness detection, a way for websites to fend off automated account creation, credential-stuffing, and other fraud. But this is still a biometric scan, collected so you can prove you’re a person and still involves turning on your cameras for Google.
Google has lined up the promises you would expect. The company says the footage is deleted once verification finishes, no audio is recorded, and the video is never tied to your identity. Its documentation adds that nothing goes to third parties and the data serves security alone, then points to the Google Privacy Policy for how everything is used and stored, a policy elastic enough to cover almost anything.
For now the feature seems optional. People who cannot perform the gestures still get the older puzzles, with Google saying reCAPTCHA “continues to provide visual and audio challenges” while it develops alternatives.
However, we all know that optional today is rarely optional forever and the older challenges survive partly because the gesture check is still being tested.
The reassurances rest on trust and Google has spent years giving people reasons to hold it back. This is a company whose business runs on gathering and monetizing personal data, now asking to switch on your camera and read your hand.
As Keir Starmer prepares to leave the UK’s highest office after less than two years, the media has lined up to explain why he failed to deliver on the enormous hype he received as opposition leader, and during his initial months in office. A repeated trope has been that Starmer was a “decent man,” but simply not cut out for mainstream politics. However, his record of concealing the UK establishment’s repulsive crimes – be that serial child sex abuse or spy agency torture – shows him to be anything but decent.
What was the reality of Starmer’s CPS role?
Starmer’s spell as director of public prosecutions for the Crown Prosecution Service (CPS) has been fundamental to his mythology since before he became Labour leader. It was during this time, according to The Guardian, that “Starmer transformed his reputation from that of a radical lawyer to that of a moderate and cautious administrator.” Missing from this account is any reference to how the CPS under his leadership covered up the crimes of notorious celebrity pedophile Jimmy Savile, while he was still alive.
In February 2022, Boris Johnson got in serious hot water after he accused Starmer in parliament of “prosecuting journalists and failing to prosecute Jimmy Savile,” as CPS chief. Condemnation from the media and UK politicians was universal. Johnson’s personal policy chief, who’d worked for him for 14 years, resigned in protest over the then-Prime Minister’s supposedly libelous statements. Such was the backlash, as pressure grew so severe, that Johnson retracted his comments in a matter of three days.
It was an extraordinarily rare example of the UK establishment moving in unanimous lockstep, to defend a single mainstream politician accused of wrongdoing. The episode was made all the more shocking by Johnson’s statement being literally true. Starmer was CPS chief when the Service made the indefensible decision to not prosecute Savile, and many aspects of that strangely downplayed and ignored scandal implicate the failed prime minister personally.
What did an inquiry say about CPS treatment of Jimmy Savile?
An internal CPS inquiry into the Savile affair was commissioned by Starmer in 2012, after it was revealed in the wake of Savile’s death that police had failed to press charges against him despite numerous witnesses credibly accusing the UK’s “national treasure” of sexually abusing and raping them when they were young girls. The inquiry found a CPS “reviewing lawyer” told investigating officers early on he “would not be inclined to prosecute these cases because they were ‘relatively minor’.”
The CPS lawyer also didn’t ask the police basic questions about the case. The inquiry report found his attitude troubling. “I would hope that any prosecutor would regard a sexual assault as being in and of itself serious,” the author stated. They found instead that “these particular assaults were far from trivial,” and “represented a course of conduct against vulnerable women and girls” by Savile, over many years. Consequently, the investigator had “reservations about the way in which the prosecutor reached his decision.”
Instead of refusing to pursue the case, the CPS had a duty “to ‘build’ a prosecution,” which its lawyers failed to fulfil. The allegations against Savile were plainly “serious and credible.” The inquiry found that “had police and prosecutors taken a different approach, a prosecution might have been possible.” These conclusions are all the more damning when you consider that all CPS files held on Savile were shredded in October 2010.
Despite these grave criticisms, the investigator concluded, “I have seen nothing to suggest that the decisions not to prosecute were consciously influenced by any improper motive on the part of either police or prosecutors.” Which might be true, if only because all CPS files on Savile were destroyed. The report was therefore “dependent on material provided by the police to show what documents were seen by the reviewing lawyer and the advice which was given.”
The Service allegedly had “no record at all” of the case, which the inquiry claimed was due to CPS records on Savile being “automatically deleted” after a decision to take no action was made, in line with internal policies. However, the Service’s publicly accessible guidelines on “disposal” of evidence clearly state documents on cases where “no proceedings have taken place or where the case was discontinued before trial” must be kept for five years.
What role did Starmer play in Julian Assange’s persecution?
The Savile deletions were not the only example of suspiciously poor CPS recordkeeping under Starmer’s watch. In 2017, it was revealed the Service deleted sensitive email exchanges about Julian Assange with Swedish prosecutors three years earlier – potentially illegally, as a criminal case was ongoing. The communications occurred from 2010 until the WikiLeaks founder sought refuge in Ecuador’s London embassy in June 2012, where he remained for almost seven years, under constant threat of CIA assassination. In 2019 British police forcibly removed him and sent him to Belmarsh, a high-security prison, where we was kept in almost total solitary confinement for five years.
The emails were deleted by a CPS lawyer who had personally advised Swedish police not to visit London and interview Assange as he had requested, on the grounds that he feared extradition to the US from Sweden. “In my view it would not be prudent for the Swedish authorities to try to interview the defendant in the UK,” they wrote in January 2011. This sentence was redacted in emails released under Freedom of Information by the CPS, but not in files provided by Swedish authorities.
Sweden dropped its investigation into Assange in May 2017. Only later was it revealed that the case could have been closed much earlier, were it not for direct CPS intervention. Beyond advising Swedish police not to interview Assange in London, a Service lawyer repeatedly sought to dissuade them from dropping their investigation outright. In August 2012, they wrote to their Swedish counterparts, “Don’t you dare get cold feet!!!”
In October 2013, Sweden’s director of public prosecutions, Marianne Ny wrote to the CPS that due to the passage of time, and lack of evidence against Assange, “we have found us to be obliged to lift the detention order… and to withdraw the European arrest warrant.” Three days later, Ny emailed a clearly affronted CPS, apologizing over the “[bad] surprise” of moving to drop charges against Assange. “I hope I didn’t ruin your weekend,” she added.
“All we can do is wait and see and perhaps be eternally grateful neither of us have to share a room in the embassy with him over Christmas!” the CPS lawyer responded.
