Editorial Misconduct, Freedom and Accountability: Amateurs at Work

If editorial freedom is thought to mean that editors should be free to do whatever they want, then it is a myth. Editors must balance the demands of many different groups, from readers to owners, and must be accountable. Perhaps because of the power of the myth of editorial freedom editors are often much less accountable than other professionals, and there are many examples of editors abusing their positions without any retribution. But at the same time, if editors are slaves to the political commands of their owners then the journals they edit will never be respected. How can the right balance be achieved? This is a question that some very grand medical organizations have failed to answer.

Sir Cyril Burt stars in the classic case of editorial misconduct (132). His important — and much disputed — work on intelligence was important in designing education systems. He founded a journal called the British Journal of Statistical Psychology and was its editor. He published 63 of his own articles and often altered the work of others without permission, sometimes adding favourable references to his own work. Once he published a letter he wrote himself under a pseudonym and a response he also wrote himself under another pseudonym in order to attack a colleague.

Another psychologist, Hans Eysenck, used the journal he edited to publish his extraordinary work that must have been fraudulent. He started a journal called Personality and Individual Differences and published in the journal studies that suggested that personality was a much bigger risk factor for cancer and vascular diseases than smoking, diet or any other known risk factor. He also proposed that psychological therapies could reduce deaths from cancer and vascular diseases. Anthony Pelosi and Louis Appleby exposed the severe deficiencies in this work, and nobody else has found similar results (236).

These cases illustrate the dangers of editors publishing in their own journals, and I described in chapter 8 the case of the editors of the British Journal of Obstetrics and Gynaecology publishing fraudulent research in the journal. Many thus argue that editors should not publish in their own journals. Even if they are not involved in peer reviewing the research (as they surely shouldn’t be), then it will be impossibly hard for other editors, particularly junior ones, to turn down the research. The result might be that inferior work will be published and the reputation of the journal damaged.

It is not so hard for editors of general journals to adopt this position as they are mostly not active researchers, but it’s much harder for editors of specialist journals. They are often appointed to be editors of journals because they are leading researchers. If the journals cannot publish their research then the journals may suffer from the appointment.

I must confess that I have submitted research to the BMJ and had it published. (The covering letter says: ‘We must declare a competing interest in that one of us is the editor of this journal.’) I’ve also had it rejected, as did my predecessor, who had his still often quoted research on peer review rejected. My reason for submitting our research to the BMJ was that it was usually research on the processes of the BMJ — for example, open peer review-performed on BMJ authors, readers and editors. Plus the research provided the evidence on which we changed our policies. It would seem strange to publish such research in another journal that would be read by only a small fraction of BMJ readers.

Disclosure — yet again — is a large part of the answer. Readers should know exactly what process the study has gone through before publication. The BMJ, which began an active research programme and had in-house researchers, developed a system whereby papers produced by the staff were peer reviewed only by external editors and not by editors employed by the BMJ. This was possible for the BMJ because external editors were central to the peer review process. This system was described on the BMJ‘s website, and editors indicated at the end of the study that this is how it had been peer reviewed.

This system is of course acceptable to the BMJ team, but critics would prefer an absolute ban on editors publishing in their own journals. What does seem to me unacceptable is for editors to publish original research in their own journals without any indication of what peer review process they have been through. This is, however, the norm.

The Burt and Eysenck cases of editorial misconduct are well known, but — just as with conflict of interest — editors have been much more interested in the misconduct of others than in their own misconduct. Editorial misconduct is thus less well described, but we begin to have a collection of cases.

Doug Altman, lain Chalmers and Andrew Herxheimer described three cases at the Second International Congress on Peer Review in Chicago in 1993 and subsequently in JAMA (237). They argued that all three cases showed editorial misconduct and the great difficulties in making editors accountable. They called for an international scientific press council. In their first paper they were unable for legal reasons to name names, but in 2003 the same authors made a second presentation — at the annual meeting of the Committee on Publication Ethics (238). They were able to give more detail of one of the cases and add two further cases. They observed that very little progress had been made in a decade to develop ways to respond to editorial misconduct.

In the first case Richard Mattingly, the editor of Obstetrics and Gynecology, republished in 1983 a paper that had appeared in the Journal of Pediatrics without the permission of the authors — although Mattingly stated that permission had been obtained. This paper by Jon Tyson and others reviewed 86 ‘therapeutic studies’ in perinatal medicine published in various journals, including Obstetrics and Gynecology, and concluded that in less than one-fifth of the studies were the conclusions supported by the data. Mattingly accompanied the paper with an editorial that described the republished paper as ‘a poor study’. Tyson and colleagues sent a response as did two others, one of whom was lain Chalmers. Mattingly did not acknowledge the letters. Tyson then sent letters to all the members of the editorial board, and eventually an editorial assistant rang him and said his letter would be published. The letter was published a year after the article was published, but the sentence that said that the paper had been republished without the authors’ permission was deleted. Again there was a hostile editorial. A letter in response by Doug Altman was not published.

Chalmers and Altman considered this poor editorial conduct and decided that the story needed to be told. They had their paper rejected by six journals, including Obstetrics and Gynecology, although brief, anonymized reports of the story appeared — including in the JAMA paper (237). Obstetrics and Gynecology said that it wasn’t interested in the misconduct of its former editor. Two journals said their readers would not be interested in misconduct at another journal. Two further journals didn’t think that they had any obligation to publish the material when they had not been involved, and one journal simply never responded (itself poor conduct). At least two of the journals were concerned about the risk of a libel action from publishing such material.

