CJNR Editorial Vol. 38, No. 2, June 2006
Conflicts between Professional Associations and Their Journals Strike
at the Heart of Professionalism
Laurie N. Gottlieb
While CJNR is an independent, academic journal not affiliated
with a professional association, the rift between several professional
associations and their official journals should be of concern to all.
This rift is indicative of a fault line in a system that has been in
place for almost a century, a system whose purpose has been to safeguard
the role of professions within society and to ensure the highest standards
of professionalism.
Many have been concerned about the growing crisis of professionalism
in North America. There is mounting evidence that the public has lost
faith and confidence in the professions, eyeing them with suspicion
and cynicism. The professions are now perceived as serving their own
self-interests rather than the public interest.
Sullivan (2005) attributes the public disillusionment with professions
to a violation of the social contract. His thesis is as follows. A social
contract was drawn up between the professions and society. Professions
had services that only they could provide. These services required specialized
knowledge and skills acquired through years of formal education and
training, extensive experience, and mandatory continuing education.
Professionals were expected to meet the highest standards of competent,
ethical practice and to always act in the "public good." In
exchange, society accorded professions status and respect and remunerated
them well for services rendered. It also gave them autonomy and the
authority to control entry into their profession, monitor and regulate
their members, set direction for the profession, and create structures
to safeguard the public.
Over a century ago, a system was developed to fulfil this contract.
The system consisted of two interdependent bodies, the professional
association and the professional journal. The primary responsibility
of the association was to govern the profession, whereas the role of
the professional journal was to provide the association's members with
access to the latest information in the field. These two bodies formed
an important partnership. Each supported the other's mission while serving,
at arm's length, as a check and balance to the other's power.
While the system functioned relatively smoothly for decades, there have
always been tensions between the two bodies. In recent years there have
been a number of well-publicized rifts between professional associations
and their journals. When the various cases are viewed together, the
pattern that emerges is indeed troubling.
In 1999 the Massachusetts Medical Society (MMS) fired Dr. Jerome P.
Kassirer, editor of its official journal, the New England Journal of
Medicine (NEJM). This incident was followed by the firing by the American
Medical Association (AMA) of Dr. George Lundberg, editor of its official
publication, the Journal of the American Medical Association (JAMA).
These firings sent shockwaves through the scientific community. The
commercialization of medicine and editorial interference were cited
as reasons for the breakdown (Hoey, 1999; Parmley, 2000). Seven years
later, in 2006, two more journals became embroiled in conflict with
their associations. I refer to the recent firing by the Canadian Medical
Association (CMA) of Dr. John Hoey, editor of the Canadian Medical Association
Journal (CMAJ), and the decision by the American Nurses Association
(ANA) to sever its ties with the American Journal of Nursing (AJN).
The recent termination, in February of 2006, of Dr. Hoey and senior
CMAJ deputy editor Ann Marie Todkill calls into question a journal's
editorial autonomy and its independence from the interests and dictates
of the professional association with which it is affiliated (see Godlee,
2006; Shuchman & Redelmeier, 2006, Suzuki, 2006; Webster, 2006).
Dr. Hoey's contract was not renewed after the CMAJ published, over the
objections of the Canadian Pharmacists Association and the CMA, an investigative
item on pharmacists' efforts to restrict access by Canadian women to
the Plan B emergency contraceptive. A few weeks later, ANA's board decided
to "drop" the AJN as its official journal and to establish
a new journal that would be distributed to its membership, thus ending
a century-long relationship.
When these events were made public, the response was quick, the outrage
great, and the ripples far-reaching. Clearly, more was at stake than
the firing of editors and the disaffiliation of professional journals.
The conflicts suggested a loss of integrity and a lowering of ethical
standards. E-mails flew across cyberspace on the listservs of the World
Association of Medical Editors (WAME) and the International Academy
of Nursing Editors (INANE). Journals around the world rushed to prepare
editorials on the subject. The events were reported in newspapers and
on network television. In response to the Hoey firing, the CMA established
a commission, headed by a retired Supreme Court judge, to make recommendations
on the journal's future governance.