Starmer’s personal role in all this has never been adequately clarified, but he visited Washington, DC in 2011, 2012 and 2013 while he was in effective charge of the Assange case, meeting with senior US officials. True to form, all records of Starmer’s trips were quickly destroyed, contrary to CPS protocol.
How did Starmer cover for MI5/MI6 torture?
After 9/11, the CIA launched a global torture program, identifying terror suspects, abducting them and sending them to black sites all over Europe and the Middle East, before torturing bogus confessions out of them to justify the War on Terror. MI5 and MI6 were not only centrally involved in the program; the two agencies ran an autonomous joint operation using “partner” agencies in the Global South to do the torturing itself.
When these activities became public, with legal actions mounting against the state by victims of the torture program and their families, UK police launched an investigation. Vast quantities of incriminating evidence were collected. However, Starmer as CPS chief consistently vetoed bringing offenders, including senior spy agency directors, to trial despite overwhelming cases against them. First, in 2010 he ruled there was “insufficient evidence” to prosecute an MI5 officer who participated in the torture in Pakistan of a UK citizen in 2002.
Police investigations into MI5 and MI6 for torture continued. However, in January 2012 Starmer again decided not to prosecute anyone from these agencies for their role in their unlawful treatment. The next April, Starmer attended the boozy going away party of MI5 chief Jonathan Evans, the first CPS official to ever attend such an event. Evans was a counter-terror veteran who’d served as MI5 director general since 2007, and would’ve been criminally liable if the CPS had decided to prosecute MI5.
Police investigations into the torture scandal weren’t finished though. Documents seized from Libyan security service offices, abandoned in the wake of Muammar Gaddafi’s October 2011 fall, were a treasure trove. This included faxes sent in March 2004 by then-MI6 counter-terror chief Mark Allen to Libyan spies, regarding a terror suspect kidnapped along with his wife in an MI6 operation. The suspect spent six years being tortured in Libyan prisons at the agency’s direction, with MI6 providing his interrogators questions to ask.
Overall, 28,000 pages of evidence on Allen’s involvement in torture were collected by police. In 2014 however, Starmer yet again decided this was “insufficient evidence” to prosecute the MI6 counter-terror chief, and the case was dropped. In return for a lifetime of serving the establishment, and assisting directly in the commission of serious criminality – if only by signing off on coverups and politicized prosecutions of dissidents – Starmer was rewarded with an empty seat in the UK’s highest office, for only two years.
June 26, 2026
Posted by aletho |
Corruption, Deception | Human rights, UK |
Comments Off on The Starmer legacy the establishment media won’t tell you: Celebrity sex crimes, imprisoning Assange and torture terror
Cuban Foreign Minister Bruno Rodríguez Parrilla has condemned US Secretary of State Marco Rubio’s claim that there is no oil blockade imposed by the United States on Cuba.
In a post published on X on Sunday, Rodríguez wrote: “When [Rubio] talks about incompetence in Cuba, he should be asked why he lies chronically and contradicts the US president and his spokeswoman by denying the existence of the total fuel blockade that the White House acknowledges.”
“There is no oil blockade on Cuba, per se,” Rubio claimed on Saturday while guest-hosting the daily White House press briefing.
Rodríguez stated that Rubio’s references to the situation in Cuba are consistently framed in a way that avoids responsibility and self-accountability, describing it as “an attempt to present himself as a savior.”
The Cuban foreign minister also denounced the “economic suffocation plan” against his country, saying it prevents foreign companies from selling parts and technology needed for the island’s thermoelectric plants.
The plan “prevents any company in the world from selling oil to our country” and also targets CUPET, the Cuban company responsible for fuel logistics and energy infrastructure, he explained.
He added that it sanctions nickel companies, threatens foreign companies involved in tourism and mining, and strips foreign citizens who visit Cuba of the right to use Electronic System for Travel Authorization (ESTA) visas to enter the US.
Rodríguez also said Washington pressures and threatens countries that maintain health cooperation agreements with Cuba.
He further stated that Rubio “openly calls for the subversion of Cuba’s constitutional order and persistently seeks US military intervention in Cuba.”
An executive order signed by Trump on January 29 authorized the White House to impose tariffs on countries exporting fuel to Cuba.
So far in 2026, Cuba has received a single shipment of 100,000 tons of crude oil from Russia.
On April 29, 2026, as Chairman of the Senate Permanent Subcommittee on Investigations, I held a hearing and released a report titled “Unmasked: How Biden Health Officials Purposely Turned a Blind Eye Toward COVID-19 Vaccine Safety Signals.” There has not been a bigger government scandal during my lifetime, and yet even now that we have documented proof of corruption, most of the legacy media refuses to report on it.
My report details how in March 2021, Peter Marks — director of the FDA center that approves vaccines and is responsible for safety surveillance (CBER) — was briefed that the algorithm they were using to analyze the Vaccine Adverse Event Reporting System (VAERS) would mask or hide COVID-19 vaccine adverse event safety signals. Twenty-six days later, using an updated algorithm, senior FDA officials were shown 25 safety signals, including sudden cardiac death, pulmonary infarction, cerebral artery occlusion, basal ganglia stroke, agonal rhythm, and Bell’s palsy.
For the next three months, they received updates showing more serious safety signals. Instead of warning or informing the public, they ordered the data analyst to “cease and desist” and then lied to the American public that “they weren’t seeing safety signals” and that any adverse events were “rare and mild.” The whole point of using sophisticated algorithms to analyze VAERS is to find needles in the haystack — nonobvious potential harms that doctors and patients should be alerted to.
With the COVID-19 injections, we didn’t need sophisticated algorithms. The sheer volume of adverse event reports overwhelming VAERS was enough to trigger my oversight efforts. We faced impenetrable stonewalling until Secretary Kennedy’s commitment to radical transparency provided my Subcommittee with 11 million pages of documents. The documents make clear that FDA and CDC officials did not use an “err on the side of caution” standard to alert the public. Rather, they insisted on definitive proof of causation — a standard they knew would never be met.
They were far more concerned about not causing vaccine hesitancy than they were about informing the public of adverse events. They wanted to ensure that the injections would receive full licensure approval so that President Biden could mandate them to the military and millions of civilians, including healthy college students.
Perhaps the most egregious coercion involved healthy children who had virtually zero chance of serious harm from COVID-19. That coercion was based on another false claim that the injections would stop transmission. Some children were killed and others have been permanently disabled from the COVID-19 injections. Imagine being the parent who believed all the lies they were told and decided to have their now deceased or injured child injected.
