unserious arguments seriously…

Posted on Wednesday 27 May 2015

This is my own sixth blog on the recent NEJM series in just over a week [a contrarian frame of mind… , wtf?…, wtf? for real…, a narrative…, and not so proud…]. The Drazen/Rosenbaum pieces may well be on the way to being the most-blogged journal articles since Paxil Study 329 – a rite of passage for new bloggers in the pharmascold set [while I don’t consider myself a pharmascold, Drazen/Rosenbaum might be turning the category into highest virtue]. I took the approach of looking into the history of the NEJM editor who would write/publish such a thing. Richard Lehman, a retired physician who writes a journal-watch for the BMJ, takes a more direct route:
[NEJM 21 May 2015 Vol 372]
British Medical Journal
26 May, 15

The NEJM has the highest reputation of any medical journal, so it’s impossible not to feel dismay when it lets its standards slip towards the near-nonsensical. When the first part of Lisa Rosenbaum’s three-part series on conflicts of interest appeared, I wondered if it might be some kind of elaborate joke: but sadly it seems not. I hate to see it when a clearly talented young writer is encouraged to write below standard, and at great length for no obvious reason. This final article, “Beyond Moral Outrage,” is an attempt to describe people who worry about conflicts of interest as beyond rationality. In a typical section she writes: “As Haidt concludes, moral reasoning is not ‘reasoning in search of truth,’ but rather ‘reasoning in support of our emotional reactions.’” Interesting that Haidt was actually citing an example not of moral reasoning but of emotional reasoning from the start [unless you count putting the American flag down the toilet as a moral issue], and in which no-one was harmed. Is Lisa actually suggesting that the pharmaceutical industry just flushes away used American flags and has never harmed anyone or concealed harm? But there I go — I am responding to wholly unserious arguments seriously, which I suppose must be the purpose of this exercise. I think the NEJM has shot itself in the foot. And also exposed some awful editorial decisions. Please, if you are going to publish someone attempting to persuade us against bias, don’t let through a sentence like “Being a pharmascold conferred the do-gooder sheen many of us coveted.” The only unbiased words in it are “being,” “a,” “the,” and “of”…
"But there I go — I am responding to wholly unserious arguments seriously" may well be the final message – this series may have a meaning, but it’s not in its frivolous content. And perhaps I should follow Lehman’s lead and look at the meta-side of what I’ve been writing. My posts are about the NEJM as I’ve known it over my life, and I can’t say enough positive things about the Editors that have come before – Arnold Relman, Marcia Angell, and Jerome Kassirer. Could I be indirectly lobbying for the NEJM to start searching for a new editor who honors the two centuries of integrity of my NEJM? When I put that question to myself directly, my mind responds, "Damned Straight!" I do notice that I’m using expletives along the way on this topic ["wtf?" x 2, and Damned Straight!"], something I do to add emphasis. So I not so secretly hope that the powers that be at the NEJM are thinking similar thoughts after reading the negative reactions to this editorial and series.The other very real possibility is that Drazen/Rosenbaum are speaking for those powers that be, and my NEJM is just the anachronistic fantasy of an old guy.

So long as I’m trying to be genuinely introspective, I fear that the second alternative is far more likely. In an article about the firing of Jerome Kassirer and the hiring  of Jeffrey Drazen [Editor Forced to Resign in Dispute Over Marketing of Medical Journal’s Name], it said of Marcia Angell,
"Dr. Marcia Angell succeeded Dr. Kassirer as editor in chief pending a search committee’s choice of a new editor. Dr. Angell, who was a finalist, withdrew recently as a candidate and said she was retiring to write a book on alternative medicine."
I don’t believe that in light of her later editorial comments [The Journal and Its Owner — Resolving the Crisis and Is Academic Medicine for Sale?], her pieces in the New York Review of Books [The Epidemic of Mental Illness: Why? and The Illusions of Psychiatry], and the book she did write [The Truth About the Drug Companies: How They Deceive Us and What to Do About It]. I think she wouldn’t  go in the direction she knew they were heading [or at least that’s what I wish]:
"It is no secret that the other Journal editors and I were dismayed by the society’s decision to let Kassirer go, and that we shared many of his concerns about the use of the Journal’ s name to promote other products. The society’s action precipitated a crisis unique in the Journal’s 187-year history. There was even talk of a mass resignation by the editors, an event from which the Journal might never have recovered. Faced with the possibility of irretrievably damaging the Journal, both the society and the editors drew back from the brink. After intense discussions between the society’s leadership and the editors, Evjy and I issued a joint statement on August 4…"
I find myself almost wishing they had "gone to the brink" and beyond all those fifteen years ago and called the question. It may  have gotten us on the road earlier. I don’t fault Relman, Kassirer, and Angell at all. They’re four-out-of-four-star heros of the realm in my book. But in hindsight, I’m afraid it’s hard for me to imagine that Dr. Drazen would’ve written "Revisiting the Commercial–Academic Interface" which challenges a firm NEJM policy without having the backing [or even urging] of the "owners" – the New England Medical Society. I wish I didn’t think that – but I do. Sigh…

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