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Ghost Counter Ghost

A reader writes, in response to Jonathan Leo’s essay about ghostwriting (go here for a link to the original essay):

Oh dear. That article is not very well researched, is it? They mention the European Medical Writers Association (EMWA) as sanctioning the practice of thanking writers for “editorial assistance”. I take it they haven’t actually read EMWA’s guidelines on the subject, since they have totally misrepresented EMWA’s position, and also fail to cite EMWA’s guidelines in their references list.

Here’s what the EMWA guidelines actually say about “editorial assistance”:

“Vague acknowledgements of the medical writer’s role, such as ‘providing editorial assistance’ should be avoided as they are open to a wide variety of interpretations.”

Anyone who wants to read EMWA’s guidelines can find them here:

Leo et al also use a rather idiosyncratic definition of ghostwriting. Most people would consider a ghostwriter to be someone who is not acknowledged, not someone whose role is transparently declared. Whether medical writers should be listed as authors is a legitimate matter for debate, but the debate is not helped by writing such an emotive and badly researched article.

(Conflict of interest declaration: I was one of the authors of EMWA’s guidelines)


Jonathan Leo responds:

Scientific Papers with Unnamed Authors = Ghostwriting

We are happy that Adam has responded to our article as it gives us a chance to clarify a couple of issues, and to highlight one of the major points in our essay. Namely, that some groups in academic medicine are trying to find ways to allow the presence of unnamed authors to be involved with scientific papers – a practice which most people would call “ghostwriting.”

In his posting Adam says that we misrepresented the EMWA stance on the appropriateness of thanking editorial assistants and he cites the EMWA guidelines. However, when we mentioned the idea that the EMWA condones the practice of mentioning editorial assistants as a way around ghostwriting we did not have the 2005 EMWA guidelines in mind, but instead had Adam’s 2007 editorial in mind where he does sanction this practice. We should have been clearer in our essay about this. We did assume that when he wrote his editorial that he was speaking in behalf of the EMWA. If he was not, then we apologize.

Adam’s 2007 Editorial

The story behind his editorial starts back in 2006 when Charles Nemeroff and his colleagues published a paper in the journal Neuropsychopharmacology. Their review article concluded that a useful treatment for depression was a vagus nerve stimulator manufactured by Cybertronics. The journal Science discussed charges that the article in question was ghostwritten because one of the main authors of the paper, Sally Laden, was not mentioned in the byline. Laden was also paid by Cybertronics. Adam’s subsequent editorial was very critical of the Science article and took the same dismissive tone with Science that he has taken with our paper. He has also taken this dismissive tone in the comments section of the BMJ and PLoS Medicine. In his editorial he never argued about the facts behind the Vagus nerve paper, Laden’s role, or who her employer was. The major point of his editorial was that the paper should not be labeled as ghostwritten because Sally Laden was mentioned in the acknowledgement section, and this is why we mentioned the EMWA. In his defense of Laden’s role he says:

“In fact, Ms Laden’s role, and the fact that the authors maintained final control over the content, were reported in the Acknowledgements section in these words [3]: ‘We thank Sally Laden for editorial support in developing early drafts of this manuscript. We maintained complete control over the direction and content of the paper. Preparation of this report was supported by an unrestricted grant from Cyberonics, Inc.’”

And just last year in a discussion about the most famous ghostwritten paper of all time, Study 329, Adam again used the “editorial assistance excuse.” In his words, “It’s also not accurate to describe this as a ghostwritten article, as I see that Sally Laden was acknowledged in the published version.” Yet, in this article, Laden was simply acknowledged for her editorial assistance. Our take is that Sally Laden should have been listed in the author byline of both the Nemeroff paper and Study 329. This is not really a very profound, or earth-shattering idea, nor do we think it solves the major problems in medicine with undeclared conflicts of interest. It just seems to be simple common sense.

