directly as he proposes…

Posted on Sunday 4 September 2016

"The old saying that ‘lightning never strikes the same place twice’ is another myth that any veteran storm observer or researcher has seen nature defy. Lightning can strike any location more than once. In fact, given enough time, it is actually inevitable."

Once, when asked why I retired to a rural area in the mountains, I joked, "So I don’t have to buy flood insurance." But I guess I didn’t take being closer to the sky where lightning comes from into account. When we were hit a few years ago, I had to replace all things electronic and many things electric. So I subscribed to a surge protection option with our power provider. At other times, when friends from Atlanta asked how I liked living in a rural area in the mountains, I had joked, "Fast internet and cable television enhance my wilderness experience." Well, that one was righter than I knew. After the first time lightning struck, I didn’t take the time to learn how to also protect the cable that delivers our telephone/television/internet connections. I thought about it, but I got busy and it just evaporated. Perhaps I was lulled into a false sense of security by that old saying. So when we were hit again on the final day of the Olympics, my power protection worked just fine. The lights didn’t even blink. But the lightning traveled down the telephone/television/internet cable like Sherman’s march to the sea – cable television modem, wireless phone system, internet modem, router, both computers, and the ATT gizmo that boosts our cell phones from one bar to six – all were terminal casualties. During the time it has taken to rebuild our electronics, we’ve been reduced to sharing an old tiny notebook computer [which had I used as a travel machine before the days of smart phones and tablets] connected to the new internet modem directly [no router, wifi, or cell phone amplifier yet]. I thought I was up and running with the new equipment on Thursday, but alas, "complications". Now we’re aiming for the day after Labor Day. Needless to say, the new system has a gaggle of lightning arresters all along its path [a false sense of security now morphed into full bore PTSD, lightning-wise]…

But I can do putting-a-positive-spin-on-things too, just like pharma. Had it not been for the lightning strike, I probably wouldn’t have been just nosing around and run across the Alastair Matheson article [see rebranding…]. And I wouldn’t have found out that Alastair Matheson had another even more comprehensive recent article [how was that for a slick segue?]…
The Disposable Author: How Pharmaceutical Marketing Is Embraced within Medicine’s Scholarly Literature
by Alastair Matheson
Hastings Center Report. 2016 46[4]:31-37.

The best studies on the relationship between pharmaceutical corporations and medicine have recognized that it is an ambiguous one. Yet most scholarship has pursued a simpler, more saleable narrative in which pharma is a scheming villain and medicine its maidenly victim. In this article, I argue that such crude moral framing blunts understanding of the murky realities of medicine’s relationship with pharma and, in consequence, holds back reform. My goal is to put matters right in respect to one critical area of scholarly interest, the medical journal publication.

Pharma relies on peer advocacy to sell its wares to prescribing doctors. This is an arrangement in which clinicians’ qualified colleagues, including “key opinion leaders,” are recruited by pharmaceutical corporations and marketing agencies to deliver commercially expedient content to their professional fellows. Precisely how this practice works in the setting of publications is not well understood because ethicists studying the problem have made too much of the narrative of corporate villainy and medical victimhood. Accordingly, criticism of industry publications has been preoccupied with the crudely dishonest practices of ghostwriting, ghost authorship, and “ghost management,” vices condemned as “dirty little secrets” perpetrated from “behind the scenes” with the connivance of academic “shills” or “guest authors,” in contempt of standards set by the International Committee of Medical Journal Editors. This account is appealing, and yet it is wrong or, at the very least, seriously incomplete, with only limited relevance to the actualities of contemporary industry practices. In truth, many commercial publications are not developed in secret but fashioned within a culture of open collaboration, where academic authors make substantial, independent contributions; pharmaceutical companies are showcased rather than hidden; and medicine’s editorial standards assist rather than impede the workings of commerce.
Like the BMJ article [Ghostwriting: the importance of definition and its place in contemporary drug marketing], this one is also behind a pay wall. I’ll try to hit the major brush strokes with some quotes, but it’s worth reading it in full if you can come by it. First, it has some more about Matheson’s credentials:

    …Following a brief career as a biologist, I worked in pharmaceutical marketing between 1994 and 2010, first in a “medical communications” company and then as a freelance consultant working directly or indirectly for most of the major pharmaceutical corporations and over thirty marketing agencies in North America and Europe. I worked on over one hundred drugs, most of which were, in my estimation, mediocre products that could be better pitched if a more persuasive scientific angle could be found for them. I visited corporate headquarters and congresses; analyzed markets, products, and competitors; groomed key opinion leaders; ghostwrote manuscripts; developed publications plans; and devised marketing strategies.