Mattingly died in 1985, and Chalmers pursued the new editor asking for an apology to the authors. The new editor declined, but Chalmers, ever persistent, asked the next editor for an apology — and finally one was forthcoming in 2003.

In a second case a scientist was invited to write a review for a journal. It was accepted, and the scientist corrected proofs. But the article never appeared. Subsequently the journal published an article with the same title but by different authors. When the scientist read the article he discovered that much of the text was identical to that in his own article. He could get no response or explanation from the editor.

A third case concerned a randomized trial of two active drugs against a placebo. The study reported serious side-effects with one of the drugs. The authors did not know this, but the editor of the journal was a paid consultant to the company that made the drug with the serious side-effects. The editor sent the paper to several reviewers, including an employee of the company. Altman, Chalmers and Herxheimer did not think it wrong that the editor used a reviewer from the company, but they argue that the combined conflicts of interest of the editor and one of the reviewers must have counted against the study. It was rejected and published in a less prominent journal two years later.

In a fourth case Dr K had a letter accepted that drew attention to possible misconduct. Despite being accepted the letter was later rejected. Dr K tried several other journals but none would publish. One journal editor said that the allegations were serious but that they were none of his business. The letter should be published in the journal that published the papers, but that journal was the problem.

These cases inevitably look like editors closing ranks, and they come from a time — before the late 1990s — when unfortunately it was normal in academia and clinical practice to turn a blind eye to research and clinical misconduct. I’m not trying to excuse editors, but it’s another example of a complacent culture. Considering these cases now, the first two seem to provide strong prima facie evidence of editorial misconduct. The correct response, to my mind, was not simply to publish the case but to persist in obliging the owners of the journals to investigate the behaviour of their editors. It is the owners who have the legal legitimacy to do so and the ability to ensure due process. The culture that meant that authorities turned a blind eye also meant that the complainants didn’t persist. As I’ve discovered after years of turning a blind eye myself, it’s exhausting to persist and often leads to disputes, threats and legal fees.

There are few fully described accounts of editorial misconduct — perhaps because there is no regulatory body anywhere — but another incomplete, although colourful, story emerged in 2003 (239). Antonio Arnaiz-Villena, head of the immunology department at a large public hospital in Madrid and professor of immunology and cell biology at Madrid’s Complutense University, was invited to be the guest editor of a theme issue of the journal Human Immunology. The theme issue was on anthropology and genetic markers. Nicole Suciu-Foca, the editor-in-chief of the journal and a professor in New York, invited Arnaiz-Villena to edit the issue because he was an expert in ‘historic genomics’. The guest editor was given little or no guidance on what was expected. Nor was it clear whether or not the language would be (or actually was) copy edited — despite English not being the first language of most of the contributors, including the guest editor.

Controversy erupted when the issue was published. Arnaiz-Villena’s keynote paper concluded that Jews and Palestinians are genetically very close and that their ‘rivalry is based on cultural and religious, but not genetic differences’ (240). It wasn’t the science that caused the problem but words and phrases in the article that seemed political — particularly in the highly emotional climate that followed the attacks on New York and Washington on 11 September 2001 (the issue was published in November 2001). Karen Shashok — an American who lives in Spain and works as a translator and editor — argues that most of the problems arose from lapses in translation and editing rather than political intent (239). Whatever the cause the response was dramatic. The editor fired the guest editor from the editorial board and had the article retracted from Medline and deleted from the online edition of the journal. Subscribers were even invited ‘to physically remove the pages’ from their copies of the journal.

Was this an over-reaction? Was the editor making the guest editor the scapegoat for her own failures? The editor, the owners (the American Society of Histocompatibility and Immunogenetics) and the publishers (Elsevier Science) have not answered these questions, and this might be an ideal case to refer to an international medical scientific press council. As it stands, we have no trustworthy ruling on the degree of transgression (some might argue it was close to nothing), why it happened, whose fault it was, whether or not it was right to retract the article and whether or not the editor over-reacted. Everybody is smeared; nobody is cleared.

The Committee on Publication Ethics (COPE) concerned itself initially with advising editors about author and reviewer misconduct and only recently concerned itself with editorial misconduct (241). Nevertheless, it has had cases of editorial misconduct reported to it — and so provides further case studies.

The first COPE case is reported in the annual report for 2000 and is headed, ‘Who ensures the integrity of the editor?’ (242). The discussion of the case asks: ‘What can be done to stop/prevent corruption within the editorial office of a scientific publication?’ and notes that this is ‘an issue that has virtually escaped discussion and consideration within the scientific community’. The case was reported to COPE by an editor who was sacked for raising questions about the behaviour of the editor-in-chief. It’s obviously unsatisfactory that the case is anonymous (as it has to be to avoid libel) and that COPE has only one side of the story. One recommendation that came from the case was that it be published in full in a major journal. But that hasn’t happened.

