Seven years ago, John Hoey, then editor-in-chief of the Canadian Medical Association Journal, leaped to the defence of his U.S. counterpart, who had been fired for publishing an article about oral sex.
The scandal over former U.S. president Bill Clinton's sexual escapades with Monica Lewinsky was nearing its climax when George Lundberg, editor of the Journal of the American Medical Association, ran a survey that found a significant number of Americans shared the presidential view that oral sex didn't constitute "having sex."
American Medical Association executives fired Dr. Lundberg for his timing, saying he had injected the journal into a political debate.
The result was an international controversy over editorial independence of the medical press, much like the one surrounding the February firing of Dr. Hoey and senior deputy editor Anne Marie Todkill.
In 1999, Dr. Hoey and his colleagues denounced the AMA in an editorial that foreshadowed conflicts to come with the Canadian Medical Association, owners of the CMAJ.
In their 1999 editorial, Dr. Hoey and other journal staffers made it clear they did not see the CMA as owners in the conventional sense.
"Any medical journal belongs, intellectually and morally, to its contributors, editors, editorial boards and readers - a sort of constituent assembly," the editorial said.
"The American Medical Association doesn't own the Journal of the American Medical Association," they wrote. "It is the custodian of it."Seven years later, Dr. Hoey too was fired after running articles and editorials that angered medical association executives. They showed they were more than mere custodians of the journal by dismissing him. But that decision and the continuing battle over his firing threaten the oldest and most important medical journal in Canada.
The crisis is of intense interest to many doctors and to the country's top medical researchers. But ordinary Canadians also have something at stake. Will the one journal that crosses the desk of almost every physician in the country have an independent voice? Will it continue to challenge and to criticize the medical profession?
Will it be able to provide information that isn't compromised by pressure from the pharmaceutical companies that advertise in its pages? Or will it become a newsletter for the CMA leadership, a profit centre rather than a knowledge broker?
Dr. Hoey and Ms. Todkill were fired on Feb. 20, and say they were given no reason.
The CMA won't say why the two were dismissed, but insists it has nothing to do with editorial independence. The journal's publisher, Graham Morris, said he wanted a fresh approach.
Dr. Hoey and Ms. Todkill say they signed confidentiality agreements that prevent them from talking freely about conflicts they had with the journal's owners. They are also negotiating severance packages.
Current employees and those who quit after the firings signed the same confidentiality agreement, which forbids them to discuss internal matters.
But the history of the growing tension can be found in the pages of the journal itself.
The CMAJ runs peer-reviewed articles in which scientists describe the results of their research, everything from the problems antidepressants can cause in young patients to waiting times for breast-cancer treatment. It also runs news stories and editorials. It was the editorials, for the most part, that riled executives at CMA headquarters in Ottawa.
The CMA opposes the medical use of marijuana, but in 2001, a journal editorial supported the idea.
In 2002, a journal editorial criticized Quebec doctors for not adequately staffing the emergency department of a regional hospital. A heart-attack patient had been turned away six minutes after the ER closed, and died en route to another hospital.
Many doctors were offended, saying it was unfair. In a letter to the editor, Dana Hanson, CMA president at the time, called for a retraction, but the journal didn't comply.
"It was no secret that there was tension," says Paul Armstrong, an Edmonton cardiologist and member of the editorial board appointed by Dr. Hoey.
In an effort to establish a mechanism to resolve disagreements, Dr. Armstrong says the CMA set up a journal oversight committee with independent members and a representative from the CMA. But it never really seemed to function, and over time, was seen by editorial staff as a pawn of the medical association.
In most of the clashes, Dr. Hoey seemed to emerge victorious. But not always.
In 2004, the journal ran an editorial announcing that it would no longer carry advertising inserts from a company called mdBriefCase about courses for doctors. Some courses, it said, were supported by grants from pharmaceutical companies, that had a say in selecting the material and the instructors, but conflicts of interest were not disclosed.
