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Authorship and Medical Ghostwriting: Plastic and Reconstructive Surgery Policy

Sullivan, Daniel M.Div.; Rohrich, Rod J. M.D.

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Plastic and Reconstructive Surgery: June 2011 - Volume 127 - Issue 6 - p 2496-2500
doi: 10.1097/PRS.0b013e3182131aa6
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According to Eastwood et al., biomedical publication documents the results of investigative efforts and communicates findings among researchers.1 Publication “documents productivity, justifies funding for research, creates reputations, and builds careers.”1 Secondarily, publication serves as a benchmark and resource for fellow scientists. In the pure sense, authorship of scientific publication serves a secondary purpose, dissemination of knowledge and technique, and application of knowledge is (theoretically) the primary reason to publish. Nevertheless, a legitimate and necessary derivative purpose is to give credit where credit is due, and that is done by listing authors on articles. Authorship indicates who should take credit for ideas and work as they furthered knowledge. In addition, authorship also indicates who is responsible for ideas and experiments, and can be used to hold people accountable if something is disproven or shown false. At its core, authorship indicates ownership and responsibility; the act of placing their names on a paper shows that authors stand by it and all it represents. It serves as a public statement of the authors' trustworthiness.


Numerous journals and biomedical publications have explicit policies and published editorials on what constitutes authorship and who can be listed as an author in their “Instruction for Authors” (to name a few, see the Annals of Surgery,2Nature,3 the The New England Journal of Medicine,4,5 and The Journal of the American Medical Association).6 Many journals are adopting authorship criteria as sponsored by the International Committee of Medical Journal Editors,7 the Council of Science Editors,8 the World Association of Medical Editors,9 and the Committee on Publication Ethics.10 These publications essentially agree that the types of authorship can be parsed and nuanced into the following basic categories (Table 1)6–15,17–21:

Table 1
Table 1:
Types of Authorship in Biomedical Publication
  1. Ghost authorship
  2. Guest authorship
  3. Gift authorship
  4. Legitimate authorship

Of these four categories, Plastic and Reconstructive Surgery (along with other journals, the World Association of Medical Editors, the International Committee of Medical Journal Editors, the Council of Science Editors, and the Committee on Publication Ethics) affirms that only authors who meet the criteria of “legitimate authorship” as authors should be listed on a manuscript.

Ghost authorship and guest authorship are not acceptable in biomedical publication. Senator Grassley, a U.S. Senator from Iowa who has long investigated financial ties between drug companies and medical professionals, has described medical ghostwriting as payment by drug and device manufacturers to marketing or medical education companies that drafted articles, editorials, or review papers. Those papers were then presented to prominent doctors and scientists who were added as authors, whether they were familiar with the content or not; these “added authors” did not meet any of the contribution criteria for authors as listed in Table 1. Participation of the ghostwriter was often not revealed.13 As stated by The New York Times, the concern with ghostwriting is that the work of industry-sponsored writers has the potential to introduce bias, affecting treatment decisions by doctors and, ultimately, patient care.12

Recently, a high-profile case of ghost authorship surfaced in publications related to rofecoxib. Articles on clinical trials of rofecoxib were ghostwritten by Merck & Company staff writers or by hired outside consultants. After they were written, clinical physicians were recruited and paid as authors and frequently placed in the first and second authorship positions, although they were not involved with the manuscript or clinical study in any substantive way. Review manuscripts were often prepared by unacknowledged authors, and authorship was subsequently attributed to academically affiliated investigators who often did not disclose industry financial support.15 Along with the articles already mentioned, a growing number of papers and journals have documented the problem of ghostwriting and inappropriate authorship, which is becoming a major concern in academic medicine, the pharmaceutical industry, and biomedical publishing.11,12,14,15,17–19

Why Correct Authorship Attribution Is Important: A Matter of Copyright and Responsibility

Most journals (with the notable exception of open-access journals) require authors to sign over copyright of their articles to the journals. The journal that publishes a report assumes responsibility to conduct peer review, determine acceptability, and ultimately publish the article for the world to see and use in the pursuit of furthering science. Journals depend on the truthfulness of authors and their peer-review panels to write and to evaluate manuscripts honestly, respectively; this is the ethical expectation on which journals exist. As has been mentioned, journals do not have the resources to conduct thorough investigations into the truthfulness of authors and reviewers.22 When everyone is truthful in the process, the journal (and individual authors and patients and science itself) benefits.

