Journal Of Community Medicine, Vol 2, No 2, July-Dec 2006, p48-54.

Issues of Editorial Independence, the Recent CMAJ Crisis, and the Medical Community

Ajai R. Singh

Most of you are aware of the rather sorry spectacle witnessed recently in which a leading biomedical journal from Canada was involved. One fine morning in February this year, the Canadian Medical Association Journal (CMAJ) found itself without an editor. No warning, no intimation. Just a letter on the table saying he was sacked. The letter was from the President of CMAJ Holdings, a company set up by the Canadian Medical Association to manage publishing activities in the journal:

On February 20, 2006, when John Hoey, editor-in-chief of the Canadian Medical Association Journal (CMAJ), returned to the Ottawa headquarters of the Canadian Medical Association (CMA) after a vacation, his journal was in excellent shape. It ranked as the fifth leading general medical journal in the world, and it received more than 100 original research papers per month, allowing the editors to be highly selective in what they published. It had nearly 70,000 subscribers — representing the more than 85 percent of Canadian doctors who are CMA members. Yet Hoey's decade as editor would end abruptly that afternoon when the journal's publisher fired him and his senior deputy editor, Anne Marie Todkill. (1)

The editor, John Hoey, was not sacked for any editorial misconduct, or for any dereliction of duty. The journal was doing pretty well under his stewardship of nearly a decade.

John Hoey, in nearly a decade at the helm (he was hired in August 1996), brought CMAJ from a modest journal to one whose impact factor is today fifth in the world of general medical journals, only less than that of the NEJM (38.6), JAMA (24.8), Lancet (21.7) and BMJ (7.0). He brought it from an impact factor of 1.6 in 1997 to an impressive 5.9 in 2004. (2)

Something similar had happened with the JAMA in 1999 when the then editor, George Lundberg, found himself sacked one fine morning after heading the premier journal, also for well over a decade (nearly 17 years). The letter emanated from the Executive Vice-President of the AMA.

Why was he sacked?

He was sacked because he fast tracked an article on college students' perception whether oral sex constituted sex. A predominant section, 59%, felt it did not. Now this coincided with the Bill Clinton-Monica Lewinsky episode, for which the Republicans wanted to impeach the President. And the publication of such a report in a prestigious Journal like the JAMA may have acted to blunt the opposition. The AMA, which owns the JAMA, predominantly supported the Republicans. Such a fast track publication by the powerful Editor was thought to be a political move by the Association Office bearers. Although it was peer reviewed and accepted for publication in a proper manner. But the fact that it was fast tracked to coincide with this episode was enough to precipitate the sacking. And no amount of outcry that the Journal fast tracked not for any other reason but that it was topical convinced the Association to change its stance. (2)  

A huge outcry followed, in the light of which a committee appointed deliberated over issues and set up a Journal Oversight Committee (JOC) and also adopted an Editorial Governance Plan for JAMA (3, 4). While the JOC was meant to act as a buffer between the Editor and the Publisher, the Editorial Governance Plan was expressly put into place so that editorial independence would be ensured. Issues of Governance and redefining of trust have been discussed in its wake (5). The WAME too has a write-up on editorial independence, revised recently in the light of the CMAJ issue (6).

The CMAJ itself is in the process of setting up its revamped JOC. (It already had one at the time of the crisis, but was skewed towards Association interests.) It has also set up an Editorial Governance Review Committee under a retired Chief Justice of the supreme court of Canada to look into and recommend on issues of editorial independence and governance. As the interim editors at CMAJ mention:

The crux of this interim period is the formation of a governance review committee chaired by former Chief Justice, the Rt Honourable Antonio Lamer, with Dr. John Dossetor, CMAJ ombudsman–ethicist, as vice chair. In the meantime, the CMA has agreed to an interim governance program (www.cmaj.ca/pdfs/governance.pdf) that reflects the structure and processes developed at JAMA after Editor-in-Chief George Lundberg was dismissed in 1999. (7)

Meanwhile, the CMA has assured full editorial independence, and the interim Editor and Editor Emeritus have agreed to continue to work only if there is no editorial interference from the publishers and the Association:

…we are assured by CMA and CMA Media that we will have complete editorial independence. (7)

Why Should It Matter To You?