He sounds well qualified to me. Matheson rejects the simple [but widely held] theory that the wicked pharma demon has corrupted an innocent medicine:

    Is medicine the manipulated victim of the pharmaceutical corporations, or their colleague in corruption? The answer, of course, is both…Yet most scholarship has pursued a simpler, more saleable narrative in which pharma is a scheming villain and medicine its maidenly victim… I argue that such crude moral framing blunts understanding of the murky realities of medicine’s relationship with pharma and, in consequence, holds back reform.

So in the article, he first reminds us of pharma’s many positive scientific contributions. But he’s no aplogist, and is quick to acknowledge the dark side:

    … On the other hand, pharmaceutical marketing is anathema to science, corrupting to medicine, wasteful to economies, and harmful to patients, and I must acknowledge the moral difficulty that for many years I sold my intellect in its service. Pharma itself, of course, has never truly acknowledged its underbelly of secrets, half-truths, corruption, power, and death, and it flaunts the language of ethics like a silk cummerbund over a paunch. If it is a lie to dissemble, distort, or omit, then pharma must be considered a liar whose subtle falsehoods stock the annals of medicine. It is to these annals — the peer-reviewed journals of the academic medical profession — that I now turn.

He paints a picture of a system in which pharma, academia [KOLs and institutions], and the journals [editors] are all stakeholders with both something to contribute and something to gain. Then he explains his title [The Disposable Author] with a point that had never directly occured to me, but one I’ll never forget:

    The art of publications development lies not in coating commercial content with an academic veneer, but in meshing commercial positioning and academic expertise as deeply as possible, creating content that is scientifically compelling but instilled with subtle commercial valence. Nonetheless, a diagnostic feature of this literature is that academic recruits and their institutions are readily replaceable by others without any decisive impact on the published product. Alternative academics and institutions might add varying intellectual content to the work, but its commercial functions will be served just as well. The leading problem with the use of academic authors in today’s industry publications is not passivity but disposability. Only the corporate project itself is fundamental, and particular academic contributions are exchangeable details.

That perspective and its ramifications are already well worth the price of admission. And one of those ramifications strikes me as also fundamental:

    The medical journal article should be a point of resistance and distinction between commerce and academia, but it operates instead as one of merger and ratification. The commercial-academic landscape is continuous.

And he includes the journal editors and their guidelines as participants in perpetuating this erasing of boundaries between academia and comerce:

    Finally, although it is beyond the scope of this essay to consider the matter in detail, medicine’s editorial guidelines lend support to this culture of misattribution. In previous work I and others showed how the ICMJE authorship formula supports commercial byline avoidance. All the forms of spin I have discussed in this section are overlooked, tolerated, or mandated by ICMJE requirements. By complying with ICMJE diktats, industry literature may lay claim to the highest ethical standards. Far from a dirty little secret, drug marketing is ostentatiously robed in the standards of medicine itself.

As to our reformist moral outrage at the use of ghostwritting and other secret maneuvers, Matheson proposes that we’ve gotten hung up on a particularly prominent tree, and missed looking at the whole forest:

    "Ghost” metaphors have shamed some egregious marketing practices and been the basis of some important scholarship. Unfortunately, the critical weakness of the word “ghost” is that it steers attention to industry’s role, and industry secrecy, and away from the multistakeholder responsibilities for mercantile literature and its misattribution. Ghostly practices are merely part of the overall activities and continuous with the subtler and less secretive ones I have described. By focusing on them, publication ethics has missed the bigger picture. Worse still, it has become bogged down in problems of definition and, in consequence, has been outflanked by commerce.

I worry about doing the same thing with this article that it’s meant to correct – reducing it to a series of bullet-points and not capturing its overall essence. Matheson is not a bullet-point writer, and it’s the gestalt of this piece that matters even more than the pearls along the way. The whole is greater than the sum of its parts. I would encourage the author or the publisher to liberate this piece from its pay wall, or publish it again in an on-line open venue. Right now, it’s available to academics with faculty access, subscribers, and people with pockets deep enough to buy it. But it’s clearly written for a much broader audience. And rather than paraphase the ending, I’ll just quote it here:

    Integration, Not Subterfuge, as the Danger
    The overenthusiastic promotion of ghost metaphors serves the popular narrative in which the primary threat posed by pharma to medicine is one of deception and external manipulation. This threat is indeed important, but it is not the foremost danger. The greatest threat is blending and assimilation, such that the distinction between the commercial and academic is by slow gradations ceasing to be apparent or even important within medical culture. This transformation in the quality of medical science and discourse is not being driven by deception or trickery so much as cultural and institutional proximity of commerce and academia, involving philanthropy, patronage, and most importantly, the increasingly routine nature of industry-academic research partnership. The medical journal article should be a point of resistance and distinction between commerce and academia, but it operates instead as one of merger and ratification, its meticulous guidelines working not to differentiate but to bring the worlds of medicine and commerce more minutely together. As the distinction between the commercial and academic diminishes, marketing has progressively less need for ghostly subterfuge in communicating its propositions; the commercial-academic landscape is continuous. Contemporary industry literature positions academics, corporations, journals, and readers side by side in the pursuit of truth: public, civilized, rational, and humane, it leads today’s assimilated medicine naturally to the point of sale.

