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What Are and What Should Be the Values of Medical Journals?

ByRichard Smith, former editor of the BMJApril 22, 2020

The following excerpt is reprinted with permission from The Trouble With Medical Journals (Taylor & Francis, 2000).

I don’t know of a medical journal that explicitly declares its values, but all journals — just like all organizations — have them. They are simply implicit rather than explicit. As journals flourish in a place where medicine, science, public health, journalism, healthcare and business meet they may pick up values from all of those disciplines. And often those values conflict.

Most medical journals think of themselves primarily as part of medicine, and so they start with the values of medicine — and medicine is the discipline relevant to medical journals which has the deepest ethical roots. The Hippocratic Oath, still valued by many but thought hopelessly outdated by others, is the inevitable starting point for describing the values of medicine. (It is reproduced in Appendix 1 (78)). It begins by emphasizing respect for your teacher and has the feel that your first commitment is not to your patients, as might be expected, but to the rest of the ‘tribe’. It happened as well in Hippocrates’ time to be an exclusively male tribe.

Respect for your teacher is straight away a problem for journals. Both Thomas Wakley and Ernest Hart, the great 19th century editors of the Lancet and BMJ respectively, were far from respectful of their teachers. The essence of ‘evidence-based medicine’, which is transforming medicine, is that you rely not on experts, who are often wrong, but on evidence. ‘In God we trust’, goes the American joke, ‘but all others must bring data’. Being respectful is not a journalistic value. Indeed, journalists are taught to be distrustful of authority. Scientific values too are about testing the old ideas until they break and new ones are needed.

It is of course possible to combine respect for your teachers and the past with the urge to question what you are taught and move inquiry on. That is perhaps a value that is shared by medicine with science and journalism, but the original Hippocratic Oath described a claustrophobic world where the sacred teaching was passed on from master to pupil. Teaching was encouraged but only within the tribe. You teach ‘pupils who have signed the covenant and have taken an oath according to the medical law, but no one else’. Some journals have catered for a closed world, where the language is arcane, identical values assumed, and intimate details of patients revealed on the assumption that only members of the tribe will see the material. All of this is anachronistic. Editors of journals cannot assume that their journals will be seen only by their fellow professionals. ‘The whole world’s watching’, chanted American anti-Vietnam demonstrators in the 1960s as they were hauled away by the National Guard. It’s true for journals.

Passing on information is central to journals, but ‘teaching’ implies more: teaching is an active process that involves interaction and change in both the teacher and the pupil. Many journals have not valued education in the broader sense: they have simply not used every means possible to improve the educational value of their material. One of the BMJ Publishing Group’s journals, Heart, has in recent years placed a heavy emphasis on education. It had always published original research and some review articles, but a few years ago it consciously created an education section. It set educational objectives, created a curriculum, and then provided first class — but not scientifically original — material to cover the curriculum. Quickly that section became the best read part of the journal. Now Heart is using the web to provide interactive cases for learning. It has decided that education is a core value. Most journals have not taken such a step.

Healing the sick is of course core to medicine — and to most medical journals. Some journals are, however, more to do with basic science, public health, and health services or policy. David Slawson and Allen Shaughnessy have also observed that many of the articles published in medical journals are not what they have cleverly called ‘POEMS’ (patient oriented evidence that matters). As a student I often fretted that too much of medicine was for the benefit of doctors rather than patients, and some journals seem to reflect that world.

Louis Lasagna, academic dean of the School of Medicine at Tufts University, wrote an updated version of the Hippocratic Oath that is used in many American medical schools today. (This is reproduced in Appendix 2 (79)). In it he says more on healing the sick, urging the avoidance of ‘overtreatment and therapeutic nihilism’, and reminding students that ‘there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug’. Some journals set great store by this human side of medicine. The Lancet, a journal famous for both its radical stance and science, has emphasized the medical humanities, and the BMJ Publishing Group has published a supplement to the Journal of Medical Ethics called Medical Humanities. The BMJ published a piece called ‘The inhumanity of medicine’, by David Weatherall, probably Britain’s most respected doctor, and it produced a huge response (80).