Also in March 2021, Dr. Avindra Nath, clinical director at the National Institute of Neurological Disorders and Stroke (NINDS), began leading a team of clinical researchers who were diagnosing and treating individuals with serious COVID-19 injection injuries. Twenty-three study participants were diagnosed and treated, then instructed to “not talk about the study” until the NIH could release its findings and conclusions. Dr. Nath maintained that early recognition and intervention were crucial for effective treatment. Yet no guidance was provided to physicians — one participant remarked that the NIH scientists had “taken the data and left us hanging.”
Adding insult to injury, in April 2021 the CDC published a report stating that similar adverse events were “anxiety” — not a problem with the shots. It was not until study participants began speaking publicly in 2022 that the NIH quietly posted its study on a preprint server that virtually no one read, leaving medical teams nationwide in the dark and the injection-injured left untreated.
We will never know the full extent of the harms (or the benefits) of the COVID-19 injections. But we do know that federal health officials were aware that serious harm was being done within months of them granting Emergency Use Authorization. We also know that those same officials turned a blind eye toward the safety signals that were screaming at them, but they refused to warn the public. The public pays federal health officials to evaluate drugs for safety and efficacy, and we have the right to be informed.
How many deaths and injuries could have been avoided had federal health officials simply done the job we paid them to do?
Currently, VAERS shows 1,676,100 cumulative worldwide adverse events and 39,099 deaths associated with the COVID-19 injection, with 9,332 (24%) of the deaths occurring within 2 days of injection. Most of these tragic adverse events occurred well after federal health officials should have informed the public about the risks they knew existed. Instead, they hid or downplayed those risks. As a result, millions were harmed after being denied their right to fully informed consent.
That’s why I consider this to be the biggest government scandal in my lifetime, and one that is crying out for full media attention and coverage.
The Wall Street Journal, The New York Times, The Washington Post, USA TODAY and Fox Digital have all declined or ignored requests to publish this op-ed.
NBC, ABC, PBS, CNN and MSNow have all refused to cover my report.
Israel’s military censor blocked or altered more than 5,700 news reports in 2025, an average of 15 items per day, making it the second-highest year for media censorship in Israel since records began 15 years ago, according to new data published by +972 Magazine.
The figures, obtained through a freedom of information request submitted by +972 and the Movement for Freedom of Information, show that the censor demanded redactions in 4,974 news items in 2025, while completely barring 753 further items from publication. Both totals remain far above the previous annual average of around 2,300 redactions and 320 full bans recorded between 2011 and 2023. The year 2024, the height of Israel’s genocide on Gaza, still holds the record for the highest number of interventions.
The censor, a unit embedded within Israel’s Military Intelligence Directorate, received 17,176 article submissions from media outlets in 2025, compared to a pre-2024 annual average of just under 12,000. Israeli law requires media organisations to submit material touching on “security” issues for censor approval before publication, under emergency regulations enacted at the time of Israel’s founding that remain in force today.
According to +972, censorship was most intensive during Israel’s war with Iran. Police, municipal inspectors, and at times civilians enforced severe restrictions on reporting the locations of Iranian missile strikes on Israeli cities, with Arab and foreign journalists disproportionately subjected to obstruction in the field. Television studios regularly hosted a representative of the censorship authority to monitor live broadcasts in real time.
Media outlets are legally barred from informing their audiences that the censor interfered in a published article. The censor is also authorised to intervene retroactively, ordering the removal of articles published without prior approval as it did last year when it demanded the deletion of a column in Haaretz that disclosed the locations of Iranian missile strikes in Tel Aviv.
The censor holds sweeping powers of enforcement, including the authority to indict journalists and to fine, suspend, shut down, or file criminal charges against media organisations that fail to comply with its orders.
The data raises questions about the political direction of the censorship apparatus. The two men who led the censor over the past two years — Kobi Mandelblit, who served as chief censor until April 2025, and Netanel Kula, who replaced him — are both relatives of senior legal figures from Israel’s religious-Zionist movement.
Three months after Kula assumed the role, reports emerged that he had suppressed coverage of Prime Minister Benjamin Netanyahu’s son purchasing an undisclosed property abroad. The story eventually reached the public through other channels.
The data also points to a striking double standard in enforcement. The far-right Channel 14, a broadcaster aligned with Israel’s ultranationalist camp, repeatedly published sensitive combat plans and military intelligence tools that security officials determined had caused “actual harm” to national security. Despite this, the channel was not penalised on any occasion.
“It is particularly important during times of emergency to receive reliable information about changes regarding the censor’s activities,” said Or Sadan, an attorney from the Movement for Freedom of Information. “Although there has been a slight decrease from last year, it is hard not to notice the alarming rise in the number of news reports being hidden from the public. Democracy is based on the transfer of information from the government to the public, and any infringement upon this is a direct infringement upon democracy.”
+972 notes that military censorship, while severe, is not the most acute form of press freedom violation committed by the Israeli military. Since 7 October 2023, more than 250 journalists have been killed across Gaza, Lebanon, Yemen, and Iran — some of them in strikes that investigators have concluded were direct and deliberate, including so-called “double-tap” attacks targeting rescue workers who arrived at the scene of a first strike.
A prospective study at a Level I trauma center in the United States examined 1,097 consecutive CT scans and asked the ordering physicians to identify, for each scan, the reason it was performed. Four hundred and sixteen of those scans (38 percent) were ordered primarily to protect the physician from a possible lawsuit, not because the clinical situation required imaging. The defensively ordered scans exposed patients to an average of 8.8 millisieverts of ionizing radiation per person. Of those defensive scans, 2.2 percent changed how the patient was managed. The remaining 97.8 percent produced no clinical benefit. What they did produce was radiation exposure to patients, charges to insurance, and legal cover for the ordering physicians.¹
The 2.2 percent represents roughly nine patients out of the 416 defensively scanned whose course of care shifted because of the scan. Those nine exist. They are the cases on which defensive practice rests its moral claim. The trade their existence requires, however, is one no consenting patient would knowingly accept: irradiating roughly forty-five people to alter the management of one, with the population-level cancer burden falling on the forty-four whose management did not change. “Management change” is also not a synonym for benefit; it includes precautionary medication, further imaging, and surveillance protocols that themselves produce iatrogenic harm. The defense of the 2.2 percent does not survive contact with the math.
Extrapolated nationally, defensive CT imaging alone is estimated to add approximately $501 million annually to American healthcare expenditure, a figure that covers only CT scans and only in the United States.¹ A 2025 paper in JAMA Internal Medicine projects that the 93 million CT scans performed in the United States in 2023 will eventually produce approximately 103,000 cancers across the lifetimes of the people who received them, accounting for roughly 5 percent of all new annual cancer diagnoses in the country.²
A subset of those cancers will arise from scans ordered to protect not the patient but the physician. The patient will never know they were exposed for that reason. By the time the cancer arrives, decades after the scan, the link between the encounter and the disease is no longer recoverable.
