The Trouble With Medical Journals: Introduction

The following excerpt is reprinted with permission from The Trouble With Medical Journals (Taylor & Francis, 2000).

Medical Journals Are Probably a Force for Good but Need Considerable Reform

Medical journals, which many imagine to be as dull as telephone directories and twice as obscure, influence the lives of everybody — and not always for the better. Not only do they affect what doctors do with individual patients and the actions taken by public health authorities on whole populations, but also they influence how we think about birth, death, pain and sickness. It may therefore make sense for you — the thoughtful but not necessarily expert reader — to pay attention to the ways of medical journals, particularly as many of those ways are deficient and need reform. That is the thesis of this book. I hope that I convince you — intriguing, even fascinating, and sometimes amusing you as we go.

Perhaps you are currently wondering whether your child should have the vaccine against measles, mumps and rubella (MMR). For many parents in many countries this has become a very difficult decision — mainly because of a short, dubious, article published in the Lancet (1). Many parents worry that the vaccine may cause their child to develop autism. Or maybe you are a middle-aged male thinking whether or not you should have yourself tested for prostate specific antigen (PSA) to see if you have cancer of the prostate. You may be perplexed by the emotion that suffuses the debate on the value of this test. Medical journals have provided the information that fuels the debate. Or perhaps you are constantly exhausted, suffering from a condition that many patients call myalgic encephalomyelitis and most doctors chronic fatigue syndrome. You look for help from your doctor, but she tells you that her medical journal tells her the condition does not exist. You are furious. How can this be?  

Or maybe you are in circumstances that don’t seem to be to do with illness. You are a woman who has lost interest in sex. You’re not sure why. One friend says that you may have ‘female sexual dysfunction’ and should think about medical treatment (2). Another friend says that she has read in the papers that the BMJ (the journal formerly known as the British Medical Journal) says that ‘female sexual dysfunction’ is a condition ‘invented’ by drug companies to create new markets (3). You wonder if you ‘have a problem’ and whether or not you need ‘to do something’. You’re also approaching the menopause and find yourself receiving very confusing, even contradictory, advice on whether or not you should take hormone replacement therapy. The medical journals have published many papers on hormone replacement therapy, most of them until recently suggesting that women will benefit substantially from taking the treatment. But now there has been a rush of papers suggesting that the treatment may increase the risk of heart disease and breast cancer and not improve quality of life. The tens of millions of women who have taken the treatment are understandably confused: have they been helped or poisoned?  

I could go on, but I want to begin to illustrate how medical journals are mixed up in reflections and debates that are important to you. I will enlarge on this theme in other chapters, particularly chapter 2, but you will, I hope, begin to see why you might be interested in what otherwise looks like an arcane subject.

My qualification to write the book is that I have given much of my life to medical journals in general and particularly to the BMJ. After training in medicine in Edinburgh and practising briefly in Scotland and New Zealand I joined the BMJ in 1979. For I0 years I worked simply as an assistant editor, reading manuscripts, writing and commissioning. During this time I also worked for six years as a television doctor on breakfast television, an experience that taught me much about the craziness and difficulties of the mass media. In 1989, at the instigation of Stephen Lock, my predecessor as editor of the BMJ, I went for a year to the Stanford Business School in California.

Soon after returning I was appointed as the editor-in-chief of the BMJ and chief executive of the BMJ Publishing Group, positions I held until I left in the summer of 2004. At the BMJ I worked roughly half of my time as an editor and half as the chief executive of the publishing group, which grew substantially during those years. I was responsible not only for the BMJ in its myriad forms, but also for nearly 30 journals intended for medical specialists, a books programme and various other publishing ventures, including one aimed at the public. When I woke at night during those 20 years, as I often did, it was more often to fret about the journal and the business than it was to think about my family. I write this with some shame, but it illustrates how deeply I was invested in this whole enterprise. My contention in this book is that there is a great deal about medical journals that is ethically sound but also much that is ethically doubtful.