The story is complex and begins with the editor who was eventually sacked (whom I’ll call ‘the editor’) discovering that the editor-in-chief had written a letter saying that he, the editor, had accepted a paper when he’d rejected it. The paper was a guideline on a common medical condition and recommended a new expensive drug as the best treatment. Reviews had been mixed, but the meeting of scientific editors had decided to reject the paper. The editor-in-chief spoke to the principal author of the paper at length and asked for a third review. Despite this being unfavourable the editor-in-chief had accepted the paper.

Editors-in-chief are ‘free’ to make idiosyncratic decisions, but the worrying feature of the first part of the story is the editor-in-chief lying, writing that the editor had accepted the paper when he’d rejected it.

The next event in this story was that the association that owned the journal stipulated that any editorial material published in the journal must have an elected official as an author even if written by somebody else. This not only seemed to compromise editorial independence but also to undermine good standards of authorship. Next, the chief executive of the association announced that the journal could not publish any letters critical of the association. The editor-in-chief said that he would protest, but the journal never did publish any more critical letters.

The editor then had further battles with the editor-in-chief over him publishing papers that were poorly supported by evidence and strongly criticized by reviewers. The editor-in-chief was also cavalier, the editor alleges, in rejecting a paper by the editor. Relationships broke down completely, and the editor was sacked. His view was that the chief executive of the organization and the editor-in-chief had made a Faustian bargain whereby the editor-in-chief compromised the independence of the journal in exchange for being able to publish what he wanted without being constrained by usual editorial standards.

The editor-in-chief would no doubt have a different story to tell, but this case illustrates how it could be difficult or impossible to do anything about an editor-in- chief who might make a bargain like the one the editor alleges. The owners would see no problem, but the journal would be debased. There is no professional accountability but only accountability to the owners.

A second COPE case is minor and concerns a journal publishing an editorial that had already been published elsewhere without disclosing the fact — despite the editors discovering the previous publication during the peer review process (243). Nor had the editors sought copyright permission. When it was later pointed out that the two articles were essentially the same the editors agreed that they had been at fault and published a notice of duplicate publication.

In the third case an editor was accused of publication bias because he had invited the same trainee in radiology to write 14 commentaries in five years. The most recent commentary covered the same ground as previous commentaries and cited mostly the trainee and the accused editor. The editor was failing to let other authors and viewpoints come through. This case was referred to the journal’s ombudsman (see discussion below) who judged it unfounded (244).

As I described in chapter 2, a similar complaint was made against me. A group of readers and authors complained that the BMJ presented a one-sided view of the condition known as chronic fatigue syndrome or myalgic encephalomyelitis. The BMJ, they alleged, published only material that supported the idea that the condition is psychological, used the same reviewers (most of whom are psychiatrists), and refused to publish studies that show that the condition is a physical condition. The complainants conducted an analysis of what the BMJ had published on the subject, and their anger was increased when we declined to publish the analysis. (One objection to the analysis was that it included information only on papers we published and not those submitted to us — so how could it show bias?)

My response was that the BMJ did not have a position on the nature of chronic fatigue syndrome or myalgic encephalomyelitis. We selected the best research studies submitted to the journal and published them. Often studies contradicted previous studies that we had published. Bias seemed to arise because we were more likely to accept randomized trials of treatments (including a psychological treatment called ‘cognitive behavioural therapy’) than we were studies reporting a small series of patients who had evidence of a previous infection. We thought of this as a bias towards rigorous science, a bias that it was right for us to have.

In addition, we would ask a variety of people to write commentaries for us, selecting those who know about the condition, argued well using evidence and wrote clearly. It did so happen that most of the experts thought that the condition does have a substantial psychological component and that it is highly unlikely to be entirely a physical condition. Indeed, most of them believe that most conditions have a physical and psychological component. They are also distressed by the implication of the complainants that a physical condition is somehow more ‘real’ than a psychological condition. This seems to perpetuate the stigma against those with mental health problems.

When it comes to letters anybody can comment, and the BMJ carries many letters from people who disagree with most of what the BMJ publishes. When I left the BMJ received well over one hundred rapid responses (electronic letters to the editor) each week and we were able to publish fewer than 10% in the paper journal. This arrangement provided a rich test bed for studying editorial bias: what were the characteristics of the fewer than 10% that we selected? We’d like to think that they were more interesting, sound and readable, but no doubt other forms of bias were at work.

This is a question of where editorial judgement ends and misconduct begins. Editors are expected to discriminate, but they should discriminate on grounds of evidence, importance, relevance, quality and clarity rather than on personal foibles. But it is also widely believed to be the job of the editor to give a publication a ‘personality’ — and that’s likely to be related to his or her personality. So some personal selection seems desirable.

The complaints against me alleging misconduct in relation to selecting material on chronic fatigue syndrome — to the British Medical Association (BMA), the owners of the BMJ, and the Press Complaints Commission — were dismissed, but the complainants saw this as an establishment cover up. Perhaps it was.

A more substantial — and justified — complaint was made against me through the website of the World Association of Medical Editors (WAME). We at the BMJ had made the mistake of selecting too many papers for our education and debate section (a section of the journal where we published not original research but essays, ‘think pieces’). We discussed what to do and decided that we would ‘cull’ the papers — weed out and reject the poorer ones. In the past we’d done this with letters to the editor and personal views (short, subjective essays).