Lasagna also included in his oath the sentence: ‘I will prevent disease whenever I can, for prevention is preferable to cure’ (79). Placing prevention above cure is one of medicine’s values that is often poorly observed, but some journals — for example, Preventive Medicine — emphasize this value.

The ancient oath talks of keeping the sick (and it’s clearly plural) from ‘harm and injustice’. This would seem to encourage the social role that has been very important to some journals — for example, the I9th century BMJ (9). Some journals are nervous about straying beyond ‘strictly medicine’ into ‘politics’. I explored this issue in chapter 3 and my conclusion was that it was impossible to avoid being political to some extent — partly because to attempt to be apolitical is in itself a political step.

The modem oath by Lasagna says: ‘I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm’ (79). Doctors in other words cannot forget that they are members of a broader society and that they have ‘special obligations’.

The Hippocratic Oath is strongly against euthanasia and abortion. Many countries have legalized abortion, making this part of the Hippocratic Oath particularly anachronistic. But many doctors — especially those who are Roman Catholics or Muslims — remain unhappy with the legalization of abortion. Some journals, particularly those intended for doctors of particular religions, may make it a fundamental value to oppose abortion. But do all journals need to adopt a particular position? Many do not. They publish widely different and often conflicting views. Some may try to avoid the subject.

The ancient Hippocratic Oath puts strong emphasis on confidentiality: ‘What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.’ Confidentiality is clearly an important value for medical practice. Patients must be able to tell their doctors everything if an accurate diagnosis is to be made. But confidentiality cannot be absolute. The law in Britain requires doctors to break confidentiality if they suspect child abuse. Clearly, if a doctor diagnoses epilepsy in a pilot of a jumbo jet who refuses to tell his employers, then the doctor must break confidentiality.

Confidentiality is a less clear value for journals to uphold. In fact they have tied themselves in knots. First, there is the confidentiality of patients. Editors and readers of journals used to assume that publishing case reports that didn’t give the patient’s name was not a breach of confidentiality. They assumed this partly because only doctors read journals, so the information was kept within the ‘tribe’. They (I should say we) also underestimated how easy it is for somebody somewhere to recognize the case. I will write more about this in chapter 13, but for now I’ll simply say that we moved to requiring written consent from the patient in almost all circumstances (81). The General Medical Council, the body that regulates British doctors, adopted similarly strict standards. But then when I was at the BMJ we concluded that we had overdone it and retreated (82). There is still uncertainty.

The BMJ also tended to adopt confidentiality in its relationships with authors. Thus the journal would not tell a third party whether or not an author had submitted a paper to it. But why did the BMJ — and most other journals — adopt such a strict standard? The BMJ did so because the editors are mostly doctors and it was easy to extend the rules of confidentiality with patients to the journal’s relationship with authors. It avoided having to invent a new code — to think, in other words. But why should information on whether an author has submitted a study be confidential? It’s hard to see why and journals may well be moving to a world where studies when submitted are immediately posted on the web. But I can think of at least one good reason why such information shouldn’t be confidential. It allows quacks to give information to gullible journalists, saying that they have submitted their studies to the New England Journal of Medicine, the BMJ, the Lancet or any journal. This gives the studies a spurious second-hand respectability that they do not deserve.

Journals have traditionally as well required peer reviewers to keep confidential studies they have been sent to review. There is some logic here in that ideas and data might be stolen if distributed too widely before publication. But ironically the secrecy of the process, with authors routinely not knowing who has reviewed their papers, probably makes it easier for ideas to be stolen. If I knew that Professor Plum had reviewed my study then it would require near pathological aplomb on the part of Plum to submit stolen ideas to another journal.

I suggest that by simply transferring the value of confidentiality from medicine to themselves, journals have created less than optimum values. They need to think through their own values.

I’ve related the values of the Hippocratic Oath to the values of journals, but the oath was created 2000 years ago — and values change. About 10 years ago the British medical profession was urged by the then chief medical officer, Ken Caiman, to consider its ‘core values’ (83). This was partly a response to a feeling that medicine was losing its way and doctors becoming disillusioned. The first summit of British medical organizations since the 1960s came up with the following core values: caring, integrity, competence, confidentiality, responsibility and advocacy (86). These are what the Americans disparagingly call ‘motherhood and apple pie’. A particular problem was that the implications and possible contradictions of the values were not thought through. A philosopher friend was scornful that the massed brains of British medicine could manage nothing better.