Defensive medicine is the operating principle that produces this arrangement. The practice is documented in peer-reviewed literature, in physician self-reports, and across the cost-accounting of the institutions that profit from it. The patient sitting across the desk from the doctor is rarely aware the principle exists. The doctor knows. What this essay describes is what happens in the consulting room as a result of that asymmetry of awareness.
What It Actually Is
The phrase “defensive medicine” is not a critic’s label. It is the term physicians use themselves, in their own surveys, to describe diagnostic and treatment decisions made primarily to avoid legal liability rather than to benefit patients. The practice has been studied for more than four decades, appearing in peer-reviewed journals, in confidential surveys conducted by professional societies, and in geographic analyses showing that physicians in high-liability states order more diagnostic tests than physicians in states with malpractice tort reform.³
A 2005 study published in JAMA surveyed physicians in six high-risk specialties in Pennsylvania. Ninety-three percent reported practicing defensive medicine, and 43 percent reported using imaging technology in clinically unnecessary circumstances. The authors noted that defensive practice was reported across all specialties studied and was not confined to physicians with prior malpractice claims.⁴ The behavior described was not the conduct of a deviant minority. It was the operating culture of the specialties surveyed.
Researchers distinguish two registers. The first, positive defensive medicine, involves ordering tests, procedures, or consultations that the physician believes are unlikely to benefit the patient but that protect against accusations of inadequate diagnostic effort. The second, negative defensive medicine, involves declining to treat patients perceived as carrying higher litigation risk regardless of their clinical need. Both registers redirect clinical decisions away from the patient’s medical interest and toward the physician’s legal exposure.
The point is not the existence of defensive medicine but its normalization. Concealment from patients is not required because the practice is invisible by default. The patient cannot tell, sitting in the consulting room, whether a test was ordered to investigate their symptoms or to insulate the doctor against a hypothetical plaintiff’s attorney. The recommendation looks identical from the patient’s chair.
From the patient’s vantage point, what is visible is a competent professional, with medical training the patient does not have, who has determined that this particular test is required. What is invisible is whether that determination was made for reasons entirely indifferent to the patient’s medical situation.
The One-Way Ratchet
The legal system creates the conditions that produce defensive medicine, and it does so through a single asymmetry. Physicians face liability for under-diagnosis and almost none for over-diagnosis.
A man whose physician declines to order a PSA test, and who is later found to have advanced prostate cancer, has a malpractice claim. The claim may or may not succeed, but it is the kind of case malpractice attorneys take and insurance carriers settle. A man whose physician ordered the PSA test, who returned an elevated reading, who underwent a transrectal biopsy, who developed post-procedure sepsis from bowel bacteria driven into the bloodstream by the needle, who survived the sepsis but was left with persistent erectile dysfunction and urinary incontinence following a radical prostatectomy for a low-grade cancer that autopsy data suggests would have killed him only if he lived to ninety, that man has no claim. In most cases, he is grateful. His cancer was “caught early.” He was never shown the autopsy data on indolent prostate cancers, never told that 16 percent of American men receive this diagnosis but only 3 percent die from it, and is unaware that his cascade of harm originated in a screening decision medical evidence does not actually justify.⁵
The doctor who ordered the unnecessary test produced durable, measurable harm. The legal system records no exposure for that doctor. The doctor who did not order the test, and whose patient happened to be the rare one whose cancer was missed, faces a lawsuit regardless of whether ordering the test would have changed the outcome. From inside the legal architecture, the safest course is always to test more, because the asymmetry between under-diagnosis liability and over-diagnosis liability mandates it.
Studies of physician behavior confirm the prediction empirically. Doctors in high-liability states order significantly more diagnostic tests than doctors in states with malpractice reform. The variation tracks the legal climate, not the underlying disease burden.³ When Texas enacted comprehensive tort reform in 2003, defensive testing patterns in the state shifted measurably, although the magnitude and durability of the shift remain contested.³ The literature is consistent on the underlying point. Physician behavior is responsive to liability exposure, and the response is toward more testing rather than less.
This is the one-way ratchet, moving in a single direction over time. Settled malpractice cases raise the practical threshold of caution. New appellate decisions enlarge the set of investigations a prudent physician must order to satisfy the standard of care. The countervailing pressure that should exist from the harms produced by overtesting does not exist, because those harms generate no legal exposure for anyone.
From the patient’s vantage point, none of this is legible. The ratchet appears as escalating recommendations for tests, scans, and follow-up procedures. The patient assumes the escalation reflects an improving understanding of their personal medical risk. It does not; it reflects an evolving legal climate that has nothing to do with the patient’s biology.
The Standard of Care as Liability Shield
The medical profession refers to “the standard of care” as if it were a quality benchmark, a threshold below which clinical performance becomes inadequate. The standard of care in legal practice is something different. It is a defense position. Meeting the standard is what a malpractice defense attorney needs to establish to defend a doctor against a claim. The phrase describes legal adequacy, not clinical excellence.
The structural problem follows from how the standard is defined. The American Society of Anesthesiologists Closed Claims Project, the specialty’s primary instrument of self-examination for half a century, contains data that makes this explicit. When anesthesia care was judged by peer reviewers as appropriate, meeting the standard of care, payment was still made in more than 40 percent of malpractice claims. When care was judged substandard, payment was more likely but not certain.⁶
The standard of care, in other words, does not predict patient outcomes. It does not even reliably predict legal outcomes. What it predicts is the defensibility of a physician’s practice in a malpractice proceeding.
The circular logic closes off accountability at the definitional level. If the standard of care is what the majority of practitioners do, and the majority of practitioners do not obtain pre-operative cognitive baselines before general anesthesia in elderly patients, do not disclose post-operative cognitive dysfunction risk before consent, and do not select anesthetic agents based on the mechanistic evidence suggesting that some agents are worse than others for cognitive outcomes, then none of these omissions constitute substandard care. The standard is self-referentially defined by the mean of existing practice. The mean of existing practice cannot, by definition, be substandard.⁷
Harm that occurs in conformity with standard practice is not negligence. Negligence requires deviation from standard practice. Standard practice is what most practitioners do. What most practitioners do is whatever protects them most reliably from claims, which is whatever the standard of care currently is. The loop closes on itself.
