John Hoey, M.D.
NEJM
May 11, 2006
On February 20, after almost 10 years as editor-in-chief of the Canadian Medical Association Journal (CMAJ), I was fired without cause.
I packed up my few personal belongings and left the editorial offices for the last time. Anne Marie Todkill, the Journal’s senior deputy editor and a 12-year veteran, was fired the same day. Deputy editor Stephen Choi was named acting editor-in-chief. Steve, a former editorial fellow of the CMAJ, conditioned his acceptance of the position on adoption by the CMA of 10 principles of editorial independence that he laid out. The CMA refused to adopt the principles, and he resigned, as did the CMAJ’s current editorial fellow, Sally Murray. Other resignations followed: Anita Palepu and Claire Kendall, both associate editors of the CMAJ; Laura Eggertson, associate news editor; Nick Barrowman, a biostatistician; and most of the CMAJ’s editorial board.1
The CMA gave no reasons for the firings other than, initially, to “freshen” the CMAJ and, later, for “irreconcilable differences” (so far unspecified) between me and the CMA. The most striking irreconcilable difference was the censoring by the CMA of a report describing the difficulties Canadian women had in obtaining Plan B (a nonprescription drug) from pharmacists.1
This action by the CMA was a clear violation of the principle of editorial independence, as formulated by the World Association of Medical Editors and adapted integrally by the International Committee of Medical Journal Editors (ICMJE), of which the CMAJ is a founding member. As required by this statement of principle, I and my colleagues publicly described the transgression in a lead editorial.2
Clearly, our ability to edit the CMAJ had been severely and, as subsequent events revealed, fatally compromised.
“Independence,” like “freedom,” is a word etched deep in human history. Although both evoke and provoke human emotions and actions, the words themselves are intangible abstract nouns, like “love.” Our understanding of these words comes with experience \ through falling in love or, in contrast, by having our freedom and independence curtailed by opposition and resistance. In Virginia Woolf’s To the Lighthouse, Lily Briscoe (not commenting on editorial independence) notes, “All that in idea seemed simple became in practice immediately complex; as if the waves shape themselves symmetrically from the cliff top, but to the swimmer among them are divided by steep gulfs, and foaming crests. Still the risk must be run; the mark made.”3
Thus, it is highly probable that each editor of a journal and each publisher and owner will have different views of editorial independence. In fact, it may be necessary for them to have differences, else the concept of editorial independence remains an abstraction, empty of meaning.
My experience is limited to editing a general medical journal owned by a national medical association. Journals owned by commercial publishers (for example, the Lancet) and those owned by other types of associations, such as the Public Library of Science (PLoS) journals, swim, perhaps, in different seas. But a common element is that editors and publishers have different perspectives on journal ownership. Owners see their legal rights and responsibilities, their corporate objectives, whereas editors gaze on authors, peer reviewers, editorial boards, journalists, and above all, interested readers, both professionals and members of the broader public. For an editor, the journal is much more than legal ownership. As some of my former colleagues and I have said, a journal is fundamentally about ideas: “The dissemination of medical science is, or should be, ultimately a humanitarian project, and not merely the special preserve of professional associations.”4
Editors must understand this broader journal ownership and convert its traditions, hopes, and aspirations into an editorial direction by recruiting editorial staff and editorial boards with the talents needed to achieve their goals both in the long term and day to day. Failure by journal owners to understand this larger constituency forced the American Medical Association to establish an independent journal oversight committee for its journal, JAMA. In Canada, former members of the CMAJ editorial board and others recently announced that they will launch their own general medical journal as early as this fall.
Medicine can be defined narrowly or broadly. In 1855, Thomas Wakley, founder and editor of the Lancet, editorialized on the Dickensian factory owners who were polluting London and lobbying the government “for the conservation of their right to fatten upon the injury of their neighbours . . . reeking in putrid grease, redolent of stinking bones, fresh from seething heaps of stercoraceous deposits.”5 Wakley saw medicine broadly and wrote about it unflinchingly. Do we? Should we?
