The recent dismissal of George Lundberg, MD, as editor of the prestigious Journal of the American Medical Association (JAMA) has created quite a stir within the medical publishing field, in professional trade associations, and among researchers around the world. Lundberg helped bring JAMA to prominence during his 17-year tenure, which frequently was marked by controversy. The lightning rod for his dismissal has been characterized in the press as Lundberg's publication of an 8-year-old survey of college students' attitudes that included their definition of sexual relations. Publication coincided with the US Senate impeachment trial of President Clinton, whose defense hinged in part around similar definitions of terms. What was perceived by one editor, Lundberg, as a timely opportunity to publish research relevant to contemporary health behavior issues confronting society, was perceived by one chief executive of the American Medical Association (AMA), E. Ratcliffe Anderson, MD, as a blatant attempt to influence national politics beyond the scope of the charter of the association or the journal.
On the surface, the firing of Lundberg might appear to be straightforward. However, a frequently advanced explanation suggests that this incident is indicative of a struggle relating to the sociopolitical agendas of Republican, corporate-oriented physicians versus Democratic, public health—focused doctors—a struggle pivoting around ownership rights of a publication versus editorial freedom. In our opinion, Lundberg's dismissal reflects the common but complex ethical-procedural dilemmas that underlie a deeper struggle between advancement of knowledge and the power agendas of groups or individuals. In the JAMA affair, ethical, procedural, and editorial judgment transgressions can be found on all sides—which is nothing new to JAMA or its sponsoring organization. Protestations from the AMA about the justifiability of it all strike a disingenuous chord. In fact, JAMA has often published papers to engage and insert political views of the AMA into the national social and political consciousness.
The dismissal of Dr. Lundberg represents the latest in a recent string of public relations disasters for the AMA. Last year's Sunbeam sponsorship debacle led to a costly lawsuit and accusations that the organization was being sold out for profit. In 1998, JAMA published a “scientific” research paper by 9-year-old Emily Rosa that disputed tenets of therapeutic touch.1 The paper garnered significant attention, both because of its impact and the questionable science and unabashedly antialternative biased agenda behind it (the estimable anti-chiropractic and alternative medicine activist Stephen Barrett, MD, was a coauthor). Dr. Lundberg vehemently defended his decision to run the piece as an original scientific paper.
Despite the trade association agenda and the questionable peer and methodologic reviews behind some of the work that finds its way into print in JAMA, Lundberg's dismissal has raised the ire of the medical publishing community and represents grounds for concern because of the precedent it sets. The International Committee of Medical Journal Editors, as well as chiropractic journal editors, have published commentaries on the importance of editorial autonomy from sponsoring organizations.2, 3 The International Committee's position on editorial freedom bears repeating:
•Medical journal owners and editors have a common endeavor—to publish a reliable and readable journal with due respect for the stated aims of the journal and for costs. However, the functions of owners and editors are different.
•Owners of medical journals have the right to appoint and dismiss editors and to make important business decisions, in which editors should be involved to the fullest extent possible. Editors must have full authority for determining the editorial content of the journal.
•This concept of editorial freedom should be resolutely defended by editors even to the extent of placing their positions at stake. To secure this freedom in practice, the editor would have direct access to the highest level of ownership, not only to a delegated manager.
•Medical journal editors should have a contract that clearly states the editor's rights and duties in addition to the general terms of the appointment and that defines mechanisms for resolving conflicts.
•An independent editorial advisory board may be useful in helping the editor establish and maintain editorial policy.
•All editors and editor's organizations have the obligation to support the concept of editorial freedom and to draw major transgressions of such freedom to the attention of the international medical community.2
Most respected publications have the infrastructure and internal arrangements in place to facilitate editorial independence. In our respective publications, autonomy from interference regarding journal content is in place (contractually for one publication and in practice for both publications). Both National College of Chiropractic and Aspen Publishers, Inc, are intimately involved with business and administrative issues and have ultimate decision-making authority about who the editor happens to be. However, neither the National College of Chiropractic nor Aspen Publishers, Inc, have ever interfered with a controversial decision made by either of us, nor have they sanctioned or threatened either of our positions when problems have arisen on such counts.
The firing of Dr. Lundberg illustrates the relevance and importance of the International Committee's position. The AMA owners have interfered with Dr. Lundberg's editorial decision-making autonomy. By removing him in the absence of any due process, they have violated the very editorial independence guidelines they have endorsed. No attempt at conflict resolution was made, and the natural initial avenues for debate about editorial decision making (letters to the editor, commentaries, and the like) were not considered. In that regard, e-mail listserves relating to evidence-based medicine have been extremely active these past several weeks, and among the persons involved in that debate have been leading journal editors, as well as board members from the AMA.
The responsibility for editorial independence and due process does not lie solely with journal owners, however. If the editor of the JMPT proceeded to use his editorial decision-making authority to publish scientifically inadequate works to advance a personal agenda (hypothetical, mind you!) for ascendancy to the position of president of the College, the issue of editorial autonomy would certainly be called into question. However, how it is called into question is the underlying issue.
For example, appropriate internal processes harnessing the resources of blind peer review to examine methodology and ensure independence are in place. Furthermore, the likelihood that such blatant favoritism would succeed is held in check through the integrity of the very processes used for making editorial decisions. If a journal's constituencies, including the owners, cannot have confidence in the integrity of the editorial decision-making process or the editor's capacity to exercise good judgment in applying that process, cause could exist for reviewing the editor's performance and making a decision for removal. Implicit in that decision is further process on the ownership side in which the journal's constituencies, including the editors, can have confidence.
In our opinion, what has transpired in the JAMA affair represents an insidious underlying organizational pathology that readily envelops trade associations whose purpose and mode of operation are directed squarely at achieving their special interests. Rather than integrity in ensuring the dissemination of new knowledge aimed at the journal's purpose (advancement of clinical practice, public health, or other laudable objectives), personal power agendas took center stage.
Is Dr. Lundberg's editorial judgment deficient? Are JAMA's editorial and peer review processes tainted or inadequate? Are such failings grounds for dismissing an editor? Perhaps, but the way to answer those questions in the world of medical publishing is to use methods to reach conclusions in which the journal's constituents (including both editors and owners) have confidence. Had an independent committee of peers and experts been established by AMA leadership to review Dr. Lundberg's editorial performance and the journal's peer review process and to evaluate the scientific merit and quality of recent published articles, no controversy would exist if the decision was reached to replace Dr. Lundberg.
One need not side with either Dr. Lundberg or the AMA to see the relevance and importance of trust in this discussion. Trust from the readership and the greater clinical and scientific communities should be the cause célèbre of both editors and owners. The independence of the scientific journal editor from the special interests of the ownership is a key component to ensuring that trust, as is the ability of the editor to remain independent of his or her bias and personal agenda in reaching publication decisions. Over time, an editor earns the trust of the readership by treating authors fairly, using the skills and expertise of the editorial advisory board to ensure a level of quality in what is published, and exercising integrity in letting the chips fall where they may, even when they do not align with an important constituent's preference.
The award given to JMPT's editor last year by the Foundation for Chiropractic and Research was dumbfounding to him and both humbling and gratifying for the chiropractic editors' community. Typically, journal editors are engaged far more in the publication of research than in conducting research. To achieve such a level of recognition for the dissemination side of scientific inquiry is testimony to importance of editorial integrity.
As journal editors, we cannot help but publish material that some readers will find questionable. That is nature of scholarly discourse and reflects the inherent constraints of scientific methods, resources, and human nature. Consider the hypothetical editorial dilemma that would be faced if, by some chance, a definitive research design and methodology allowed for a project that could once and for all demonstrate by an agreed-upon fashion whether vertebral subluxation existed. What if the study were performed in a rigorous fashion, withstood careful scientific and clinical peer review and methodologic scrutiny, and demonstrated persuasively that vertebral subluxation did not exist? Would you publish that paper?
If the paper survived our editorial peer review processes, was strong in design, and undeniably was good science, we certainly would publish it. We would do so knowing full well the ammunition it could provide for our profession's detractors and the risks of professional disparagement of our publications and ourselves that could ensue. We would publish it even under pressure from our respective journals' ownerships not to do so. To do otherwise would begin a treacherous decline down a road of censorship, parting from the path of process and trust that is essential for our maturation as a profession and the ability of the public to have confidence in our integrity as a profession.
We would hope that the reactionary and political power approach used by the AMA would not be the template chiropractic journal owners would follow. We would hope that our respective track records in adhering to process and integrity would serve as the basis for evaluating our performance in the job. We believe that what the AMA did in Dr. Lundberg's case was censorship, not performance appraisal, as their organizational spinmeisters would have the public believe. Trust in scientific publishing requires balance between autonomy and accountability, with due process infused throughout.
Editorial integrity deserves prioritization within our profession's agenda for the future. The JAMA affair provides the chiropractic profession with an opportunity to reflect on the importance that editorial independence plays in our cultural credibility and should serve as precedent for how not to evolve.
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