The result is a body of harm that the accountability system cannot see by its own architecture. The Closed Claims Project, for all its methodological rigor, measures only what generates a claim. Acute, visible, legally contested events register: death, brain damage, esophageal intubation. The reduction in respiratory-related anesthetic deaths between 1985 and 2000 followed exactly this mechanism. The harms were acute and visible, pulse oximetry made them detectable in real time, malpractice exposure existed, the insurance system promoted the monitoring standard, and uptake was rapid.⁶ Chronic, diffuse, legally uncontested events do not register in any meaningful volume. Post-operative cognitive dysfunction, the slow cascade of overdiagnosis triggered by routine screening, the accumulation of pharmaceutical harm over decades: these generate no claims. They produce no signal in the accountability system the specialty uses to identify and correct its harms.
The Closed Claims architecture, the standard of care doctrine, and the malpractice insurance system together form a coherent legal-administrative apparatus whose function is to defend physician behavior against external challenge. Protecting patients from the iatrogenic consequences of defensive practice was never within the apparatus’s design brief, and it does not perform that protective function in practice.
The Cascade
What patients experience inside the defensive system is rarely a single unnecessary test. It is a sequence of tests, each triggered by the previous, each individually defensible, none of them collectively defensible.
Consider a fifty-year-old executive who opts in to a whole-body CT scan offered by a private screening clinic. The scan reveals a small lung nodule. The nodule is asymptomatic and almost certainly benign, since incidental findings of this kind appear on roughly 25 percent of all CT scans.⁸ The clinic recommends a follow-up CT in three months to assess for growth. The follow-up shows the nodule unchanged but identifies a small adrenal mass in the same imaging field. A PET scan is recommended to characterize both findings. The PET scan is negative for malignancy but introduces ambiguity about a mediastinal lymph node. A bronchoscopy is performed to sample tissue. The pathology returns benign scar tissue. The bronchoscopy is complicated by a pneumothorax requiring chest tube placement. The chest tube placement is uneventful. The executive returns to work three weeks later, having paid approximately $14,000 out of pocket, with no disease detected, no condition improved, and a measurable cumulative radiation exposure that did not exist before the cascade began.
The pattern is not exceptional. Incidentalomas trigger an average of $1,100 to $3,500 per patient in additional testing, with no associated improvement in mortality.⁸ Lung cancer screening trials found that one-third of patients had false-positive findings after two scans, and that one in fifteen underwent unnecessary invasive procedures as a result.⁸
The PSA cascade follows the same architecture in a different organ. An elevated PSA reading, which can result from prostatitis, benign prostatic hyperplasia, recent ejaculation, a urinary tract infection, or simply a larger-than-average prostate, triggers a transrectal biopsy. The biopsy punctures the bowel wall and introduces fecal bacteria into otherwise sterile tissue. Post-procedure sepsis is a documented complication, with antibiotic-resistant E. coli identified as the most commonly cultured organism, and hospitalization rates have risen alongside global antibiotic resistance. The 2022 GRAM Report published in The Lancet attributed approximately 1.3 million annual deaths worldwide to what it terms antimicrobial resistance, identifying E. coli as the most significant contributing organism.⁹ Tuncel and colleagues found that 41 percent of men reported erectile dysfunction at one month post-biopsy, with 15 percent still affected at six months.¹⁰ Cardiovascular events increase by a relative risk of 1.3 in the first year after diagnosis. Suicide risk rises by a relative risk of 2.6, with the highest risk in the first week.¹¹ These complications do not appear on the consent form.
The thyroid cascade follows the same architecture in a different specialty. A postpartum woman is screened for thyroid dysfunction. Her labs are abnormal during the transient hypothyroid phase of postpartum thyroiditis, a condition that typically resolves within twelve to eighteen months without intervention. She is started on levothyroxine and told she will need it indefinitely. The ultrasound performed to evaluate her thyroid identifies nodules, which are common and usually benign. The nodules require monitoring. Monitoring reveals minor changes. The changes prompt biopsy. The biopsy is indeterminate. A partial thyroidectomy follows. The woman who had a self-resolving postpartum condition is now missing part of her thyroid, on lifelong hormone replacement, and entered as a chronic patient in the disease registry.¹²
No single doctor along the cascade feels responsible for the cumulative outcome. Each one acted on the previous finding, documented their reasoning, and met the standard of care for their step in the sequence. Stopping the cascade at any point would have required a particular doctor to accept the legal risk of letting an uncertain finding go uninvestigated, and that doctor would be the patient’s doctor, not the patient. The asymmetry of where risk lands is the engine of the cascade. Legal risk is borne by the physician’s career, clinical risk by the patient’s body.
The cascade is the natural product of an accountability system that punishes physicians for missed diagnoses but not for downstream harms. It is what the system is structurally calibrated to produce. From the patient’s chair the cascade looks like a sequence of reasonable medical decisions; from the physician’s, the same sequence looks defensible at every step. The two perspectives never meet, and the gap between them is where the iatrogenic harm accumulates.
What the Doctor Will Not Say Out Loud
The defensive arrangement depends on a structural information asymmetry. A patient cannot make an informed decision about a recommended test if the test’s purposes, risks, and statistical performance are not disclosed. The published data are consistent across multiple settings and countries: this information is not disclosed.
Among American academic medical centers, only 15 percent routinely inform patients about radiation risks before CT scanning. By contrast, 84 percent of the same institutions discuss the risk of contrast reactions, which is a less significant long-term risk for most patients.¹³ Only 9 percent of surveyed sites inform patients about non-radiation alternatives to CT that might avoid radiation exposure entirely.¹³
The communication gap has been measured directly. In one emergency department study, 78 percent of physicians reported that they routinely discussed CT radiation risks with patients. Twenty percent of patients in the same encounters recalled being told.¹⁴ Both groups were describing the same conversations.