I was asked to write this book by Sandy McCall Smith, professor of medical law at Edinburgh University, editor of a series on medicine, law, and ethics for Cambridge University Press, and chairman of the BMJ‘s ethics committee (as well as much else, including being a best selling novelist). I replied that I’d love to but could never find the time. ‘I think,’ he responded, ‘that you could probably just sit down and write it.’ That was a loaded phrase that lodged in my brain.

Slowly but ineluctably the idea of writing the book combined with an idea that had come to me about five years earlier — the idea that I would love to be in Venice not as a tourist but as somebody with a job to do. I don’t speak Italian and so couldn’t work in a cappuccino bar, but I could write a book. So there I was in February 2003 in a huge room in Palazzo Venier-Sanudo-van Axel-Barozzi, built in 1473 and within touching distance of Santa Maria dei Miracoli, which John Ruskin thought one of the finest buildings in Venice.

While writing the book in Ruskin’s ‘the ghost on the sands’, I fed on a daily diet of Bellini, Carpaccio, Titian, Tintoretto and Veronese. Maybe some of the voluptuousness of their paintings reflected itself in overambitious prose, but one painting fits particularly with this book. It is Carpaccio’s picture ‘St Augustine in his Study’ in the Scuola di San Giorgio degli Schiavoni. Carpaccio has the unusual ability to paint exquisite paintings that make you not only gasp with their beauty but also laugh. St Augustine, who is squeezed into the right hand side of the picture, is having a vision of the death of St Jerome. I identify with the study, the vision and the apparatus surrounding St Augustine — not a computer with internet access but an astrolabe, sheet music, archeological fragments and shells. I was in a not dissimilar room struggling with a vision of what my book would say. It might conclude that medical journals are lost and corrupt. But I’m most attracted to the small dog that occupies the middle of the picture and looks up at St Augustine thinking, ‘What on earth is he up to now?’ Not only my dog but also my family and staff often wonder that about me, and this book is written for that dog — and I hope that he or she will understand.

The flat that I lived in was once inhabited by Joseph Brodsky, who now lies in the cemetery of San Michele, less than a mile from the flat. The owner of the flat explained to Signora Elida who looked after the palazzo that I was a ‘scrittore like Brodsky’. I felt very silly.

I don’t expect — as did Brodsky — to win the Nobel prize for literature for this book, but I would like to produce a book that anybody might read, enjoy and end by thinking: ‘I’m glad I read that. I understand just a little more about the world.’ The most obvious audience for the book is one interested in what is now called ‘publication ethics’, but we are an inbred coterie. The next audience is anybody who reads medical and scientific journals. They are counted in millions and I should perhaps have been content with them. But I wanted to try and reach further because the journals deal in issues — birth, death, pain, sickness and sexuality — that affect us all and are perhaps not thought about as deeply as they might be. Richard Horton — a friend, the editor of the Lancet, and perhaps touched by the same hubris as me — said that I needed to convince the world that the discourse around health and disease was as important as the discourses around politics, business and the arts. I wanted to try and write a book for everybody because I’m suspicious of experts. After millennia of being a mysterious priesthood, medicine is discovering that better outcomes are to be had by treating patients as partners not supplicants. I’m suspicious too of ideas that are supposed to be so profound and complex that they cannot be expressed in language that everybody can understand. There may be such ideas, but I don’t know any.

So I am setting out with the intention of writing this book in language that can be understood by anybody. I will define any technical terms it would be clumsy to try and avoid defining. The book will include many stories and examples, and I will try to avoid being too abstract. Philosophers may enjoy abstraction, but doctors, I’ve discovered the hard way, do not. In this I judge that the broader public is more akin to doctors than philosophers. Popular newspapers contain few abstractions. I will provide evidence and data to support my statements. The data will be presented in as straightforward a way as I can manage. This talk of evidence and data may suggest that I am writing ‘truth’. I will not consciously be writing ‘untruth’, but I am sufficiently postmodern not to believe that there is one truth. There are many truths. As I’ve already shown, I plan to write in an unashamedly personal way. My justification is that I’ve been personally involved in much of what I will be describing. Plus I’m more of an editor than an ethicist — and by exploiting my strengths I hope to write a more useful book. Somebody else can write a book that is less subjective and stronger on ethics and law. Indeed, a distinguished group, many of them friends, already has (4).

