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Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance 

Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance
Ethical and Legal Considerations

Annette Flanagin

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Subscriber: null; date: 23 October 2018

Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance

Interference with editorial freedom has affected several prominent medical journals and has been well documented in the biomedical literature and the press. However, many other cases of such interference have not been made public or are discussed only anecdotally, privately, or via restricted electronic mailing lists. The experiences of JAMA, the New England Journal of Medicine, and the Canadian Medical Association Journal (CMAJ) are presented here for the following reasons: there is sufficient literature documenting the relevant events; effective protective oversight mechanisms and governance plans were lacking or insufficient at the time; and the mechanisms for protection of editorial freedom that were developed as a result of these events are informative and may be helpful for other journals, editors, publishers, and owners.

The Case of JAMA.

Since 1982, George D. Lundberg, MD, had served as editor in chief of JAMA, a weekly, peer-reviewed, general medical journal, and the Archives specialty journals that are owned and published by the American Medical Association (AMA). JAMA had operated under a set of goals and objectives that were developed by Lundberg and the journal’s editorial staff and that were approved by the journal’s editorial board and AMA management.34 These goals and objectives had protected the editor on several occasions from external pressures to restrict the journal’s editorial freedom, and in 1993 the AMA House of Delegates (the policy-setting and governing body of the association) passed a resolution reaffirming editorial independence for all of its scientific journals.35 Although JAMA had a defined mission that included editorial freedom that had been publicly supported by its owner, it did not have sufficient oversight and a governance plan in place to help promote a trust relationship between the editor and AMA leadership, facilitate resolution of conflicts, and help prevent interference and threats against editorial freedom and authority.

During Lundberg’s editorship, there had been tension between him and representatives of the AMA leadership and executive staff related to editorials and articles that were published in JAMA that were controversial or contrary to AMA positions. In 1999, Lundberg was abruptly fired by the AMA after he accelerated the publication of an article in JAMA (after peer review and acceptance) that reported the results of college students' attitudes toward sex to coincide with the impeachment hearings of President Clinton. According to the AMA’s executive vice president, the publication of that article was an act of “inappropriately and inexcusably interjecting [JAMA] into a major political debate that has nothing to do with science or medicine.”10,11,21 At the time, JAMA had as 2 of its objectives “to foster responsible and balanced debate on controversial issues that affect medicine and health care” and “to inform readers about nonclinical aspects of medicine and public health, including the political, philosophic, ethical, legal, environmental, economic, historical, and cultural.”34 In addition, the journal had a long history of publishing articles that were pertinent to ongoing national and international political discussions, that were directly or indirectly related to medicine or public health, and that were released at a specific time to influence those discussions.

The AMA was widely criticized for the firing, which was considered interference with the journal’s editorial independence and which damaged the reputation of the journal and the AMA and harmed JAMA’s previously demonstrated integrity.12-15,21,36 Immediately after Lundberg’s firing, the journal’s remaining editors, led by 2 interim coeditors, and the editorial board published an editorial in protest.16 The senior editorial staff considered resignation but decided to stay on to support the journal. However, 2 members of the journal’s editorial board and some members of the AMA resigned, and some readers cancelled subscriptions to the journal. Many authors threatened to withhold manuscript submissions to JAMA, and others threatened not to serve as reviewers.

The AMA appointed an independent 9-member search committee, chaired by a member of the JAMA editorial board who was also an editor of one of the Archives Journals. Other members of the committee included leaders in academia and research who were independent of the AMA, other journal editors, and a JAMA deputy editor; it did not include AMA executive staff or officers. The search committee’s objectives were to identify a new editor, review the journal editor’s job description and reporting relationships, determine how to evaluate the editor’s performance, and review existing practices and develop safeguards to ensure the journal’s editorial independence, integrity, and responsibility.37,38

Before the search committee had completed its work, the JAMA editorial board (which included 10 editors of the AMA-owned Archives Journals) met with the remaining editors, other editorial staff, publisher and publishing staff, and AMA senior management during its regularly scheduled annual meeting. During that meeting, an executive session was called that included the editorial board members and senior editorial staff, but excluded representatives of AMA senior management and the journals' publishing staff. The editorial board voted unanimously to resign en masse if the journal’s complete editorial freedom and a new governance plan to repair the journal’s integrity was not accepted by the AMA leadership.