Some editors thought that we shouldn’t do it for these longer papers, but I argued that this was a trade off between the needs of present authors and readers and future authors. If we published all these papers then we would have to reject most of the papers we received in the next few months, which would be unfair both to future authors (some of whom would undoubtedly submit papers better than those we were about to publish) and to readers (because we would be giving them a collection of less good papers). I carried the day (probably because of my position rather than the strength of my argument), and we culled the papers.

‘Culled’ authors were furious, and one wrote to WAME asking for advice. WAME decided that an anonymized version of the case should be put on the list serve. A flood of comments followed. Virtually every commentator thought that ‘unknown editor’ (me) had behaved unethically and many were strongly abusive — as is often the case with list serves. I was on the list serve, and I recognized the case. There was a delicious irony in the debate in that I had been one of three people on the stage at the only meeting that WAME had ever held on ethics. Having been displayed as some sort of ‘ethical expert’ I was now being accused of the most unethical behaviour yet shown by a WAME editor.

I weighed in with a signed contribution, starting it, ‘I am that wicked editor …’ I advanced my argument and was perhaps too cocky and unapologetic — but I did agree that I had done the wrong thing and would publish the papers. A torrent of criticism and abuse followed, and the chairman of the ethics committee of WAME was obliged to ask for calm.

Firing editors can be hard — because the editor may well invoke editorial freedom — but it’s my misfortune to have fired four editors. In one case the processes of the journal had collapsed. Authors had waited years for a response, papers had been lost, and the journal was close to disintegration. In two cases the editors had simply run out of steam, and their journals were sliding down. In both cases the editors walked out during our conversations, and I’ve never seen them since. In the fourth case we had taken over a moribund journal and decided that we needed new blood if we were to have any chance of making the journal a success.

We have no good data, only stories, but I suspect that cases of editors performing poorly far outnumber cases of frank misconduct. But most editors like being editors. It gives them a platform and status. People are inclined to flatter editors — because they want them to publish their papers and advance their views. Grandiosity and self-importance are thus occupational hazards of editors, and getting rid of them may prove difficult. Many associations go on with poorly performing editors for fear of the fuss that might result from firing him or her. One way to avoid this predicament is to give the editor a fixed-term contract, usually for five years, and that is what we did with the editors of the BMJ journals.

Although it may be hard to fire editors, the world of medical editors has seen a spectacular case that made the lead story on CNN. As I first described in chapter 2, it was in 1999 when E Ratcliffe Anderson, the executive vice president of the American Medical Association (AMA), fired George Lundberg, the editor of JAMA. In characteristic style Anderson rang Lundberg, who was at home with a wrist in plaster, and told him not to come back. He was fired not for publishing but for speeding up the publication of a small paper that suggested that many American students did not think of oral sex as sex (29). This was important because of the impeachment of President Clinton which featured a discussion of whether or not he had had sex with Monica Lewinsky and lied about it. As one of the newspaper commentators observed, it was strange to fire an editor for publishing something highly topical.

Perhaps what was remarkable was that Lundberg hadn’t been fired sooner. Many, perhaps even most, editors of JAMA had been fired, and Lundberg had come close a few times — not least when, as an ex-pathologist, he said on television that doctors were ‘burying their mistakes’. The AMA has a firing culture — Anderson was himself fired not long after — and there is, I believe, a structural problem in the relationship between the AMA and JAMA.

The AMA now has less than 30% of doctors in membership — and compared with non-members they tend to be older, less likely to work in managed care and Republican. They are, in short, highly conservative. But the editors of JAMA are trying to produce a journal that will appeal to all the doctors in America and to doctors beyond the United States (in a world where the gap in attitude between Americans and the rest of the world seems to be growing). This, it seems to me, is bound to produce tensions. The BMJ has tensions with the BMA, but the BMA is a much broader church than the AMA. About 80% of doctors belong — as do 60% of students. There is not a major mismatch between the beliefs and attitudes of the owners of the journal and the target audience.

Anderson, when he fired Lundberg, argued that he was — paradoxically — respecting editorial freedom. It would have been wrong, he said, for the AMA to interfere with individual decisions of the editors but it had to have the ‘nuclear option’ to fire the editor when he went too far.

Lundberg didn’t do badly from the firing. A lover of publicity, his firing received massive media coverage worldwide — almost all of it sympathetic (partly because many journalists hate the AMA). Although many editors around the world found Lundberg’s egocentricity unattractive, they all rallied round — supporting him and condemning the AMA. Some researchers called for a boycott on submitting papers to JAMA. Full of dirt on the AMA, Lundberg was paid a substantial sum for signing a confidentiality agreement. And he got another highly paid job, only this time with equity. Fired in the upswing of the dot.com boom, he was appointed as editor of Medscape and reappeared on the editorial scene dressed in black with gold rim glasses.

The firing of Lundberg was the most dramatic firing of a journal editor of recent years, but the firing of the editors of the Canadian Medical Association Journal (CMAJ) came close. John Hoey, the editor, and Anne Marie Todkill, the deputy editor, were fired at a moment’s notice on 20 February 2006. The Canadian Medical Association (CMA) insisted that the firings were nothing to do with editorial independence but simply that a fresh approach was needed. Most of the world, including the CMAJ editorial board, found this unbelievable. The journal had improved dramatically in the 10 years that Hoey had been the editor, and even if the CMA did want a fresh approach why would it put the whole journal at risk by such precipitous action?