I want the book to be as international as possible. Science has always been universal and medicine is a branch of science. Much of it is, however, culturally bound. Psychiatry in China is very different from psychiatry in Britain, which in its turn is surprisingly different from psychiatry in Germany or the United States. Some major medical journals — particularly the BMJ, JAMA (formerly the Journal of the American Medical Association), the Lancet, Annals of Internal Medicine and the New England Journal of Medicine (often known as ‘the big five’) — have long been international in that the scientific studies submitted to them and their subscribers come from all over the world. They have, however, been dominated by the countries they come from and have been particularly poor at reaching out to the developing world, the home of most sickness and premature death. Chapter 15 discusses how medical journals are trying to stop failing the developing world. I will strive for an international scope, but the book will, I know, feel British to some. Globalization is still in some ways an aspiration and national identity is not easily discarded.

Before travelling to Venice to write this book I re-read Death in Venice. I have no intention of dying in Venice, but nor did Aschenbach. I see no signs of the plague in Venice, but I do see the public being deceived about medical information in the way that Venetians were deceived about the extent of the danger presented by the plague. This thus seems a good place to reflect ethically on medical journals. There seems much to be proud of but also much that is wrong. It occurs to me that this is probably true of most human activities observed closely with an eye that is knowledgeable but attempts to be dispassionate.

Once I had finished the first draft of my book I sent it to Cambridge University Press, recognizing that I had written a distinctly non-academic book. The press wanted to make the book more academic — partly by removing my stories. I decided that I’d try and find another publisher, and I’m very grateful to RSM Press for agreeing to publish the book. I’m grateful as well to Sandy McCall Smith, who rang me between talks to the Palm Beach Literary Society to say that I’d done exactly the right thing to write the book as I wanted.

Scientific journals began in the 17th century with the French Journal des Savants and the British Philosophical Transactions of the Royal Society. The journals complemented scientific meetings, which had until then been the main way of communicating science. The history of journals since then has been one in which each new discipline eventually grew tired of simply being part of a larger whole and so started its own publication. General medical journals began at the end of the 18th century and specialist medical journals at the beginning of the 20th century. Later in that century came subspecialty journals, and the growth in scientific and medical journals was exponential until a decade or so ago when the whole venture hit the economic buffers.

Some societies and some commercial publishers have grown rich from their journals, earning profit margins of 40%. These were ‘must have’ journals, quasi-monopolies. New paper journals ceased to appear in such large numbers a decade or so ago because the traditional business model — of selling subscriptions primarily to institutions — would no longer work so well.

The exponential increase in journals may, however, return because new electronic journals can be started with minimal funds. These journals are about the fundamental business of disseminating science rather than making societies or publishers rich. The final chapter, chapter 22, considers the ethical implications of four different but plausible futures for medical publishing.

Some journals have always been about more than publishing science, and chapter 3 asks who and what medical journals are for. Most medical communities have had some sort of journal and journals provide a forum for them to debate an issue in depth. I’ve always been interested in the question of whether journals can lead or just simply reflect what is happening in their communities. This is a question that has interested scholars in the new discipline of ‘media studies’, but in reference to the mass media rather than medical journals. I reflect on some of their studies in chapter 4 and my tentative conclusion is that journals can, indeed, lead — but if they are to do so then they cannot be more than a whisker ahead of those they are attempting to lead.

Chapter 5 examines the values that underpin journals, almost always implicitly. Medical journals might be expected to have the values of medicine, science and journalism — and these values conflict. The values of both science and journalism, for example, might favour publication of a weak study with a conclusion that could cause a ‘scare’ among the public — because publication and debate are fundamental values to both, whereas medical values, which put a strong emphasis on ‘doing no harm’, might favour waiting until stronger evidence emerged.

