Dalla Lana School of Public Health, University of Toronto, Clinical Epidemiology Unit, Sunnybrook Health Sciences Centre, Ontario, Canada; chair, WAME Ethics Committee. (Ferris)
Harvard Medical School, Boston, Massachusetts; chair, WAME Policy Committee. (Fletcher)
Editor's Note: The World Association of Medical Editors (WAME) recently made the following editorial available to its member journals to publish. I was impressed by the editorial's treatment of its important topic and felt that it would be of interest to many of our readers. This editorial may also appear in medical and biomedical journals whose editors are members of WAME. - — Steven L. Kanter, MD
Conflict of interest in medical publishing exists when a participant's private interests compete with his or her responsibilities to the scientific community, readers, and society. While conflict of interest is common, it reaches the level of concern when “a reasonable observer might wonder if the individual's behavior or judgment was motivated by his or her competing interests.”1 Having a competing interest does not, in itself, imply wrongdoing. But it can undermine the credibility of research results and damage public trust in medical journals.
In recent years, the extent of conflict of interest in medical journal articles has been increasingly recognized. Medical journals and the popular media have published numerous examples of competing interests that seemed to have biased published reports.2–4 Organizations have expressed concern for the effects of conflicts of interest on research,5 publication,1,6,7 teaching,8 and continuing medical and nursing education.9
The World Association of Medical Editors (WAME) is one of the institutions engaged in this discussion. WAME was established in 199510,11 to facilitate worldwide cooperation and communication among editors of peer-reviewed journals, improve editorial standards, and promote professionalism in medical editing.12 Membership in WAME is open to all editors of peer-reviewed biomedical journals worldwide; small journals in resource-poor countries are well represented. As of December 2009, WAME had 1,595 individual members representing 965 journals in 92 countries. WAME has broad participation, as there are no dues and WAME activities are largely carried out through the member listserv and the member password-protected Web site.
In March 2009, WAME released an updated policy statement, “Conflict of Interest in Peer-Reviewed Medical Journals.”1 It details the issues WAME believes journals should address when establishing their own policies for conflict of interest. The editor of this journal thought that the issues were important enough to share with its readers. A summary statement is presented in Table 1 and the full statement1 can be found on WAME's Web site.12
How does this statement differ from earlier conflict-of-interest statements?
First, WAME expands the scope of competing interests. Other statements have been concerned almost exclusively with conflicts of interest related to financial ties to industry – companies that sell health care products. The assumption is that financial incentives are especially powerful and are not readily recognized without special efforts to make them apparent. WAME has extended the concept of financial conflict of interest to include the effects of clinical income. For example, physicians who earn their livelihood by reading mammograms or performing colonoscopies may be biased in favor of these technologies. WAME has also included nonfinancial conflicts of interest (or the appearance of them) related to scholarly commitment: “intellectual passion” (the tendency to favor a position that one has already espoused or perhaps even established); personal relationships (the tendency to judge the works of friends/colleagues or competitors/foes differently because of the relationship); political or religious beliefs (the tendency to favor or reject positions because it affirms or challenges one's political or religious beliefs); and institutional affiliations (the tendency to favor or reject results of research because of one's institutional affiliations).
Second, WAME did not prescribe a universal standard for when meaningful conflict of interest exists. Rather, it defined and recommended elements of conflict-of-interest policies and encouraged journals to establish their own standards. WAME left operational definitions and standards on the basic issues to member journals, recognizing that journals exist in very different contexts across the globe, standards for conflict of interest are evolving, and some journals already have well-established policies and standards. WAME does not presume to judge which conflicts require action and what the appropriate action may be, although its policy does offer factors to consider.1 Obviously, excessive concern for these and more comprehensive lists of possible competing interests could paralyze the peer review and publication process and is not feasible. Editors must make judgments as to the strength of the conflict, but to do so must have uncensored information. Similarly, readers need transparency about conflicts, and therefore editors should publish with every article all relevant author disclosures.1
Third, WAME confirms the seriousness of failure to disclose conflict of interest by indicating that editors have a responsibility for investigating, and, if relevant, acting if competing interests surface after a manuscript is submitted or published. The intent is that allegations of failure to declare conflicts of interest must be taken seriously by journals.