(An aside that I hope you might find interesting. There was intense debate and a major split over one particular value. The older members of the gathering, the majority, thought that a central value of medicine was to put your patient first, even before your own family. Many older doctors describe, almost with pride, ‘never having seen their children grow up’. Younger members disagreed strongly. ‘Not only do I think it’s wrong, but I wouldn’t want to be looked after by doctors who put patients before their families. They would be weird people.’ The division continues.)

Although the values proposed by the good and the great of medicine don’t seem very valuable, those proposed by Ken Caiman, who suggested the meeting, are: a high standard of ethics; continuing professional development; the ability to work in a team; concern with health as well as illness; patient and public focus; concern with clinical standards, outcomes, effectiveness and audit; ability to define outcomes, interest in change and improvement. research and development; and ability to communicate (83).

I find it interesting that he put ‘a high standard of ethics’ first. This applies as much to journals as it does to doctors and implies two things, the second of which I have only recently come to understand. The first implication is that ethical problems are not something that crop up once a year when you have to make a dramatic decision on whether or not to switch off the ventilator for somebody rendered brain dead in criminal circumstances. Ethical decisions arise all day every day in both medicine and editing. Most doctors, I think, now understand that ethical issues are ubiquitous. Many editors don’t. I was once at a seminar for editors on ethical issues, and Raanan Gillon, who at the time was editor of the Journal of Medical Ethics and who was conducting the seminar, began by asking the dozen or so assembled editors to describe ethical problems they’d encountered recently. Almost all said that they hadn’t encountered any ethical problems. This was, I must say, at least eight years ago. It might be different now, particularly since the founding of the World Association of Medical Editors and the Committee on Publication Ethics (see chapter 12) (85).

Caiman’s second implication is that ‘high ethical standards’ or ‘integrity’ is not something you have and lose if you fall into wicked ways. You need to work every day at integrity. You are constantly presented with ethical issues where it is far from clear what is the ‘right’ thing to do. In fact there may be no ‘right’ thing. You have alternatives, none of which is wholly wrong or wholly right. To flourish in such a morally complex universe you need to be helped with how to think about the problems that confront you and to constantly exercise your ethical muscles. You probably also need help and more than one mind for the problem — together with a transparent process for identifying and addressing ethical problems. That is why the BMJ founded an ethics committee and is the reason (apart from an excuse to spend eight weeks in Venice) that I am writing this book (86).

Caiman’s second value was continuing professional development, meaning that you are never complete as a professional. You must learn constantly, not least because you are continually presented with new challenges and new circumstances. This is as true for journals and editors as it is for doctors, and yet traditionally many medical journals have been edited by academics who have no training in editing. One day they are professors of cardiology, the next editors of major journals. Nobody would launch into being a cardiologist, inserting a catheter into an artery of the heart, without training. Yet it is routine the other way round. Editors similarly often do not seek training and to improve their craft. Drummond Rennie, the organizer of the congresses on peer review, castigated editors at the end of the last congress for not coming in greater numbers and for neglecting their craft (87).

The ability to work in a team is another excellent value for editors. One of my favourite sayings is that ‘any journal that can’t be better than its editor’ is doomed. Yet there is a long tradition of editors working alone, like St. Jerome translating the bible in his desert cave. Good journals depend on many different ideas, contacts, views and attitudes. Diversity is a virtue, but will be beneficial only if it is combined with effective team work.

‘Concern with health as well as illness’ and ‘patient and public focus’ are values that seem essential to good journals, but ‘concern with clinical standards, outcomes, effectiveness, and audit’ again is an excellent value for journals. All journals would claim to be high quality, but, as I describe in chapter 6, there is lots of evidence of poor quality. There was no tradition of measuring the effectiveness of journals and their processes, and little tradition of audit. Many journals take months to make decisions on whether or not they will publish papers and then months, even years, to publish them. Some papers fall into ‘black holes’, and the standard of what might be called ‘customer service’ is generally lousy. Journals have been able to get away with it because they are mostly equally bad.