A second reason why the importance of truthfully reporting authorship cannot be overstated lies in the legal nature of the transfer of copyright. Transfer of copyright requires authors to sign statements indicating that they are the authors of and thus are solely responsible for the content in the article. The copyright form is a legal document transferring ownership to a journal. If the authors are not the ones responsible for the content of an article but sign the copyright form that says they are, they are making a false statement on a legal document.

If the stated authors are not the real authors of a paper but sign the copyright to the effect that they are, who then bears the responsibility if and when a paper is discredited? The journal? Investigations into the real authorship usually uncover fraudulent authorship, at which point the stated (but fraudulent) authors typically reveal who did write the paper: a ghostwriter, industry-sponsored writers, or someone else. The question of responsibility thus becomes muddied, and attempts at distributing responsibility usually result in the discrediting of not only the stated authors but also the actual (ghost) authors, the sponsor of that author (industry), the journal that published the article, and science itself. Authors, not industry sponsors, or ghostwriters, sign the copyright form, and thus have the responsibility for what goes into a manuscript. Authors, not industry writers or legal teams, must have the final edit of their manuscripts, precisely because they are the ones responsible for it and sign statements to this effect.


In light of the current heightened concern over ghost authorship of biomedical articles, Plastic and Reconstructive Surgery in this article articulates its formal policy on authorship. Plastic and Reconstructive Surgery takes a clear stand on the practice of medical ghostwriting: we do not allow it. In addition, Plastic and Reconstructive Surgery does not allow guest or “gift” authorship (Table 1). All authors of all manuscripts submitted to the Journal submit papers with the understanding that their name on a manuscript indicates they had a major part in the generation and creation of that document. Idea generation and research, study organization and design, data collection, supplying clinical material and data, and actual writing of the document all constitute acceptable roles appropriate for authorship. Any and all authors must be directly related to the generation of the manuscript and/or the research it presents. Plastic and Reconstructive Surgery abides by and endorses the current International Committee of Medical Journal Editors, Council of Science Editors, Committee on Publication Ethics, and World Association of Medical Editors criteria for authorship. If a person was not directly related to the research, we do not allow the individual to be listed as an author.

Role of Authors in a Manuscript

A number of activities qualify a person as a legitimate author of a paper; including their names as authors is appropriate and acceptable. Authorship requires substantial contributions to the conception, analysis, interpretation of data, and drafting and revision of manuscript submissions. Beginning with the publication of this policy statement, Plastic and Reconstructive Surgery now requires all authors of manuscripts to state their role in the generation of their submission. This declaration should be placed as the second or third page of the manuscript, after the title page and financial disclosure page.

Changes in Authorship

Any changes to the authorship after the initial submission of a paper must be explained by a letter to the Editor from the authors, indicating why the change is being requested. Changes to authorship include adding an author, deleting an author, or changing the order of authors. That letter must be signed by all authors on the paper, indicating their acknowledgment and approval of said changes. Copyright assignment also must be signed by every author. The Editor-in-Chief will determine whether the authorship of an article can be changed, based on the explanation made in the request letter. Authorship of an article will not be changed after an article is published.

Authorship of Clinical Articles

Plastic and Reconstructive Surgery now requires that any clinical manuscript (the subjects of which are humans, not experimental papers, or manuscripts that have clinical implications or applications) have as its first and corresponding author a practicing physician(s). Coauthors from industry can certainly be included on a paper, but the corresponding author who takes ultimate senior responsibility on the paper must be a practicing clinical physician.

Medical Writers

Plastic and Reconstructive Surgery recognizes the important role of medical writers, and we support the recent position statement of the American Medical Writers Association.22 In brief, medical communicators who contribute substantially to the writing or editing of a manuscript should be acknowledged with their permission, and should disclose any pertinent financial or professional relationships. The online poster “How to Acknowledge a Medical Writer”23 provides helpful guidance on which medical writers should be identified as authors, and who should be acknowledged in the acknowledgments of a manuscript.

Responsibility of the Senior Author

Plastic and Reconstructive Surgery now will hold senior authors to a higher standard for their manuscripts. Beginning with the publication of this policy statement, the senior author/corresponding author must sign a statement indicating that they attest to the accuracy of the authors' statements regarding their roles as authors. The senior/corresponding author must sign a form indicating that the author group listed is solely responsible for the generation of content of the article, and that the article was not ghostwritten and did not have any other unlisted authors.

Authors accept responsibility and accountability for the content of the article; the authors—not an industry sponsor—have the final say in what goes into a manuscript. The senior author acknowledges that there may be severe penalties incurred if it is later discovered that the authorship is not what they attested it to be.

