Ghostwriting – from “The Inside”: Outrage Hinges on Unclear Definitions

Ghostwriting from “The Inside” : Outrage Hinges on Unclear Definitions

By Kate Johnson

The Journal of the American Medical Association’s latest revelation of ghostwriting within its own pages and those of other top medical journals should come as no surprise to most medical academics. 

Why then the outrage from the general public?

My view “from the inside” reveals some glaring discrepancies in our understanding of the definition of authorship.
In a recent paper published in the scientific journal Maturitas (Maturitas 62 (2009) 109–112), medical writer Elizabeth Wager points out that while most pieces of literature and journalism are the work of one person, clinical research is nearly always a collaborative effort. It is standard to see three, four, or more names attached to a scientific study.

“Not everybody who contributes to the project will necessarily wield a pen,” she points out. “So a distinction starts to emerge between roles, and authorship starts to become dissociated with writing.”

Obviously, if four names appear on a paper, it is unlikely that all four people sat down and typed individual sections. As a medical editor I strongly discourage this degree of “co-operation” because of the disjointed and chaotic results. But it is when an additional, unnamed person is responsible for the writing, that the notion of ghostwriting takes shape.

The ghostwriting scandal revealed in August by the New York Times hinges on this type of ghostwriting, but here a further distinction should be made regarding the definition of ghostwriting.

Although the JAMA study does not make this distinction, the Times focuses on ghostwriters who were hired by drug companies to spin the science in favor of their products. This is clearly a corruption of science and an indisputable attempt to mislead doctors and the public.

Few medical academics could see anything except extreme dishonesty in this practice.

But the distinction that is less clear deals with ghostwriters who are independent of all industry, simply medical wordsmiths whose services are sometimes hired to help improve a paper’s grammar, flow, and overall clarity.

Frederic Curtiss, editor-in-chief of the Journal of Managed Care Pharmacy, recently told Brendan Borrell of Reuters Health he’s found a way to suss out undisclosed writers by analyzing the metadata on Word documents that he receives. 

“During the editing process, changes made by additional authors are also sometimes labeled with authors’ names. Curtiss estimates that every third manuscript he receives has metadata that doesn’t match listed authors,” writes Reuters’ Brendan Borrell. The journal’s authorship policy requires disclosure of anyone who contributes more than 1% of a manuscript, while anyone who contributes more than 25% of a manuscript must be a listed author, writes Borrell. In June, Curtiss’ journal published its first article featuring both a scientist and a medical writer as co-authors. (J Manag Care Pharm. 2009 Jun;15(5):383-95).

In a recent blog and op-ed newspaper article I wrote about my freelance role as an independent  medical writer and editor. The response I received from scientific researchers was almost unanimously supportive (except for one), while the general public tended to react negatively to what some people labeled as plagiarism.

It has occasionally occurred to me that my contributions are extensive enough to justify a spot in the authorship line-up. But, although I recognize my role as important, and often essential to the successful publication of an article, I wouldn’t feel right taking credit for the science. After all, in the world of science, isn’t it the ideas and outcomes that count?

So, what is medical authorship?

According to the World Association of  Medical Editors, “everyone who has made substantial intellectual contributions to the study on which the article is based (for example, to the research question, design, analysis, interpretation, and written description) should be an author. It is dishonest to omit mention of someone who has participated in writing the manuscript (“ghost authorship”).”

Based on this description, it’s pretty clear that some, but not all editing should confer authorship.

But the WAME statement continues: “Only an individual who has made substantial intellectual contributions should be an author.” Performing “technical services”, among a list of other things, is not sufficient for authorship, “although these contributions may be acknowledged in the manuscript, as described below.”

So it comes down to whether or not a writers makes substantial intellectual contributions to the text.

The International Committee of Medical Journal Editors (ICMJE) says authorship should meet three conditions: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published.

In other words, intellectual contribution alone is not enough.

Suffice it to say, there is no widely accepted definition of what precisely constitutes medical authorship, so it is not surprising that the idea of ghostwriting, even when it is clearly independent of all industry connections, is accepted by some, while vehemently rejected by others.