‘Ability to define outcomes, interest in change and improvement, research and development’ are values related to what I’ve already discussed, but I’ve always been interested that professors of neurology who have learnt to base their neurological opinions and practice on evidence are happy to make strong statements about ways of editing journals with no evidence. The tradition of research into journal processes — what I sometimes pretentiously call ‘evidence-based editing and publishing’ — is only at the beginning (88).

‘The ability to communicate’ would seem like the sine qua non value of journals (and in that spirit, and despite horror from the literati, the BMJ banned Latin and Greek because many readers didn’t understand them and many authors got their classical languages wrong), but many journals have bothered little with the clarity and comprehensibility of what they publish. Many studies have shown that journals have very low readability scores (89), and Michael O’Donnell, one of British medicine’s great medical communicators, can keep an audience laughing for an hour with egregious examples of medical writing (90, 91). He calls doctors’ style of writing ‘decorated municipal gothic’. It’s full of wind and pomposity and designed to make the author look important, not to let the reader understand. Journals also tend to look awful, with pages and pages of unbroken prose.

So far I have discussed the values of medicine and how they may apply to medical journals, but I want now to move on to other relevant values. I was part of a group called the Tavistock Group (after Tavistock Square where we first met) that tried to derive a set of principles that might apply to everybody in healthcare, not just doctors (92). We observed — following the American ethicist Will Gaylin (93) — that much of the universal disarray in healthcare arises from people trying to solve ethical problems with technical solutions. We also observed that conflicts in values among those in healthcare — particularly doctors and managers — were part of the problem. Doctors with their ancient ethical codes might use those codes more as battle implements than as a means to elucidate a problem. The Tavistock Group, which was predominantly American and British, went through an elaborate process to derive principles for everybody in healthcare. I have to say that they have not been widely adopted, but they are useful for this process of exploring the values of medical journals.

Rights: People have a right to health and healthcare.

Balance: Care of individual patients is central, but the health of populations is also our concern.

Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease and promote health.

Cooperation: Healthcare succeeds only if we cooperate with those we serve, each other and those in other sectors.

Improvement: Improving healthcare is a serious and continuing responsibility.

Safety: Do no harm.

Openness: Being open, honest and trustworthy is vital in healthcare.

Many of these principles overlap with values I’ve already discussed, but some provide a new twist. The principle that healthcare is a right is uncontroversial almost everywhere apart from America, but one of the leading American journals, the Annals of Internal Medicine, has argued that the right to healthcare ought to be incorporated into the American constitution (94). (As my friend, Ian Morrison, observes, only in America is carrying a gun a right and healthcare a privilege.) The principle that health might be a right seems at first strange. Isn’t it like suggesting a right to be tall or beautiful?

Amartya Sen, Nobel prize winning economist, explained to a meeting organized by the Tavistock Group why it was not absurd to make health a right. He began by explaining how Immanuel Kant distinguished between ‘perfect’ and ‘imperfect’ obligations. Perfect obligations impose a duty on particular people and institutions, whereas imperfect obligations do not. In many countries healthcare has become a perfect obligation (for instance, in Britain, where the government has accepted the duty to provide healthcare), although it remains an imperfect obligation in others. But imperfect obligations can move — perhaps through legislation — to become perfect obligations.

By making health a right, Sen argued, we gain people’s attention: a debate begins on who might have the duty to try to achieve health for everybody. There is a pressure to begin implementation. And it’s important also to make health a human right because the main health determinants are not healthcare but sanitation, nutrition, housing, social justice, employment and the like. Health as a right is a value that many medical journals might like to adopt.

‘Do no harm’ is a central value of medicine and the Tavistock Group thought that it should adopt the principle for everybody. It is not only doctors who can do harm but also politicians creating new policies and managers implementing new systems. Doctors are sadly familiar with the idea that they can act in what they think is the best interest of patients but do them more harm than good. But this is perhaps a less familiar idea to politicians and managers who deal in words not knives and drugs. Some are perplexed by the principle ‘do no harm’ because they know that all effective interventions may harm, but the intention behind the principle is not that practitioners should never make an intervention: it is that they should struggle to maximize benefit, minimize harm and reduce error.