Company president Greg Cook complained. He said the pharmaceutical companies that sponsor courses don't design them or choose the instructors.
Dr. Hoey ran a clarification, and the journal continued to carry the advertising inserts.
"They reversed the policy," Mr. Cook says.
It wasn't only what Dr. Hoey published that bothered the CMA. It appeared to many observers that there were philosophical differences.
The CMA had discussed changing the direction and focus of the journal, which under Dr. Hoey had an international flavour and became one of the top five general medical journals in the world. The CMA enjoyed the prestige, but there was discussion internally about whether the approach was serving the needs of its 62,000 members - the doctors of Canada.
However, Dr. Hoey, it appeared, wasn't interested in changing direction. His resistance was part of a culture clash common at medical journals between the "town and the gowns," the researchers in academe and the docs on the front lines. Former contributors to the journal who asked not be named said Dr. Hoey was seen as arrogant in the eyes of some doctors.
In 2005, the CMAJ became a for-profit venture, and was transferred to a holding company owned by the medical association.
There were fears at the journal that the drive to make money would mean pressure not to run articles critical of the pharmaceutical industry, the major advertisers. Staff at the journal had to sign confidentiality agreements saying they wouldn't discuss internal matters even after their employment was terminated.
The new structure meant that for the first time, the journal had a full-time publisher, Mr. Morris. He had no experience in medical publishing.
At one meeting, he talked openly about whether it was necessary for the journal to annoy its advertisers.
At the same time, however, Bill Tholl, the chief executive officer of the CMA, continued to play a role in how the journal was run.
Unlike many other medical journals, the CMAJ editorial staff did not have a written guarantee of editorial independence from its owners, despite repeated requests for one.
In December, 2005, it became clear why that guarantee was needed.
Two experienced journalists at the journal were preparing a news story about Plan B, a new generation of morning-after pill that can prevent unwanted pregnancies if it is taken within 72 hours of unprotected sex. The report quoted privacy and women's health experts concerned that pharmacists were collecting detailed personal information from women who wanted the drug, which is kept behind the counter.
The Canadian Pharmacists Association says it was given a heads- up about the story by the federal Privacy Commissioner. The two CMAJ reporters had asked 13 women across the country to go to a pharmacy to buy the drug, and to report on how they were treated.
George Murray, the elected president of the pharmacists association, was concerned. In an interview, he said his executive director called the CMA to ask whether it was true its reporters were conducting covert research, and whether the research was being carried out in an ethical manner.
Mr. Tholl agreed there was cause for concern, and went to the journal publisher, Mr. Morris.
Mr. Morris told Dr. Hoey not to run the story because the research involved had not received ethical approval.
Dr. Hoey and his staff were upset. They argued it was legitimate investigative journalism, not medical research per se. They considered resigning.
But they decided it was better to run the story - even without the women's comments - than not to publish at all. Mr. Tholl agreed that if the comments from the informal survey were cut out, the story could run.
Dr. Hoey wrote an editorial explaining to readers what had happened.
"We have a transgression to report," the editorial said. He announced the formation of a committee to investigate, which included former New England Journal of Medicine editor Jerome Kassirer, a member of Dr. Hoey's editorial board and Carleton University professor Kathryn O'Hara. It found fault with Dr. Hoey for responding to pressure from the CMA, but more serious fault with the CMA for "blatant interference with the publication of a legitimate report."
The controversy over the Plan B story publicly revealed the schism between Dr. Hoey and the CMA. Mr. Murray says he had no idea that the phone call would lead to such a crisis at the journal, and said his reaction to the coverage of the story has been "stunned disbelief."
"I don't think we have the powers to do the things that are being alluded to. It is their journal, they do what they want with it."
The final skirmish was over an unflattering story in the on-line edition of the journal about new federal Health Minister Tony Clement that angered Mr. Tholl because it left the impression the CMA was critical of Mr. Clement. The new version had a kinder headline and fresh, positive quotes from the CMA president about the new minister.