Why must you, a member of the medical community in far away India, know all this?

Because Journals may be published in any country, and be owned by any Association or publisher. But they belong to the whole world in so far as communication of biomedical advance is concerned. Because Journals are an important source of information about recent advances in your branch. Because an independent editor will ensure you get the recent advance uncluttered with other, extra-scientific, considerations.

Some of you may think it is a private matter between an employer and an employee. In response to this viewpoint, please consider the following:

Some of you may feel this is not an issue for us to discuss at all.  It is only a private matter between an employer and an employee. We beg to differ. This will be the argument of any employer who holds the cards, and would want to regulate the game. For long have we believed that he can.

It is not only a private matter between an employer and an employee. The product of this employer-employee interaction is scientific knowledge and research advancement, which are of great importance to society. Hence, let us realise that it is really speaking a matter of scientific concern, biomedical advance, ethical conduct, and editorial independence.  For all of which we toil day in and day out. Our unequivocal stand will have far reaching ramifications if we do not allow our minds to be paralysed by analysis of subsidiary concerns. (2)

Journals and Journal Editors perform a tight-rope walk. On the one hand, they must present the most rigorous scientific studies that forward patient welfare. On the other they must not appear to trample upon Publisher/Association interests: for they own, and often sustain, them. At times, in trying to forward the former, they may enter into conflict with the latter. What do we do in such matters is a crucial issue.

Consider things from the point of view of the ordinary members of the medical community. Both these are of great concern to them. They want both scientific evidence/patient welfare to be ensured, as well as Association interests to be furthered.  They would not want these to come in conflict at all. Or if they do, to be resolved amicably so that both patient welfare/scientific evidence and Association interests get forwarded.

While the feeling is understandable, it is easier said than done. And lest you feel this is not an issue, consider what prompted the two dismissals we discussed above.

We saw what happened at JAMA. Let’s look at CMAJ.

What Prompted the Dismissals?

Hoey was dismissed because he published an investigative report on a morning after pill, levonorgestrel, which was made available OTC ostensibly for patient interest but involved a stiff consultation fees to be paid to the dispensing pharmacist for counselling.  Moreover, the patient was supposed to disclose confidential information with regard to her identity. (2, 8) CMAJ’s medical reporters found obvious resentment to both and wanted to put it into print. The Chemist Association objected, for obvious reasons. They pressurized the CMA to retract the story. The Association intervened, and wanted the editor to withdraw the story. The editor refused. Ultimately, a considerably scaled down story was published, and the Chemist Association had also to be granted a say.

The Editor earlier acquiesced, but later reported it in the journal as an example of editorial interference. (This has been removed from the CMAJ site at present for obvious reasons. Even articles citing it have no links to the original article.)

The Association bosses were obviously incensed.

The editor asked an Ad-hoc Committee of the Editorial Board to review a series of recent events that he asserted compromised the editorial independence of CMAJ. Amongst many other things, this is what they reported:

We find fault with the willingness of the editorial team to respond to pressure from the CMA by modifying a report slated for publication in the journal. We also fault them for failing to follow appropriate channels of protest, namely through the Journal Oversight Committee (JOC). We find far more serious fault, however, with the CMA for blatant interference with the publication of a legitimate report.

The documents prepared by the editors outline how CMA, acting through senior management of CMA Holdings, the journal's present owner, violated the journal's editorial independence through its censure of the Plan B article. The editors rejected as both incorrect and spurious the claim that the article did not meet acceptable standards for publication in the journal.

