Editorial Freedom and Integrity
Ethical and Legal Considerations
Editorial independence is crucial for the viability of a journal and editors have many masters−the public, the readers, the authors and the owners. Negotiating the resultant minefield requires a purposeful and independent stance. This is particularly so in instances of a relatively modern phenomenon: concerted attempts by clinical groups to influence, or even abort, publication of articles, which may threaten their practice. Moreover, modern social media facilitates this manipulation. . . . To be an editor is to live dangerously!
Martin B. Van Der Weyden1
Editorial freedom is the independence an editor has to make editorial decisions without control or interference from others; it implies a range of independence, from complete absence of external restraint and coercion to merely a sense of not being unduly hampered or frustrated. Integrity is the state of honesty, credibility, incorruptibility, and accountability. A biomedical journal has editorial integrity if it adheres to these values, but different journals have different levels of editorial freedom. The First Amendment of the US Constitution affirms several freedoms, including the freedom of the press.2 Thus, communication through the US press or other media is a right that should not be interfered with by the government, other institutions, or individuals. Many countries guarantee similar freedoms of the press.3 Freedom of the press is a foundation for editorial independence, “which is the distinct right of the editor to publish any material that passes defined criteria for quality and that fits within the mission of the publication, without suffering undue interference from others.”4(p2344)
A journal’s editorial independence must be balanced against the need for appropriate authority, responsibility, and accountability as well as trust between the editor and the journal’s many stakeholders: readers, authors, reviewers, deputy/associate and other journal editors, editorial staff, editorial board members, publishers, owners, subscribers, advertisers, and others4 (see 5.11, Editorial Responsibilities, Roles, Procedures, and Policies). The level of editorial freedom differs among different biomedical journals, from maximum independence for those peer-reviewed journals in which the editor has complete authority and responsibility for the journal, its content (including all editorial and advertising content), reuse of its content, and use of the journal name and logo to no independence for those journals that are not peer reviewed or in which all authority and responsibility rests completely with others (eg, publishers or owners). Journals that are published primarily to serve business, political, or other concerns of their owners may be viewed as house organs. For some biomedical journals and editors, the level of editorial freedom may be best described as somewhere between complete editorial independence and no independence. Furthermore, editorial freedom may be assumed to exist by an editor and the journal’s readers until or unless a major conflict occurs. A 1999 survey of the editors of 33 peer-reviewed medical journals owned by professional societies (10 journals represented in the International Committee of Medical Journal Editors and a random sample of 23 specialty journals with high impact factors) found that 23 of the 33 editors (70%) reported that they had complete editorial freedom, and the remainder reported that they had a high level of freedom.5 However, many of these editors reported having received at least some pressure in recent years over editorial content from the professional society’s leadership (42%), senior staff (30%), or rank-and-file members (39%).5
Editors and journals have experienced incursions from interpersonal, social, political, and economic forces. Editors have been dismissed from their posts and journals have ceased publication after a mere “stroke of the editorial pen.”6 In one case, the Irish Medical Journal was voted out of existence in 1987 after the editor published an editorial against physician strikes that angered some influential members of the Irish Medical Organisation.6,7
Editors of several leading general medical journals have been unwillingly removed from their positions after publishing articles that were considered inappropriate by various entities (eg, owners, publishers) and for having disagreements with owners or publishers about the editor’s level of autonomy and authority over the journal’s content and the journal’s name and brand (eg, logo).8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24 In these cases, long-term struggles between the editors and the owners of the journals resulted in loss of trust between the parties. Because of a lack of effective protective oversight and governance and apparent lack of an effective system for conflict resolution, precipitate decisions to remove the editors resulted in widespread criticism of the owners and threats to the integrity and continued existence of the journals (see 5.10.1, Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance).
An earlier example of a medical editor credited for his struggles to maintain editorial freedom is Hugh Clegg, editor of the BMJ from 1944 to 1965. In 1956, Clegg wrote an unsigned editorial entitled “The Gold-headed Cane” in which he castigated the president of the Royal College of Physicians for taking office for the seventh successive year.25 He also admonished the college for its failure to recognize the modern welfare state and its lack of attention to postgraduate medical education. With much difficulty, Clegg kept his editorial position and freedom and purposely published a reply from the president that rebutted all of Clegg’s criticisms. Clegg believed that medical editors are the protectors of the conscience of the profession, and he is well known for his assertion that editors who maintain this ideal will often find themselves in trouble. This trouble may come in the form of incursions into editorial freedom, which editors must be able to defend. For more detailed examples, see 5.10.1, Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance.
Editors of biomedical journals that have editorial freedom must have complete authority for determining all editorial content of their publications.4,26,27,28,29,30,31,32,33 (Unless otherwise dictated by a journal’s specific mission, this may not be the case for journals that are house organs or that have minimal editorial freedom.) Although many stakeholders may offer useful input and advice, editorial decisions must be free from restraint or interference from the publication’s owner, publisher, advertisers, sponsors, subscribers, authors, editorial board or publication committee members, reviewers, and readers. Owners, publishers, boards, and publication committees may have the right to select, hire, evaluate, and dismiss the editor, but they should not interfere with day-to-day editorial decisions and policies.4,13,27,28,33
Without a clear delineation of editorial freedom and the authority to maintain it, an editor might not be able to ensure the integrity of the publication. Thus, owners, publishers, and editors must have a clear and mutually understood definition of the editor’s level of editorial freedom, authority, responsibility, and accountability.4,27,28 Editors of journals with complete editorial freedom should not comply with external pressure from any party—including owners, publishers, advertisers, sponsors, authors, reviewers, and readers—that may compromise their autonomy or their journal’s integrity.27,28 Examples of such inappropriate pressures include, but are not limited to, the following:
■Pressure from an owner or a politically powerful or motivated individual or group on the editor to avoid publishing certain types of articles or to publish a specific article
■Pressure or requirement of an editor by a publisher or owner to modify or suppress specific content before publication
■Demand from an owner or publisher or external group or entity to censor or remove published content deemed controversial or contrary to a specific position or that includes negative outcomes about a specific product or service
■Harassment of an editor by a reader who is motivated politically or competitively to force the journal to publish an allegation about an article or author or to retract or remove a published article before a formal investigation or for which the allegation is without merit
■Demand from an owner or publisher or external person or organization to have access to confidential editorial or peer review records (see 5.7.1, Confidentiality During Editorial Evaluation and Peer Review and After Publication)
