As the country moves from Joe Biden as the anti-Trump option to Joe Biden as leader of the free world, I’ve been thinking about how things might change in medicine, media and technology under his administration.

I want to drill down on this idea of censorship and content moderation which became a thing during the 2020 election. It’s become normalized on some level. And it’s something that we all need to think about as citizens and health professionals who create and consume information.

Social media as mainstream media

A moment on the recent evolution of the media.

Let’s start with the fact that social media platforms have become the new mainstream media for many of us. A 2019 Pew Research survey found that 55% of Americans report getting their news from social media — up from 44% in 2016. 18% of Americans identify social media as their primary source of information with Facebook as their site of choice. Not so surprising.

And back when print and broadcast media had sole responsibility of delivering news, it bore the obligation of delivering information in a way that was objective (this has gone off the rails with cable news). But in the process of social morphing into the mainstream, social media platforms never took the baton on this traditional responsibility. Since their inception they’ve seen themselves as providing nothing other than a comfortable playground for all of us. Moderation was a dirty word. It was believed that the wisdom of the crowd would somehow sort things out. It absolved them from being accountable.

In fact, the policing of health information in the early years of Twitter was seen as the collective moral responsibility of doctors and health professionals. And it was something a lot of us enjoyed. But policing presidents, political PACS and Russian trolls is a whole other deal.

The social media ecosystem came into its own during the 2016 election when Facebook’s lack of oversight was blamed for Donald Trump’s victory. But the tables have turned. Moderation, once not a thing, is now everything. In fact, during the 2020 campaign Twitter and Facebook’s response to political messaging has lead to allegations of censorship and political bias.

Moderation – Born during the 2020 presidential campaign

Part of this move to moderate stemmed from pressure to control the wild Twitter gyrations of President Donald Trump — Something, it seemed, had to be done. So they did – we saw the flagging and censoring of Tweets believed to contain misinformation and abusive stuff. What’s important here is that with this Facebook and Twitter set a new precedent. And with this high profile moderation they have nominated themselves the arbiter of truthiness going forward. The pickle is that they can’t walk it back.

To me this is good and bad.

To eat the dog food, I’ve been hollering for the moderation of anti-vaxxers for years. The pediatricians fighting the socially organized anti-vaxx movement a decade ago begged Twitter for help (here’s me in 2008 trying to break Jenny McCarthy). We had no faith in the wisdom of the crowd and media literacy didn’t exist. Clamoring for moderation seemed like the right thing.

But this level of control comes with a cost.

What’s the cost? Look at what happens when Harvard and Stanford scientists raise questions about the prevailing approach to COVID. Their call for dialog was initially banned by Google as it didn’t meet the singular view of COVID policy. You can disagree with the Great Barrington Declaration but you can never disagree with the importance of doctors and scientists and health policy experts sitting together to discuss ideas. As it turns out the conversations spawned by this very statement in places like Johns Hopkins Bloomberg School of Public Health and even in JAMA media show that critical conversation is part of our social and scientific emergence around COVID.

The climate of social media has trained us to see the world in the binary. We are this or that, zero or one. But when you listen to the Johns Hopkins Bloomberg debate on John Snow and Great Barrington you can see how epidemiologists handle nuance, compromise, and tradeoff. This is how the world of science and medicine works. This is what’s missing. We need more opposing dialog, not less. 

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Then there is section 230

But we may be inching toward deeper regulation of public discourse.

A little background: Until now internet companies have enjoyed protection from liability under Section 230 of the Communications Decency Act — the foundational law that says online platforms aren’t liable for things their users post on them, with some exceptions. BUT, while considered central to the modern flow of information on public platforms, this protective law may go the way of the hula hoop.

As part of this evolution of social media into mainstream media and now public utility, there have been a number of legislative proposals in the U.S. Senate to amend Section 230. But the president-elect has suggested that Section 230 should be entirely revoked. And with that, companies like Google, Facebook and Twitter should be held responsible for what appears on their platform. This is one of president-elect Biden’s few recorded opinions on Section 230 from a December 2019 New York Times Interview:

Section 230 should be revoked, immediately should be revoked, number one. For Zuckerberg and other platforms….It should be revoked because it is not merely an internet company. It is propagating falsehoods they know to be false, and we should be setting standards not unlike the Europeans are doing relative to privacy. You guys (referencing the New York Times editor conducting the interview) still have editors. I’m sitting with them. Not a joke. There is no editorial impact at all on Facebook. None. None whatsoever. It’s irresponsible. It’s totally irresponsible.