Later in February, Dr. Hoey's 10-year run as the editor was finished, and Ms. Todkill was dismissed as well.
The fallout seemed to take the Canadian Medical Association by surprise. It had no one lined up to take over as interim editor, and seemed unprepared for the avalanche of resignations and international condemnation that followed the firings.
The CMA negotiated with one of its editors, Stephen Choi, to take over. They had agreed on a number of conditions to ensure he had editorial independence. But they couldn't agree on the length of his term. He quit, as did fellow staffer Sally Murray.
An editorial in the Lancet, a prestigious British medical journal, called the firings "deeply troubling." The New England Journal of Medicine published a detailed account titled "Politics and Independence - The Collapse of the Canadian Medical Association Journal."
It was a public-relations nightmare, and crisis management consultants Hill and Knowlton were called in for advice.
Although Dr. Hoey couldn't speak publicly, members of the editorial board he appointed could, and they were extremely critical of the CMA in interviews they gave to the media. They were considering resigning and began negotiations with the CMA, which saw board members as loyal allies and friends of Dr. Hoey.
But the two sides talked. Both PJ Devereaux, a McMaster University cardiologist and editorial board member, and CMA president Ruth Collins-Nakai, said they believed they were making progress.
Then Dr. Devereaux sent a memo to the CMA outlining where the discussions stood. It made a number of demands, including the reinstatement of Dr. Hoey and Ms. Todkill, and a written guarantee of editorial autonomy that Mr. Choi and Mr. Tholl had already agreed on.
Dr. Collins-Nakai says she viewed the memo as an ultimatum, and didn't respond.
Dr. Devereux said he took the lack of response as a sign the CMA was not negotiating in good faith. He and 14 members of the board resigned after a fierce debate over whether their actions would help or harm the journal over the long run. In their attempt to save an editor, were they destroying the journal?
Another member, Dr. Kassirer, had already quit.
They aren't the only ones demanding the reinstatement of Dr. Hoey. Almost 4,000 people have signed an on-line petition; almost half of them are members of the CMA.
The Plan B story was recently nominated for a Michener Award for public-service journalism.
This week, a dozen respected scientists, including Gordon Guyatt at McMaster University, announced they would not submit their research to the journal unless it clarified the events around the firing of Dr. Hoey and Ms. Todkill.
The CMA announced that a panel headed by Antonio Lamer, the former chief justice of the Supreme Court of Canada, would make recommendations on the future governance of the journal. But he doesn't have the mandate to examine why Dr. Hoey and his colleague were fired, a serious flaw in the eyes of many critics.
Lost somewhat in coverage of the drama of the resignations was the news early last month that the CMA had, for the first time, adopted a written policy guaranteeing editorial autonomy for the journal, based on the principles adopted by the American Medical Association after the oral-sex controversy.
The first principle says the CMA and its holding company "accepts and respects the necessity of editorial independence of the Editor-in-Chief. The Editor-in-Chief assumes total responsibility for the editorial content in the CMAJ."
A new journal oversight committee is being put in place, one that CMA members won't dominate.
This is an interim policy, while a panel chaired by the former chief justice reports.
"Those things were meaningful progress," says Paul Armstrong, one of the few members of the editorial board who did not quit.
The guarantee of editorial independence was what convinced Noni MacDonald, a pediatric infectious-disease specialist at Dalhousie University in Halifax, to step in as interim editor for three months.
She is now flying to Ottawa one day a week in a attempt to keep the journal functioning. She has received a number of vitriolic e-mails from fellow researchers and doctors who see her decision to take the job as a betrayal of Dr. Hoey.
For Dr. MacDonald, the key issue is editorial independence, and she says she is satisfied by the moves the CMA has made to guarantee it. She credits Dr. Devereaux and other former editorial board members for pressing the medical association to make the changes. She says she understands why some of them may be upset she agreed to step in.