The Committee fully endorses the editors' argument that the objections raised by the CMA obscure the essential facts of the conflict, namely that the CMAJ attempted to publish material that, as it happened, was politically awkward for the CMA, and that the CMA attempted to suppress the publication of that material and, to an important degree, succeeded. (9)

The committee also reported on the scaled down version of the Plan B report published, coming down on the Editor for catapulting, but more on the Publisher for making him do so:

A violation of editorial independence. The interference of CMA/CMAH with the Plan B story was a clear and overt infringement of editorial independence. It is a blatant example of editorial interference — the first time that the current editors had ever been instructed to pull a story. Moreover, although the Plan B story was not entirely suppressed, the version that was published on Dec. 6, 2005, was not the story that the journal set out to publish; the pressure exerted on the editors resulted in a "sanitized" version from which the direct testimony of individual women was expunged.

5. Response of CMAJ's editors. The response by the editors, in our view, was inappropriate. Rather than agreeing to modify the text of the article, the editors should not have capitulated to such an inappropriate demand. Faced with this unreasonable demand, the editors should have appealed immediately to the JOC, which, in theory, is responsible for preserving CMAJ's editorial independence. ⁽⁹⁾

Matters came to a head when the Journal wrote less than charitably about the new health minister, who wanted to privatize medical practice on a large scale. That was of obvious benefit to the medical practitioners, and the Association which represented them, but was not for patients who would have to pay heavy sums for medical help as a result. The Journal questioned this move. Since the Journal occupies a prestigious place in the biomedical community and is an opinion maker, the Association was further angered. Such writing hurt the financial interests of its members, and moreover, compromised its equation with the ruling political party, specifically with the new health minister. The Ad hoc Committee also noted this as an example of editorial interference:

Further incursion on editorial independence. As this report on the Plan B commentary was being finalized, we became aware through a communication of the Canadian Health Coalition that another news story published electronically on Feb. 7, 2006, was subsequently removed from the CMAJ Web site (online Appendix 1, www.cmaj.ca/cgi/content/full/174/7/945). The article was a report on the appointment of the federal Minister of Health by the new Conservative government. It pointed out the health minister's favourable stance toward privatization of health care delivery during his tenure as the Minister of Health for Ontario. On Feb. 22, 2006, a different report on the federal Minister of Health appeared in the original's place (online Appendix 2, www.cmaj.ca/cgi/content/full/174/7/945). Though the revised article contains some of the same phraseology as the original, it is more supportive and less critical of the health minister and seems more beneficial to the CMA. We pose the question as to whether the extensive revision of this article is another instance in which the political interests of the CMA exerted an influence on CMAJ publishing decisions. Some days before the firing of the editor in chief and senior deputy editor, the JOC was informed about a disagreement concerning the original Tony Clement article, but the JOC turned down a request for an emergency meeting. The editors are not willing to comment on how the changes came about; the publisher has also declined comment. (9)

It is worth noting that the two Appendices mentioned in the quote above are not traceable on the website on this date (July 13, 2006). Why, is anybody’s guess.

For quite some time before this, the Association office bearers were being given a harrowing time by the independent attitude of the Editor who was bent on exposing wrong wherever he saw it. It was, as though, the Editor, and the journal, had gone out of control. The Association was waiting to clip its wings. Furore over the Plan B article and probable displeasure of the political bosses served as the last straw.

Summary dismissal was the method adopted. Knowing how the clamour would cease after a while, as it had in the earlier JAMA case, the Association bosses probably felt they could get away with it.

All is hunky dory as long as the Editor does not take his job too seriously. In other words, is prudent enough not to tread on powerful toes. But if and when he does, for whatever reasons, howsoever justified, he gets the pink slip, no explanations given. This, incidentally, sends a strong signal to other editors to start toeing the line, or face the axe. Most do the former.

The first casualty in such cases is editorial independence.