EMWA Guidelines

We are glad that Adam has brought up the guidelines and we are happy to address those here. At one point in the EMWA guidelines they say, “The involvement of medical writers and their source of funding should be acknowledged. Identifying the writer, either as an author or contributor or in the acknowledgements section.” To us this seems to suggest that EMWA believes that mentioning editorial assistance in the acknowledgment section is considered acceptable. Later in the document, they do say, “Vague acknowledgements of the medical writer’s role, such as ‘providing editorial assistance’ should be avoided as they are open to a wide variety of interpretations” but it is important to point out that the EWMA is still trying to find a way to have unnamed authors on papers. Instead of using the term “editorial assistance” they are simply proposing another term. In their words: “We suggest wording such as ‘We thank Dr Jane Doe who provided medical writing services on behalf of XYZ Pharmaceuticals Ltd’.” However simply changing the term of “editorial assistance” to “medical writer” is just another way to keep deserving authors off the byline.

The acknowledgement section is traditionally seen as a spot to mention people who don’t rise to the level of “author” – for instance, colleagues who looked at the paper and made comments, a grammar guru who tweaked the composition, or Mom and Dad who provided the necessary motivation. The EWMA seems to be doing their best to figure out a way to include deserving authors in the acknowledgement section – something we have previously referred to as “an academic sleight of hand.” It is not that we are against the term “editorial assistance,” it is that we are against leaving a deserving author out of the byline. Keeping them in the acknowledgement section but calling them something else is just a way to sanction ghostwriting. What we should have said in our paper is that simply mentioning authors in the acknowledgement section as editorial assistants or medical writers or any other term is not a solution.

Legitimizing Ghosts

At the end of Adam’s posting he says that whether medical writers should be listed as authors is a legitimate debate, but why should this be considered a legitimate debate? If academic medicine allows papers to have unnamed authors, as Adam is saying, then they are sanction ghostwriting. Shouldn’t the ICJME just require that writers of papers be listed as authors? We did point out that we think ICJME has a loophole that can allow ghostwriting, but we don’t think their intention is to condone the use of unnamed authors, and we don’t think they are debating whether this should be allowed.

The Twilight Zone

This is a very weird discussion. It seems to us that we are the ones calling for increased recognition for a group of very bright and skillful people. Rather than be hidden in the shadows we think that their skills and intelligence should be given the credit they deserve by rising to the level of authors. Medical writers do provide a very valuable service and there is no reason they should not be used but why not list them as authors? Sally Laden is surely one of the brightest and most prolific people in the scientific literature yet a pub med search would not reveal this. Yet, for our efforts, this group’s spokesperson attacks us on the basis that his group is not deserving of this credit. Welcome to the world of academic medicine. Adam has taken on the task of attacking anyone in the medical literature who suggests that writers should be called authors. But he seems to be leading his organization down a path that we are not sure his constituency wants to follow. If he is not careful his organization is going to become the EMGWA -The European Medical Ghost Writers Association.

Margaret Soltan, August 1, 2011 7:14AM
Posted in: ghost writing

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11 Responses to “Ghost Counter Ghost”

  1. Adam Jacobs Says:

    I’m grateful to Jonathan Leo for taking the time to respond with such a detailed post.

    It seems to me that there are two separate, but related issues here:

    1. What is a ghostwriter?

    2. Should medical writers be listed as byline authors?

    On the first point, it seems that we disagree on the definition of ghostwriting. My definition is that a ghostwriter’s role is invisible. Therefore someone is a ghostwriter if they are neither a byline author nor mentioned in the acknowledgements.

    That’s not just my definition, however, it’s also the definition used by the World Association of Medical Editors. Their positionstatement states that “Ghost authorship exists when someone has made substantial contributions to writing a manuscript and this role is not mentioned in the manuscript itself.” Clearly, if someone’s role is mentioned in an acknowledgements section, then it is mentioned in the manuscript, and is therefore not ghostwriting.

    No doubt much confusion has arisen as a result of our using different definitions of the term. To be clear: I unhesitatingly condemn ghostwriting, when defined as an undisclosed contribution to a manuscript. I do not have a problem with transparently disclosed contributions, even though Dr Leo would also describe some of those as ghostwriting.