After multiple discussions and negotiations between the search committee and AMA leadership, a new governance structure for JAMA and the Archives Journals was developed by the search committee, AMA senior management, and the AMA Board of Trustees to “insure editorial freedom and independence for JAMA, the Archives Journals, and their Editor-in-Chief.”37,38 This governance structure was set in place before Catherine D. DeAngelis, MD, MPH, became editor in chief of JAMA and the Archives Journals in January 2000, and it was a condition of her acceptance of the position. The governance plan was subsequently reaffirmed by AMA leadership.39

The governance plan is republished here as a model for other peer-reviewed journals, editors, publishers, and owners to consider (see Box 1 and Figure). This governance structure supports the editor in chief’s editorial independence, facilitates access of the editor in chief to the decision-making body and top management of the AMA, and provides mechanisms for review of the editor in chief’s performance and conflict resolution. For all editorial responsibilities, the editor in chief reports to the Journal Oversight Committee, which in turn reports to the AMA Board of Trustees. For business responsibilities (including editorial finances and budget), the editor in chief reports to the AMA executive vice president (the top management position), who reports to the AMA Board of Trustees. The journal’s publisher reports through an administrative channel similar to that of the editor in chief for business and does not have supervisory or other authority over the editor in chief. The editor in chief and publisher work as a team.

Figure. Reporting structure for JAMA’s Editor in Chief. Reprinted from JAMA. 2004;291(1):109.39

Figure. Reporting structure for JAMA’s Editor in Chief. Reprinted from JAMA. 2004;291(1):109.39

The Case of the New England Journal of Medicine.

Since 1991, Jerome P. Kassirer, MD, had served as editor in chief of the New England Journal of Medicine, a weekly, peer-reviewed, general medical journal that is owned and published by the Massachusetts Medical Society. In 1999, Kassirer was dismissed as editor in chief of the New England Journal of Medicine after a struggle over authority with leaders of the Massachusetts Medical Society could not be resolved.17-20,40 Kassirer objected to the society’s plans for reuse of the journal’s content and co-branding of the journal name with other information providers over which he had no control or authority.19 He also objected to plans to move the journal’s editorial staff from its academically affiliated location at Harvard University to the publisher’s commercial offices because he believed that these plans threatened the journal’s credibility and autonomy.19 According to Kassirer, the decision to dismiss him was made by the Massachusetts Medical Society’s Committee on Administration and Management, which did so without input from the society’s trustees or the Committee on Publications.19 According to the society’s bylaws, the Committee on Publications was responsible for the publication of the journal and was the authority to which the editor in chief had reported for decades.

In response to the firing of Kassirer, there was much criticism from the international medical community as well as resignations of members of the Committee on Publications, the journal’s editorial board, and members of the Massachusetts Medical Society.17,20,21 In addition, the journal’s remaining editors discussed a plan for mass resignation in response.20 Deciding that such an action could irreversibly damage the journal, the remaining editors discussed and negotiated with the Massachusetts Medical Society a set of principles to maintain the journal’s editorial independence and the editor’s authority and responsibility for all content, editorial policies, use of the journal’s content, name, and logo, and location of the editorial office.20 With these assurances, Marcia Angell, MD, then the journal’s executive editor, agreed to serve as editor in chief until a search committee with representation of the editorial staff and the wider academic community could identify a new editor in chief for the journal. In May 2000, Jeffrey M. Drazen, MD, was appointed editor in chief, and it was reported that the editorial freedoms negotiated previously by Angell would remain.40

The Case of the Canadian Medical Association Journal (CMAJ).

Since 1996, John Hoey, MD, had served as editor in chief of the CMAJ, a weekly, peer-reviewed general medical journal owned by the Canadian Medical Association. In 2006, the CMA abruptly fired Hoey and the journal’s senior deputy editor, Anne Marie Todkill.25,26 Initial public reasons from the publisher and CMA leadership for the dismissals were to “freshen” the CMAJ and because of “irreconcilable differences” between the editor in chief and the CMA, but no specific differences were cited.25,26 While the CMA denied that the decisions had anything to do with editorial independence, Hoey, other editors, editorial board members, and members of the journal’s oversight committee have all described several examples of censorship and interference with the CMAJ by CMA leaders and executives dating back to 2001 or earlier.25,26,41-43

In 2001, CMAJ published an editorial supporting medical use of marijuana, which contradicted the CMA’s position and for which the CMA’s general counsel complained to Hoey.25 In 2002, the CMAJ published an editorial criticizing Quebec physicians for not properly staffing an emergency department after a patient with a myocardial infarction died while being transported from an emergency department that had closed at midnight to a second open emergency department.25 Members of the CMA board called the editorial irresponsible, and the CMA president called for the editorial to be retracted. The CMAJ editorial board responded that the CMA was threatening the CMAJ’s editorial independence.25,42 Following these incidents, a journal oversight committee was established in 2002. However, the oversight committee’s roles and functions were unclear and interpreted differently by the CMA leadership, the editor in chief, and even the chair of the committee.25