In the wake of the outcry following this at journals like the BMJ (10), The Lancet (11), MJA (12) and write-ups at WAME (13), ICMJE (14) [and I can share some of the blame for writing rather relentlessly in the WAME Editor’s list serve, at MSM (2), as well as at other places (15-19)], the Association office bearers ultimately relented. They agreed to have a revamped JOC, and an Editorial governance plan for editorial independence; and the CMA President publicly declared they were committed to it:

 In addition, interim governance guidelines confirming editorial independence at the CMAJ are in place, and a panel chaired by a former chief justice of the Supreme Court of Canada, Antonio Lamer, and cochaired by the CMAJ's ombudsman–ethicist, Dr. John Dossetor, reviews the governance structure of the journal. This panel will issue its report shortly. (20).

Some solace in a rather murky state of affairs.

However, the editor lost his job, as did many who resigned in support. The Association President acknowledged his contribution but cited irreconcilable difference to account for the sacking:

The fact is, the relationship between the CMAJ’s editorial leadership and its publisher had reached an impasse. A very productive 10-year relationship, one of the longest CMAJ has had with an editor in its 95- year history, had become a case of irreconcilable differences. (21)

What were the reasons for the irreconcilable differences? Not given. As Hoey himself asks:

The CMA gave no reasons for the firings other than, initially, to "freshen" the CMAJ and, later, for "irreconcilable differences" (so far unspecified) between me and the CMA. (22)

Well, one can only guess that the independent and disconcerting attitude of the editor must have been a major thorn in the flesh.

Different Agendas

Associations and Publishers have agendas different from Editors. They want to ensure financial and other viability issues. Editors have to consider research and scientific credibility issues. Actually, when both complement each other, a quality journal is ensured. When they work at loggerheads, all hell breaks loose, as happened recently at the CMAJ.

How do we ensure that they complement each other? How do we ensure that Associations/Publishers do not ride roughshod over Editors and Journals? How do we ensure that Editors are sensitive to Association/Publisher interests and do not get their quixotic swords out at every opportunity?

What processes will ensure an amicable resolution of such issues? We have presented some as The Action Plan and The Inevitable Conclusions (2). However, it may help to look at certain basic presumptions on the basis of which one could formulate an agenda for thought and further action.

Basic Presumptions And The 10 Point Agenda

Certain basic presumptions are outlined and presented here as a 10 Point Agenda:

1. Editorial independence is fundamental and sacrosanct. Nothing that compromises its highest expression should be allowed to come in the way. Processes like Journal Oversight Committees and Editorial Governance Plans that ensure it must be firmly in place.
2. Associations/Publishers do own Journals, but cannot decide what editorial/research content gets published therein. They may decide whom to appoint, must appoint competent and independent minded people, but must not interfere in the work of those appointed unless they are incompetent, corrupt etc.
3. Editors cannot be insensitive to Association/Publisher interests. They must avoid publishing articles derogatory of their interests, without giving them a chance to offer their point of view. Or create a situation wherein the Association/Publisher is painted a villain and hanged in the name of editorial independence. In other words, the editor must choose his battles wisely, and strive to bring about change that grows rather than disrupts.
4. Associations must listen to Editors carefully and conduct a debate in their Councils/Boards on issues raised by upright editors. Rather than getting incensed and adopt a confrontationist attitude, they must look carefully into any suggestions/criticisms offered, and rectify matters.
5. Editors must listen to the collective wisdom of the Association Councils/Boards when matters come to a head. They must be ready to explain their position on the basis of available evidence, debate it with them, and accept a consensus in issues of conflict. However, in case the consensus appears to go against patient welfare and/or scientific evidence, they must reject consensus. But at all points, discretion and patience are the key words, not bravado and intemperance.
6. Further, Editors must always be ready, and willing, to present the contrary point of view. Especially that which, based on evidence, may contradict their own position or so called established opinions. What this means is: i) The editor must demonstrate the ability to publish viewpoints contrary to their own, if sufficient evidence is produced to warrant it. ii) Moreover, he must also be ready to publish reports contrary to established thinking or dominant scientific positions, again, if sufficient evidence warrants it.
7. Editors should be especially wary of conducting war on Association/Publisher interests under the guise of editorial independence. The forum to improve Association activities is the Association itself, and its legitimate redressal forums. While Journals can discuss how inadequate such forums maybe in certain cases, they cannot become an extra constitutional source of power to force change. They should be especially wary of being involved in proxy wars by forces hostile to current Association/Publisher leadership. Journals can debate the need for change, can point out faults, but cannot become a predominant forum to change Association/Publisher activities and policies. Here they transgress their limits, and will land themselves in irreconcilable conflict with Associations/Publishers. This will invariably result in a struggle for power, and the Editor is most likely to be the loser.
8. Both parties must respect the boundaries of their activities. And avoid transgressing into the others’. For Editors it is publication based on scientific evidence and patient welfare. For Associations it is members welfare and welfare of all its multifarious activities, including the Journal. For Publishers, it is the logistics and economic viability of their Journal.
9. In all their activities, however, the twin pillars of scientific evidence and patient welfare can never be compromised. That must always remain the litmus test for all, whether they are Editors, Associations or Publishers. Whenever compromises have to be made here, under whatever name, conflicts are bound to arise, and then editorial independence is either compromised or editors sacked.
10. Members of the medical community have to get sensitized to these issues if the long-term goals of ethical advance in biomedicine are to be forwarded.