    The second point, which I agree is a matter for legitimate debate, is whether a medical writer should be listed as a byline author. I don’t have any objection to that happening, but it is important to realise that this goes against the definition of authorship as practised by the majority of medical journals. The ICMJE specify 3 criteria for authorship, all of which must be met if someone is to qualify as an author. Medical writers seldom meet all 3 criteria.

    The EMWA guidelines were written taking into account the framework for authorship as laid down by the community of medical journal editors. It was our intention to propose a way of working that increased transparency and was compatible with existing journal policies.

    Note that plenty of high profile journals agree with this position. For example, The Lancet specifically mentions the acknowledgements section as an appropriate place to describe the role of medical writers. The BMJ and PLoS Medicine both specifically recommend following the EMWA guidelines when medical writers are involved.

    As I’ve said before, I have no objection to medical writers being listed as authors provided that complies with a journal’s requirements, but that’s not something over which I have control. It is for journal editors to determine their own policies about who should be an author. If journal editors wish to list medical writers as authors, I doubt they would receive any resistance from the medical writing community, but that is their call to make.

  2. A Medical Writer Says:

    Adam. Ghosts are not necessarily invisible, perhaps just hard to see. It is understandable for medical writers, like yourself, to not want to be considered a Ghost, as you see it as an emotive term with negative connotations. However, I’m sure that most of the general public would agree with the assertion that medical writers are ghostwriters… I’m not suggesting the practice (medical writing) is wrong or unethical, just that you shouldn’t get too hung up on semantics.

  3. Adam Jacobs Says:

    I actually think semantics are quite important here. We all agree that ghostwriting is wrong, but seems that we don’t agree what it is.

    I (and I believe most informed commentators, although I don’t have any evidence about what the general public think) would define a ghostwriter as someone who is invisible. We can all agree that someone who writes a paper and whose name doesn’t appear on it at all is bad, yes?

    But Leo goes further, and says that it’s bad even if a medical writer is transparently acknowledged, just as long as the medical writer isn’t listed as an author. I think Leo is in a minority there: most major medical journals (Neurology being a notable exception, but as far as I know the only one) believe it’s perfectly acceptable (and indeed required) for a medical writer not to be listed as an author.

    That seems to be the nub of the argument, which does in fact turn on semantics.

  4. Jonathan Leo Says:

    I completely agree that right now, the idea that we propose in our paper, “that an author be called an author” is the minority view in medicine – and that this is the crux of the problem. I hope that medicine comes around and follows the rest of the academic world.

  5. Adam Jacobs Says:

    I’m not sure the crux of the problem is quite as you describe. Everyone agrees that an author should be called an author: where you differ from most of the world of medical publishing is in either what constitutes authorship, or what the byline of a paper should signify.

    To most, authorship equates with controlling the work and taking responsibility for it. Someone who merely provides a technical service is not necessarily an author. Writing the draft of a paper, based on someone else’s data, and under the direction of someone else, does not constitute authorship in my opinion, nor in the opinion of a great many other people. Do we disagree on that point?

    I think the real question is whether the byline of a paper should reflect true authorship (as it mostly does now) or any reasonably substantial contributions to the paper (even if falling short of true authorship). That, as I have said before, is an entirely legitimate matter for debate.

  6. Jonathan Leo Says:

    “Writing the draft of a paper, based on someone else’s data, and under the direction of someone else, does not constitute authorship in my opinion” I am glad you put this print. I hope other people see this. I urge everyone reading Adam’s post over the last several days to also read the two articles in PLOS yesterday, written by medical writers pointing out that all of Adam’s arguments are really nothing more than ways to get around not mentioning the real authors in the byline. Dont take it from me, take it from the medical writers.

  7. Adam Jacobs Says:

    Well, I’m pleased that you’re glad I put it in print, and I’m guessing from the tone of your reply (even though you don’t say so explicitly) that you disagree with that statement. Yes?

    Would you like to explain why?

    No-one is trying to “get around” anything. The reason why we don’t mention medical writers in bylines is because ICMJE criteria don’t allow us to. I realise you disagree with the guidelines, but given that they are the guidelines in place at the moment, do you think medical writers should deliberately ignore them?