For journal owners and publishers, generally risk avoiders, such a wide compass may be perceived (wrongly, I believe) as of little interest to their dues-paying members and as potentially damaging to their political or economic priorities. Owners may wish to limit the scope of their journal, to restrict its editorial perspective to matters of bedside medicine and the narrower interests (as perceived by the usually nonphysician publishers) of their physician readership.
This is neither my vision nor that of the other editors who were fired or resigned from the CMAJ. For Foucault, medicine is a political act. The notion that politically sensitive topics can be expunged from a medical journal is folly. It is also irresponsible. Physicians and their patients must have faith that professional journals facilitate a discourse unencumbered by the economic and political interests of their owners.
“Still the risk must be run; the mark made.”3 This effort must be made by the editor-in-chief and the senior editorial staff on a daily basis. Editorial decisions cannot be discussed or even divulged to the publisher until the articles have been published. To do otherwise, to enter into an operational partnership of some sort with the publisher, is to gut the editorial independence of a journal. The ability of an editor to edit depends to an important degree on the editor’s own outlook and self-assurance (often mistakenly interpreted as arrogance). An eager propensity to poke a stick into something or somebody is also useful. It is a characteristic so widespread, at least among the editors I have known, members of the ICMJE and others, that it may be essential. But the defining characteristic of an editor is quixotic idealism, a characteristic that makes publishers nervous.
The interests of publishers and owners need to converge on the shared objective of maintaining a profitable operation. A journal editor will not last long if the journal does not break even. For the editors of the few journals that make money, the pressures to agree on budgets are similar, since owners want profits maintained or increased.
But once a budget is negotiated, how should the money be spent and the resources allocated? It is here that the objectives of owners (both economic and political) can influence broad editorial direction. Usually, journal budgets have been based on previous years, with slight increases or decreases based on the bottom line. Now, however, even at journals where relations between owners and editors have been tranquil, dramatically expanding online readerships and the growth of open-access journals are beginning to threaten that tranquility, altering the relationship between editorial content and financial success.
Readers of the CMAJ, before it went full-text and free online in mid-1999, were mainly Canadian physicians, members of the CMA, who received the print journal as a benefit of membership. Online readers now outnumber print readers by more than 6 to 1, and only about a third are residents of Canada \ ratios that are undoubtedly similar to those of other general medical journals. Contributing little or no revenue, online readers now contribute most of the CMAJ’s content (manuscripts and letters), interest, and general buzz.
Online readers are a puzzlement to traditional journal publishers, who tend to concentrate on print readers and their associated revenue streams, derived from classified and display advertising. Are what they are reading Canadian, British, and American medical journals, or are they global medical journals? As journal editors stroke eagerly into the more open seas of worldwide readership, will owners be able and willing to follow?
I hope they will. In a world where political correctness obfuscates and public discussions are managed by public-relations firms and paid experts, there is a desperate need in medicine for open, plain-spoken discourse. Without it, the current erosion of public trust in science and medicine will continue and will ultimately translate into poorer individual and population health.
As an editor, I worked with wonderful people at the CMAJ and around the world. I’ll miss it.
Source Information
Dr. Hoey, former editor-in-chief of the Canadian Medical Association
Journal, lives in Perth, Ontario, Canada.
References
1. Shuchman M, Redelmeier DA. Politics and independence — the
collapse of the Canadian Medical Association Journal. N Engl J Med
2006;354:1337-1339. [Full Text]
2. The editorial autonomy of CMAJ. CMAJ 2006;174:9-9. [Full Text]
3. Woolf V. To the lighthouse. New York: Harcourt, Brace & Company,
1929:235.
4. Hoey J, Caplan CE, Elmslie T, et al. Science, sex and semantics:
the firing of George Lundberg. CMAJ 1999;160:507-508. [Full Text]
5. Wakley T. Editorial. Lancet 1855;1:634-635. [CrossRef]