■Demand from an author or group of authors to bypass the journal’s standard editorial and peer review processes and publish their manuscript without review or revision (eg, a society demanding acceptance and publication without review or revision of its meeting abstracts, proceedings, or papers)
■Demand from an author for exceptions to a journal’s editorial policies or requirements for specific manuscripts
■Attempt by an author or peer reviewer to have an editorial decision reversed by threatening the journal’s editor or owner
■The use or repurposing of the journal’s content or name by the publisher, owner, or external entity without the editor’s knowledge and consent or in a manner that could harm the journal’s editorial integrity
Demand by an advertiser to insert an advertisement adjacent to an article about or related to the advertised product or a threat to withdraw advertising support because of publication of a specific article (see 5.12, Advertisements, Advertorials, Sponsorship, Supplements, Reprints, and e-Prints)
■An advertiser or publisher’s attempt to publish an advertisement or sponsored content disguised as editorial content (advertorial) (see 5.12, Advertisements, Advertorials, Sponsorship, Supplements, Reprints, and e-Prints)
A publisher demanding information about accepted articles in advance of publication to sell that information to advertisers or sponsors or for other commercial purposes
■A sponsor attempting to exert influence over editorial decisions or selecting specific content for publication (eg, sponsored supplements) (see 5.12, Advertisements, Advertorials, Sponsorship, Supplements, Reprints, and e-Prints)
■A publisher demanding publication of an advertisement that the editor deems inappropriate (see 5.12, Advertisements, Advertorials, Sponsorship, Supplements, Reprints, and e-Prints)
■Request from a company to an editor to purchase reprints or e-prints of an article under consideration but not yet accepted for publication
■Demands by a commercial entity or governmental agency to publish or censor specific content
■Compliance with governmental or other external policy to not consider manuscripts from authors based on their nationality, ethnicity, race, political beliefs, or religion (see 5.11, Editorial Responsibilities, Roles, Procedures, and Policies)
■Pressure from a news organization or journalist or sponsor to publish information about a journal article before the news embargo is lifted (see 5.13.3, Embargo)
■Social media pressure from advocates or those motivated by political or commercial interests regarding a specific published article
■Pressure or demands from advocates to change policies or access rules after publication
Editors may need to educate and remind the journal’s various stakeholders about the fundamentals of editorial freedom and its direct relation to the publication’s integrity.
5.10.1 Maintaining Editorial Freedom: Cases of Editorial Interference and the Rationale for Mission, Trust, and Effective Oversight and Governance.
Interference with editorial freedom has affected several prominent medical journals and has been well documented in the biomedical literature and the press. However, many other cases of such interference have not been made public or are discussed only anecdotally, privately, or via restricted electronic exchanges or posts. The experiences of JAMA, the New England Journal of Medicine, and the Canadian Medical Association Journal (CMAJ) are presented here for the following reasons: there is sufficient literature documenting the relevant events, effective protective oversight mechanisms and governance plans were lacking or insufficient at the time, and the mechanisms for protection of editorial freedom that were developed as a result of these events are informative and may be helpful for other journals, editors, publishers, and owners.
18.104.22.168 The Case of JAMA.
Beginning in 1982, George D. Lundberg, MD, served as editor in chief of JAMA, a weekly, peer-reviewed, general medical journal, and a group of specialty journals, then known as the Archives journals, which are owned and published by the American Medical Association (AMA). JAMA had operated under a set of goals and objectives that were developed by Lundberg and the journal’s editorial staff and that were approved by the journal’s editorial board and AMA management.32 These goals and objectives had protected the editor on several occasions from external pressures to restrict the journal’s editorial freedom, and in 1993 the AMA House of Delegates (the policy-setting and governing body of the association) passed a resolution that reaffirmed editorial independence for all its scientific journals.33 Although JAMA had a defined mission that included editorial freedom that had been publicly supported by its owner, it did not have sufficient oversight and a governance plan in place to help promote a trust relationship between the editor and AMA leadership, facilitate resolution of conflicts, and help prevent interference and threats against editorial freedom and authority.
During Lundberg’s editorship, there had been tension between him and representatives of the AMA leadership and executive staff related to editorials and articles that were published in JAMA that were controversial or contrary to AMA positions. In 1999, Lundberg was abruptly fired by the AMA after he accelerated the publication of an article in JAMA (after peer review and acceptance) that reported the results of college students’ attitudes toward sex to coincide with the impeachment hearings of President Clinton. According to the AMA’s executive vice president, the publication of that article was an act of “inappropriately and inexcusably interjecting [JAMA] into a major political debate that has nothing to do with science or medicine.”8,9,10,11 At the time, JAMA had as 2 of its objectives “to foster responsible and balanced debate on controversial issues that affect medicine and health care” and “to inform readers about nonclinical aspects of medicine and public health, including the political, philosophic, ethical, legal, environmental, economic, historical, and cultural.”32 In addition, the journal had a long history of publishing articles that were pertinent to ongoing national and international political discussions, that were directly or indirectly related to medicine or public health, and that were released at a specific time to influence those discussions.
The AMA was widely criticized for the firing, which was considered interference with the journal’s editorial independence and which damaged the reputation of the journal and the AMA and harmed JAMA’s previously demonstrated integrity.8,9,10,11,12,13,34 Immediately after Lundberg’s firing, the journal’s remaining editors, led by interim coeditors, and the editorial board published an editorial in protest.14 The senior editorial staff considered resignation but decided to stay on to support the journal. However, 2 members of the journal’s editorial board and some members of the AMA resigned, and some readers cancelled subscriptions to the journal. Many authors threatened to withhold manuscript submissions to JAMA, and others threatened not to serve as reviewers.
The AMA appointed an independent 9-member search committee, chaired by a member of the JAMA editorial board who was also an editor of one of the AMA-owned Archives specialty journals. Other members of the committee included leaders in academia and research who were independent of the AMA, other journal editors, and a JAMA deputy editor; it did not include AMA executive staff or officers. The search committee’s objectives were to identify a new editor, review the journal editor’s job description and reporting relationships, determine how to evaluate the editor’s performance, and review existing practices and develop safeguards to ensure the journal’s editorial independence, integrity, and responsibility.35,36
Before the search committee had completed its work, the JAMA editorial board (which included 9 editors of the AMA-owned Archives specialty journals) met with the remaining JAMA editors, other editorial staff, publisher and publishing staff, and AMA senior management during its regularly scheduled annual editorial board meeting. During that meeting, an executive session was called that included the editorial board members and senior editorial staff but excluded representatives of AMA senior management and the journals’ publishing staff. The editorial board voted unanimously to resign en masse if the journal’s complete editorial freedom and a new governance plan to repair the journal’s integrity were not accepted by the AMA leadership.