In late 2004, the CMA had reorganized its publishing services and placed the ownership and direction of the CMAJ under a subsidiary, CMA Holdings Inc.44 This change reduced the editor in chief’s contact with the CMA and increased his interactions with the holding company and publisher, whose primary objective was profit.41,43 However, this change did not decrease the CMA’s attempts to influence the editorial direction and decisions of the journal. In late 2005 and early 2006, 2 other incidents of interference and censorship by CMA leadership and executives occurred.25,26,41 In one case, a CMAJ news story reported on the difficulty Canadian women had in obtaining nonprescription emergency contraception (Plan B) from Canadian pharmacists. Apparently, the Canadian Pharmacists Association complained to the CMA’s chief executive officer and objected to CMAJ’s plan to run this news story after one of the CMAJ reporters interviewed an executive with the association. The CMA’s chief executive officer took the objections to the CMAJ publisher, who told Hoey not to run the news story. Faced with what was thought to be an unreasonable demand and to avoid a crisis, the editors and reporters then modified the news story to address some of the objections and a revised article was published.25,26,41 An unsigned editorial was subsequently published in the CMAJ to alert readers to the incident of editorial interference and to “set in motion a process to ensure the future editorial independence of the journal.”45

The second case of such interference involved a CMAJ news story that was critical of a Canadian public health official. The news story was published in the online version of CMAJ on February 7, 2006, and was subsequently removed from the website.41 On February 20, Hoey and Todkill were fired, and 2 days later, a revised version of the original story was posted online that was less critical of the health official and more supportive of and beneficial to the CMA.41

During this time, Hoey had lost confidence in the journal’s oversight committee and asked an ad hoc committee to review these events.25,26 The ad hoc committee faulted the editors for modifying the news story on Plan B before it was published and for failing to follow the appropriate channel for conflicts (ie, the journal’s oversight committee).41 However, the ad hoc committee found more serious fault with the CMA for “blatant interference with the publication of a legitimate report” and concluded that the “CMAJ’s editorial autonomy is to an important degree illusory.”41

Following the abrupt dismissals of Hoey and Todkill, the remaining editors, led by acting editor Stephen Choi, MD, published an editorial in protest of the firings.46 Choi and colleagues drafted a proposal that included editorial independence for the CMAJ and aimed to ensure that the CMA and the publisher would not make decisions about editorial content.25 The CMA did not agree to the proposal, and Choi and another editor resigned.25 Other editors and most of the editorial board also resigned, and there were calls from academic leaders not to send papers or serve as peer reviewers for the journal.24,47,48 The journal’s former editor in chief, Bruce P. Squires, MD, was asked to serve as acting editor, but under pressure from editors of other journals, he too was unable to serve unless the CMA would agree to the journal’s editorial independence.25

Like the events at JAMA and the New England Journal of Medicine, the abrupt firing of CMAJ’s editors and the refusal of the CMA to recognize the journal’s editorial independence resulted in widespread news coverage of the conflicts, and a number of other leading journals published articles in support of the CMAJ editors.22,23,25,49 In the wake of such criticism, in March 2006 the CMA announced the establishment of a panel to assess the journal’s governance and management and agreed to an interim plan granting the editor in chief total responsibility for editorial content. With this plan in place, Noni MacDonald, MD, agreed to serve as interim editor and Squires agreed to serve as editor emeritus. The CMAJ governance review panel released its final report on July 14, 2006.44 The report contained 25 recommendations, all of which were accepted by the CMA.50-52 The recommendations included the following:

  • Assurance that the editor in chief would have editorial independence

  • Amendment of the CMAJ’s mission statement to enshrine the “principle of editorial integrity, independent of any special interests”

  • Confirmation that the CMA has no right to alter any editorial content, but should be given the same advance notice of potentially controversial content that is given to the news media (see also 5.13.3, Release of Information to the Public and Journal/Author Relations With the News Media, Embargo)

  • Proposal that the CMA take back direct ownership of the CMAJ from its for-profit holding company

  • Proposal that the CMAJ editor in chief have separate and discrete reporting structures for editorial and business matters (ie, the editor in chief has access to the CMA Board of Directors if needed to defend or explain editorial positions or other concerns that cannot be resolved through administrative mechanisms such as the journal’s oversight committee; and the editor in chief reports directly to an officer of the CMA rather than to the publisher about the journal’s business matters, and the publisher reports to the same officer)

  • A recommendation for a reconstituted journal oversight committee that permits it to more effectively help resolve potential disputes between the journal’s owner, publisher, and editor in chief

For more details on the makeup and responsibilities of the CMAJ’s oversight committee and the panel’s other recommendations, see the CMAJ Governance Review Panel’s final report.44 In January 2007, Paul C. Hébert, MD, was appointed editor in chief of the CMAJ with assurance of the journal’s independence as outlined in the CMAJ Governance Review Panel’s report.53

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