Ethics of Publishing: Balancing the routine and

revolutionary

Peter A. Singer, MD, MPHUniversity of Toronto

peter.singer@utoronto.ca

What is the greatest ethical challenge in medical publishing?

A) Publishing information from patient-doctor relationship

B) Editors’ duty to warn of unethical clinical or research practice

C) Conflict of interest

D) Open access

E) Global health equity

My point in this talk

• The greatest ethical challenge in medical publishing is global health equity

• Develop action plan that goes beyond open access to bi-directional information flow (turning Southern readers into authors)

• The routine stuff should be thought of in terms of ethics processes in journals using framework of accountability for reasonableness

Routine publication ethics

• Publishing information from patient-doctor relationship, duty to warn, COI, etc

• How shall we think about these?

• Knee-jerk reaction is write guidelines

• Risk of this approach: overlong, overpompous, a bit of a crusade

A focus on process

• Think about this as how to institutionalize ethics processes into journal

• This is in fact what BMJ has done empirically with its ethics committee, first journal to do so and fine model to study

• Of course this may also result in guidelines but they will be more case-based

• Ethical framework: Accountability for reasonableness

Accountability for ReasonablenessDaniels BMJ 2000

• Relevance: priority setting decisions based on reasons upon which fair minded people can agree in the circumstances

• Publicity: reasons publicly accessible

• Appeals: mechanism for challenge and dispute resolution

• Enforcement: voluntary or public regulation to ensure 3 conditions met

Implications for BMJ

• Leadership in routine publication ethics, but lessons must be captured and used for improvements within BMJ and sharing lessons with other journals

• Create a learning platform under process: describe (case study), evaluate (a4r), improve (action research)

• Example: developing country membership

Open access

Open access: Ethical arguments

• Ownership of research

• Scientific progress

• Public accountability

• Global public goods for health

• Global health equity

• Web hits• Scoring article• Letters• Rapid responses

• Peer review including new open forms• Citation analysis including new contextual forms• Secondary reviews such as ACP Journal Club and Evidence Based Medicine

• BMJ’s “What this paper adds”• “Most important papers” list with explanation

From open access to global health equity, from Southern

readers to authors

Health InterNetworkAccess to Research Initiative

“Global Information Flow”Godlee, Horton, Smith 2000

“The ecology of information will change dramatically in the next 20 years in ways that we cannot fully understand. There seems,

however, every chance that information exchange among those interested in health should improve dramatically, leading ultimately to an improvement in health itself.”

Horton R. Lancet 2000; 355: 2231-6

Bridging the North-South GapWhat can editors do?

• Broaden geographical reach of editorial boards, reviewer panels

• Seek out primary research for publication through these networks

• Raise priority of research submitted from LDCs

• Commission work from authors in LDCs

• Review more papers from LDCs

Horton R. Lancet 2000; 355: 2231-6

Bridging the North-South GapWhat can editors do? (2)

• Write editorials to raise awareness about these issues

• Invest in manuscript editors to assist non-English speakers

• Establish pre-print servers for international health

• Create writing fellowships for Southern investigators

• Invite a "Letter of intention"

Horton R. Lancet 2000; 355: 2231-6

Bridging the North-South Gap:What can editorial bodies do?

• Prepare and distribute information describing range of primary research journals, including instructions to authors

• Hold publication workshops to train prospective researchers

• Twin journals in North and South to promote editorial training and to support journal development.

Horton R. Lancet 2000; 355: 2231-6

Bridging the North-South Gap:What can editorial bodies do? (2)

• Create a core group of journal-editor mentors who might assist colleagues thinking of either writing papers or starting journals

• Include representatives from less-developed countries in governance of editorial organisations

Further suggestions: Authorship

• Look for the missing co-author on Southern research papers

• Look for the superfluous Northern author ... are Southern authors “authentic”?

• Give precedence to Southern author's article on Southern topics (even if less perfect ms, especially if submitted earlier)

Further suggestions: Incentives

• Pay attention to the lack of incentive to publish in many developing country settings

• Offer research grants for good writers

Further suggestions: 10% solutions

• Devote 10% of journal to research relevant to 90% of the world

• Create regional editions of journals (e.g., BMJ Asia or Lancet Africa) that devote 10% of space to regional research

Further suggestions: Mindset

• Make serious attempt to view article through eyes of writer and not UK reader, and be receptive to things you don’t want to hear since they make you uncomfortable

Closing comment“[Editors] have to first accept that what they publish is

mostly irrelevant to the 90% of the world. What is the point of having free access to a journal, when they don't publish what is relevant to the developing world? They have to come out of their cocoon and cross this barrier of relevance and the notion of serving a limited section of the world. Once they start looking beyond what is relevant to them, they would automatically start looking at research from the south ...

Closing comment (cont’d)They can make a humble beginning by only allowing a

small space in their journals. It is possible that their regular readers may not read those articles but I can assure you that if all journals started with this effort it would make a world of difference to the diseases and suffering in the developing world.Unfortunately their current agenda is too narrowly focused. If there is a policy change it would be dictated by the will of the people who matter at the helm of affairs.”

Questions for discussion

• Routine group: Top three ideas for improvement in BMJ ethics committee in light of accountability for reasonableness framework?

• Revolutionary group: Top three action steps to push beyond open access towards global health information equity?

Acknowledgements

I am grateful to the following colleagues whose suggestions I paraphrase or quote on slides 17-22 of this presentation: Solomon Benatar (South Africa), Abdallah Daar (Oman and Canada), John Gyapong (Ghana), Nandini Kumar (India), Richard Muga (Kenya), Jens Mielke (Zimbabwe), Joseph Ochieng (Uganda), and Asad Raja (Pakistan).