After multiple discussions and negotiations between the search committee and AMA leadership, a new governance structure for JAMA and the Archives specialty journals was developed by the search committee, AMA senior management, and the AMA Board of Trustees to “insure editorial freedom and independence for JAMA, the Archives Journals, and their Editor in Chief.”35,36 This governance structure was set in place before Catherine D. DeAngelis, MD, MPH, became editor in chief of JAMA and the Archives journals in January 2000, and it was a condition of her acceptance of the position. The governance plan was subsequently reaffirmed by AMA leadership and served the journal through DeAngelis’ editorship.37,38,39 The Journal Oversight Committee served DeAngelis and the journal during her position as editor in chief.
In 2011, Howard Bauchner, MD, was appointed editor in chief,40 with similar terms and reporting to the Journal Oversight Committee for editorial administrative matters but with one modification: for business and financial matters he would report to the publisher (both positions, editor in chief and publisher, are senior vice presidents within the AMA). Illustrations of the current and previous governance models are presented in Figure 5.10-1 for other peer-reviewed journals, editors, publishers, and owners to consider. The journal’s current governance structure supports the editor in chief’s editorial independence, facilitates access of the editor in chief to the decision-making body and senior management of the AMA, and provides mechanisms for review of the editor in chief’s performance and conflict resolution (Box 5.10-1). For editorial administrative responsibilities, the editor in chief reports to the Journal Oversight Committee, which is an independent committee of the AMA. The AMA Board of Trustees approves the membership of the Journal Oversight Committee as recommended by the Journal Oversight Committee. The JAMA Editorial Board is appointed by the editor in chief and serves in an advisory capacity. The editors of the JAMA Network journals are appointed by and report to the JAMA editor in chief; their editorial independence flows through editorial independence of the JAMA editor in chief. As noted in the Editorial Governance Plan (Box 5.10-1), the editor in chief has total responsibility for editorial content and does not report to management for any aspect of the editorial content of JAMA, the JAMA Network journals, or other publications under his or her jurisdiction.
Figure 5.10-1. Governance Models for JAMA
Box 5.10-1. Editorial Governance Plan for JAMA and the JAMA Network
1.There will be a seven (7) member Journal Oversight Committee (JOC). This committee will function and be recognized not only as a system to evaluate the Editor in Chief but also as a buffer between the Editor in Chief and American Medical Association (AMA) management and as a system to foster objective consideration of the inevitable issues that arise between a journal and its parent body.
2.The JOC will prepare an annual evaluation of the Editor in Chief, which will be reported to the Executive Vice President (EVP) and to the Board of Trustees of the AMA. The Committee will have the charge to evaluate the performance of the Editor in Chief on the basis of objective criteria, and deliver that evaluation on an annual basis to the EVP and Board of Trustees of the AMA. The JOC will be responsible for determining the criteria for evaluation of the Editor in Chief. These criteria will be established in writing and made available to each member of the JOC, the JAMA Editorial Board, the Editor in Chief and the EVP and approved by the Board of Trustees of the AMA. The JAMA Editorial Board will be solicited for input to the evaluation process by the Committee. Correspondence about the performance of the Editor of JAMA received from constituent groups will be shared with the Committee. The Editor in Chief will be offered a five-year contract. If the Editor in Chief is dismissed during the term of the employment contract, other than for cause, the contract will be paid in full. Should such dismissal occur in year 5 of the contract, the minimum payment to the Editor in Chief shall be 12 months’ salary.
3.The JOC will be charged, in addition, with reviewing and, if necessary, making additional recommendations to the AMA EVP/CEO and Board concerning governance and structural reforms necessary to ensure the AMA Journals’ editorial independence. For this purpose, the Editor in Chief and SVP for Publishing will serve as advisors to the committee. This function will be ongoing.
4.The seven members of the JOC will include one member of AMA senior management, one member from outside the AMA with publishing business experience, and five members representing the scientific, editorial, peer reviewer, contributor and medical communities. The Committee members shall serve four-year staggered terms, although a new member may complete the remainder of another individual’s term when a vacancy occurs. A Committee member may serve no more than two (2) full terms for a maximum tenure of eight (8) years, with the exception of the AMA senior management member, whose term shall be a continuing one, without term limits, as determined by the EVP/CEO. If a member of the JOC is completing the partial term of another individual who created a vacancy, he or she will then be eligible for one additional four-year term so that the staggering of terms remains intact.
5.No member of the JOC may be an AMA employee except for the member from AMA Senior Management. No AMA employee may be Chair of the committee, who shall be elected by the JOC.
6.JOC members are to be selected by the AMA Board only from a list of recommended persons submitted by the JOC. The list will include at least one alternate candidate except, if the JOC recommends an incumbent for reappointment, the JOC may recommend the incumbent alone. In the event that the Board does not select one of the submitted names, additional names will be recommended by the JOC, as necessary. Members of the JOC can be appointed or removed only by a 2/3 supermajority vote of the AMA Board of Trustees in the exercise of its oversight function.
7.Any proposal to dismiss the Editor in Chief for any reason shall be brought before the JOC for evaluation and a formal vote. The recommendations and views of the JOC shall be presented to the AMA Board along with the recommendation and views of the EVP/CEO. A supermajority (2/3) vote of the AMA Board would be required for dismissal of the Editor in Chief.
8.The Editor in Chief will report to the Senior Vice President for Publishing only for business and financial operations. The Editor in Chief will not report to management for any aspect of the editorial content of JAMA, the JAMA Network journals, or other AMA publications under his or her jurisdiction. Editorial independence of the Editor in Chief will be absolutely protected and respected by AMA management. In order to exercise its evaluative functions, the JOC will have full access to financial information including revenue and expense statements, budgets, and actual results. In order to have access to this proprietary information each member of the JOC who receives it will execute the AMA’s standard Confidentiality and Conflict of Interest Agreements.
9.The Editor in Chief will have total responsibility for the editorial content of JAMA and responsibility for the performance of the JAMA Network Editors and other AMA publications under his or her jurisdiction. AMA management recognizes and fully accepts the necessity of editorial independence for the Editor in Chief at all times.
May 26, 1999
Revised: December 2001
Revised: November 2005
Revised: September 2008
Revised: April 2014
22.214.171.124 The Case of the New England Journal of Medicine.
Beginning in 1991, Jerome P. Kassirer, MD, served as editor in chief of the New England Journal of Medicine, a weekly, peer-reviewed, general medical journal that is owned and published by the Massachusetts Medical Society. In 1999, Kassirer was dismissed as editor in chief of the New England Journal of Medicine after a struggle over authority with leaders of the Massachusetts Medical Society could not be resolved.15,16,17,18 Kassirer objected to the society’s plans for reuse of the journal’s content and cobranding of the journal name with other information providers over which he had no control or authority.17 He also objected to plans to move the journal’s editorial staff from its academically affiliated location at Harvard University to the publisher’s commercial offices because he believed that these plans threatened the journal’s credibility and autonomy.17 According to Kassirer, the decision to dismiss him was made by the Massachusetts Medical Society’s Committee on Administration and Management, which did so without input from the society’s trustees or the Committee on Publications.17 According to the society’s bylaws, the Committee on Publications was responsible for the publication of the journal and was the authority to which the editor in chief had reported for decades.
