Tuesday, May 30, 2006

Questions raised by firing of CMAJ editors

Heated discussion continues about the Canadian Medical Association Journal (CMAJ) since my post May 20. The bitter dispute between the journal owners and the editors raises fundamental questions.

What should a medical journal strive to be?
As pointed out in this BMJ editorial from several years ago a journal’s niche could occupy any point on a broad spectrum, “from being like Brain, a forbidding, research based journal, to Cosmopolitan, a magazine full of froth and colour.” But such a niche needs specific definition. Confusion results when a journal tries to be too many things. Therein lies part of the problem at CMAJ. The journal should define what it intends to be---a scholarly research journal, a medical news magazine or a political rag. It can’t be all those. Who, for example, would think of publishing peer reviewed research in Medical Economics?

What is the appropriate role of an editor?
Perhaps that depends on the type of journal in question. If the journal purports to be a scholarly scientific publication the editor should be objective, neutral and “disinterested.” There should be no social or political agenda and no personal bent that might bias the selection or editing of articles. Dr. John Hoey, though, seems to have other ideas. In the May 11 NEJM piece in which he recounts his firing from CMAJ he writes that “the defining characteristic of an editor is quixotic idealism….” Quixotic idealism? Well, whatever that means it sounds anything but objective or neutral. Concerning the attributes of an editor he writes that “An eager propensity to poke a stick into something or somebody is also useful.” Useful, perhaps, for The American Spectator.

What is editorial independence and are there limits?
Dr. Hoey’s absolute notion of editorial independence amounts to a lack of editorial accountability. But editorial independence must be balanced against accountability. In a May 23 piece in CMAJ the interim editors write “Editorial independence should not confer immunity from accountability.” In that same article the authors note that the World Association of Medical Editors (WAME), which Hoey cites in defense of his views, has reconsidered the concept of editorial independence. Indeed, in its May 15 2006 revision, the section titled "Editorial Independence" has been retitled "The Relationship Between Journal Editors-in-Chief and Owners."

Is Hoey’s concept of absolute independence realistic? As pointed out in a recent Lancet editorial on this matter “The CMA might legitimately argue that they should not be saddled indefinitely with an editor whose policies and perspectives were not in keeping with its own views. The publisher of The Economist might not hire the editor of The Nation, and vice versa. So what is the voice that should be reflected in a journal owned by a medical association?” Consider the American Medical Association and its lobbying efforts for tort reform. Suppose the editor of JAMA, the AMA’s general medical journal, wrote and selected articles predominantly in opposition to tort reform. Would it be appropriate for the AMA to intervene? It would in such political issues where the membership had a stake, as opposed to purely scientific questions in which detached neutrality is essential. The only way to avoid such a conflict is to avoid mixing political commentary and science in the same journal.

What are the risks of political influence in a scholarly scientific journal?
Science influenced by any sort of agenda is biased and corrupt. I have given examples in the pages of this blog here, here and here. Orac gives an example here. Scientific discourse differs so fundamentally from political debate that the two are hardly compatible. The former involves objective discussion between disinterested parties while the latter involves impassioned contests between those with competing interests, with participants bolstering their positions according to their own biases. But as I posted on May 20, Hoey seems to have no problem mixing scientific inquiry with politics.

Should there be a demarcation between scientific reporting and other content such as journalism and political commentary?
Although the essential importance of demarcation should be self evident, not all agree. Another Lancet editorial on the firing said “To distinguish between a journal's responsibility to publish peer-reviewed research and investigative journalism is false.” But all sorts of problems emerge when the distinction is not clear. As the same Lancet editorial points out, “According to the CMAJ, the journal's publisher ordered a news article containing a survey of women's experiences of trying to obtain the Plan B morning-after pill (levonorgestrel) to be withheld, after receiving a complaint from the Canadian Pharmacists Association. The CMA's withdrawal request was justified on the grounds that the survey of women's experiences constituted scientific research, rather than journalism, and the editorial team should therefore have sought ethical counsel and peer review of the article.” Jerome P. Kassirer and others in this CMAJ editorial disagreed with “Contrary to the claims of the CMA that the Plan B article could be construed as a scientific study and was subject to all the requirements of such an investigation, in the opinion of the Committee, the report (both as it was intended to be published and as it eventually appeared) does not meet the definition of 'research' as understood in medical science.” Though the informal survey of women seeking emergency contraception was not research these comments indicate that the point was in dispute. The distinction was blurred, and one of the essential points of contention between the publisher and the editors was whether it did in fact constitute research. Perhaps a clear distinction would have averted the crisis.

Are there solutions?
Political debate, medical journalism and rigorous scientific reporting, each of which has an important role, are best played out in separate venues. This not only avoids confusing the different forms of writing but also minimizes conflicts of interest by keeping politics and personal bias at arm's length from scientific inquiry. Structures are already in place to accomplish this. Most professional societies have companion publications which serve separate purposes. I’ll draw an example from my own specialty organization, the Society of Hospital Medicine, which has just launched its scientific journal, The Journal of Hospital Medicine. It is a pristine, scientifically rigorous publication devoid of politics, self-promotion or items of personal or economic interest to hospitalists. The Society’s companion tabloid style publication, The Hospitalist, contains all those things. That’s just fine, because it makes no pretense at being a scholarly scientific journal.

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