Finally, WAME has addressed in a single statement the conflicts of interests threatening all participants in the research and publication continuum, including authors, peer reviewers, and editors. Conflicts between editors and journal owners, which might affect both the accuracy of articles and the credibility of journals, have been addressed in another WAME policy statement.13
What can be done about conflicts of interest in medical journals?
Conflicts of interest cannot be eliminated altogether but they can be managed so that they have the smallest possible effects on journal content and credibility. The backbone of managing conflicts of interest is full written disclosure; without it, nothing else is possible. Currently, authors may not reveal all of their competing interests and even if they do, journals too often do not publish them,14 so there is plenty of room for improvement. Even so, disclosure alone is an imperfect remedy; editors still must determine whether a conflict has sufficient potential to impair an individual's objectivity such that the article should not be published. Even more work may be needed on reviewers' and editors' competing interests, given their critical role as gatekeepers for the medical literature.
No statement will solve the conflict of interest problem, nor will it ever be solved altogether. As understanding of the problem and its management evolves, journals should be given latitude to establish their own standards, matching their policies to the best standards of their discipline and culture. WAME believes journals should make these policies readily accessible to everyone. All of us—editors, authors, reviewers, and readers–should be paying more attention to conflict of interest than we have been. We hope this statement serves that purpose.
The authors wish to warmly thank the WAME officers for their helpful comments on an earlier version of this editorial. Many thanks to President Margaret Winker (USA); Past President Michael Callaham (USA); Vice-President John Overbeke (Netherlands); Treasurer Tom Lang (USA); and Secretary Farrokh Habibzadeh (Iran).
The WAME Statement on Conflict of Interest in Peer-Reviewed Medical Journals was approved by the WAME Board in March 2009. Many thanks to the members of the WAME Ethics Committee and to the WAME Policy Committee for their insightful and helpful comments on an earlier version of the statement. Warm thanks to the WAME Board for their input and comments: Margaret Winker; Michael Callaham; John Overbeke; Tom Lang; Farrokh Habibzadeh; Adamson Muula (Malawi), and Rob Siebers (New Zealand).
As a WAME director, Lorraine Ferris did not participate in the WAME Board vote to approve the statement or the vote to endorse the editorial. The authors have no conflicts of interest to declare.
2Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research: A systematic review. JAMA 2003;289:454–465.
3Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: Systematic review. BMJ 2003;326:1167–1170.
6International Committee of Medical Journal Editors (ICMJE). Uniform requirements for manuscripts submitted to biomedical journals; ethical considerations in the conduct and reporting of research: conflicts of interest. Available at: http://www.icmje.org/ethical-4conflicts.html
. Accessed March 4, 2010.
7International Committee of Medical Journal Editors (ICMJE). Uniform format for disclosure of competing interests in ICMJE journals. October 2009. Available at: http://www.icmje.org/format.pdf
. Accessed March 4, 2010.
8Association of American Medical Colleges. Industry Funding of Medical Education: Report of an AAMC Task Force. Washington, DC: AAMC, 2008.
10Squires BP & Fletcher SW. The World Association of Medical Editors (WAME): Thriving in its first decade. Science Editor. 2005;28: 13–16.
11Launching the World Association of Medical Editors: Report of the Conference to Promote International Cooperation Among Medical Journal Editors, 1995. http://www.wame/org/Bellagio.htm
[no longer available].
14Bhargava N, Qureshi J, Vakil N. Funding source and conflict of interest disclosures by authors and editors in gastroenterology specialty journals. Am J of Gastroenterology 2007;102:1146–1150.