The science that underpins medicine is presented in journals and most journals can point to landmark studies that have changed medicine. The BMJ, for example, published some of the first studies in anaesthesia, on the cause of malaria, and linking cigarettes to lung cancer. It also published the first randomized controlled trial, which for reasons that I explain in chapter 6 was scientifically a major development. The journals might also be said to have become ‘more scientific’ over the years in that the rigour of the methods of the studies they publish has improved.

Yet medical journals often contain poor science. Basic scientists who work in biology and chemistry are often scornful of the mostly applied science that appears in medical journals. The journals have, for example, published many reports of treatments applied to single cases and of series of cases, which rarely allow confident conclusions because it is impossible without ‘controls’ to know what would have happened without the treatment. Journals have also been part of what might be called an ‘unscientific’ method of encouraging treatments that seem to make anatomical, physiological or biochemical sense but without insisting that they be properly evaluated in practice.

The history of medicine is littered with treatments that seemed to make sense but which ultimately did more harm than good. Sir Arbuthnot Lane, who was mercilessly parodied in George Bernard Shaw’s The Doctor’s Dilemma, removed the colons of Londoners who were severely fatigued and rich enough to meet his high fees. The operation was supposedly removing toxins. One-tenth of his patients were killed by the operation. I belong to a generation who had their tonsils removed to no benefit, while my wife when having our first child in 1982 was given an enema and had her pubic hair shaved, procedures which are unpleasant and of no benefit.

Medicine itself probably deserves most criticism for its unscientific behaviour, but the journals are the major link between science and practice. Journals have been severely criticized in recent years for publishing studies that are scientifically weak (in that their conclusions are not supported by their methods and data) and irrelevant to practitioners (and so patients)(5-8).

Peer review — asking peers of the authors of scientific studies to review the studies critically before publication — is the process that is supposed to ensure the scientific quality of journals. It is a sacred process — and the phrase ‘peer reviewed journal’ is supposed to guarantee quality. But clearly peer review is deficient. Despite being central to the scientific process, it was itself largely unstudied until various pioneers — including Stephen Lock, my predecessor as editor of the BMJ, and Drummond Rennie, deputy editor of JAMA — urged that it could and should be studied. Our studies so far have shown that it is slow, expensive, ineffective, something of a lottery, prone to bias and abuse, and hopeless at spotting errors and fraud. As Rennie says, ‘If it were a drug it would never get onto the market.’ Nevertheless, no journal would dare to abandon peer review. Editors are convinced — even though we are finding it hard to prove — that peer review is invaluable. I will discuss peer review further in chapter 7.

Medical journals differ from scientific journals in that they are mainly read not by scientists but by practising doctors. ‘But aren’t doctors scientists?’ you might ask. We are in that when we were medical students our heads were filled with anatomy, biochemistry, physiology and (if we are under 40) molecular biology, but such teaching does not a scientist make. Most doctors feel uncomfortable describing themselves as scientists. Most are not even trained to appraise critically a scientific article.

Why then do we send them journals filled with increasingly complex science, most of which depends on statistical methods that they do not understand? It is, I think, a historical hangover and we have lots of data to show that doctors spend little time reading the original research in journals. They are sensible not to do so. The average doctor spends not much more than an hour a week on professional reading. It thus doesn’t make sense for him or her to spend most of that time reading one complex study. Doctors sensibly should read synoptic, educational material, and mostly that’s what doctors do. Often they read this material not in journals but in what are condescendingly known as ‘throwaways’, newspapers that use journalists to summarize complex material and which are free because they are funded by pharmaceutical advertising.

Journals have long recognized that they are unlikely to flourish if they publish only scientific studies. Increasingly they publish reviews that update practitioners on new developments, educational material, news, reviews of books, articles that are more journalism than science, letters and obituaries. Slowly they have begun to look less like traditional scientific journals and more like popular magazines with shorter articles, brief summaries and graphics.