Plus there had been lots of disputes over editorial independence. Indeed, the CMA, like the AMA, has a firing culture — and many editors have been fired. Hoey’s predecessor almost came unstuck by publishing a picture of a person holding a mug saying, ‘My GP is a nurse practitioner.’ The general practitioners in the CMA were not amused.

The issue that caused the final rupture was an article about how pharmacists were collecting too much information from women seeking over-the-counter emergency contraception. The CMAJ journalists working on the story had asked 13 women to go to a pharmacy, ask for the drug, and describe how they were treated. The Canadian Pharmacists Association found out about the article and contacted the CMA to ask if the research was being conducted in an ethical manner. The chief executive officer of the CMA asked Graham Morris, the publisher of the CMAJ, and he told Hoey not to run the story because it had not had ethical approval. The editors argued that the ‘research’ was simply investigative journalism and didn’t need ethical approval. The editors and Morris agreed that the story should be run without the quotes from the women.

Hoey set up a committee to investigate the episode. The committee included Jerry Kassirer, former editor of the New England Journal ofMedicine, who had himself had plenty of battles with the Massachusetts Medical Society, the owners of the New England Journal of Medicine. The committee ruled that Hoey had transgressed in giving in to the CMA but also judged that the CMA was guilty of ‘blatant interference with the publication of a legitimate report’.

Another battle that came just before the end was caused by an online news report that was critical of the new Canadian health minister, referring to him as ‘two tier Tony’. The CMA was upset, and the version that appeared in the paper version of the journal was toned down and included positive quotes about the new minister from the CMA president.

After Hoey and Todkill were fired one of the other editors, Stephen Choi, took over — but he couldn’t reach agreement with the CMA and so left together with another editor. The editorial board was very critical of the CMA but attempted to reach agreement. The board wanted the editors reinstated and a written guarantee of editorial independence from the CMA. Neither happened, and so the editorial board resigned. Prominent Canadian researchers have also said that they will not submit studies to the journal, and the CMAJ faces extinction. As I write, attempts are being made to rescue the journal with a temporary editor and a former chief justice of the Supreme Court of Canada preparing a report on future governance.

Two other major general medical journals in North America — the New England Journal of Medicine and the Annals of Internal Medicine — also lost editors in inauspicious circumstances. The Massachusetts Medical Society, did not fire Jerry Kassirer, editor of the New England Journal of Medicine, but they did not renew his contract — which is effectively a firing. Relationships between the editors and the society had long been fraught, mostly over commercial matters. The society, which is financially heavily dependent on the journal, wanted to exploit its asset through activities like launching a New England Journal of Primary Care. The editors were anxious about the quality of such publications and worried — in marketing speak — that the brand would be devalued.

Having declined to renew Kassirer’s contract, the society appointed Marcia Angell, a longstanding deputy editor (and, many thought, the power behind Kassirer’s throne) for a year. The hostility between the journal and the society was there for all to see, and then the society appointed Jeffrey Drazen to a blaze of publicity about his extensive contacts with the pharmaceutical industry. Ironically, the journal’s strict rules on conflict of interest would stop him writing editorials in his own journal.

Business problems were also the main cause of the American College of Physicians losing Bob and Suzanne Fletcher, the editors of the Annals of Internal Medicine. There were probably several factors that led the Fletchers to decide that they would rather be professors at Harvard than editors of the Annals, but one factor was them publishing a study that showed that many drug advertisements in medical journals made unwarranted claims (226). The advertising revenue of the journal fell, heightening tension with the business side. The Fletchers were keen to have more involvement with the business side. What was the point in them producing a great journal if the marketing was lousy? The chief executive of the college, however, didn’t want them bothering ‘their pretty heads’ about that kind of thing. There was tension. Somebody had to go. It was the Fletchers, not least because the college was heavily involved at the time in political lobbying that was led by the chief executive.

The British mostly do these things more quietly. Richard Horton just after he was appointed editor of the Lancet showed a graph of the average tenure of a Lancet editor. At the time it was almost a straight line down from the more than 30 years of Thomas Wakley, the founder and first editor. Horton joked that his editorial life expectancy was months, but he has now been editor for approaching 10 years.

In contrast, I was only the sixth editor of the BMJ since 1898. The journal has, however, had a famous bust up between the editor and the association — in 1956. Hugh Clegg, the editor, was a fierce fellow who loved a fight. Very interested in medicopolitics, he might well have preferred to be secretary of the association rather than editor. His relationships with the secretaries were difficult, and when I met him once towards the end of his life he told me that one of the secretaries, Charlie Hill (later Lord Hill), was ‘evil incarnate’. I can report it now because both are dead (245).

The battle with the association arose after he wrote and published an editorial entitled ‘The gold-headed cane’ (9, 246). The title was a reference to the cane that belongs to the president of the Royal College of Physicians, and the editorial was an attack on the college — arguing that it was archaic, degenerate, confused, rudderless and out of touch with its members and fellows. Clegg also criticized the college for electing Lord Brain to a seventh year as president. In the first draft of his editorial — which as always he wrote standing up while drinking a bottle of claret, his invective becoming stronger as his blood alcohol rose — he compared this election to Caligula electing his horse to the Senate. This image, much treasured by subsequent editors, disappeared from the final version.