In 1999, Federman and colleagues published a study in Effective Clinical Practice examining whether informed consent actually occurred before PSA testing. Of the men who had received PSA tests, 31 percent were unaware their physicians had ordered the test. Of those who were aware, only 47 percent recalled any discussion of risks and benefits.¹⁵ Some men were tested without their knowledge. The study is more than twenty-five years old. Subsequent investigations show that the pattern has not changed. A qualitative analysis of men’s lived experience after PSA-driven diagnosis found that patients felt inadequately prepared and unsupported from the point of screening through biopsy and treatment decisions, and that the harms of overdiagnosis and overtreatment were rarely explained.¹⁶
The Australian and New Zealand College of Anaesthetists publishes a position statement on informed consent (document PS26(A)) that sets out what the specialty formally requires of its practitioners. The standard is specific: patients must be provided with information that a reasonable person in their position might wish to know and to which they might attach significance. The document includes the threshold that risks should be disclosed when “an adverse outcome is rare but the detriment severe, and an adverse outcome common but the detriment slight,” states explicitly that a surgical consent form does not constitute informed consent for anesthesia, and notes that time pressure does not eliminate the requirement for genuine consent.¹⁷
Applied to a documented condition such as post-operative cognitive dysfunction in elderly surgical patients, measurable in approximately one in four at one week after general anesthesia and one in ten still impaired at three months, with no known treatment, the ANZCA standard produces an unambiguous conclusion. The risk satisfies both disclosure thresholds, the detriment is significant, and the standard requires that the disclosure be made. Disclosure does not occur in clinical practice in the overwhelming majority of cases.¹⁸
The disclosure standard exists in writing. The disclosure itself does not occur in the consulting room.
The reason is not that physicians lack knowledge of these risks. The relevant studies appear in journals to which the practicing physicians subscribe and which they cite in their own work. The information has accumulated for more than two decades in some cases, more than seventy years in others. The reason disclosure does not occur is simpler than ignorance. Disclosing risks creates two adverse consequences for the physician. First, some patients decline the recommended intervention, which reduces the procedure rate and exposes the physician to liability if the rare missed diagnosis occurs. Second, patients who proceed and experience the disclosed complication have documented grounds for claiming they were misinformed about the relevant probabilities if the disclosure was incomplete. The path of least legal resistance is a generic, time-pressured consent process that satisfies the formal documentation requirement without producing a genuinely informed decision.
The consent form records that the patient was informed; the evidence shows they were not. Both statements are simultaneously true within the legal and clinical architecture as currently structured.
The Trapped Clinician
A complete account of defensive medicine has to address what is happening to the doctor inside the structure, because reducing the practice to physician greed or laziness misses what the evidence shows. Most doctors who order defensive tests are not behaving unethically by the standards of the system they trained in. They are responding rationally to the incentive structure they are embedded in.
That structure has several layers. The first is education. American medical training increasingly emphasizes adherence to clinical practice guidelines, many of which are written by panels with substantial financial ties to the manufacturers of recommended products. A widely cited analysis published in the BMJ found that the majority of panelists on the National Cholesterol Education Program guidelines had current or recent financial ties to pharmaceutical companies whose products the guidelines would mandate.¹⁹ Roughly two-thirds of American medical school department chairs hold financial relationships with industry of some kind.²⁰ A physician trained to follow guidelines that emerged from such panels is trained to order more tests, prescribe earlier, and intervene more aggressively, and to consider this evidence-based medicine.
The second layer is employment. Physician practice in the United States has shifted dramatically from independent practice to employment by health systems. The employed physician is subject to productivity metrics that reward volume: number of patient encounters per day, number of procedures per quarter, billing per visit. A physician who orders fewer tests, sees patients longer, or recommends conservative observation is not rewarded, and in many systems is penalized. Performance reviews and bonuses turn on whether the physician’s practice patterns align with institutional throughput targets, which are set to amortize the cost of expensive imaging equipment and staffed procedural suites.²¹
The third layer is time. A primary care visit in the American system is typically scheduled for fifteen to twenty minutes. That visit is meant to address whatever the patient came in for, plus all the screening reminders generated by the electronic medical record: colonoscopy overdue, bone density scan overdue, mammogram overdue, annual physical overdue. The path through this consultation that minimizes liability and maximizes billing is to order the indicated screenings, prescribe what the algorithm suggests, and move to the next patient. The path that protects the patient requires more. It requires taking time to ask whether each screening is appropriate for the particular person sitting in the chair, discussing harms as well as benefits, and documenting an informed refusal where indicated. That work adds twenty to thirty minutes of unbillable time to a visit that the system already says is too long.
The fourth layer is the broader commercial logic. A 2018 Goldman Sachs analyst report titled The Genome Revolution, written by Salveen Richter, included a section addressing the financial implications of curative therapies. The question, posed in writing within an investment research document published by one of the largest investment banks in the world, was direct: “Is curing patients a sustainable business model?” The report’s analysis indicated that one-time cures produce short revenue arcs, while chronic disease management produces long ones.²² The economic logic surrounding the physician, including the institutions that employ them, the products they prescribe, and the diagnostic technologies they order, is calibrated to manage disease rather than to cure it. The defensive medicine arrangement is consistent with this calibration. A patient subjected to a cascade of testing and treatment generates recurring revenue. A patient told that observation is reasonable does not.
None of this absolves the doctor. The structural pressures are real and explain why the system produces the outcomes it does, but the patient sitting across the desk is still being subjected to risks they have not been told about. A doctor who orders a defensively motivated CT scan, who fails to disclose its radiation risks, who refers an incidentaloma for follow-up imaging that initiates a cascade, is participating in iatrogenic harm whether they intend to or not. The structural account explains how the participation occurs without absolving the physician of having participated.
The honest version of the consultation would be something close to the following. I am going to order this test primarily because I will face legal exposure if I do not, and missing the rare cancer it might detect would be a career-ending event for me. I have no good way to predict whether the test will produce useful information in your case. If it produces a false positive, I will refer you for further investigation, and the cascade that follows may harm you. You can decline the test, and I will document your decision.
That consultation does not take place. Conducting it would expose the arrangement as it actually operates, and the arrangement depends on the patient’s continued belief that the recommendation reflects clinical necessity rather than legal self-preservation.
There is a question every doctor reading this should be willing to ask themselves before their next clinic. Of the tests, procedures, prescriptions, and referrals I will recommend today, how many would I recommend if there were no liability exposure attached to declining to recommend them? The honest answer, for most physicians in most American practices, would substantially shrink the volume of recommended interventions. That difference is the iatrogenic harm. The volume of intervention that exceeds what would be recommended on purely medical grounds is the volume the patient is being asked to absorb on the doctor’s behalf.
What to Do in the Consulting Room
The structural problem is not solved at the individual level. A single patient cannot reform American medical training, the employment structure of physicians, or the asymmetry of the legal system. What a single patient can do is recognize the arrangement, refuse to participate in the parts of it that produce harm, and document the refusal.
Three questions interrupt almost any cascade at the point of entry.
The first is what happens if we wait? Most diagnostic decisions are not emergent. The doctor will typically describe a worst case, because the legal exposure forces them to describe a worst case, but the relevant question is what happens in the average case if observation is chosen over intervention. For most screening tests, the answer is that nothing happens. The natural history of the condition, in the absence of detection, would not have caused symptoms or harm within the patient’s lifetime. The cascade was triggered by the test, not by the underlying disease.
