Credibility, it is often said, takes a long time to build, and only an instant to destroy. This is unfortunate, because lately the Canadian Medical Association's attention span is measured in instants when it comes to managing its flagship publication, the Canadian Medical Association Journal (CMAJ). Its actions are an embarrassment to this country.
Two weeks ago, the CMA, acting through a holding company that publishes the journal, scandalized the medical world by sacking the CMAJ's editor and deputy editor. Their offence? To attempt to publish an investigative article demonstrating that some pharmacists, acting without medical cause, and sometimes in violation of privacy laws, inquired into women's sexual history before permitting them to buy the "morning-after" pill. The editors were sacked after the Canadian Pharmacists Association complained to the CMA that the editors' investigation caused controversy "at the expense of another health profession," and made their members appear prurient and unprofessional.
But that is hardly the trouble. What should be a minor tale of pinched pharmacists' pride has triggered a conflagration, in which smoulder the principles of editorial and academic freedom. Hardly one week after the CMA sacked the two editors, their replacements quit because the CMA would not agree to their future freedom to publish. Specifically, the CMA rejected an explicit statement that "editorial independence of the editor-in-chief [should] be absolutely protected and respected."
Thus, in deeds and, now, in words, the CMA has insisted on its authority to censor. Within days the decision was condemned by the CMAJ's editorial board, and by writers and editors of The Lancet, the British Medical Journal, PLoS Medicine, the Annals of Internal Medicine, the New England Journal of Medicine, and the Journal of the American Medical Association - basically, all the world's best medical journals.
Surprisingly, the CMA seems unable to take the hint that its journal has just been excommunicated from this exalted company, none of which believes that what the departed editors did was wrong. Rather than reply, the CMA is cowering behind its own processes. It has now asked former Supreme Court chief justice Antonio Lamer to head a panel on the journal's independence. Mr. Lamer, who, in 1997, authored a forceful defence of judges' own independence, is a brilliant man, but his panel is totally unnecessary. Only three years ago, the CMA appointed a journal oversight committee to be responsible for the journal's independence.
Why the CMA needs another process is something it hasn't explained and, doubtless, hopes not to be asked.
Science and medicine are among the institutions of our society that most express reason and love. When any of us, in our personal lives, loses grasp on the powers to reason or love, we make bad choices and often need a friend or counsellor to speak up and tell us. Dialogue, not censorship, is how people regain their equilibrium.
It is the same with the reason and love that our society terms science and medicine. Editors' freedom to publish when our society makes bad choices for its health is necessary for society to regain its equilibrium. When a journal's publishers interfere, it seems to me that they exhibit a breathtaking lack of sensitivity.
The world's best medical journals publish fearlessly. In the past year, The Lancet published evidence that U.S. prisons use medically insufficient anesthesia, and have executed the death penalty cruelly on semi-awake offenders. It also published a report condemning health-care workers who abet the illegal force-feeding of hunger strikers at Guantanamo Bay, and a study revealing that the World Health Organization unethically participated in supplying African children dying of malaria with an obsolete medicine. Did these articles anger the Americans, Reed Elsevier and the World Health Organization? Of course they did. But they also shone a light on problems, helping them to be solved. Citing The Lancet, a U.S. court recently ordered an injunction on half-awake executions, and nobody at the WHO takes it in stride any more when African children receive obsolete malaria medicines.
The CMA stands alone. Only a lack of sensitivity prevents it from admitting that censorship is shameful, and that its actions have made Canada the object of derision in medical journals worldwide. A puppet medical journal manipulated by the CMA is something Canadians can ill afford, as our society braces for meaningful debates on private health care, better access to medicines, wait times, and so on.
If the Canadian Medical Association has reasons not to invite the departed editors back, with full independence, I'd like to hear them.
If their reasons fail to persuade, then I and many of my colleagues believe there should be a general boycott of the journal - by authors, by peer-reviewers, and by advertisers alike, none of whom ought to gift a minute of their time or a single dollar until the CMAJ's independence is restored.
It would be sad if such action were to lead to the CMAJ's demise, but it would still be preferable to accepting anything less than a fully free journal of the highest standards. Anyway, Canada's best scholars could create a new, freer, and better journal to replace the CMAJ in short order. The integrity of our country's science, medicine and conscience may depend on it.
Amir Attaran is Canada Research Chair and associate professor of law, population health and global development at the University of Ottawa. He is an editorial consultant of The Lancet.
2