Schedule of Penalties

Penalties for misrepresentation of authorship should be severe, because misrepresentation of authorship constitutes fraud, and Plastic and Reconstructive Surgery will consider it to be a breach of ethics. Plastic and Reconstructive Surgery will investigate cases of ghostwriting and will consider such cases as scientific misconduct. The Journal's policy of investigating instances of plagiarism, duplicate publication, and other forms of scientific misconduct has been previously formulated, and will be applied to allegations of ghostwriting (Table 2).24

Table 2
Table 2:
Schedule of Penalties for Ghost, Guest, and Gift Authorship

The above-mentioned policies concerning authorship are in accord with the accepted guidelines and policies of many internationally accepted biomedical journals, authorship councils, and consortia. Plastic and Reconstructive Surgery takes the role of authorship seriously. In publishing a policy statement on authorship criteria, we believe the role of authorship will be clarified and hope that authors will better understand what activities constitute legitimate authorship on their manuscripts. We encourage authors to read the updated “Instructions for Authors,” published twice a year in the printed Journal and always available on the Plastic and Reconstructive Surgery Enkwell website (, and to contact the Editorial Office with any questions.


1.Eastwood S, Derish PA, Berger MS. Biomedical publication for neurosurgery residents: A program and guide. Neurosurgery 2000:47:739–748; discussion 748–749.
2.Annals of Surgery. Instruction for authors. Available at: Accessed February 3, 2010.
3.Nature. Authorship policies. Available at: Accessed February 3, 2010.
4.Drazen JM, Curfman GD. On authors and contributors. N Engl J Med. 2002;55:55.
5.Davidoff F, DeAngelis CD, Drazen JM, et al. Sponsorship, authorship, and accountability. N Engl J Med. 2001;345:825–826; discussion 825–827.
6.JAMA authorship responsibility, financial disclosure, acknowledgment, and copyright transfer/publishing agreement. Available at: Accessed December 23, 2009.
7.International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals: Ethical considerations in the conduct and reporting of research. Authorship and contributorship. Available at: Accessed January 20, 2010.
8.CSE's white paper on promoting integrity in scientific journal publications. Available at: Accessed December 23, 2009.
9.World Association of Medical Editors. Policy statements. Available at: Accessed December 23, 2009.
10.Albert T, Wager L. How to handle authorship disputes: A guide for new researchers. The COPE Report 2003. Committee on Publication Ethics. Available at: Accessed December 23, 2009.
11.O'Brien J, Baerlocher MO, Newton M, Gautam T, Noble J. Honorary coauthorship: Does it matter? Can Assoc Radiol J. 2009;60:231–236.
12.Wilson D, Singer N. Ghostwriting is called rife in medical journals. The New York Times: September 10, 2009. Available at: Accessed September 11, 2009.
13.Tanne JH. Senator asks US medical schools about rules on ghostwriting. BMJ. 2009;339:b5013.
14.Rennie D, Flanagin A. Authorship! Authorship! Guests, ghosts, grafters, and the two-sided coin. JAMA 1994;271:469–471.
15.Ross JS, Hill KP, Egilman DS, Krumholz HM. Guest authorship and ghostwriting in publications related to rofecoxib: A case study of industry documents from rofecoxib litigation. JAMA 2008:299:1800–1812.
16.Collier R. Prevalence of ghostwriting spurs calls for transparency. CMAJ. 2009;181:e161–e162.
17.PLoS Medicine Editors. Ghostwriting: The dirty little secret of medical publishing that just got bigger. PLoS Med. 2009:6;e10000156.
18.Paul M. On transparency, responsibility, and accountability. Clin Microbiol Infect. 2009;15:1100–1102.
19.Tanne JH. US survey favours acknowledging medical study ghostwriters. BMJ. 2009;339:b3968.
20.Rennie D, Yank V, Emanuel L. When authorship fails: A proposal to make contributors accountable. JAMA 1997;278:579–585.
21.Rohrich RJ. The promise and perils of peer review. Plast Reconstr Surg. 2006;118:795–797.
22.American Medical Writers Association. AMWA position statement on the contribution of medical writers to scientific publications. Available at: Accessed January 7, 2010.
23.American Medical Writers Association. How to acknowledge a medical writer. Available at: Accessed January 7, 2010.
24.Rohrich RJ, Sullivan D. Plagiarism and dual publication: Review of the issues and policy statement. Plast Reconstr Surg. 2009;124:1333–1339.
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