Science, sex and semantics: the firing of George Lundberg

John Hoey, MD; Caralee E. Caplan, MD; Tom Elmslie, MD, MSc; Kenneth M. Flegel, MD, MSc; K.S. Joseph, MD, PhD; Anita Palepu, MD, MPH; Anne Marie Todkill, MA

CMAJ 1999;160:507-8

© 1999 Canadian Medical Association

• Letter: They should be ashamed

Lundberg's faux pas was to publish in JAMA's Jan. 20 issue a brief report by Drs. Stephanie Sanders and June Reinisch of the Kinsey Institute on their 1991 questionnaire survey of almost 600 college students.² The objective of the study was to determine what behaviours were thought by respondents to constitute "having sex." The provoking question was "Would you say you 'had sex' with someone if the most intimate behavior you engaged in was ..." followed by a list of possibilities. The finding that roughly 60% of the respondents did not consider that engaging in oral sex amounted to "having sex" was evidently even more provoking, and Lundberg was fired.

The executive vice-president did not dispute the study's methods or findings, but objected to the timing of its publication. President Clinton has maintained that his sexual activities with Monica Lewinsky did not constitute "having sex." It is partly on this point of semantics that he is accused of lying, at least by the Republicans in the House of Representatives. The authors of the study have been forthright in their view that their study is relevant to the "current public debate," which, they argue, reflects "a lack of empirical data on how Americans as a population define these terms."² Their research question has some clinical relevance: sexual history-taking and counselling on safe sex are impeded when there is confusion about terms. Evidently the AMA considers that even if the authors are right to conclude that "Americans hold widely divergent opinions about what behaviors do and do not constitute having 'had sex' "¹ it is unacceptable for a prestigious medical journal to point out this fact at this awkward juncture in American politics. By this logic, not only are medical journal editors responsible for determining the content of their publications, but they must strive to control the ways in which new research findings might be received by the greater world. If this does not constrain editorial independence and the free exchange of ideas, what does?

Sanders and Reinisch's manuscript arrived at JAMA unsolicited. Their results had been presented at scientific meetings shortly after the survey was completed in 1991 but remained unpublished until Reinisch's colleagues urged her to publish the 8-year-old data. The manuscript went through peer review successfully and was accepted for publication. At this point Lundberg and his senior editors must have paused and legitimately considered a difficult decision. Here was a question of behaviour and language that had caught the interest of researchers before it arose, most unfortunately, in a very public sphere. To fast-track the paper might be interpreted as politically motivated. But to delay publication until after the Senate proceedings would be no less political, and perhaps even more damningly so, as it would lead JAMA dangerously close to censorship. To his cost, Lundberg chose the first solution.

Anderson justifies Lundberg's firing on the grounds that he allowed the journal to stray from "science and medicine" into politics. Newspapers across the US have been quick to point out that the AMA is a political organization. Since 1989 the AMA Political Action Committee has given more than US$14 million to US Senate and House candidates; these donations have favoured Republicans over Democrats by a ratio of 2 to 1.³ It is perhaps idle, but irresistible, to speculate that had the college students taken a view of oral sex that was more convenient to the Republican cause, the AMA might not have objected.

Is it the case that JAMA strayed from its proper, scientific domain into political debate? General medical journals are not just a repository of science, nor must they limit their radius to "medicine." Surely the AMA realizes with the rest of us that the results of scientific research often exert an influence in the social and political realm; indeed, policy-makers, among others, crave the contributions of "science." Moreover, it is naïve to think that scientific inquiry is conducted on a rarefied plane free of values and political perspectives in the first place. True, there are generally accepted parameters for the content of a medical journal. These are based on conceptions of what constitutes good science, what is relevant to health, health care and health care policy and, not least, what will be of interest to readers and meet their expectations. But it is for the editors, authors and readers — not the owners — of a journal to define those parameters. This is what "editorial freedom" means. The International Committee of Medical Journal Editors, of which JAMA is a founding member, makes this unequivocal: "Editors must have full authority for determining the editorial content of the journal."⁴ The committee does not presume to define in concrete terms what the scope of legitimate content is. To do so would be to put shackles on free inquiry. Medical journals are not the repositories of absolute truth, but when they foster curiosity and debate, they have some hope of approaching it.

We can recast this controversy as a wider question: Who "owns" a general medical journal? In what sense does the AMA own JAMA? The AMA appoints the journal's editor-in-chief, and the financial risk and potential profit from JAMA are the AMA's. But the ownership of a medical journal is much broader. Any medical journal belongs, intellectually and morally, to its contributors, editors, editorial boards and readers — a sort of constituent assembly. It also belongs to the world: the dissemination of medical science is, or should be, ultimately a humanitarian project, and not merely the special preserve of professional associations. Within the narrower context of medicine and the medical profession, JAMA's constituent assembly, whose history is the history of the journal and will continue after both Dr. Lundberg and Dr. Anderson have moved on, has come to expect and demand that medical journals have the independence to decide what to publish and what to reject, on the basis of scientific merit, interest to readers and relevance to society. The AMA does not own JAMA. It is the custodian of JAMA.

The constituent assembly has already been harshly critical of the AMA. Richard Horton writes in the Lancet of the "Sacking of JAMA" and calls for Anderson's dismissal.⁵ Members of JAMA's editorial board have condemned the firing,⁶ and Marcia Angell of the New England Journal of Medicine, although critical of the merits of the article and the decision to publish it, writes: "The decision to fire Lundberg over the sex survey was harmful to both JAMA and the AMA."⁷ Richard Smith points out in the BMJ that medical associations that "own" medical journals, (such as the British Medical Association, the AMA, the Massachusetts Medical Society and the CMA) must be extremely careful in exercising their custodial prerogative.⁸ It is interesting that the editor of the BMJ stands at a greater distance from his journal's corresponding association than his counterparts at other journals, including CMAJ, do from theirs.⁹

Editors can of course be fired, like anyone else. But firing a respected editor in the absence of any frank misconduct on his part, without debate or witnesses, does not meet anyone's criteria for fairness. This is not to say that readers will not be critical of the article Lundberg decided to publish. Some will say that it stretches the domain of medical journals too far. Others will argue that data collected 8 years ago are no longer relevant. But by squelching debate and snatching JAMA from the hands of its true owners, the AMA has done itself and medical publishing a great disservice.

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1. American Medical Association. AMA announces change of leadership at JAMA [press release]. Chicago: 1999 Jan 15. Available: www.ama-assn.org/advocacy/statemnt/99jan15.htm
2. Sanders SA, Reinisch JM. Would you say you "had sex" if ... ? JAMA 1999;281:275-7.
3. Jones T. Journal editors question their independence after medical group's firing. Chicago Tribune 1999 Jan 17.
4. Uniform requirements for manuscripts submitted to biomedical journals. Additional statements from the International Committee of Medical Journal Editors. CMAJ 1997;156:571-4.
5. Horton R. The sacking of JAMA. Lancet 1999;353(9149).
6. Chalmers I. JAMA now under dark cloud of heavy handed censorship [letter]. BMJ Web site www.bmj.com. Accessed: 1999 Jan 25.
7. Angell M. AMA wrong to oust editor. Boston Globe 1999 Jan 21;SectA:15.
8. Smith R. The firing of Brother George. BMJ 1999;318:210.
9. Smith R. Could it happen here? BMJ Web site www.bmj.com. Accessed: 1999 Jan 25.