In the case of the AJN, nurse editors around the world expressed their
consternation in a letter to the ANA (see www.inane.vcu.edu).
Why have there been such strong, visceral reactions to these cases?
Many believe that associations are being driven by greed, the "bottom
line," at the expense of professional considerations and the public
good.
The official journals of some professional medical associations have
become cash cows (Hoey, 1999). Journals with high impact factors have
translated their prestige into high subscription rates and large advertising
revenues. With minimal investment, associations have reaped great profits.
(Case in point: the NEJM brings the MMS revenues of over $20 million
annually [Hoey].) In the past 15 years, professional journals have become
a marketable commodity. It was this very issue that caused the rift
at the NEJM. The MMS board saw an opportunity to "brand" the
NEJM by creating other imprints bearing its logo. When Dr. Kassirer
requested that, as NEJM editor, he be given some responsibility for
the quality of these new imprints, he was turned down and his contract
terminated. The fact that the Canadian Pharmacists Association was involved
in the CMAJ issue raises the possibility that commercial considerations
played a role, directly or indirectly. The ANA has stated that its decision
to drop the AJN as its official journal was based on business considerations.
For some time now, there has been growing scepticism about the ability
of professional associations to monitor themselves. New structures have
been created to serve as "watchdogs." Journal editors have
formed associations (WAME and INANE) and have published editorials alerting
their members to the existence of dangerous practices. They have established
committees to develop guidelines for improving the quality of scientific
papers and to ensure that authors and editors meet the highest standards
of ethical conduct. They stand on guard for signs of interference with
editorial independence or violations of the principles of scientific
publishing. When seeking to publish their work, researchers monitor
the scientific and scholarly standards of journals and make their decisions
accordingly. Clinicians look to many new sources for reliable and credible
information rather than depend solely on "official" journals.
The public have assumed greater responsibility for their own care, demanding
to be treated as partners instead of as passive recipients. Interest
groups monitor the professions and have become powerful lobbyists. They
have found a voice in numbers and have become key drivers of the research
agenda and essential sources of credible information. Foundations are
and always have been valued partners of professional bodies. A case
in point is the Preparation for the Profession Program of the Carnegie
Foundation for the Advancement of Teaching. This program has committed
large amounts of money to the study of professions, including nursing,
with a view to developing a new system to address the crisis of professionalism.
Until the issues eroding professionalism are better understood and a
new social contract between professions and society is drawn up, we
can expect to see more rifts between professional associations and their
journals. These rifts should be seen as symptoms of serious malfunctioning.
During this period of breakdown and transition, as we await the emergence
of a new system, we must be prepared to defend the integrity of our
professions and to safeguard the public good. We all have a role to
play.
Laurie N. Gottlieb
Editor-in-Chief
References
Godlee, F. (2006). A big mistake. British Medical Journal, 332(7540),
0.
Hoey, J. (1999). When journals are branded, editors get burnt: The ousting
of Jerome Kassirer from the New England Journal of Medicine. Canadian
Medical Association Journal, 161(5), 529-530.
Parmley, W. W. (2000). What did we learn from the New England Journal
of Medicine? Journal of the American College of Cardiology, 35, 254.
Shuchman, M., & Redelmeier, D. A. (2006). Politics and independence
- The collapse of the Canadian Medical Association Journal. New England
Journal of Medicine, 354, 1337-1339.
Sullivan, W. M. (2005). Work and integrity: The crisis and promise of
professionalism in America. San Francisco: Jossey-Bass.
Suzuki, D. (2006). Medical journal fracas makes everyone look bad. Science
Matters, March 10. Retrieved May 10, 2006, from http://www.davidsuzuki.
org/about_us/Dr_David_Suzuki/Article_Archives/weekly03100601.asp
Webster, P. (2006). Canadian researchers respond to CMAJ crisis. Lancet,
367, 1133-1134.
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