"There are a lot of people who are sad and angry about what happened to John and Anne Marie," she said, and the fact that no one knows why they were fired increases the angst.
But Dr. MacDonald says she wasn't prepared to let the journal fall apart.
"People are interpreting [that]we did something bad. But JAMA did not stop publishing when people went ballistic over the firing of their editor."
She has set up her own interim editorial board, which includes Dr. Armstrong and other respected researchers, such as Donna Stewart, an expert in women's health at the University of Toronto.
Dr. Stewart says the decision to join was "very difficult to make."
She did not want to do anything that would undermine Dr. Hoey and Ms. Todkill, and is appalled that the decision to fire them appears to have been made without forward planning. She has agreed to a 90-day term, which will end around the time that Mr. Lamer's governance panel reports.
"I wanted to see the journal live through this," she says.
"I recognize my decision will make a lot of people unhappy. But I tried to satisfy myself that it was the right thing to do."
There is then, a division between prominent and respected members of Canada's medical research.
Some, like Dr. MacDonald, believe the crucial issue of editorial independence has been resolved in a satisfactory manner - at least in the interim. Much still depends on what Mr. Lamer recommends, and whether the CMA adopts it.
But others, like Dr. Devereaux, are still pushing for the reinstatement of the two fired editors, even though he acknowledges it is a long shot. He and other critics argue that if the CMA hand-picks a new editor to do its bidding, guarantees of editorial independence won't make much difference.
They argue that the CMA cannot be trusted until it comes clean about why it fired Dr. Hoey and Ms. Todkill.
"They can't be that incompetent," Dr. Devereaux said. "Why fire them on the heels of issues of editorial autonomy?"
If the CMA does offer a frank explanation - which he believes is related to editorial autonomy - it will have no choice but to hire them back, Dr. Devereux said.
Dr. Collins-Nakai says that she won't discuss the dismissals, and that the journal is moving forward without the fired editors. Watching the continuing drama from the safe distance of California is Drummond Rennie, who was deputy editor of JAMA when Dr. Lundberg was fired and who spent what he describes as a "grim" six months trying to save the journal.
Dr. Rennie, who remains deputy editor, has been following the crisis at the CMAJ closely, and has been in contact with many of the players.
He is appalled by how the CMA has handled the kind of disputes that regularly occur at scientific and medical journals around the world.
"It is very sad that they should have this blow up and not have been frank about it.
"You don't plunge a famous and excellent journal, which was getting better by the minute, into extreme peril and threaten to destroy it."
JAMA survived because the AMA agreed to a mechanism that protected editorial independence, similar to the interim measures the CMA has adopted.
"Everybody, particularly the owners, are happy because they can't get into this mess again. It may be in the future they will be upset with an editor, and the editor will have to leave. But there won't be this instantaneous lunacy, there will a process."
He said the CMAJ must regain the trust of the country's top researchers, otherwise they will choose other journals for their research papers. There is already talking of setting up an on-line competitor to the CMAJ.
"A journal can become third rate very rapidly," Dr. Rennie said.
There is little chance, he said, that Dr. Hoey will be reinstated.
"I really like John Hoey, and I really admire what he has done. But I'd say it sounds to me as though the relationship is irrevocably broken."
This week, Dr. Hoey made his first public appearances since he was fired. He spoke generally about the issue of editorial independence, and repeated his view that medical journals belong to readers, editors and editorial boards, not to professional associations.
But he has been reading Don Quixote, a novel about an idealist who attempts to enforce a moral code of honour and justice.
"The whole notion of editorial independence is quixotic. It's an ideal, right, that things are independent and you can fight for them and run around with your sword and defend editorial independence, but it doesn't really exist," Dr. Hoey said.
"We're all kind of independent, but ultimately we're dependent on the advertisers. . . . It's an idealistic fight to go after something that you're never going to obtain."
With a report from Jeffrey Hawkins