The CMAJ episode was sparked off by two separate but related incidents (although, to be fair, the CMA and the CMA Media Inc President deny any such links).
One was in September 2005, when a Plan B morning-after pill (levonorgestrel), a pill for contraception to be used by females, was investigated in the CMAJ
. (It is not only a morning after pill. Well it is in a way, for supposed to be taken the morning after, but effective if taken up to even 72 hours later). The pharmacists had a big stake in the product. It was changed from a prescription to a non-prescription emergency contraceptive drug, but with an important rider. The pill was costly enough, but the pharmacist was supposed to charge almost an equal amount for counselling about the appropriateness of the drug. Moreover, they were supposed to collect personal details, including sexual history, during this counselling. The CMAJ
probed this by asking a few ladies whether they approved of this, which obviously they did not (Eggertson and Sibbald, 2005
). The Canadian Pharmacists Association objected, saying a medical journal had no business to do investigative journalism. The CMA, the controlling body, concurred with the pharmacists for obvious reasons. Also, they probably wanted a stick to beat an uncompromising editor with. The article was published with alterations suggested by the CMA. But the Editor wrote an editorial on 3 January 2006 (early release 12 December 2005), denouncing the act, accusing the publisher of editorial interference since they removed a sidebar to the journal's news article which suggested that pharmacists were infringing on women's privacy rights by demanding and registering personal information on the Plan B contraceptive (CMAJ, 2006
We have a transgression to report. While the Dec. 6, 2005, issue was in preparation, the editorial independence of the journal was compromised when a CMA executive objected strenuously to a news article we were preparing on behind-the-counter access to emergency levonorgestrel (Plan B). The objection was made in response to a complaint from the Canadian Pharmacists Association, who had learned about the article when they were interviewed by our reporters. The CMA's objection was conveyed to CMAJ's editors, and to our publisher, who subsequently instructed us to withhold the article.
The stated objection was to our reporting method; as one component of the story, we had asked 13 women from across Canada to attempt to purchase Plan B from a pharmacy in their community and then tell us what the experience was like. The CMA questioned the propriety of our investigation and the boundary between news reporting and scientific research. Our story was not scientific research, however, but legitimate journalism (CMAJ, 2006
The editorial further said:
We felt that we had a choice between pulling the entire story, or getting most of it out by publishing a negotiated revision. We opted for the latter: what our readers saw omitted the results of our informal survey. This transpired without the story having been read by those who were raising the objection.
Our objective in making this incident public is to set in motion a process to ensure the future editorial independence of the journal. Readers expect CMAJ editors to select content without interference, and authors expect their work to be judged without regard to the interests of any third party. Readers and news media who rely on our reporting need to know that our journalists are not subject to censure (CMAJ, 2006
There has been a history of confrontation between the Editor of CMAJ
and the CMA. On Sept 17 2002, the journal had carried an editorial criticising Bill 114, a proposed Quebec legislation that was meant to force family physicians to work on emergency duty during shortage of staff (CMAJ, 2002
). This had lead to an altercation between the then CMA President Dana Hanson who called it, on October 29th, 2002, ‘seriously flawed’ and said further that the ‘conclusion that physicians have betrayed a trust which we all hold at the very heart of medicine is repugnant’ (Hanson, 2002
). On November 26th 2002, the CMAJ
Editorial board called it a ‘clear and present danger’, in a letter in the journal, and said ensuring editorial independence was critical to its progress (Armstrong et al, 2002
). They said further:
Whether or not one agrees with the opinions stated in the Sept. 17 editorial is not the fundamental issue here: rather, it is the right to articulate such an opinion without concern forretribution by an organization or corporation that holds ownership or operating responsibility for the journal (Armstrong et al, 2002
In December 2002, a Journals Oversight Committee to ensure smooth functioning between the CMAJ and CMA was formed and had its first meeting. The love-hate relationship between a prosperous Journal wanting greater editorial independence and a wary Association trying to control and clip its wings continued till the Plan B episode, in which a powerful lobby like the pharmacists′ interests were involved.
The other precipitating factor, the final straw in a way, was critical remarks on the coming to power of the present Health Minister of Canada, Tony Clement. He is known to favour privatization and corporatisation of the health sector by introducing private provision within the public sector. The CMA supports this move. It will obviously benefit both CMA members and the pharmaceutical industry. Both important constituencies, and both would want, and support, such a move. Kassirer et al (2006
) give the lowdown on this rather murky state of affairs:
As this report on the Plan B commentary was being finalized, we became aware through a communication of the Canadian Health Coalition that another news story published electronically on Feb. 7, 2006, was subsequently removed from the CMAJ Web site (online Appendix 1, www.cmaj.ca/cgi/content/full/174/7/945
). The article was a report on the appointment of the federal Minister of Health by the new Conservative government. It pointed out the health minister's favourable stance toward privatization of health care delivery during his tenure as the Minister of Health for Ontario. On Feb. 22, 2006, a different report on the federal Minister of Health appeared in the original's place (online Appendix 2, www.cmaj.ca/cgi/content/full/174/7/945
). Though the revised article contains some of the same phraseology as the original, it is more supportive and less critical of the health minister and seems more beneficial to the CMA. We pose the question as to whether the extensive revision of this article is another instance in which the political interests of the CMA exerted an influence on CMAJ publishing decisions. Some days before the firing of the editor in chief and senior deputy editor, the JOC was informed about a disagreement concerning the original Tony Clement article, but the JOC turned down a request for an emergency meeting. The editors are not willing to comment on how the changes came about; the publisher has also declined comment.
Under such circumstances, to continue to have an upright editor at the helm of an important opinion maker like the CMAJ would have been risky. Already relations were strained between the CMA and CMAJ Editor. To expect the latter to toe the CMA line was improbable. Hence, the CMA, under cover of its associate company CMA Holdings (recently changed to CMA Media Inc) used the services of a newly appointed President, Graham Morris, to do the act. The salvo was fired in a three-paragraph termination by the last named gentleman. (Well, English is a civilized language):
The Canadian Medical Association Journal (CMAJ) announced that Dr. John Hoey would be leaving his post as Editor-in-Chief today.
During the ten years that Dr. Hoey has been Editor-in-Chief of CMAJ, he has broadened the scope of the publication and raised its international reputation as a respected peer-reviewed scientific journal.
The CMAJ's mission in serving its 69,000 readers is to provide accurate and up-to-date scientific and clinical information on the promotion of health and the treatment of disease (Media Advisory, 2006
So, if the first reason was economic, the second was political. And the two scourges of modern medicine, economics and politics, managed to do in the credibility of a respectable Journal. While we know the economic-political compulsions of Associations and its office bearers, that they could not rise above their petty considerations in the larger interest of science and research is a sorry tale to recount.
The outcry at such a summary dismissal has been unanimous. Editorials by reputed journals like the Lancet (2006
), the BMJ
(Van Der Wayden, 2006
), articles in the NEJM
(Shuchman and Redelmeier 2006
; Hoey 2006
), as also the ICMJE (2006
) and WAME (2006
), and even the lay press, have all decried the act. One of us has written rather copiously on the topic in the WAME List serve and elsewhere (Singh 2006a
). The editors concerned have not spoken earlier about the action because they are purportedly bound by a confidentiality clause, but Hoey has since written an article discussing editorial independence (Hoey 2006
) in the wake of the CMAJ
crisis; while the CMA president has promised full editorial independence to the interim editorial board and editors, and urged all concerned to move ahead (Sullivan, 2006
). At the time of writing, an interim editor, Noni Macdonald, and Editor Emeritus, Bruce Squires, are handling matters since March 7, 2006 (Shibbald, 2006).