Mixing Politics and Medicine: A Case Study

Like physicians and scientists around the globe, I have been deeply saddened over the past months by the death, destruction and psychological harm wrought on noncombatants across a large swath of the Middle East. However, I was equally distressed by the July 28, 2014 publication in the Lancet, one of the world's leading medical journals, of an anti‐Israel diatribe by Manduca et al. entitled “An open letter for the people of Gaza.”1 Initially, I took a reductionist view of the article: academic journals have no place mixing medicine and science with politics. Indeed, this view was supported by 77.5% of respondents to an August 2014 poll by MedPage Today.2 However, as I read the responses to the original letter, reviewed the guidelines for editors and perused the very limited literature related to the topic of medicine and politics, I realized that the issues were complex and that the publication provides an important case study that can inform future editorial decisions by both our own journal and by others. A case study about the publication of political treatises in a medical or scientific journal evolves around three questions: 1) Did the journal meet the established codes of conduct for journal editors? 2) