Doctors without borders: why you can't trust medical journals anymore

Washington Monthly, April, 2004 by Shannon Brownlee

This deafness to the power of money to corrupt medical science leads physicians and scientists to display an arrogance and a remarkable naivete, both of which were very much in evidence in a snippy editorial entitled, "Avoid Financial 'Correctness,'" written in 1997 by the editors at Nature. They derided disclosure as a waste of time, writing, "This journal will persist in its stubborn belief that the research as we publish it is indeed research, not business." The Nemeroff case has not changed the editors' view substantially, although they did alter their policy after it broke. Nature Publishing now requires editorial and review writers, along with the authors of original research papers, to inform readers whether or not they have conflicts of interest, or to say they decline to declare. Charles Jennings, executive editor of Nature, says they have no intention of following the New England Journal in barring editorialists who have conflicts. "I flatly disagree with that policy," he told me. "That would exclude many of the leading experts. Yon don't want a policy that prevents Thomas Edison from writing about the future of electricity. Our position is for readers to decide for themselves about whether an author is biased."

Of course, most readers, especially practicing physicians, don't have the expertise or the resources to decide for themselves--to know how the studies might have been constructed differently, whether the conclusions have been shaded to favor the author's sponsor, or which data the author decided conveniently to leave out of the article. Knowing that an author might be biased doesn't aid in determining the extent and nature of the bias. It's not as though there will be two articles, one by a biased writer and one by an unbiased writer, published side by side to allow readers to identify the differences. Besides, conflicts of interest are now so pervasive, says Rennie, many readers scarcely take note, even when they're disclosed.

Race for the cure?

It's tempting to wonder what medical research would look like if universities and medical associations and editors of journals stopped talking about how to manage conflict of interest and started thinking about how to expunge it. Just say no. Proponents of Bayh-Dole will object, claiming the pace of medical advances will slow to a crawl, but bear with me for a moment and just imagine a different universe. Let's start with the medical schools--those temples of higher learning. They would be the first to cast out the drug merchants. Hospitals would pay their medical residents a decent wage so they can afford to buy their own beer and pizza. FDA advisory panelists who have a financial stake in the drug being considered would not be allowed to vote. And if the journals stopped publishing papers and editorials penned by academic clinicians with conflicts of interest, authors would be forced to choose between taking scientific credit and taking the money.

Of course, that's not going to happen unless academic clinicians somehow decide there's something wrong with the status quo. In Sheldon Krimsky's view, the only way to deter conflict of interest is for academics to feel shame. Maybe so, but as a journalist who has spent a decade and a half peering at medicine from the outside, nose pressed to the glass, I'm struck more than anything by the apparent lack of shame among clinicians when it comes to this issue.