In response to the firing of Kassirer, there was much criticism from the international medical community as well as resignations of members of the Committee on Publications, the journal’s editorial board, and members of the Massachusetts Medical Society.15,16,17,18,19 In addition, the journal’s remaining editors discussed a plan for mass resignation in response.18 Deciding that such an action could irreversibly damage the journal, the remaining editors discussed and negotiated with the Massachusetts Medical Society a set of principles to maintain the journal’s editorial independence and the editor’s authority and responsibility for all content, editorial policies, use of the journal’s content, name, and logo, and location of the editorial office.18 With these assurances, Marcia Angell, MD, then the journal’s executive editor, agreed to serve as editor in chief until a search committee with representation of the editorial staff and the wider academic community could identify a new editor in chief for the journal.18 In May 2000, Jeffrey M. Drazen, MD, was appointed editor in chief, and it was reported that the editorial freedoms negotiated previously by Angell would remain.41 The journal’s editor in chief reports to the Committee on Publications of the Massachusetts Medical Society, which is appointed by the Board of Trustees; the editor in chief also has a dotted-line relationship with the society’s executive vice president, who reports to the society’s Board of Trustees. Drazen served as editor in chief until 2019, when Eric J. Rubin, MD, PhD, was appointed.
126.96.36.199 The Case of the Canadian Medical Association Journal (CMAJ).
Beginning in 1996, John Hoey, MD, served as editor in chief of the CMAJ, a weekly, peer-reviewed general medical journal owned by the Canadian Medical Association (CMA). In 2006, the CMA abruptly fired Hoey and the journal’s senior deputy editor, Anne Marie Todkill.20,21 Initial public reasons from the publisher and CMA leadership for the dismissals were to “freshen” the CMAJ and because of “irreconcilable differences” between the editor in chief and the CMA, but no specific differences were cited.20,21 Although the CMA denied that the decisions had anything to do with editorial independence, Hoey, other editors, editorial board members, and members of the journal’s oversight committee have all described several examples of censorship and interference with the CMAJ by CMA leaders and executives dating back to 2001 or earlier.20,21,42,43,44
In 2001, CMAJ published an editorial supporting medical use of marijuana, which contradicted the CMA’s position and for which the CMA’s general counsel complained to Hoey.23 In 2002, the CMAJ published an editorial criticizing Quebec physicians for not properly staffing an emergency department after a patient with a myocardial infarction died while being transported from an emergency department that had closed at midnight to a second open emergency department.23 Members of the CMA board called the editorial irresponsible, and the CMA president called for the editorial to be retracted. The CMAJ editorial board responded that the CMA was threatening the CMAJ’s editorial independence.23,44 Following these incidents, a journal oversight committee was established in 2002. However, the oversight committee’s roles and functions were unclear and interpreted differently by the CMA leadership, the editor in chief, and even the chair of the committee.23
In late 2004, the CMA had reorganized its publishing services and placed the ownership and direction of the CMAJ under a subsidiary, CMA Holdings Inc.45 This change reduced the editor in chief’s contact with the CMA and increased his interactions with the holding company and publisher, whose primary objective was profit.45 However, this change did not decrease the CMA’s attempts to influence the editorial direction and decisions of the journal. In late 2005 and early 2006, 2 other incidents of interference and censorship by CMA leadership and executives occurred.21,22,23 In one case, a CMAJ news story reported on the difficulty Canadian women had in obtaining nonprescription emergency contraception (Plan B) from Canadian pharmacists. Apparently, the Canadian Pharmacists Association complained to the CMA’s chief executive officer and objected to CMAJ’s plan to run this news story after one of the CMAJ reporters interviewed an executive with the association. The CMA’s chief executive officer took the objections to the CMAJ publisher, who told Hoey not to run the news story. Faced with what was thought to be an unreasonable demand and to avoid a crisis, the editors and reporters then modified the news story to address some of the objections and a revised article was published.21,22,23,42 An unsigned editorial was subsequently published in the CMAJ to alert readers to the incident of editorial interference and to “set in motion a process to ensure the future editorial independence of the journal.”46
The second case of such interference involved a CMAJ news story that was critical of a Canadian public health official. The news story was published in the online version of CMAJ on February 7, 2006, and was subsequently removed from the website.42 On February 20, Hoey and Todkill were fired, and 2 days later, a revised version of the original story was posted online that was less critical of the health official and more supportive of and beneficial to the CMA.42
During this time, Hoey had lost confidence in the journal’s oversight committee and asked an ad hoc committee to review these events.21,22 The ad hoc committee faulted the editors for modifying the news story on Plan B before it was published and for failing to follow the appropriate channel for conflicts (ie, the journal’s oversight committee).42 However, the ad hoc committee found more serious fault with the CMA for “blatant interference with the publication of a legitimate report” and concluded that the “CMAJ’s editorial autonomy is to an important degree illusory.”42
Following the dismissals of Hoey and Todkill, the remaining editors, led by acting editor Stephen Choi, MD, published an editorial in protest of the firings.47 Choi and colleagues drafted a proposal that included editorial independence for the CMAJ and aimed to ensure that the CMA and the publisher would not make decisions about editorial content.21 The CMA did not agree to the proposal, and Choi and another editor resigned.21 Other editors and most of the editorial board also resigned, and there were calls from academic leaders not to send papers or serve as peer reviewers for the journal.21,48,49 The journal’s former editor in chief, Bruce P. Squires, MD, was asked to serve as acting editor, but under pressure from editors of other journals, he too was unable to serve unless the CMA would agree to the journal’s editorial independence.23
Like the events at JAMA and the New England Journal of Medicine, the abrupt firing of CMAJ’s editors and the refusal of the CMA to recognize the journal’s editorial independence resulted in widespread news coverage of the conflicts, and a number of other leading journals published articles in support of the CMAJ editors.20,21,22,44,48,49,50 In the wake of such criticism, in March 2006 the CMA announced the establishment of a panel to assess the journal’s governance and management and agreed to an interim plan granting the editor in chief total responsibility for editorial content.51 With this plan in place, Noni MacDonald, MD, agreed to serve as interim editor and Squires agreed to serve as editor emeritus.52 The CMAJ governance review panel released its final report on July 14, 2006.45 The report contained 25 recommendations, all of which were accepted by the CMA.51,52,53 The recommendations included the following45:
■Assurance that the editor in chief would have editorial independence
■Amendment of the CMAJ’s mission statement to enshrine the “principle of editorial integrity, independent of any special interests”
■Confirmation that the CMA has no right to alter any editorial content but should be given the same advance notice of potentially controversial content that is given to the news media (see 5.13.3, Embargo)
■Proposal that the CMA take back direct ownership of the CMAJ from its for-profit holding company
■Proposal that the CMAJ editor in chief have separate and discrete reporting structures for editorial and business matters (ie, the editor in chief has access to the CMA Board of Directors if needed to defend or explain editorial positions or other concerns that cannot be resolved through administrative mechanisms, such as the journal’s oversight committee; the editor in chief reports directly to an officer of the CMA rather than to the publisher about the journal’s business matters; and the publisher reports to the same officer)
■A recommendation for a reconstituted journal oversight committee that permits it to more effectively help resolve potential disputes between the journal’s owner, publisher, and editor in chief
For more details on the makeup and responsibilities of the CMAJ’s oversight committee and the panel’s other recommendations, see the CMAJ Governance Review Panel’s final report.45 In January 2007, Paul C. Hébert, MD, was appointed editor in chief of the CMAJ with assurance of the journal’s independence as outlined in the CMAJ Governance Review Panel’s report.54 He led the journal for 5 years, and in 2012, John Fletcher, MB BChir, MPH, was appointed editor in chief,55,56 and the journal was served by a 7-member Journal Oversight Committee and the governance plan developed in 2006.45 In 2016, the CMA abruptly announced a “restructuring and modernization plan,” fired the editor in chief, and disbanded the journal’s oversight committee.57 Once again, public criticism ensued.58,59 In January 2017, the CMAJ announced the formation of yet another new governing council, based on the previous 2006 governance plan, to protect editorial independence and facilitate “healthy communication between editors of the journal’s owners.”60