Concluding Remarks

Biomedicine will advance, but will it do so ethically is the crucial issue. No one can remain immune to such concerns. For, howsoever varied our activities and different our concerns apparently, scientific evidence and patient welfare are the two common denominators in all our disciplines. And these variations, whether in the form of specialities, subspecialities or superspecialities, are, in essence, just convenient modalities to forward these two concerns.

To summarise, if at any point, an Editor, Association leader, or biomedical Publisher has a doubt, he must just ask himself the following four questions. One or more of them will be his guiding star:

1.      Is what I contemplate based on current/new scientific evidence?

2.      Will it bring about patient welfare based on such current/new scientific evidence and knowledge?

3.      Is scientific evidence/patient welfare being furthered or compromised as a result of my action, whatever else it maybe guided by: economics of journal running, association members’/office bearers’ interests, personal ambitions, irreconcilable differences?

4.      Will what I propose to do in/with the publication now, and in my long term planning, forward these two goals? *

Conflict of Interest

None declared

REFERENCES

1.      Shuchman M, Redelmeier DA. Politics and Independence – The Collapse of the Canadian Medical Association Journal. NEJM 2006; 354:1337-1339. Available at:  http://content.nejm.org/cgi/content/full/354/13/1337?ijkey=656c8ea8756c9164a10b7651d52d3102727b68a9&keytype2=tf_ipsecsha (Accessed 30 June 2006).

2.      Singh AR, Singh SA. A Look At CMAJ: A Misty Image Indeed. The Looking Glass, Mens Sana Monographs 2006; III: 6. Available at:  http://mensanamonographs.tripod.com/id140.html  (Accessed 30 June 2006).

3.      Signatories of the Editorial Governance Plan. Editorial Governance for JAMA. JAMA 1999; 281:2240-2242.  Available at: http://jama.ama-assn.org/cgi/content/full/281/23/2240  (Accessed 30 June 2006).

4.      DeAngelis CA, Maves MD. Update of the Editorial Governance Plan for JAMA. Editorial. JAMA 2004; 291:109. Available at http://jama.ama-assn.org/cgi/content/full/291/1/109 (Accessed 30 June 2006).

5.      Davies HTO, Rennie D. Independence, Governance, and Trust. Redefining the        Relationship Between JAMA and the AMA. Editorial. JAMA 1999; 281: 2344-2346. Available at: http://jama.ama-assn.org/cgi/content/full/281/24/2344 (Sign in).

6.       WAME Policy Statements. The Relationship Between Journal Editors-in-Chief and Owners (formerly titled Editorial Independence). Originally posted June 19, 2000; modified version posted May 15, 2006.  Available at: E:\WAME Policy Statements.htm  (Accessed 30 June 2006).