In a study published in 2007, Elizabeth Wager revealed that 41% of 234 biomedical journals she surveyed gave no guidance regarding the definition of authorship. Another 29% based their instructions on the ICJME criteria, while 14% proposed other criteria and 14% stated only that all authors should approve the manuscript (Wager E. Do medical journals provide clear and consistent guidelines on authorship? Medscape Gen Med 2007;9:16.) Earlier this year, her survey results from 231 international journal editors revealed that most are not worried about the issue of publication ethics, and many are unfamiliar with authorship guidelines.

Speaking about the new revelations of ghostwriting in top medical journals, Ginny Barbour, chief editor of PLoS Medicine, the journal of the Public Library of Science, reacted to the news of her own journal’s 7.6% ghostwritten content with shock. “We are a journal that has very tough policies, very explicit policies on ghostwriting and contributorship, and I feel that we’ve basically been lied to by authors,” she told the New York Times.

Ironically, earlier this year PLoS Medicine and the New York Times championed the campaign to uncover court documents that revealed the extent of the latest ghostwriting scandal.

In an editorial after the story broke, entitled Ghostwriting: The Dirty Little Secret of Medical Publishing That Just Got Bigger, the PLoS editors wrote “attempting to hide the presence of ghostwriters or the involvement of writers beyond technical support, such as copyediting, is unacceptable”. But even in condemning ghostwriting they revealed the complexities of its definition.

Clearly, deliberately omitting legitimate names from the authorship line-up is unethical,  and medical writers are justified in demanding that they be appropriately acknowledged. But demanding inappropriate acknowledgement is also considered unethical. Without a clear definition of authorship, the extent of a writer’s contribution is subjective, and the issue becomes very delicate indeed.

A survey published earlier this year of approximately 800 medical writers and members of the European and American Medical Writers Associations, found that ghostwriting remains “unacceptably high”, although the percentage of respondents who reported being undisclosed as an author dropped from 62% to 42% between 2005 and 2008. 

But the same survey also found that writers’ requests for authorship are not always granted. In 2008, the percentage of respondents who said their requests for authorship were always or usually granted was 48% and 40% respectively.

Perhaps the easiest way to avoid the involvement of legitimate medical writers in allegations of ghostwriting is to standardize a spot in the authorship line-up reserved for a “writing and editing” author. As Roger Collier recently pointed out in the Canadian Medical Association Journal, “Ghostwriting is common in published literature, from the autobiographies of politicians to the memoirs of celebrities. Of course, in those cases, the name of the ghostwriter typically appears on the cover. Some would like to see that practice adopted by medical publishers”.

4 thoughts on “Ghostwriting – from “The Inside”: Outrage Hinges on Unclear Definitions

  1. Couldn’t agree more with Roger Collier, at CMAJ. Adding the name of someone who provided editorial help is a no-brainer. The challenge is getting the institution (of medical publishing) to change its ways.

  2. A useful tour through what is indeed a complex subject. The distinction between writing and authorship is indeed a fine one, and this article explains the issues nicely.

    However, it does seem grossly unfair on medical writers hired by the pharma industry.

    You write “the Times focuses on ghostwriters who were hired by drug companies to spin the science in favor of their products. This is clearly a corruption of science and an indisputable attempt to mislead doctors and the public.”

    Well, yes. If ghostwriters are hired by drug companies to spin the science, pretty well everyone would agree that’s unethical. But you only seem to acknowledge the existence of 2 categories of medical writers in your article: the above kind, and ethical medical writers who are independent of industry.

    There is a third kind, which I suspect outnumbers the other 2 put together: ethical medical writers who work for the pharma industry.

    My own research ( has shown that medical writers who work for pharmaceutical companies are less likely to have their contributions unacknowledged (ie be ghostwriters) than those working elsewhere. My own experience, as a medical writer working for drug companies, suggests that most of the medical writing funded by the pharmaceutical industry is perfectly ethical, with no attempts made to “spin” the science. Just because there have been a few well-publicised instances of pharma companies behaving extremely badly, let’s not tar everyone with the same brush,

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