188.8.131.52 Other Major Medical Journals.
Editors in chief of other major medical journals owned by medical societies in Australia and Norway have been dismissed or forced to resign because of seriously different or conflicting views with the publishers or owners about the management of the journal and how and when management decisions were made.61,62,63,64 Editors and publishers of smaller journals (in terms of size, resources, and bibliometric ranking) also need to consider the journal’s organizational structure and protection for editorial independence. For example, the editors in chief of the Croatian Medical Journal, which is owned by 4 medical schools with a governance agreement for the journal,65 were threatened to be removed and there was a threat to remove the journal’s editorial independence from the governance agreement after complaints were lodged about how the editors handled ethical breaches by an author with an academic appointment at one of the universities.66,67 This did not occur because the editors had previously published an article about the agreement in the journal to make it public,65 and the editors received public support from within Croatia and internationally. In these cases, as in those described for JAMA, the New England Journal of Medicine, and CMAJ, concerns were raised about the integrity and perceived quality of the journals following the actual or threatened dismissals or forced resignations of the editors.
Editors have also been removed or dismissed for failing to follow best practices as recommended by the International Committee of Medical Journal Editors, Council of Science Editors, Committee on Publication Ethics, and World Association of Medical Editors. For example, in 2006 the editor in chief of Neuropsychopharmacology was asked to resign after he published articles in the journal for which he was an author that had commercial funding without complete publication of the commercial ties of the authors68 (see 5.11, Editorial Responsibilities, Roles, Procedures, and Policies, and 5.5, Conflicts of Interest).
5.10.2 Ensuring a Trust Relationship Among Journal Editors, Publishers, and Owners.
As described by Davies and Rennie,4 the relationship between editors and publishers/owners is interdependent and must be based on mutual trust. However, there are bound to be uncertainties, concerns, and occasional conflicts that could threaten the trust relationship.4 To maintain trust, a formal agreement between the editor and owner should specify each party’s expectations and the mission of the journal (for example, see JAMA’s governance plan in Box 5.10-1 and JAMA’s Key and Critical Objectives69 reproduced in Box 5.10-2). If these expectations are not formalized in a governance plan or other document, are not mutually understood, or are intentionally disregarded (as happened in the cases described above), either party (but usually the owner) “may seek new (and possibly costly) mechanisms of accountability, reassurance, and control,”4 which would result in loss of trust and potentially serious damage to the integrity, credibility, and reputation of both the journal and the owner.
Box 5.10-2. JAMA’s Key and Critical Objectives69
To promote the science and art of medicine and the betterment of the public health.
1.To maintain the highest standards of editorial integrity independent of any special interests
2.To publish original, important, well-documented, peer-reviewed articles on a diverse range of medical topics
3.To foster responsible and balanced debate on issues that affect medicine, health, health care, and health policy
4.To provide physicians with continuing education in basic and clinical science to support informed clinical decisions and ongoing career development
5.To enable physicians to remain informed in multiple areas of medicine, including developments in fields other than their own
6.To improve health and health care internationally by elevating the quality of medical care, disease prevention, and research
7.To inform readers about various aspects of medicine and public health, including the political, philosophic, ethical, legal, environmental, economic, historical, and cultural
8.To recognize that, in addition to these specific objectives, the journal has a social responsibility to improve the total human condition and to promote the integrity of science
9.To achieve the highest level of ethical medical journalism and to produce a publication that is timely, credible, and enjoyable to read
10.To use technologies to drive innovation and improve the communication of journal content
Uncertainty, concerns, and disputes are best resolved informally through reciprocally open communication between the editor and publisher/owner and by maintaining a trust relationship. However, formal procedures for conflict resolution must be in place in the event that a dispute cannot be resolved informally.4 These procedures should rely on the journal’s mission and objectives to direct the assessment of the dispute, should require measured consideration of the facts involved (with appropriate evidence), and should not result in hasty decisions that do not consider the outcomes of such decisions for the editor, owner, and journal. In the cases described in the previous section, the continued existence and reputation of each journal was suddenly and unexpectedly put at risk because there was no effective independent mechanism to help achieve resolution of conflict or, if resolution proved impossible, allow time for an orderly change of editors. Such an orderly system and buffer and, if all else fails, such an orderly transition best serves the interests of journals, owners, publishers, and editors.4 In a case of serious conflict, if a contract with term limit exists between editor and publisher/owner, then the publisher can opt to not renew the contract rather than abruptly dismiss the editor.
The following recommendations, many of which are supported by the International Committee of Medical Journal Editors,27 World Association of Medical Editors,28 Council of Science Editors,29 and Committee on Publication Ethics,30 may help editors, publishers, and owners develop policies for maintaining editorial freedom for their publications. Such policies should be regularly reviewed and made publicly available to the extent possible. For example, an individual editor’s contract would not be made public, but a general description of the editor’s level of authority, responsibility, and accountability can be published along with the journal’s mission in an editorial, on the journal’s masthead, or elsewhere. These recommendations are offered to help journals protect against threats to editorial freedom and integrity, but even if all these recommendations are followed, they will not provide absolute immunity from such threats.