They try to be useful tools to doctors in their practice, but they have only limited success. Doctors suffer from what Muir Gray, a public health doctor and director of Britain’s National Electronic Library of Health, calls ‘the information paradox’: they are overwhelmed with material of limited relevance and quality but can’t find answers to the many questions that arise when they meet with patients and which thus go unanswered. Journals are not good at getting doctors to change and improve their practice. Words on paper rarely lead directly to change.

What journals can do is to make people think, set agendas, encourage debate, draw doctors’ attention to new things that may be important and even legitimize subjects. In short, they are very like newspapers and Robbie Fox, the great editor of the Lancet in the 20th century, liked to call his journal a newspaper.

Should journals then abandon publishing science? In the end science might abandon them and be posted on publicly available websites rather than appear in journals, but it is unlikely that the journals will abandon science first (although I can think of at least one American journal of family practice that has done so). Most of a journal’s kudos comes from the science it publishes, and it is the science rather than the rest of the material that attracts worldwide media attention and causes subscribers (mostly institutions) to purchase the journals. Some of the scientific studies that journals publish are hugely important, and the science gives journals an authority and legitimacy that separates them from the (usually much more readable) ‘throwaways’.

Despite my criticisms of journals I still believe that a good journal can be a major asset to a medical community. It can move medicine forward, less through providing a clear direction of travel but more through highlighting the deficiencies of the present and providing a hundred ideas on how to do better. Most medical communities — be they national or specialist — have journals, and at least some members of those that don’t (some Italian doctors, for example) pine for a good journal.

But do journals benefit patients? Medical journals have been intended for doctors not patients. Any benefit to patients would come from improvements in their doctors. Now with the arrival of the internet patients can access the same information as doctors, and sometimes the patient is better informed than the doctor. This is a new world for both doctors and patients, but there is growing evidence that doctors and patients taking decisions together — rather than doctors taking decisions on behalf of patients — leads to patients doing better and being more satisfied. Even if patients have not been readers of medical journals, they have certainly featured in their pages. As recently as 10 years ago journals might publish pictures of patients naked without them knowing a thing about it. Now we are moving into a world where we have patients on editorial boards and even patient editors. Chapter 13 describes how journals are trying to move from a world where patients were objects to one where they are partners, but journals are here, I judge, lagging behind the practice of medicine.

Abuse of patients has been one ethical failing of journals, but section 4 describes others. Chapter 11 deals with the failure of medical journals to manage conflicts of interest. Until very recently journals did not ask authors and reviewers about conflicts of interest and so did not declare them to readers. But most authors in medical journals do have financial conflicts of interest, particularly in their relations with pharmaceutical companies. These undeclared conflicts of interest can have profound effects on the studies authors undertake and the conclusions they reach. On some major issues — like whether passive smoking (exposure to other people’s smoke) is harmful or whether new contraceptive pills are more likely to cause clots in the legs and lungs than earlier pills — studies linked to the manufacturers reach completely different conclusions from those that are not. So journals have to do a better job at managing conflict of interest. This doesn’t mean getting rid of conflicts of interest because such conflicts are inevitable and all pervasive.

Most journals also face an ethical problem in being so closely associated with pharmaceutical companies. These companies are important in that almost all the new drugs of the past 50 years have been discovered by them, and those drugs have transformed medicine. But the interests of pharmaceutical companies and doctors, patients and so journals (as they should put doctors and patients first) are not always the same. A company might want patients to take its drug even though another drug might be better. Companies will push drug rather than non-drug treatments, even though for many conditions — for example, diabetes — non-drug treatments are often more important. Some journals have been captured by pharmaceutical companies in that they have come to depend on them. Many, including some of the most prestigious journals, publish mostly trials that are funded by the industry. They depend on income from pharmaceutical advertising and sales of reprints (a company might pay over $1m for reprints of one study, which it funded in the first place). Journals should not attempt to separate themselves from pharmaceutical companies, but the relationship should be ethically more sound. This relationship is discussed in chapter 16.