    Let me then define contemporary advocacy-based marketing punctiliously, as a practice in which content with potential commercial or promotional utility is planned, convened, funded, influenced or owned by a company, but communicated by, or disproportionately attributed to, the peers or opinion leaders of the intended customers . Advocacy marketing thus defined is routine in medicine and its scholarly literature, and the chief policy conclusion of this essay is that it should be banned outright. This is a matter for academic medical institutions and societies as well as journals, and the first step to achieving it is to understand the nature of attribution. This concept has never been adequately understood by medicine’s editors and is not even discussed in the ICMJE guidelines. Medicine’s construction of authorship has long envisaged a “two-sided coin” of credit and responsibility, and in thus focusing on the author has not adequately ad – dressed the needs of the reader; but in any case, as I have shown here, attribution runs far wider than authorship and turns on what readers perceive as much as what is disclosed. If a project is instigated and funded by a company and its data are privately owned, then it is a commercial project, and by means both of authorship and other attributive devices, it should be presented clearly to readers as commercial, not the ambiguous, supposedly academic-led fare that is a staple of medicine’s intellectual diet.

    To ensure that readers perceive mercantile content for what it is, it would ideally be published separately from noncommercial research. Publishers could, for instance, restrict industry-funded content to new publications such as a “JAMA Commercial Medicine” or quarantine it in clearly labeled “Commercial Pages” within existing journals. Failing this, there should at least be conspicuous commercial attribution. Mercantile science should be welcomed with scholarly courtesy and respected on its merits but presented as commercial from the outset. Companies could, for instance, be identified in the titles of articles they finance [“A Pfizer Trial,” for example] or listed as corporate coauthors. Abstracts should clearly state commercial finance, instigation, planning and data ownership, and identify the product the article promotes. Ideally, such measures would be introduced in a cross-media standard. If every commercial article, web page, and lecture was introduced to its audience with stark labeling, this would encourage readers to think twice, expose the advocacy function of the academic authors, limit the unmarked seepage of marketing into medicine, and counter the creeping cultural merger of science and commerce. Differentiation can reverse integration…

In a way, I’m an outsider to this issue myself – having pursued my own career outside of the domain of what’s called the academic-industrial complex. So I still feel like a newcomer, having turned my sights to these issues after retiring. And I’ve gone through some phases since arriving on the scene as I’ve learned more about the lay of the land – moral outrage followed by latching onto various solutions. While I still contend that Data Transparency is a bottom line essential, and that oversight of published clinical trial reports by some independent agency is an absolute requirement, both of those things [like many previous reforms] aim to force industry, editors, and KOLs to adhere to strict academic and scientific standards. And as an old friend once said, "I don’t think I can get drunk enough to believe that." It just ain’t gonna happen. Those articles don’t belong in our academic journals/literature. They didn’t used to be there and they shouldn’t be there now – certainly not in their current form. I don’t know how to change that other than directly as he proposes ["should be banned outright"]. But not having a simple sure solution doesn’t detract from his eloquent analysis of the problem…
    September 5, 2016 | 6:30 AM
    James OBrien, M.D.
    September 6, 2016 | 7:24 PM

    It will never end because there are too many places for garbage to end up with the veneer of respectability.

    If there were only ten psychiatric academic journals there would be conscientiousness and standards. With God knows how many there is agreeableness and log rolling.

    If the Major League consisted of 300 instead of 30 teams, the Braves and Twins would actually appear quite excellent. But not really, they’re still terrible but the standards have dropped. The metaphor applies to academic dilution as well. Any piece of garbage can get published:

    No that’s not an Onion satire.

    Alastair Matheson
    September 6, 2016 | 8:50 PM

    Hi there and many thanks for posting these interesting thoughts on my recent work. Lots to think about!

    On the access point, I’ve created a WordPress site where anyone can get a toll-free link to my BMJ piece. I don’t have permission from the Hastings Center to post my article there, but I’ll happily send a pdf to anyone who requests one. There’s some other interesting material posted there too.

    The URL is

    All the best

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