Complete editorial freedom is recommended for all peer-reviewed biomedical journals because it ensures the highest level of editorial quality, credibility, and integrity. However, it is recognized that not all journals operate under complete editorial freedom, and achieving all the elements necessary for complete independence may not be possible or desirable for some journals. Thus, these recommendations are provided for peer-reviewed journals with complete editorial freedom (highly preferred) and those journals with limited editorial freedom.
■The editor should have a written contract or job description that clearly defines the editor’s duties, rights, level of authority, responsibility, accountability, term of appointment, relationship to the publication’s owner, reporting relationship, oversight and governance plan, objective criteria for evaluating the performance of the editor and journal, rights if removed from the position before term expiration, and procedures for conflict resolution. An explicit and mutually accepted definition of the editor’s authority, responsibility, and accountability before the editor accepts the position will enable the editor to make an informed decision about accepting the position. Editors should carefully consider the ramifications of signing any nondisclosure agreements that would prevent them from speaking publicly if unwillingly removed from their positions.
■A governance plan should be in place that defines oversight and evaluation policies and procedures for the editor, conflict resolution mechanisms for the editor and owner of the journal, and the level of editorial freedom provided the editor and the journal. This plan should be published or otherwise made publicly available.
■Ideally, as in journals with complete editorial freedom, the editor should have direct access to the highest level of management in the organization or company that owns the publication. If this is not possible, as in journals with limited editorial freedom, the editor’s line of authority and reporting relationship should be specified in a formal agreement.
■All journals should have a published and easily accessible mission statement that clearly defines the journal’s goals and objectives; for journals with editorial freedom, the mission statement should include explicit reference to editorial freedom. The mission statement should serve as a guide for the editorial direction of the journal and should be relied on by the editor, editorial board, and members of the oversight or governance body when conflicts or disputes arise; it should be reviewed regularly by the editor and editorial board.
■An independent editorial oversight committee may help the editor establish and maintain the specified level of editorial freedom and resolve conflicts. To be independent, this committee’s chair should not be a representative of the owner’s employed, appointed, or elected leadership, and representation of the owner’s employed, appointed, or elected leadership on the oversight committee should be limited (ideally to a single individual) or at most should have fewer voting positions on the committee than would constitute a majority. Although this may require a different appointment procedure for some societies, the importance of an independent oversight committee for helping to maintain the journal’s integrity and manage contentious conflicts cannot be overstated. Note: An oversight committee differs from an editorial board, which serves to advise the editor on editorial content and policies (see 5.11.11, Role of the Editorial Board).
■In journals with complete editorial freedom, editors should have complete authority to hire, evaluate, and dismiss all editorial staff as well as the authority to appoint, evaluate, and dismiss editorial board members and peer reviewers (see 5.11, Editorial Responsibilities, Roles, Procedures, and Policies). If this arrangement is not possible for all editorial staff (eg, manuscript editors or other editorial staff employed, provided, or outsourced by the publisher), editors should at a minimum be able to review and evaluate their performance. For journals with limited editorial freedom in which the owner may make recommendations about editorial board members or peer reviewers, the editor should have final authority to approve their appointment, evaluate their performance, and terminate their appointment.
■The editor should have the opportunity to interview and comment on candidates for a new publisher being considered during the editor’s term. The publisher should have the opportunity to interview and comment on candidates for a new editor being considered by the journal owner and/or search committee. For society-owned journals using outside publishers, editors should be involved in the selection and performance review of the publisher and other external commercial companies or vendors (eg, advertising, marketing, and research agencies; printers; suppliers of editorial systems; and online vendors or hosts) as well as decisions to renew or terminate publishing agreements.
■In journals with complete editorial freedom, editors should have complete authority over use and reuse of the name, logo, and content of the journal in print, online, and other media. Content includes editorial content, covers, mastheads, design, formatting, online features and linking, and approval of advertising and sponsorship. Although the editor must not be involved in the business (ie, selling) of advertisements and sponsorship, the editor should have authority over policies on appropriate types of advertisements and their placement and over policies on sponsorship activities (see 5.12, Advertisements, Advertorials, Sponsorship, Supplements, Reprints, and e-Prints). At a minimum, for journals with limited editorial freedom, the editor’s level of authority and responsibility for content should be specified in a governance plan, contract, or other formal document.
■Owners and publishers should not interfere in the evaluation, review, selection, or editing of editorial content that is under the authority of the editor. For journals with complete editorial freedom, this pertains to all content. All changes and corrections made to content during production and publishing and after publication should be reviewed and approved by the editor or the editorial team reporting to the editor and production staff involved in producing the content but not the journal’s owner, publisher, or sales and marketing staff.
■Editors and owners should establish mutually understood policies and procedures that guard against the influence of external commercial and political interests as well as personal self-interest on editorial decisions (see 5.5, Conflicts of Interest).
■Editors should be accountable for their editorial decisions, which should be based on the validity and credibility of the content and its relevance and importance to readers, not the commercial success of the journal or political interests of owners or other groups. Editors’ decisions and communications with stakeholders should be based on competence, fairness, confidentiality, expeditiousness, and courtesy and should be governed by a policy on management of conflicts of interest (see 5.11, Editorial Responsibilities, Roles, Procedures, and Policies, and 5.5.7, Requirements for Editors and Editorial Board Members). However, editors need to understand the requirements for financial management and sustainability of their journals and they should publish content that attracts readers, authors, peer reviewers, subscribers, advertisers, and other stakeholders. Note: This does not mean that stakeholders should determine specific editorial content to publish or not to publish. For journals to maintain editorial freedom and integrity, editors should be free to express critical but responsible views without fear of retribution, even if these views are controversial or conflict with the commercial goals of the publisher or the policies, positions, or objectives of the owner or external forces.
■Editors should understand the business models that support their journals and should review financial operations with the publisher or journal owner. Any proposed changes to business models should be discussed with the editor.
■For journals with complete editorial freedom, the journal should publish a statement about its editorial independence and a prominently placed disclaimer that identifies and separates a publication’s owner and sponsor from the editorial staff and content. For example, JAMA regularly publishes its objectives69 (which include “to maintain the highest standards of editorial integrity independent of any special interests”) and a statement that it is editorially independent of its owner and publisher. The following appears in the masthead of the journal:
All articles published, including opinion articles, represent the opinions of the authors and do not reflect the official policy of JAMA, the American Medical Association, or the institutions with which the author is affiliated, unless otherwise indicated.