Some would also argue that journals have an unhealthy relationship with the mass media. Journals might, indeed, be degenerating into a branch of show business. Our competitors, I told my staff, were not just the New England Journal of Medicine and the Lancet but Hollywood films and Manchester United. I meant that we were part of the ‘attention economy’ and that we competed all the time with rich pleasures for the attention of doctors. I didn’t mean that we should abandon our fundamental principles and seek publicity at any price, but there is no doubt that coverage in the mass media is good for journals in both prestige and business terms. All the major journals put out press releases (and some in the United States video clips) and are disappointed if an issue receives no coverage. Sometimes, even often, there will be global coverage. But are journals debasing themselves in pursuit of publicity? I will explore the relationship between journals and the mass media in chapter 14.

Sometimes journals receive coverage in the media that makes them squirm, particularly when they are exposed as having published research that is fraudulent. Fraud in science is as old as science itself — because science is a human activity. But fraud was not high on anybody’s agenda until about 20 years ago. As recently as five years ago I heard a fellow of the Royal Society (a position in British science one step short of a Nobel prize) argue that fraud was exceedingly rare, didn’t happen with ‘proper scientists’, had never harmed anybody and didn’t matter because science was self-correcting. It’s now impossible to take this position in public and there are increasing examples of fraud. In one phone call in December 2002 I had to tell the editor of the Lancet that I had compelling evidence that two major trials he had published were fraudulent.

Some countries — particularly the United States and the Nordic countries — have mounted a coherent, national, legally based response to scientific fraud, but most countries, including Britain, have not. Medical editors in Britain have created the Committee on Publication Ethics (COPE), a sort of self-help group for responding to fraud — or as it is better called research misconduct. (Fraud is a severe word that is excessive for much of the comparatively minor forms of misconduct that seem to be common — and has connotations of financial fraud.) COPE started in 1997 and has now dealt with about 250 cases. For some editors it has caused a transformation in how they deal with misconduct. Whereas editors were inclined to look the other way, especially as most of the problems arose in studies they had no intention of publishing, many now feel an obligation to act. This transformation is similar to what has happened in medicine itself, where regulatory bodies will discipline doctors who fail to act on signals of clinical, research or financial misconduct.

But I still feel that editors are at the beginning of responding to research misconduct. Many editors are not sensitized to the problem. Most of COPE’s cases come from a few journals, and it’s impossible to believe that those journals have many problems while others have none. But even when editors do decide that they need to respond to problems they are often unclear what action to take. And when universities or other employers are alerted to the possibility of misconduct they either will not or cannot take action. I worry that journals are polluted by misconduct and that editors are not responding adequately. I will discuss research misconduct in chapter 8, and to show that I have not forgotten a form of misconduct that editors are most inclined to forget — editorial misconduct — I’ve devoted the whole of chapter 12 to the subject. Some say that editors are as unaccountable as kings.

Chapter 9 deals with the difficult question of authorship of scientific research. Jane Austen wrote every word of her novels and was indisputably the author. But conducting scientific research often depends on large teams of people with different skills. Deciding who should be listed as an author is not simple and too often the decision is made on the basis of power. The powerful are included, even when they have done nothing, and the weak are excluded, even those who have done most of the work. This unethical behaviour becomes a major problem if the study proves to be fraudulent, as has happened many times. For authorship implies not just credit, which authors love, but also accountability, about which they are much less enthusiastic. Senior authors suddenly say that they cannot be held responsible for a corrupted study because they had nothing to do with it. Such a position does not impress. One radical but rational response to the problem of authorship is to abandon the idea within science. Instead, we should go for contributorship, where the contribution of everybody is simply described, rather as with film credits.

One form of misconduct that seems minor at first thought is publishing the same study — or large parts of it — more than once. This is irritating but surely not serious. In chapter 10 I will try to convince you that this problem is, indeed, serious for patients and the public. It so happens that studies that find a treatment, often a drug, to be effective tend to be published more than once, whereas those studies that find that the treatment does not work are often not published at all. The result is a systematic bias in medical information that makes some treatments seem much more effective than they actually are. Patients are then mistreated.