The college was furious about the editorial (perhaps because it contained much truth), and the BMA wasn’t pleased because it was trying to get closer to the college. The council of the association tried to persuade Clegg to get approval for all political editorials from BMA officers. He refused, and the council passed a motion disassociating itself from the editorial. At its annual representative meeting (the supreme body of the association) a motion was debated that said that BMJ editorials should reflect association policy. The motion was heavily defeated, with some speakers emphasizing that editorial freedom was essential if the journal was to remain at ‘the top in world approbation’.

BMJ editors remember this vote as if it happened yesterday and think it crucial in securing editorial freedom for the BMJ, but Peter Bartrip, the journal’s historian thinks that the editorial ‘changed nothing’. He quotes Clegg some years after the episode as saying that he didn’t feel he had a right to advocate a policy contrary to that of the association.

The BMJ has, however, many times in recent years — almost routinely — published editorials that depart from BMA policy. Indeed, we would ask somebody to write us an editorial on a political issue in just the way that we asked somebody to write an editorial on liver pathology. We identified authors who know about the subjects and let them say whatever they want. We also wrote editorials ourselves that contradicted BMA policy. Leaders of the association would write us letters for publication disagreeing with the editorials, and there might be mutterings about ‘foolish editorials’. But there were no serious attempt to have me sacked or to pass motions saying that BMJ editorials must comply with BMA policy. There was a debate of a motion regretting me cutting coverage of BMA political affairs from 10 pages to one — but it wasn’t passed.

Somehow editorial independence has got deep into the BMA culture. This is partly because there is another publication — BMA News — that is the association’s creature. There is no pretence of editorial independence. It was increasingly accepted that the BMJ was an international journal and not expected to record the activities or views of the BMA. We did have news stories on the BMA, but we covered the BMA as we covered other organizations. The news stories and editorials being signed probably helped (editorials were not signed in Clegg’s day), but perhaps the biggest factor securing independence for the BMJ is its financial independence. The journal has been highly profitable, and money flows from the journal to the association. Most BMA members imagine that a big chunk of their subscription goes to the journal — but in fact none of it does. If money flowed from the association to the journal then independence would, I suspect, be severely compromised.

Another factor that may have accounted for the editorial stability of the BMJ was that the editor of the BMJ was also the chief executive of the BMJ Publishing Group and on the same level as the secretary of the association. It was the secretary of the AMA who fired Lundberg and the publisher of the CMAJ who fired Hoey and Todkill. This couldn’t have happened at the BMJ, and as the two main pressures on editors come from politics (the central activity of the associations) and from business (the main concern of the publisher) the position of the editor of the BMJ may have protected him. After I left, however, the relationships changed so that the editor now reports to the chief executive of the BMJ Publishing Group who in turn reports to the chief executive of the association. It remains to be seen if this will cause problems as it has for the editors of other association journals.

Editorial freedom cannot mean that editors are free to do what they want and are wholly unaccountable. The difficult question is how to make them accountable — because editors have to balance the interests of many groups: owners, readers, authors, reviewers, staff, advertisers, the broader medical community, patients and the media. And editors must obviously ensure that their journals comply with the law and pay attention to financial constraints.

The relationship with owners is the one that seems to cause the most difficulty. Often owners are not very clear what they want from their journals. Nobody from the BMA ever told me what they want from the BMJ. Stephen Lock, my predecessor, said that all I needed to do was to make sure that the journal came out regularly and be sure not to introduce American spelling. It was for me to try and divine what the BMA wanted. The BMA cannot really know what it wants because there is no BMA: instead, there are over 100,000 members, all probably with different ideas on what they want from the BMJ, and many different factions. The leaders of the BMA understandably spend little time thinking about the journal. They have a hundred more immediate problems.

Rarely, I suspect, are the owners of medical journals clear about what they want. The most precise they can be is that they want more of the same, only better. They appoint the best editors they can find and let them get on with it. The owners hope for improvement, but they accept the status quo and resort to firing the editor only if something goes horribly wrong.

This lack of clarity of what owners want from their journals and editors is the starting point of a cascade that has been appallingly amateur. There was no job description for the editor. Selection of the editor was more opaque than the selection of a pope. There was no training for the editor and no adequate system of accountability. I exaggerate — but only just.

I’ve now been involved in appointing around 40 editors — mostly of BMJ journals — but also of some other journals. My first experience was having to appoint an editor for the British Journal of Ophthalmology. There seemed to be no system. When I asked the retiring editor how he had been appointed he said that the previous editor had put his hand on his shoulder and said ‘You’re it.’ Without direction, training or much support he’d muddled through for many years.

We clearly needed a better system for appointing a new editor, but in 1991 it seemed far too dramatic a step to advertise (which is what now happens routinely). I decided that I would identify three possible candidates and then make a selection. I rang various ophthalmologists to get suggestions and was astonished by their willingness to make poisonous comments about colleagues to somebody they didn’t know.

Eventually I identified three candidates — from Aberdeen, Belfast and Manchester. The candidate from Aberdeen began to emerge (probably the best verb to describe the process) as the likely editor. At this point I was visited by a senior consultant in a very expensive suit who told me that nobody outside London knew anything about ophthalmology and that the candidate was ‘a boy’. (He was actually in his 40s and older than me.) I ignored him, and appointed the professor from Aberdeen. He did an excellent job, and now the journal is edited by a professor from San Francisco who was appointed — against stiff opposition — by a panel after open advertisement.