For journals that have limited or no editorial authority over specific types or sections of content (eg, pages reserved for the owning society or association or other content stipulated to be out of the editor’s control), authority and responsibility for such content should be made clear to readers.
■Owners have the right to hire and fire editors. However, except for provisions contractually stipulated (eg, term limits or contract expiration), owners should dismiss editors only for substantial reasons that are incompatible with a position of trust, such as editorial mismanagement, scientific misconduct, fiscal malfeasance, undisclosed conflicts of interest that result in biased editorial decisions, unsupported changes to the long-term editorial direction or stated mission of the journal, criminal behavior, or specific activities that violate terms of a formal agreement.
Editors should inform editorial board members, advisory committee members, owners, publishers, and editorial and publishing staff of the journal’s policies on editorial freedom.
■Editors should publish articles on editorial integrity freedom when appropriate and should alert readers and the wider international community to major transgressions against editorial freedom.
Principal Author: Annette Flanagin, RN, MA
I thank the following for review and helpful comments: Howard Bauchner, MD, JAMA and JAMA Network; Timothy Gray, PhD, JAMA Network; Iris Y. Lo, JAMA Network; Ana Marušić, MD, PhD, Journal of Global Health and University of Split School of Medicine, Croatia; Fred Rivara, MD, MPH, JAMA Network Open and University of Washington, Seattle; and Joseph P. Thornton, JD, JAMA Network and American Medical Association.
1.Van Der Weyden MB. On being editor of the Medical Journal of Australia: living dangerously. Mens Sana Monogr. 2012;10(1):150-157. doi:10.4103/0973-1229.91295
2.The United States Constitution Online. Accessed December 27, 2018. https://www.usconstitution.net/const.html#Am1
3.Reporters Without Borders. 2018 Worldwide Press Freedom Index. Accessed December 27, 2018. https://rsf.org/en/ranking/2018
4.Davies HTO, Rennie D. Independence, governance, and trust: redefining the relationship between JAMA and the AMA. JAMA. 1999;281(24):2344-2346. doi:10.1001/pubs.JAMA-ISSN-0098-7484-281-24-jed90044
5.Davis RM, Mullner M. Editorial independence at medical journals owned by professional associations: a survey of editors. Sci Eng Ethics. 2002;8(4):513-528.
6.Death of a journal. Lancet. 1987;2(8573):1442. doi:10.1016/S0140-6736(87)91138-X
7.O’Brien E. Closure of the Irish Medical Journal. Ir Med J. 1987;80(5):247-248.
8.Goldsmith MF. George D. Lundberg ousted as JAMA editor. JAMA. 1999;281(5):403. doi:10.1001/jama.281.5.403
9.Tanne JH. JAMA’s editor fired over sex article. BMJ. 1999;318(7178):213. doi:10.1136/bmj.318.7178.213
10.Smith R. The firing of brother George. BMJ. 1999;318(7178):210. doi:10.1136/bmj.318.7178.210
11.Horton R. The sacking of JAMA. Lancet. 1999;353(9149):252-253. doi:10.1016/S0140-6736(99)00019-7
12.Davidoff F. The making and unmaking of a journal. Ann Intern Med. 1999;130(9):774-775. doi:10.7326/0003-4819-130-9-199905040-00019
13.Kassirer JP. Editorial independence. N Engl J Med. 1999;340(21):1671-1672. doi:10.1056/NEJM199905273402109
14.JAMA Editors, AMA Archives Journals Editors, JAMA Editorial Board Members. JAMA and editorial independence. JAMA. 1999;281(5):460. doi:10.1001/jama.281.5.460
15.Horton R. An unwilling exit from the NEJM. Lancet. 1999;354(9176):358. doi:10.1016/S0140-6736(99)90251-9
16.Kassirer JP. Goodbye, for now. N Engl J Med. 1999;341(9):686. doi:10.1056/NEJM199908263410909
17.The departure of Jerome P. Kassirer. Letters and response. N Engl J Med. 1999;341(17):1310-1313. doi:10.1056/NEJM199910213411712
18.Angell M. The Journal and its owner—resolving the crisis. N Engl J Med. 1999;341(10):752. doi:10.1056/NEJM199909023411008
19.Bloom FE. Scruples or squabbles? Science. 1999;285(5431):1207. doi:10.1126/science.285.5431.1207
20.Sacking of CMAJ editors is deeply troubling. Lancet. 2006;367(9512):704. doi:10.1016/S0140-6736(06)68277-9
21.Spurgeon D. Owner fails to guarantee editorial independence. BMJ. 2006;332(7541):565.
22.Spurgeon D. CMA draws criticism for sacking editors. BMJ. 2006;332(7540):503. doi:10.1136/bmj.332.7540.503
23.Shuchman M, Redelmeier DA. Politics and independence—the collapse of the Canadian Medical Association Journal. N Engl J Med. 2006;354(13):1337-1339. doi:10.1056/NEJMp068056
24.Hoey J. Editorial independence and the Canadian Medical Association Journal. N Engl J Med. 2006;354(19):1982-1983. doi:10.1056/NEJMp068104
25.The gold-headed cane. BMJ. 1956;1(4970):791-793.
26.Booth CC. The British Medical Journal and the twentieth-century consultant. In: Bynum WF, Lock S, Porter R, eds. Medical Journals and Medical Knowledge. Routledge Chapman Hall Inc; 1992:259-260.
27.International Committee of Medical Journal Editors. Recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. Updated December 2018. Accessed January 14, 2019. https://www.icmje.org/recommendations
28.World Association of Medical Editors. The relationship between journal editors-in-chief and owners (formerly titled Editorial independence). Modified version posted July 2009. Accessed January 14, 2019. http://wame.org/editorial-independence
29.Council of Science Editors. Relations between editors and publishers, sponsoring societies, or journal owners. White Paper on Publication Ethics. Updated May 2018. Accessed January 14, 2019. https://www.councilscienceeditors.org/resource-library/editorial-policies/white-paper-on-publication-ethics/
30.Committee on Publication Ethics website. Accessed December 27, 2018. https://publicationethics.org/
31.Smith R. Editorial independence and the BMJ. BMJ. 2004;329(7205):272.
