It's all about the money for these companies, and pretending otherwise is insane.

I have been to a lot of biotech conferences — and I mean a lot: regional investor summits, awards dinners with seafood buffets and tepid sauvignon blanc, regional “innovation” days where every podium is an altar to a near-future cure, and the big predictable circuit (Biotech Showcase, JPM, and the rest). At every one of these, in the same voice that once delivered the pledge of allegiance, someone somewhere — usually, but not always, wearing a pocket square and an investor-grade smile — will pause between slides and deliver the line as if it were the weather report: “We are the good guys.”¹ The line is meant to short-circuit all further thought; it is a moral catchall, a PR talisman, the equivalent of saying “bless you” after a sneeze and expecting that to be the end of contagion.

The Illusion of Mission

To be clear — this is not a sermon about villainy. I am not accusing pharma executives of night-time plotting. The problem is more structural: these entities exist within capitalism, and incentives mold their behaviors. There is a small army of appendices and caveats that executives will cite — the cost of clinical trials, the need to amortize risk across dozens of failed candidates, the sanctified R&D budget lines that supposedly justify a $30,000 list price for a year of drug X — and to some extent those things are real. Look at the oft-invoked DiMasi estimates, which place the cost of bringing a single new molecular entity to market in the ballpark of billions once you account for failures and time costs.² Yet those numbers themselves are contested, opaque, and rife with assumptions that favor the existing order. Even granting their premises for a moment, one empirical pattern is hard to ignore: much of pharmaceutical capital flows not into radical cures, but into protecting incumbent revenue streams — reformulations, “me-too” molecules that secure new patent life, branding, marketing, payer maneuvers.³'⁴

That is how rhetoric becomes function rather than conviction. The “we save lives” line soothes boards, placates regulators, reassures patients, and keeps consumer backlash just shy of policy revolt. It is performative: the copy that overlays spreadsheets, the tagline that accompanies soft music and smiling families. But if you trace the money, the choreography becomes clear. Take insulin, for instance: under political pressure, major manufacturers announced list-price cuts and capped patient costs in 2023 — superficially a moral pivot. But behind that press release lies decades of structural entrenchment: negotiations with states, safeguards for margins, strategic adjustments to preserve profitability elsewhere.⁵'⁶ The message sent is both true and deceptive — a dual narrative that grants relief to some while preserving systems unchanged.

Incentives and Innovation

The question of which drugs get made is the question of which incentives are rewarded. Should a company bet on a disruptive cure or a low-risk follow-on that lands in a known market? The latter frequently wins — because investors, boards, and executives optimize for predictability. Thus many recently approved drugs are not first-in-class breakthroughs but marginal variants of existing therapies; clinical value can be incremental but market return is safer. (See for instance the analyses of “me-too” innovation in pharmaceutical markets.)⁷'⁸

Meanwhile, the abstraction of “the patient” is ever present as rhetorical figure but seldom present in operational matrix. The lived experience — someone forced to choose between rent and a refill — is not a spreadsheet dimension. Patient assistance programs often appear as moral offset, but they are carefully engineered business instruments: narrow in reach, tied to brand loyalty, and often baked into pricing models themselves.⁹'¹⁰ Patients benefiting from safety nets become amortized components of a pricing ecosystem. And the marketing engine — blockbuster sales forces, physician outreach, key opinion leader (KOL) dinners, sponsored education — plays a heavy role in shaping adoption. Sometimes the marketing spend in a year exceeds the R&D budget, a fact that complicates the narrative that high pricing is purely about paying for science.¹¹'¹²

The Absorption of Idealism

Every biotech founder I’ve met (and I mean every single one, with rare exceptions) begins with idealism: the itch, the curiosity, the desire to fix something broken. Some small labs operate in nonprofit mode or with mission-first charters. But as they scale, the external logic of the market exerts its gravitational pull. The founder’s idealism becomes a line item on a term sheet: will the asset move quickly enough? Will it fetch a favorable valuation? Can you design a business model around it? The compromises often multiply. And once a company becomes a public entity, the moral calculus is subsumed by quarterly guidance, margin expectations, and investor optics.

So we arrive at a kind of tragic conformity: idealism, when scaled, folds into the monetary constraints. Some actors resist; some fall back on rhetorical shields. But the architecture of incentives rarely accommodates sustained deviation. The deeper lie is not that pharma is greedy, but that it convinces itself — and us — that it is not.

Toward Honest Medicine

What would honest medicine look like? For one thing, it might begin with candidness. A company could say: “We develop and sell treatments. We want to help patients, but we also have obligations to shareholders.” That admission, as blunt as it sounds, might generate more respect than the customary veneer of salvific mission. It would force more rigorous discussion of tradeoffs, distribution, and access.

But honesty alone won’t rewire incentives. Structural reforms are needed: stronger public investment in early-stage platforms, push–pull models that reward high societal value therapies, regulation to tighten transparency around pricing and rebate flows, and enhanced negotiating power for payers and national health systems. These ideas are not new, nor are they frictionless, but without them the industry continues to operate as a closed loop in which moral branding masks deep structural status quo bias.¹³

I don’t pretend this critique is wholly original — policy scholars, investigative journalists, and health economists have been mapping these dynamics for years. But what still surprises me, after all these conferences and all that soft lighting and earnest mission statements, is how completely the public language conceals the arithmetic, how ever-present the moral rhetoric is even as incentives do the heavy lifting behind the scenes. The next time someone at a biotech event declares “we are the good guys,” listen not just for the applause, but for what is not said: the spreadsheets, the margin requirements, the timeline pressures, the long quiet calculations that turn compassion into cash flows.

If nothing else, perhaps we can demand a more mature discourse — not one that shames pharma for profit per se, but one that refuses to allow profit to appropriate the language of altruism with impunity. Because medicine is supposed to heal, and capitalism is supposed to grow, and sometimes the intersection of those two is a fault line. Pretending otherwise softens the tension; calling it by name demands accountability.

Footnotes