The second is what are the alternatives? Most diagnostic algorithms admit multiple paths. Ultrasound and MRI can substitute for CT in a wide range of clinical situations; active surveillance is a documented option in many cancers where biopsy is reflexively recommended; lifestyle modification has demonstrated effects in conditions for which pharmaceutical intervention is the default. The default path is rarely the only path. It is the path of lowest legal exposure for the physician, which is not the same thing as the path of lowest harm for the patient.
The third is is this required, or recommended? “Required” is almost never the correct answer. The patient who receives a flat recommendation often assumes the test is mandatory. It is not. It is recommended. The distinction matters because a recommendation can be declined.
Declining is the operative skill. Pressure converges on the patient from multiple sources to maximize the rate of test acceptance: electronic medical record reminders for “overdue” screenings, clinic staff who raise the issue at every visit, automated reminder letters, partner and family pressure, the doctor’s recommendation itself, and the patient’s own fear of missing something serious. None of these constitutes medical necessity. They constitute the operating environment of a system that profits from compliance.
Specific phrases work. I have reviewed the evidence on this test and decided the harms outweigh the benefits for someone in my situation. Please note my informed refusal in my record.I understand you recommend this. Can you tell me the number needed to screen and the overdiagnosis rate? I would like to make an informed decision. *I am not declining medical care. I am declining this specific test based on the published evidence. I would like to discuss what, if anything, I should monitor instead.*²³
The documented refusal protects the patient and, by an arrangement the system rarely advertises, also protects the doctor. A patient who has formally declined a recommended test, with the refusal documented in the medical record alongside the doctor’s recommendation and the discussion of evidence, has produced exactly the consent process that the system claims to require. The doctor’s liability exposure for the refused test is substantially reduced because the patient now owns the decision. The patient’s exposure to the iatrogenic harms of the unnecessary test is eliminated because the test does not occur.
This outcome is available to any patient who insists on it. The system does not offer it spontaneously because it is the system’s least profitable configuration.
Closing
The trauma center study identified 416 patients out of 1,097 who received CT scans ordered for reasons that had little to do with their medical condition. Each of those patients sat through the procedure believing the scan had been ordered because the doctor’s clinical judgment required it. Each absorbed, on average, 8.8 millisieverts of ionizing radiation. A small percentage of them will develop cancers from that exposure decades from now, and by that point the link between cause and effect will be unrecoverable. None of the doctors who ordered the scans will be sued, none of the institutions that performed them will be sued, and the eventual cancer patients will not know which encounter caused the disease. If they did know, the standard-of-care defense would close the case before it began.
What is happening in the American consulting room, and increasingly in clinical encounters across every country that has adopted the American model, is a form of risk transfer. The legal risk that the physician would otherwise carry is transferred to the patient in the form of unnecessary radiation, biopsies, cascades of investigation, lifelong prescriptions, and the diminished autonomy of being managed rather than cared for. The transfer is invisible from the patient’s chair because it is denominated in a currency the patient cannot read.
The standard of care functions as a liability defense rather than a clinical benchmark, and the consent form that accompanies it operates as an administrative shield rather than a record of genuine disclosure. A defensive test recommended on these foundations is calibrated to the doctor’s legal exposure first and to the patient’s clinical situation second. The cascade that follows a positive result is not the pursuit of the patient’s recovery; it is the completion of a documentation chain demonstrating that the system did everything it was supposed to do.
You can decline. The right to decline is the last patch of ground in the consulting room that the system has not yet enclosed. The document the doctor wants you to sign is consent to a process calibrated for everyone except you. The document you can produce, a written and dated refusal of a specific recommended intervention with your reasoning attached, is the only piece of paper in the room that says what it claims to say.
How I’d Explain This to a Six-Year-Old
Pretend your school has a rule. If you fall down at recess, even just a little bit, the teacher has to send you to the nurse. Not because the teacher thinks you are hurt. The teacher knows you are fine. But if the teacher doesn’t send you and your knee turns out to be a bit bruised, your mom might call the principal, and the principal might get cross with the teacher.
So you go to the nurse. The nurse looks at your knee. To be safe, the nurse takes a picture of inside your leg with a special machine. The machine uses a tiny bit of bad stuff that goes into your body. Just a little. Not enough to hurt today. But every time the machine takes a picture of you, a little more bad stuff goes in, and after lots of pictures the little bits add up.
The picture shows your knee is fine. The nurse already knew that. But the picture also shows a tiny spot somewhere else that is probably nothing. To be safe, the nurse sends you for more pictures. The more pictures show another small thing. Now you are scared. Your mom is scared. Nobody can stop, because if they stop and the small thing turns out to be something, the nurse and the doctor and the school could get into trouble.
You came in with a scraped knee. You leave with three pictures of your insides, a worried mom, and a bit of the bad stuff inside you. Nothing was wrong. Nothing got better. All the grown-ups feel safer, because they did everything they were supposed to do.
That is what happens to grown-ups at the doctor every day. There is a name for it. The name is defensive medicine. It means the people taking care of you are mostly trying not to get into trouble themselves, and those two things, looking after you and not getting into trouble, almost never point the same way.
Here is the thing nobody tells you. You can say no. When the grown-up says “I think we should do this test,” you are allowed to ask, “what happens if we wait?” You are allowed to say, “no thank you, not today.” You are allowed to leave with a scraped knee and nothing else.
References
The prospective study at a Level I trauma center identifying 38 percent (416/1,097) of CT scans as defensively motivated, with associated radiation exposure of 8.8 mSv per patient and a 2.2 percent management-change rate, is documented in Unbekoming, The Screening Trap, v1.0, 2026, chapter on CT scan overuse. The $501 million annual estimate for defensive CT imaging in the United States is drawn from the same source, which synthesizes figures from Mello MM, Chandra A, Gawande AA, Studdert DM. “National Costs of the Medical Liability System.” Health Affairs 2010;29(9):1569–1577.
Smith-Bindman R, Miglioretti DL, Lacson R, et al. “Projected Lifetime Cancer Risks From Current Computed Tomography Imaging.” JAMA Internal Medicine 2025. The study projects approximately 103,000 future cancers from the 93 million CT scans performed in the United States in 2023.