Is this a principle that journals should adopt? I think that it would be hard, although many — particularly public health practitioners — would like journals to adopt such a principle. Perhaps if the Lancet had done so it would not have published the study that linked the measles, mumps and rubella (MMR) vaccine with autism (see chapter 2). But journals must surely value debate and must have a bias towards publishing rather than not publishing. And because they deal very much with provisional truths, the nature of science, there is a huge uncertainty about what may flow from what they publish. If journals were to become anxious about everything they might publish that might cause harm then they would, I fear, become paralysed.

As I read this previous paragraph, some three months after I first wrote it, I worried that it seemed breathtakingly complacent. After arguing strongly that not only doctors but also politicians and managers should adopt the principle, I suggest that it would be bad for journals. It reads to me now as if I was supporting the idea that editors could be cavalier about doing harm — because of some higher commitment to open debate. The position reads to me now overstated, but rather than simply revise the paragraph I thought that I should keep it to illustrate how l — and I suspect many other editors — are not as bothered by harm as perhaps we should be.

Medical students who come and worked with us at the BMJ were often able to publish something within the journal — usually a news story — within days of arriving. I told them that: ‘Medical journalism is not like neurosurgery. You can’t go guddling around in people’s brains a few days after beginning neurosurgery, but you can write a news story in your first week at a medical journal. Most students do.’ Maybe this statement betrays the same complacency about harm.

After first writing the overstated paragraph I became embroiled in a controversy over a highly critical obituary that the BMJ published, as I discussed in chapter 2 (50, 95). It described the dead man, the founder of the pharmaceutical company Scotia, as a ‘snake oil salesman’. The family were understandably upset. They were harmed; so, they argued, was the reputation of the dead man. A complaint was made to the Press Complaints Commission, the body that self-regulates the press in Britain, and we apologized for the upset we caused but not for publishing the obituary. Even if it was ‘true’ (which of course we believed it to be), should we have published such a thing? My conclusion today is that journals must think about harm, and there will be times when they shouldn’t publish because of the harm they might cause. Journals have clearly adopted that position in relation to publishing information about patients without their consent.

The problem is to balance ‘good’ and ‘harm’. There is substantial good in the free flow of information, even when particular pieces of information are trivial, caviling and offensive. Hence the high value placed on free speech and the freedom to publish, but editors cannot use the excuse of the substantial good to publish whatever they want regardless of harm — which is what I seemed almost to be arguing. Editors must consider harm, but — unlike doctors — I don’t think that we should put it first. The bias towards publishing should come first. Many readers will, I’m sure, not agree.

I again had to consider the issue of harm when Nature published a news piece in which AIDS researchers criticized the BMJ for posting on its website many rapid responses (electronic letters to the editor) that argued that HIV was not the cause of AIDS (96). The AIDS researchers argued that the BMJ was causing harm by giving respectability to a scientifically ridiculous case that was leading to some authorities — for example, in South Africa — holding back antiretroviral treatments that would save lives. I responded by arguing for free speech and suggesting that most readers of the BMJ were well aware of the speciousness of the arguments (97). The rapid responses appeared on the BMJ‘s website, not in print where the journal is more selective. I don’t believe that any serious harm resulted, but if the critics could have shown me corpses I would probably have thought differently.

The Tavistock principle of being ‘open, honest and trustworthy’ might be both the most banal and the most profound (94). Nobody could argue against being open, honest and trustworthy, and yet every day in every healthcare system people fail on all three counts. It’s difficult to be open and honest about deficiencies in your hospital or practice, or the bleak fate awaiting a patient. There’s always a way to ‘soften the blow’ or ‘be economical with the truth’.You worry that you might lose the trust of patients or the public if you tell the unvarnished truth, yet nothing destroys trust faster than being found to have been deceived.

We live in a world, I believe, where, whether we like it or not, what is not open is assumed to be biased, corrupt or incompetent until proved otherwise. Yet journals are often not very open. Classically their peer review systems are closed in that neither authors nor readers know who have reviewed papers. Journals are also not open about their finances.