7.      MacDonald N., Squires B. Why we agreed to step into the breach. CMAJ April 11, 2006; 174 (8). First published March 16, 2006; doi:10.1503/cmaj.060352. Available at: http://www.cmaj.ca/cgi/content/full/174/8/1063 (Accessed 30 June 2006).

8.      Eggertson L, Sibbald B. Privacy issues raised over Plan B: women asked for names, addresses, sexual history. CMAJ • December 6, 2005; 173 (12). First published December 2, 2005; doi:10.1503/cmaj.051461.  Available at: http://www.cmaj.ca/cgi/content/full/173/12/1435?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=plan+b&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT (Accessed 30 June 2006).

9. Kassirer JP, Davidoff F, O'Hara K, Redelmeier DA. Editorial autonomy of CMAJ. Commentary. CMAJ • March 28, 2006; 174 (7). First published February 28, 2006; doi:10.1503/cmaj.060290. Available at: http://www.cmaj.ca/cgi/content/full/174/7/945 (Accessed 30 June 2006).

10. Fiona Godlee.  Editor's choice. A big mistake. BMJ 2006; 332 (4 March); doi:10.1136/bmj.332.7540.0-f.  Available at: E:\A big mistake -- Godlee 332 (7540) 0 -- BMJ.htm (Accessed 30 June 2006).

11. Sacking of CMAJ editors is deeply troubling. Editorial. The Lancet 2006; 367:704; DOI:10.1016/S0140-6736(06)68277-9. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140673606682779/fulltext (Accessed 30 June 2006).

12.Weyden MBVD. Sackings at the Canadian Medical Association Journal and editorial independence. MJA 2006; 184 (11): 543-545. Available at: http://www.mja.com.au/public/issues/184_11_050606/van10463_fm.html (Accessed 30 June 2006).

13. WAME.WAME Letter in response to the firing of CMAJ Editors. February 23, 2006.  Available at: http://www.wame.org/cmajed.htm (Accessed 30 June 2006).

14. ICMJE. ICMJE Expresses Concern Over Firing of CMAJ Editors. 2006. Available at: http://www.icmje.org/cmaj.htm (Accessed 30 June 2006).

15. Singh A. Reinstate Sacked Editors Of CAMJ. 9 March 2006. eLetter BMJ. Available at: http://bmj.bmjjournals.com/cgi/eletters/332/7540/0-f#129631 (Accessed 30 June 2006).

16. Singh A. The Ground Realities And The Action Plan. 13 March 2006. eLetter CMAJ. Available at: http://www.cmaj.ca/cgi/eletters/cmaj.060276v1#3805 (Accessed 30 June 2006).

17. Singh A. Why only damage control, why not redeem yourself CMA? 21 March 2006. eLetter BMJ. Available at: http://bmj.bmjjournals.com/cgi/eletters/332/7542/624-a#130262 (Accessed 30 June 2006).

18. Singh A. From Interim to Long Term. 27 March 2006. eLetter CMAJ. Available at: http://www.cmaj.ca/cgi/eletters/cmaj.060352v1#3891 (Accessed 30 June 2006).

19. Singh A. Some Clarifications from the CMA President. 19 April 2006. eLetter CMAJ. Available at: http://www.cmaj.ca/cgi/eletters/cmaj.060352v1#3964 (Accessed 30 June 2006).

20. Collins-Nakai R. The Canadian Medical Association Journal. Correspondence. NEJM 2006. 354:2832-2833.Available at: http://content.nejm.org/cgi/content/full/354/26/2832-a (Accessed 30 June 2006).

21. Collins-Nakai R. CMAJ: moving forward. eLetter CMAJ. Available at: http://www.cmaj.ca/cgi/eletters/cmaj.060352v1#3957 (Accessed 30 June 2006).

22. Hoey J. Editorial Independence and the Canadian Medical Association Journal. NEJM 2006. 354:1982-1983. Available at: http://content.nejm.org/cgi/content/full/354/19/1982 (Accessed 30 June 2006).

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*In, as applicable to editors, with as applicable to Association owners/Publishers.