It’s unclear whether Joe Biden is blown’ steam here or if it represents a hard-line position that will spell change for all of us. It’s hard for me to imagine that Facebook, Twitter and Google will ultimately be exposed to civil damages for tweets and search results.

Trump’s view on this is less important than Biden’s since he’s been shown the door. But in August 2019, he penned an executive order that would require the Federal Communications Commission to limit Section 230 protections. But, as described by Casey Newton when he was at The Verge, …the White House seemed to lose interest in the order, and it was tabled until May 2020 when a feud with Twitter brought the order back into active consideration.

This position of Joe Biden, however, is potentially a big deal and it got little attention during the campaign

Truth moderation as a politically motivated fad

Gilad Edelman in Wired suggested that this new precedent of truth moderation will just go away after Trump is gone.

So, even if the companies don’t change anything at all after today, I still think the problem of disinformation is going to at least seem less urgent—to the broader public and the political press, if not to the researchers, activists, and journalists specifically focused on it—starting in a few months..

I’m skeptical. This move to massage the prevailing narrative is bigger than putting a digital muzzle on the President. The genie is out of the bottle with respect to moderation and everyone’s going to be holding Twitter accountable for their own brand of truth.

My skepticism is supported by a clear trend toward truth moderation happening in other places. Editorial macromanagement among the mainstream media (the old mainstream media, that is) reflects rising intolerance for opposing views. To understand how this works read about the experience of Bari Weiss and the recent exit from her editorial position at the New York Times. Weiss, who is a centrist with strong anti-Trump views, was forced from the paper over her failure to goose step in time with the Gray Lady’s ideological monoculture.

Weiss remarked on Twitter,

A new consensus has emerged in the press: that truth isn’t a process of collective discovery, but an orthodoxy already known to an enlightened few whose job is to inform everyone else.

For a deeper dive into the ideological homogeneity eating America’s newsrooms from the inside, New York Magazine Intelligencer has a solid overview.

And activism isn’t just limited to newspapers.

There’s also the emergence of the medical mob in the filter bubble that has become medtwitter. Mobtwitter, as coined by Dr. Vinay Prasad, has created the frightening belief that we can we can adjudicate our differences with coordinated cancel tactics, intimidation and bullying. We saw this groupthink-gone-wild with MedBikini as well as the tragic outcome of two young Korean emergency physicians working to battle endemic sexism.

How do you moderate truth?

How do we balance the mitigation of medical misinformation with our ability to express concern or participate in meaningful scientific debate?

Thought experiment: During our process of understanding COVID in the months ahead, what happens if some piece of contradictory knowledge is discovered? What if a scientist or citizen scientist legitimately identifies a weakness in a New England Journal of Medicine study concerning an established COVID containment strategy. Is this public discussion prohibited if Jack Dorsey considers it a threat to the prevailing policy and, ultimately, the public well-being? Perhaps it could be adjudicated through Mark Zuckerberg’s new kangaroo court.

These kinds of questions about accuracy and truth can go on and on. And I’m not sure we will ever really get ahead of them. The control of medical mis/disinformation needs attention but how we do it is frighteningly complex.

More speech and the dual responsibility of media

And is this really Jack Dorsey’s burden to figure out?

Tom Standage in Writing on the Wall suggests that those in authority always squawk, it seems, when access to publishing is broadened. But Supreme Court Justice Brandeis suggested that the solution to any bad speech is more speech, not forced silence. This follows from the earliest social media wisdom I received about health information and reputation management: the solution to pollution is dilution (credit to Andy Sernovitz).

Rather than trying to control information perhaps efforts should focus on how citizens process and consume information. I have suggested that there is a dual responsibility around media – the responsibility of those who create it and the countering duty of the consumer. We have some duty to understand our sources of information. As I told my patients during the earliest days of the internet: With great access comes great responsibility.

As we’ve seen during our brief journey with COVID, science is a process of iteration, challenge and discovery. Unfortunately it’s been packaged, sold and exploited as a politically motivated, black-and-white enterprise with boundaries that must be obeyed in the public commons. To not obey the prevailing orthodoxy is to face censorship. But the scientific process and scientific communication will never thrive in the face of editorial or legislative tyranny.

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