I want now to tum to the values of journalism, many of which ought to be fundamental to journals but haven’t been. Journalists put great value on being interesting. One of the worst things that you can say about a mass media publication is that it is boring. Medical journals have not worried about being boring. A closely related journalistic value is putting readers first. Without readers a newspaper is nothing. Medical journals, in contrast, have often put authors first. Journalists also see themselves as being on the side of the governed rather than the governors. Medical journals have, in contrast, often been organs of the establishment. Innovation and creativity are important within journalism. A publication should innovate and reward creativity. These have not been fundamental values for medical journals, but I believe they should be.

What about ‘getting things right’? I remember once being shocked by a BBC reporter declaring at a press conference, ‘It is not my duty to get things right.’ How could this be, I wondered? He explained, ‘I get things as right as I can, but I know that I often have only part of the story. Sometimes people won’t tell me things. They deliberately keep them hidden. And I’m always against the clock. I don’t have time to check every fact, speak to everybody involved. I have to get a story out.’ All this is true, particularly with electronic media. We would be unlikely to watch CNN if it were to say, ‘Something important has probably happened, but we won’t be telling you until we’ve checked every fact and spoken to all parties. We’ll hope to bring you a report tomorrow.’

The idea that we can arrive at ‘the truth’ is anyway an illusion. Ask five people to give you an account of what happened in front of all their eyes 20 minutes ago, and you will have five accounts which will probably conflict. Historians know that truth is unachievable. EH Carr, a great historian, famously argued that history tells you more about the time when it was written than the time that is written about (98). Most modern historians would agree.

Scientists too would agree. Science deals in provisional truths. The theory of science proposed by Karl Popper is that you propose a falsifiable hypothesis to explain the facts you observe (99). (The falsifiable part is important: it is unscientific to create hypotheses that cannot be falsified, which is why some fundamentals like ‘love’ and ‘freedom’ are not easily investigated by science.) You then try as hard as you can to devise experiments that will show your hypothesis to be false. Until an experiment disproves your hypothesis it stays intact — but as a hypothesis not truth. The expectation of science is that eventually the hypothesis will be found to be false and a more elegant one proposed. An alternative theory of science proposed by Thomas Kuhn is that scientists fit together pieces of data to create a paradigm for explaining the world (100). New data emerge, and the model of the world is adapted. Eventually the paradigm is so shaky, so patched that it collapses, and a new paradigm emerges. Newtonian physics replaced Aristotelian physics but was in its turn replaced by Einstein’s theories.

Science sets great store by evidence, and so should medical journals. Medicine has often not been scientific. Medical grandees have pronounced on methods of diagnosis and the best treatments, and medical journals and ordinary doctors have followed. Increasingly at the BMJ we have been concerned with raising the standard of the science we published and avoiding conclusions that are based on poor evidence.

Interestingly the values of scientists, journalists and historians combine to be highly sceptical about claims to be publishing the truth. We at the BMJ did not believe that we were publishing truth. But this did not mean that we were consciously publishing untruths. We inclined towards the dictum of CP Scott, the great editor of the Manchester Guardian, that ‘comment is free, but facts are sacred’ (101). We hoped that the ‘facts’ that we publish were true. If somebody told us that there were 234 patients in a trial, then we trusted (note the word) the authors that there were. If we were writing pieces ourselves we checked every fact we could. We expected journalists who worked for us to do the same. But — perhaps unlike Scott — I do not believe the world divides neatly into ‘facts’ and ‘comment’. If I say that there are six people in a room that is a verifiable fact. If I say two of them are bad people that is comment. But what if I say two of them were dark skinned? Is this a fact or a comment? I think that it’s somewhere between the two. Analyse this chapter and you will find that you cannot put every assertion into two neat boxes, one labelled ‘facts’ and the other ‘comment’.

Journalists and scientists also share a ‘publish and be dammed’ view of the world. Both exist to publish. A scientist who never publishes is as dead as a journalist who never publishes. For both too it is often important to be the first to publish. Thus both journalistic and scientific ethics support the publication of the paper linking the MMR vaccine with autism (see chapter 2) (1). For the journalist it’s a strong story and it would be wrong to keep it from the public. For the scientist it’s data, albeit weak data, supporting a potentially important hypothesis.