Most editors of the world’s 10,000 or so biomedical journals have received no training. One day you’re a professor of cardiology; the next you’re editing a journal with a turnover of £5m a year. For an editor with no training in cardiology to become a cardiologist overnight would be unthinkable, but it’s routine the other way round. I wouldn’t argue that being an editor is as complex as being a cardiologist or that the consequences of working without training will be so dire, but editing — like most other occupations — is becoming steadily more complex. Journals are the main route for the research that underpins medicine to reach doctors and patients. If the process is poor — as I’m arguing in this book it often is — then something is rotten at the root of medicine.

The lack of training is compounded by many editors working largely alone. The World Association of Medical Editors was founded with the idea of providing training, support and guidance to editors, particularly in the developing world. But ironically the position of many editors in the developed world is similar to that of editors in the developing world in that they are untrained and work alone: the difference might be that the journal, although often not the editor, has a substantial budget.

There does now begin to be training for editors, but the courses available are few and short — and most editors still learn on the job. The major general medical journals are different in that they are edited mostly by professional editors, people who might have been doctors once but who have become full-time editors. Most of the journals provide training positions, although the training is unstructured and mostly through apprenticeship. There is no college of editors, no formal qualification, no obligation to stay up to date and competent. Perhaps these things will come if medical editing becomes more professional, but many of us, including me, revelled in the amateurishness.

There is a major difference between the big American and the big British journals in that the American journals appoint distinguished academics as editors, whereas the British journals appoint professional editors who have come up through the ranks. This difference probably relates to the differences in the journals: the British journals are much more journalistic. My bias is that the American journals will need to move to having professional editors. The American system works now only because the academic editors have teams of professional editors under them. The Lancet experimented with the American model, appointing an academic, but the owners quickly reverted to the traditional British model.

The lack of training of editors has been matched by the lack of a research base for what editors do. I’ve often been struck by how, for example, neurologists on editorial boards who would expect to base their treatments of patients on evidence will make dogmatic statements about editorial processes without any evidence whatsoever. Until recently professional editors behaved in the same way. We spent a great deal of time scrutinizing the evidence in the studies submitted to us but didn’t think to examine systematically and experimentally what we did ourselves. Now we do, but there are still many editors who don’t agree with studying journal processes. They see it as unproductive navel gazing. Drummond Rennie, the force behind the congresses on peer review, lambasted editors at the end of the last congress for neglecting their craft. Only a small fraction of all the editors in the world attended the conference, and yet it is the only editorial conference that presents evidence and data rather than opinion.

Perhaps standards would rise if editors were more accountable and organizations expected more of their editors. Similarly editors might expect more of their organizations. In the case of the major general medical journals both the owners and the editors are stewards of the journals. The editors take responsibility for the journal for a limited period, and ideally they will hand on an improved journal. But owners are also stewards in the sense that these major journals are important for the international medical community. The AMA, I would argue, abused its stewardship of JAMA when it fired George Lundberg to suit its short-term aims. John Hoey and colleagues argued the same when they were editors of the CMAJ: ‘Any medical journal belongs, intellectually and morally, to its contributors, editors, editorial boards and readers …The American Med- ical Association doesn’t own the Journal of the American Medical Association, it is the custodian of it’ (247). Seven years after writing that Hoey was fired by the CMA in conflict with the journal’s contributors, editorial board and readers.

As I learnt at business school, all problems are opportunities, and the firing of Lundberg led to some deep thinking — by Huw Davies, a scholar, and Drummond Rennie, the deputy editor of JAMA — on what is needed for a trusting and productive relationship between owners and editors (248).

First, the two need to recognize their mutual accountability. Second, there should be ‘a clearly defined and shared vision for the enterprise’. For most journals, I suspect, this is missing, but logically the owners should know what sort of journal they want before they appoint an editor. If they appoint an editor who wants to produce a very different sort of journal from them then there is sure to be trouble. Editors and their teams will want to develop and enhance the vision, but it’s primarily for the owners to define the vision. Increasingly we did this at the BMJ Publishing Group before appointing a new editor.

Third, editors should be responsible for delivering measurable objectives — perhaps an increase in the impact factor of the journal or the time to process manuscripts — from a defined and agreed strategy. [The impact factor of a journal is the number of times articles in the journal are cited divided by the number of articles that could be cited. It’s a rough and ready measure of quality that is easily abused and manipulated.] Again this is, I think, unusual. Fourth, the editors should be free to decide the tactics to deliver the strategy. Regular interference with short-term objectives is ruinous for a journal. Fifth, there should be a regular flow of information for communication rather than for judgement. This should help build trust. Sixth, owners and editors should always try to resolve disputes informally, but there needs to be a formal system as a back-up.

Most journals don’t have these things. They muddle through, and there are many who think that mutual trust and respect between owners and editors are enough. If they are present, the journal will flourish. If they are lacking, then elaborate governance cannot compensate.

Editors need other forms of accountability. They must be accountable to readers, authors, reviewers and the broader medical community. Most of this accountability is far from explicit, and there are no institutions to enforce it — but we perhaps need some. I will discuss the Lancet‘s ombudsman and the BMJ ethics committee in chapter 19, but I want to consider now whether or not editors might develop institutions to make themselves professionally accountable — in the way, for example, that doctors are accountable to professional bodies. Such accountability may be important not only for raising standards but also for counterbalancing the accountability to owners.