Many of these ethical problems I’m introducing — weak science, an inadequate response to conflicts of interest, too cosy a relationship with the pharmaceutical industry, research misconduct — could be said to be problems of medicine itself rather than simply journals. The two are inextricably entwined, which is why the author who wrote a history of the BMJ called it The Mirror of Medicine (9). But the last ethical problem I want to introduce is more a problem that is squarely the responsibility of journals rather than medicine. It is the problem of journals exploiting — let’s say ripping off — the academic community.

‘All publishing is theft’, the BMA’s librarian used to joke — before he left to join the world’s largest scientific publishers, Reed Elsevier, and so giving a bitter twist to his joke. As somebody who was something to do with publishing I was offended. But more to the point I didn’t understand. Now I do. Most medical journals comprise almost entirely research articles. These articles are written by the researchers and submitted to the journals for free. Consider the value in a major trial published in a medical journal. Such trials can cost millions of pounds to conduct. Almost all of the value is in the trial itself. (By ‘value’ I mean the unique contribution that customers are willing to pay for.) Most of these trials are conducted by academics and many are funded with public money. The journals conduct peer review, but I have already argued that this is a process that adds little value. What’s more the peer review is usually done by academics without pay. Indeed, many journals are edited by unpaid academics. Often it is academics, again unpaid, who edit the studies before they are published. The journals are then sold to academic libraries — and often at huge prices. An annual subscription to some journals may be over $20,000. Publishers — sometimes commercial companies, although often medical or scientific organizations — make substantial profits, but without adding much value. Indeed, publishers may subtract value by ‘Balkanizing’ the scientific literature, severely limiting accessibility.

Robert Maxwell, a publisher of newspapers and journals who became famous for stealing his employees’ pension fund, got rich through publishing scientific journals. The ethics of the business of scientific publishing are highly suspect and I will discuss them in chapter 17.

Section 6 of the book considers attempts to raise the probity of research and increase the accountability of editors. Chapter 18 looks at how descriptions of highly unethical medical research conducted after the Second World War led to the creation of research ethics committees (or institutional review boards in the United States). Across the globe these committees are now proving to be overworked, under-resourced and insufficiently skilled. Radical reform is needed. Medical journals have also been poor at ensuring the ethical acceptability of what they publish — often failing to ensure that research has had approval from research ethics committees. But journals sometimes identify failings in the research ethics committees, and chapter 18 discusses how the committees and journals might work more creatively together.

Chapter 19 looks at the ethical competence and accountability of journals themselves. The Lancet took the bold step of introducing an ombudsman to consider complaints against authors. The experiment seems to have been a success but has not been widely copied. The BMJ introduced an ethics committee of its own, and almost immediately we wondered how we managed for 160 years without one. But these are small experiments. Much more needs to be done to improve the ethical accountability of editors and journals.

Medical journals, just like any other publications, are covered by the laws of libel. In Britain these are strict and the BMJ was involved in one of the longest running libel cases in British legal history. Chapter 20 describes that case and discusses how the law of libel has to balance injury to individuals against freedom of speech. British law is tipped towards the individual, American law towards freedom of speech. Unsurprisingly, I would like British law to move in the American direction.

Chapter 21 examines the case — put most forcefully by Sir Richard Peto, one of Britain’s most distinguished medical researchers — that concern with ethical issues in publishing medical research is causing more harm than good. The problem, he argues, is minor, but clamour around the problem is making research much harder to do. The result is that the public is harmed rather than benefited. I agree with some — but by no means all — of his analysis.

So you can see why I was pensive in my palazzo. I’m proud to have been part of such an energetic, exciting and, I hope, ultimately useful enterprise as the publishing of journals, but I’m concerned that much of what journals do is ethically weak. The rest of this book will explore those concerns, searching always for possible means to do better.

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