Public health values, which are understandably utilitarian (the greatest good for the greatest number), would not perhaps support publication — and certainly many public health doctors have condemned the publication. The benefit for the many, their argument goes, is small. The paper contains very weak, possibly (even probably) misleading data supporting a connection between the vaccine and autism. Even if the connection is real it’s unlikely to be important in public health terms. But the risks are many. People may be put off having their children vaccinated, and then the infections may return. Herd immunity might be lost.

Great enthusiasts for public health might even be strongly against publishing something that was highly likely to be true and yet which might have negative effects on a population. Consider, for example, the evidence that smoking might be beneficial for some particular conditions — for example, inflammatory bowel disease. This does seem to be the case, although even for an individual with inflammatory bowel disease the overall effect of smoking would probably be harmful because the small benefit to the bowel disease would be outweighed by harmful effects on heart, lung, brain, blood vessels and the many other organs damaged by smoking. The population risk is that this small ‘positive’ message on smoking might be used by tobacco companies and the public relations firms they employ to confuse the otherwise clear message that smoking is harmful. If even a few people, particularly young people with their lives before them, were to take up smoking (or fail to give up) then the overall harm would be large. The utilitarian public health doctor would see little benefit in publication, particularly in a major journal, and would advise against.

The BMJ experienced a storm of protest after publishing a study that suggested that passive smoking may not kill (see chapter 2) (51). The authors had links with the tobacco industry, as the journal declared. Many people were furious, and the BMA. the journal’s owners, put out a press release dissociating itself from what it considered to be a flawed study. Some critics were upset that the BMJ should publish anything that undermined the case against tobacco, regardless of its ‘truth’. Others objected to us publishing anything linked with the tobacco industry — partly because it gave respectability to the industry and partly because nothing linked with the industry could be believed.

The study presented us with an interesting clash of values. We were for health and against both tobacco and the industry. I resigned as an unpaid professor of medical journalism at Nottingham University because it accepted £3.8m from British American Tobacco. How then could I publish a study from the industry? The answer was that we put the scientific importance of publishing completed research above our concern about health. Some American journals have policies of refusing to publish research linked with the tobacco industry, but we decided in 1996 that such a policy was unscientific (52).

This is back to journals doing harm. For me — and, I suspect, many editors — the idea of suppressing information and debate for some supposed greater good was unacceptable. The channels of information must flow freely and the debate must rage.

And might we in that debate publish information that we thought — or even knew — to be wrong? The answer from me was yes, but this was probably a step too far for many editors. As an editor I published information, particularly letters, with which I strongly disagreed and which in some sense I thought to be ‘wrong’. I put a higher value on free speech and debate than on the value of ‘truth’ — partly because, as I’ve explained above, I think truth to be very slippery. It was obviously true to many that the sun went round the earth, and Galileo Galilei was put before the inquisition for suggesting otherwise. John Milton, whom I’ve already quoted, said that, ‘If it come to prohibiting, there is not ought more likely to be prohibited than truth itself.’

This putting a very high value on debate and free speech came to the fore in intense discussions we had over ‘rapid responses’ (electronic letters) to the BMJ. We adopted a policy of posting within 24 hours all responses that were not obscene, libellous, incomprehensible, wholly insubstantial or included information on patients without accompanying consent. We posted around 20 a day and many were poorly written, inconsequential, ungrammatical, rude or plain bonkers. They also provided an excellent forum for mavericks and those with highly unpopular views. They were like a cross between the letters pages of The Times, conversations in a pub, questions after a lecture, and Speakers’ Corner, a place in London where anybody can climb onto a soap box and say whatever he or she wants. They were also very international. Rapidly increasing numbers of people in the developing world had access to the web, and we were also quite happy to post responses in Italian-English or even in Italian (although responses in foreign languages were rarely sent).