On geographic variation in physician test-ordering tracking liability climate: Kessler DP, McClellan M. “Do Doctors Practice Defensive Medicine?” Quarterly Journal of Economics 1996;111(2):353–390; Kessler DP, McClellan M. “How Liability Law Affects Medical Productivity.” Journal of Health Economics 2002;21(6):931–955. On the specific effect of Texas tort reform (enacted 2003) and subsequent damage cap analysis: Paik M, Black B, Hyman DA. “The Receding Tide of Medical Malpractice Litigation: Part 2, Effect of Damage Caps.” Journal of Empirical Legal Studies 2013;10(4):639–669.
Studdert DM, Mello MM, Sage WM, et al. “Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment.” JAMA 2005;293(21):2609–2617. The study surveyed physicians in six high-risk specialties in Pennsylvania; 93 percent reported defensive practice, and 43 percent reported imaging used in clinically unnecessary circumstances.
National Cancer Institute, “Prostate-Specific Antigen (PSA) Test,” cancer.gov. The 16 percent lifetime probability of diagnosis and 3 percent probability of mortality figures are the standard reported values. Autopsy data on indolent prostate cancers: Bell KJL et al. “Prevalence of incidental prostate cancer: A systematic review of autopsy studies.” International Journal of Cancer 2015;137(7):1749–1757.
American Society of Anesthesiologists Closed Claims Project data summarized in Unbekoming, Before You Go Under, v1.0, 2026, chapter on the consent gap and the standard of care. Original source: Domino KB, Posner KL, Caplan RA, Cheney FW. “Awareness during anesthesia: a closed claims analysis.” Anesthesiology 1999;90(4):1053–1061. Additional Closed Claims data on standard-of-care judgments and payment patterns from the ASA Closed Claims Project as documented through the early 2000s.
The circular logic of standard-of-care doctrine and the self-referential definition of negligence-by-deviation is analyzed in detail in Unbekoming, Before You Go Under, v1.0, 2026, chapter on the closed claims ceiling. The argument applies generally across surgical specialties.
Incidentaloma rates and associated downstream costs documented in Unbekoming, The Screening Trap, v1.0, 2026, drawing on Berland LL, Silverman SG, Gore RM, et al. “Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee.” Journal of the American College of Radiology 2010;7(10):754–773. Lung cancer screening false-positive rates: Croswell JM et al. “Cumulative incidence of false-positive results in repeated, multimodal cancer screening.” Annals of Family Medicine 2009;7(3):212–222.
GBD 2019 Antimicrobial Resistance Collaborators. “Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis.” The Lancet 2022;399(10325):629–655. The report attributes approximately 1.3 million deaths directly and 5 million deaths in association with antibiotic-resistant bacterial conditions.
Tuncel A, Toklu H, Belenli O, et al. “The impact of transrectal prostate needle biopsy on sexuality in men and their female partners.” Urology 2008;71(6):1128–1131.
Fang F, Keating NL, Mucci LA, et al. “Immediate risk of suicide and cardiovascular death after a prostate cancer diagnosis.” Journal of the National Cancer Institute 2010;102(5):307–314. Discussed in Unbekoming, The Screening Trap, v1.0, 2026, and in Unbekoming, The PSA Trap, 2026.
Postpartum thyroid cascade documented in Unbekoming, Medicalized Motherhood, edition 1.0, 2026, chapter on postpartum screening. See also Stagnaro-Green A et al. “Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum.” Thyroid 2011;21(10):1081–1125, for the conventional clinical pathway.
Lee CI et al. “Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks.” Radiology 2004;231(2):393–398. The 15 percent / 84 percent and 9 percent figures are widely cited and appear in subsequent surveys of academic medical centers.
Caoili EM et al. “Patients’ knowledge and perception of CT scan radiation risks.” American Journal of Roentgenology 2014;202(3):W232–W237. The 78 percent / 20 percent physician-patient recall gap is documented in emergency department settings and is broadly consistent across studies of CT consent.
Federman DG, Goyal S, Kamina A, et al. “Informed consent for PSA screening: does it happen?” Effective Clinical Practice 1999;2(4):152–157.
Hersch JK, Nickel BL, Ghane A, et al. “Resisting recommended treatment for prostate cancer: a qualitative analysis of the lived experience of possible overdiagnosis.” BMJ Open 2019;9(5):e026960.
Australian and New Zealand College of Anaesthetists. PS26(A) Position Statement on Informed Consent for Anaesthesia or Sedation. Melbourne: ANZCA; 2021. The thresholds and standards quoted are from the publicly available document.
Post-operative cognitive dysfunction (POCD) prevalence figures and the disclosure gap are documented in Unbekoming, Before You Go Under, v1.0, 2026, drawing on Li LY, Staffaroni AM, Whitlock EL. “Subjective Cognitive Complaints and Anecdotal Descriptions of Postoperative Cognitive Decline: Missing Pieces of the Postoperative Neurocognitive Disorder Puzzle.” Advances in Anesthesia 2024;42(1):27–40; and Moller JT et al. “Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study.” The Lancet 1998;351(9106):857–861.
Lenzer J. “Majority of panelists on cholesterol guidelines have current or recent ties to drug industry.” BMJ 2004;328(7452):8. See also Abramson J, Wright JM. “Are lipid-lowering guidelines evidence-based?” The Lancet 2007;369(9557):168–169.
Campbell EG, Weissman JS, Ehringhaus S, et al. “Institutional academic-industry relationships.” JAMA 2007;298(15):1779–1786. The two-thirds figure for medical school department chairs holding industry relationships is widely cited and is documented in Unbekoming, The Architecture of Deception, v1.0, 2026.
Casalino LP et al. “External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases.” JAMA 2003;289(4):434–441. The broader literature on the shift toward physician employment and productivity-based compensation in American health systems is extensive.
Goldman Sachs Equity Research, Salveen Richter. The Genome Revolution. Industry note, April 2018. The “sustainable business model” question and the report’s analysis of revenue arcs for curative therapy are widely cited; the document was subsequently the subject of multiple public commentaries. Discussed in detail in Unbekoming, Chronic Conditions, v1.0, 2026.
Specific patient phrases for documented refusal adapted from the patient toolkit in Unbekoming, The Screening Trap, v1.0, 2026.
When the House of Commons was debating how much to increase the time limit for detention without trial the question of torture came up. Officially this was limited to the nice considerations of whether it was all right to send people to places where torture is used and whether Britain can use information collected by the use of torture in other countries. This discussion gave an impression of democratic Britain as the home of civilised behaviour where the very idea of torture is repugnant to our legislators – unlike, say, the US with its secret CIA jails… In reality, the British state has a long history of using and developing a whole range of torture techniques. … continue
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