The Committee on Publication Ethics (COPE) has made a start by publishing a code of conduct for editors, and readers, authors, peer reviewers, other editors or publishers can make complaints to COPE — so long as the complainants have first been through the complaints procedures of the journals (241, 249). There are, however, no sanctions apart from expulsion from COPE.

Altman, Chalmers and Herxheimer in their paper on editorial misconduct proposed an International Medical Scientific Press Council (236). They imagined that the council might produce a code of good conduct and a taxonomy of misconduct. Journals would sign up to abide by the code and agree to abide by a specified investigation procedure. Readers and authors would know which journals agreed to follow the code, and any failure to follow the code would be publicized. If a complaint against a journal or editor was upheld then the judgement would be published, and the owners of the journal might decide to take some action.

A model for the International Scientific Press Council is Britain’s Press Complaints Commission, a successor to the Press Council (230). The commission is funded by the press that it regulates and has a code that editors must follow. The first chairman, Lord Wakeham, describes how the commission was ‘established in break neck speed …[because] a Damoclean sword — in the shape of the Calcutt Report, a privacy law and statutory controls — dangled menacingly over our free press (251). The commission includes editors but has a majority of independent outsiders.

There is no cost to those who complain, and in 2002 the commission received 2630 complaints that editors had breached the code. Most are settled by conciliation, and in 2002 only 36 went to the commission for adjudication. There is no hearing. The commission makes its decision based on the offending article and correspondence between the complainant and the editor.

Although 92% of those who complain to the commission are satisfied with the response they receive, there are many anxieties about the commission. Complainants feel that the commission favours the editors. The commission has very little capacity for investigation, and the only punishment if editors are found in breach of the code is that they have to publish an account of the adjudication. They are inclined to bury this at the back of the publication and will sometimes publish a more prominent piece explaining why they disagree with the adjudication. A House of Commons select committee was critical of the commission, and some day there may be legislation to make the press more accountable.

The problem is that freedom of the press is undoubtedly a major asset, enshrined, for example, in the American constitution. The press acts for the governed not the governors and can act powerfully against despotism, corruption and misconduct. In what I always think of as the strongest argument for press freedom, the Nobel prize winner, Amartya Sen, has shown that famine does not occur in countries with a free press (252). Famine arises not because of total lack of food but because of maldistribution: a free press will expose those eating three-course dinners while others starve. So how do you strike a balance between allowing the press the freedom that is ultimately good for all and making it accountable? It isn’t easy, and the wise thing is probably to err on the side of freedom, accepting that some will be abused.

Complaints about the BMJ have been made several times to the Press Complaints Commission, but only once has a complaint got as far as an adjudication. As I described in chapter 2, we published an obituary of a doctor, David Horrobin, in which we made clear that he was unusually clever, charming, and creative but also suspect (50). The obituary suggested that his ethics were ‘dubious’ and that he ‘may prove to be the greatest snake oil salesman of his age’.

His family unsurprisingly were distressed, and his many friends were furious. We received over one hundred rapid responses to our website, almost all of them protesting strongly against the obituary. We published three alternative obituaries (253-255), all positive, in the paper edition of the journal together with a summary of the responses (95) The obituary also contained some errors that we corrected. We did, however, stand by the obituary as we believed it to be essentially ‘true’. Initially I declined to apologize because it seemed hypocritical to do so: we knew that publishing such an obituary would cause distress. But then I was persuaded that I was sorry about the distress to the family — which I was — and that therefore it wouldn’t be hypocrisy to apologize. So we did.

The complainants said that we had breached article one of the code by publishing ‘inaccurate, misleading or distorted material’ and article five by intruding into grief by handling the obituary ‘insensitively’. The commission noted that we had published corrections and said it was not set up to decide whether the obituary was ‘true’ or not. It also decided that we had not breached article five. In short, we ‘got off’, but I can easily understand that the complainant would feel let down in that he strongly believed that the obituary was ‘untrue’.

This account of the Press Complaints Commission and one experience of its workings illustrates why creating a body to regulate international scientific journals and making it work would be formidably hard. This is one reason — in addition to lack of will and the absence of a sword of Damocles — that it hasn’t happened. The body would experience the greatest difficulty when there was a dispute between the organization and the journal. The journal might simply walk away, or lawyers might become involved generating large bills and finding large defects in the constitution of the organization. Nevertheless, COPE has made a beginning. The creation of a forum to hear cases against editors could be useful not only for making editors more accountable but also for setting standards. The vision of an International Medical Scientific Press Council, which is already 12 years old, is probably at least another 12 years away.

More From The Trouble With Medical Journals

• Introduction: Medical Journals Are Probably a Force for Good but Need Considerable Reform
• Why Bother With Medical Journals and Whether They Are Honest?
• What and Who Are Medical Journals For?
• Can Medical Journals Lead or Must They Follow?
• What Are and What Should Be the Values of Medical Journals?
• The Complexities and Confusions of Medical Science
• The Death of the Author and the Birth of the Contributor
• Publishing Too Much and Nothing: Serious Problems Not Just Nuisances
• Conflicts of Interest: How Money Clouds Objectivity

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