  8. Karen Shashok Says:

    Many critics of medical writers seem to feel that all medical writers are, without exception, dishonest ghostwriters with no ethics. Critics may not be aware of the many intensive efforts by med writers themselves to improve transparency regarding the published record of their role in publications.

    Medical writers have been pioneers in getting the industry to sign on to publishing more transparent info about med writers. But as those who have worked toward greater transparency could tell you, it’s very slow going to bring about changes in attitude and behavior, especially when the firm’s lawyers are consulted–as they inevitably are.

    Everyone wants to do what’s right and members of EMWA and AMWA (the professional, high-end practitioners) know they need to make efforts individually to convince their clients to change their policies. Med writers want change and due credit, and want to comply with ICMJE guidelines on authorship and contributorship. They are not collectively trying “get around” the guidelines by using “semantics”.

    Of the many med writing, contract research organization and medical communications outfits that have not joined any professional organizations for med writers, little is known about their views, but there is justifiable concern that some of these competitors may attract clients by using a “no issues with ethics or authorship” policy rather than encouraging the client to agree to abide by newer professional practice guidelines.

    The result is a Catch 22 for med writers who want their role to be reported appropriately and publicly. If the med writer accepts whatever the client’s policy is even if it is inconsistent with current professional guidelines in favor of transparency, the med writer is viewed as an evil ghostwriter. If the med writer tries to convince a reluctant client to accept the more ethical position consistent with EMWA and AMWA guidelines as well as ICMJE and WAME guidelines, the writer runs the risk of losing the client to a more “flexible” competitor.

    Winning over clients to the improved professional guidelines for reporting the role of med writers is a case-by-case battle each med writer wages with each client on each project, unless of course the industry client has already signed on to the new, more transparent guidelines. This situation puts individual med writers in a very difficult position. Professional organizations for med writers deserve due credit for trying to bring about change–even though these efforts may sometimes put their income at risk.

    It takes very high standards of ethics and great personal commitment to these standards to attempt to change a client’s mind about appropriate reporting of the med writer’s role. It’s time lay experts in medical research publishing (i.e., politicians, policy-makers, philosophers, bioethicists, and others who have never worked as med writers) stopped using “ghostwriter” as a pejorative synomym for “medical writer”. Not all medical writers are ghosts, and not all ghosts are willingly invisible or happy with their invisibility.

  9. Jonathan Leo Says:

    Hi Adam, Yes. I disagree. A major point of our paper was that the ICMJE guidelines are flawed as they provide a loophole for companies to get around mentioning the true authors. And we think the guidelines need to be changed. Apparently we are not alone. In the recent PLOS article by a ghostwriter, he stated, ” In sum, the current ICMJE guidelines provide pharmaceutical and medical communications companies with the opportunity to sequester their contributions in the small print of publications, despite bearing responsibility for conception, design, and analysis of many studies, retaining control of databases, and frequently writing manuscripts, scheduling publications, and selecting journals.”

    I do not believe that the problem lies with the ghostwriters. I do not think they are the unethical ones. I think most people would agree that the major problem lies with the named authors who are not mentioning that they had a lot of help with the paper.

  10. Adam Jacobs Says:

    I think most people would agree that the major problem lies with the named authors who are not mentioning that they had a lot of help with the paper.

    Well, if named authors don’t mention that they had a lot of help with the paper, then I agree with you entirely. There is no excuse for putting your name to a paper and dishonestly pretending to have written it all yourself. Although I would go further and blame the ghostwriters as well in that case.

    However, in many of the papers you object to, the authors did mention that they had help with the paper, via the acknowledgements section. I appreciate you would prefer that medical writers be listed as authors (although you have still not really explained why), but if an acknowledgements section credits a medical writer for drafting the paper, then it’s really not true to claim that the authors don’t mention that they had help.

  11. S&P, Ghostwriters and the Ethics Police « pipet2pen Says:

    […] addition of medical writers in the author byline (see Leo Jonathan’s commentary and ensuing discussion at the University Diaries blog.  Unfortunately, there is little incentive to disclose the use of […]

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