32.Lundberg GD. Goals for The Journal. JAMA. 1982;248(5):553. doi:10.1001/jama.1982.03330050035025
33.Lundberg GD. House of Delegates reaffirms editorial independence for AMA’s scientific journals. JAMA. 1993;270(10):1248-1249. doi:10.1001/jama.1982.03330050035025
34.Kassirer J. Should medical journals try to influence political debates? N Engl J Med. 1999;340(6):466-467. doi:10.1056/NEJM199902113400609
35.Rosenberg RN, Anderson ER Jr. Editorial governance of the Journal of the American Medical Association: a report. JAMA. 1999;281(23):2239-2240. doi:10.1001/jama.281.23.2239
36.Signatories of the Editorial Governance Plan. Editorial governance for JAMA. JAMA. 1999;281(23):2240-2242. doi:10.1001/jama.281.23.224
37.DeAngelis CD, Maves MD. Update of the Editorial Governance Plan for JAMA. JAMA. 2004;291(1):109. doi:10.1001/jama.291.1.109
38.DeAngelis CD. JAMA and its editor—thinking forward. JAMA. 2000;283(1):105. doi:10.1001/jama.283.1.105
39.DeAngelis CD. Onward. JAMA. 2011;305(24):2575-2576. doi:10.1001/jama.2011.876
40.Bauchner H. My vision for JAMA. JAMA. 2011;306(1):98-99. doi:10.1001/jama.2011.936
41.Johannes L. New England Journal of Medicine appoints Drazen as editor in chief. Wall Street Journal. May 12, 2000:1.
42.Kassirer JP, Davidoff F, O’Hara K, Redelmeier DA. Editorial autonomy of CMAJ. CMAJ. 2006;174(7):945-950. doi:10.1503/cmaj.060290
43.Armstrong PW, Cashman NR, Cook DJ, et al. A letter from CMAJ’s editorial board to the CMA. CMAJ. 2002;167(11):1230.
44.Kuehn BM. CMAJ governance overhauled: firings, resignations, compromised independence cited. JAMA. 2006;296(11):1337-1338. doi:10.1001/jama.296.11.1337
45.CMAJ Governance Review Panel: final report. July 14, 2006. Accessed December 27, 2018. http://www.cmaj.ca/sites/default/files/additional-assets/site/pdfs/GovernanceReviewPanel.pdf
46.The editorial autonomy of CMAJ. CMAJ. 2006;174(1):9. doi:10.1503/cmaj.051608
47.Choi S, Flegel K, Kendall C. A catalyst for change. CMAJ. 2006;174(7):901, 903. doi:10.1503/cmaj.060276
48.Spurgeon D. Most of CMAJ editorial board resigns. BMJ. 2006;332:687.
49.Webster P. Canadian researchers respond to CMAJ crisis. Lancet. 2006;367(9517):1133-1134. doi:10.1016/S0140-6736(06)68492-4
50.Ncayiyana DJ. Journal ownership versus editorial independence tug-o’-war. S Afr Med J. 2006;96(6):470-471.
51.CMAJ. CMAJ and editorial autonomy. CMAJ. 2006;175(4):339. doi:10.1503/cmaj.060917
52.MacDonald N, Squires B, Hawkins D. Editorial independence for CMAJ: signposts along the road. CMAJ. 2006;175(5):453. doi:10.1503/cmaj.060985
53.Payne D. Panel gives CMAJ editorial independence. The Scientist. July 17, 2006. Accessed January 14, 2019. https://www.the-scientist.com/?articles.view/articleNo/24159/title/Panel-gives-CMAJ-editorial-independence/
54.Hébert PC. A new year and new opportunities. CMAJ. 2007;176(1):9.
55.Weeks C. John Fletcher to helm CMA Journal. Globe and Mail. January 18, 2012. Accessed December 27, 2018. https://www.theglobeandmail.com/life/health-and-fitness/john-fletcher-to-helm-cma-journal/article1358910/
56.Fletcher J. What’s next for CMAJ? CMAJ. 2012;184(5):507. doi:10.1503/cmaj.120275
57.Canadian Medical Association. CMA Board of Directors announces restructuring and modernization plan for CMAJ. February 29, 2016. Accessed January 3, 2018. https://www.cma.ca/En/Pages/cma-board-of-directors-announces-restructuring-and-modernization-plan-for-the-cma-journal.aspx
58.Weeks C. Critics decry Canadian medical journal’s “Orwellian” revamp. Globe and Mail. February 29, 2016. Accessed December 27, 2018. https://www.theglobeandmail.com/news/national/critics-decry-canadian-medical-journals-orwellian-revamp/article28960721/
59.Kassirer JP. A Canadian purge. BMJ Opinion blog. March 4, 2016. Accessed December 27, 2018. http://blogs.bmj.com/bmj/2016/03/04/jerome-p-kassirer-a-canadian-purge/
60.Kelsall D, Flegel K, Patrick K, Russell E, Sibbald B, Stanbrook MB. Renewal for CMAJ. CMAJ. 2017;189:E1. doi:10.1503/cmaj.161478
61.Kmietowicz Z. Editor in chief of Journal of the Norwegian Medical Association resigns. BMJ. 2015;350:h766. doi:http://dx.doi.org/10.1136/bmj.h766
62.Smith P. Former MJA editor files claim against AMA. Australian Doctor. September 10, 2012. Accessed December 27, 2018. https://www.australiandoctor.com.au/news/former-mja-editor-files-claim-against-ama
63.Scott S. Backlash over decision by Australia’s top medical journal to outsource to company with history of “unethical” behavior. ABC News. May 1, 2015. Accessed December 27, 2018. http://www.abc.net.au/news/2015-05-01/academic-outrage-as-leading-health-journal-editor-sacked/6435850
64.McCook A. Editor of Medical Journal of Australia fired after criticizing decision to outsource to Elsevier. Retraction Watch. May 1, 2015. Accessed December 27, 2018. http://retractionwatch.com/2015/05/01/editor-of-medical-journal-of-australia-fired-after-criticizing-decision-to-outsource-to-elsevier/#more-27943
65.Marušić M, Bosnjak D, Rulic-Hren S, Marušić A. Legal regulation of the Croatian Medical Journal: model for small academic journals. Croat Med J. 2003;44(6):663-673.
66.Callaham M, Sahne P, Winker M, Overbeke J, Habibzadeh F, Ferris L. World Association of Medical Editors: support of the Croatian Medical Journal’s editorial independence. Croat Med J. 2008;49(1):100. doi:10.3325/cmj.2008.1.100
67.Marušić M, Marušić A. Threats to the integrity of the Croatian Medical Journal: an update. Croat Med J. 2008;49(1):8-11. doi:10.3325/cmj.2008.1.8
68.Pincock S. Journal editor quits in conflict scandal. Scientist. April 28, 2006. Accessed January 14, 2019. http://www.the-scientist.com/?articles.view/articleNo/24267/title/Journal-editor-quits-in-conflict-scandal
69.For Authors. About JAMA. JAMA’s key and critical objectives. Updated September 2018. Accessed January 14, 2019. https://jamanetwork.com/journals/jama/pages/for-authors#fa-about