Former BMJ editor Dr. Richard Smith weighs in on the ethical woes plaguing medical journals

The Trouble with Medical Journals, by Richard Smith, published by the Royal Society of Medicine Press, 292 pages

God knows that medical journals today have enough troubles without having a heavyweight point it out. But Dr. Richard Smith, who until two years ago was the well-respected editor of the British Medical Journal(BMJ), has stepped up to expose the highly profitable and at times unethical business of publishing medical research articles. In what may be his unwitting farewell to medical journalism, he has prescribed a poison pill for the current systemic disorders of the holy writs of caring and curing.

Dr. Smith knows well the malaise of medical journals. He writes about the disastrous results of a 1998 Lancet article that suggested the MMR vaccine could cause autism. The “suggestion,” made on what proved to be faulty research, snowballed in the U.K. Parents refused vaccination for their children. The author, when challenged by the recanting of the paper by 10 of 13 of the collaborators, briskly confronted the medical profession and asserted his research was valid. Eventually, after it was exposed that his funding came from a group seeking evidence to support legal action against the manufacturers, he decamped to the lotus land of the litigious, the U.S.

The Lancet never withdrew the article.

There was no canary in the mine shaft when the Journal of the American Medical Association(JAMA)published an article on a survey that found American college undergraduates did not think of oral sex as sex when asked, “Would you say you ‘had sex’ . . . ?” The timing of the publication coincided with then-president Bill Clinton’s indiscretions in the Oval Office with Monica Lewinsky. Dr. George Lundberg, editor of JAMA at the time, was fired, at least partly for publishing the piece. Dr. Smith notes one newspaper commentator observed it was strange to fire an editor for publishing something highly topical.

Time also trumped a schadenfreudish NEJM, after Dr. Jerome Kassirer was terminated for refusing the dictates of the Massachusetts Medical Society. He was replaced by Dr. Marcie Angell. During her time, a blockbuster article on COX-2 inhibitor use for arthritis was published as the VIGOR study. The journal published that there was more than a 50% reduction of GI side-effects. But the journal, which sold several hundred thousand dollars in reprints, mainly to the pharmaceutical industry, did not take the time to check with the U.S. Food and Drug Administration, with whom a different version of the safety factor had been filed.
It took a long time for the world-leading journal to clean up the mess—and appoint its third editor in one year.

The problems are wider than publishing without verifying the substance of an article or looking at any collateral damage. The Journal of Medical Ethics queried editors about ethical problems. “I don’t have any,” was the standard reply. There is no code of ethics for journals. To address this, a group of editors meeting in Vancouver in 1997 established a Committee on Publication Ethics. This advisory group gives advice on how to deal with misconduct of authors, and has established guidelines on good publication practice, peer reviewers and the conduct of editors.

But there is a sidebar here. The editor’s job is also shaped by who owns the journal. Rarely are journal owners clear about what they want. To communicate? To judge the research papers? To make a profit? There are even fuzzier job descriptions for editors, and the meaning of editorial freedom is unclear. Dr. John Hoey, seven years before he was canned by the Candian Medical Association Journal, wrote: “Any medical journal belongs intellectually and morally to its contributors, editors, editorial board and readers.” According to Dr. Smith, it is a myth that editors are free to do and print whatever they want.

But Dr. Smith is not just a Cassandra. He proposes what can be done to save medical journals. He points out that we can continue, as at present, with increased vigilance, or we can provide the consumer with the complete database for each new breakthrough. A third program is to expand our electronic net so that medical personnel, patients and others can discuss and decide. The last alternative he suggests is that publications be produced by the big corporations whose mission, to make money, is clear to all—the result being there is no longer a place for rigorous, traditional science in medical journals.

The Trouble with Medical Journals hoists a red flag for editorial aspirants. It also raises the yellow flag of possible pestilence. The conduct of medical practice is dependent on a continuing flow of non-corrupted information. Evidence-based medicine must stand on that rock; Dr. Richard Smith raises concerns about the porosity of the base.

Charles Godfrey is writing a history of Sunnybrook Health Sciences Centre.