For me — an irrepressible lover of free speech — these responses were a marvel of nature. In their sum they provide as rich a debate on health and medicine as was to be had anywhere. But even those with the strongest stomachs got bothered by them at time, particularly when people were rude, promoted crazy — even dangerous — ideas, or sent us a dozen responses every week. Twice we debated at our editorial board whether we should raise the bar and be more selective. Both times the board voted against, the last time unanimously.

One editorial aphorism that I value perhaps more than any other is that of the great pathologist and thinker Rudolf Virchow, ‘Anybody,’ he said, ‘is free to make a fool of himself in my journal.’ But after I left the journal the editorial team decided that it would raise the bar for rapid responses (102). The weeds were choking the flowers.

So journals do have values, even if they rarely make them explicit. Different journals and different editors of the same journals will have different values, which must be a good thing and will add to the rich mix that will, I believe (and this is a value that a strictly religious person would not accept), lead to greater wisdom. But there are — and this may be overly bold — some values that should apply to all journals. Here’s my list.

  • Be interesting — don’t be boring
  • Set high store by debate
  • Raise the quality of medical science
  • Check facts
  • Promote team work
  • Improve
  • Innovate
  • Communicate clearly
  • Promote high standards of ethics
  • Be concerned with health and illness not just disease
  • Encourage a public and patient focus
  • Engage in research and audit
  • Be open
  • Celebrate creativity

Appendix 1: Hippocratic Oath — Classical Version

I swear by Apollo Physician and
Asclepius and Hygieia and Panaceia
and all the gods and goddesses,
making them my witnesses, that I will
fulfill according to my ability and
judgment this oath and this covenant:

To hold him who has taught me this art
as equal to my parents and to live my
life in partnership with him, and if he is
in need of money to give him a share
of mine, and to regard his offspring as
equal to my brothers in male lineage
and to teach them this art — if they
desire to learn it — without fee and covenant; to give a share of precepts and oral
instruction and all
the other learning to my sons and to the sons of him who has
instructed me and to pupils who have signed the covenant and
have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according
to my ability and judgment; I will keep them from
harm and

I will neither give a deadly drug to anybody who
asked for it, nor
will I make a suggestion to this effect. Similarly I
will not give to a
woman an abortive remedy. In purity and holiness I
will guard my
life and my art.

I will not use the knife, not even on sufferers from
stone, but will
withdraw in favor of such men as are engaged in
this work.

Whatever houses I may visit, I will come for the
benefit of the sick,
remaining free of all intentional injustice, of all
mischief and in
particular of sexual relations with both female and
male persons,
be they free or slaves.

What I may see or hear in the course of the
treatment or even
outside of the treatment in regard to the life of men,
which on no
account one must spread abroad, I will keep to
myself, holding
such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be
granted to me to
enjoy life and art, being honored with fame among
all men for all
time to come; if I transgress it and swear falsely,
may the opposite
of all this be my lot.

Translation from the Greek by Ludwig Edelstein: Edelstein L. The Hippocratic Oath: text, translation, and interpretation. Baltimore: Johns Hopkins Press, 1943.

Appendix 2: Hippocratic Oath — Modern Version

I swear to fulfill, to the
best of my ability and
judgment, this covenant:

I will respect the
hard-won scientific gains
of those physicians in
whose steps I walk, and
gladly share such
knowledge as is mine
with those who are to

I will apply, for the benefit of the sick, all measures which are
required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science,
and that warmth, sympathy, and understanding may outweigh the
surgeon’s knife or the chemist’s drug.

I will not be ashamed to say ‘I know not,’ nor will I fail to call in my
colleagues when the skills of another are needed for a patient’s

I will respect the privacy of my patients, for their problems are not
disclosed to me that the world may know. Most especially must I
tread with care in matters of life and death. If it is given me to save
a life, all thanks. But it may also be within my power to take a life;
this awesome responsibility must be faced with great humbleness
and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous
growth, but a sick human being, whose illness may affect the
person’s family and economic stability. My responsibility includes
these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable
to cure.

I will remember that I remain a member of society, with special
obligations to all my fellow human beings, those sound of mind
and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while
I live and remembered with affection thereafter. May I always act
so as to preserve the finest traditions of my calling and may I long
experience the joy of healing those who seek my help.

Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

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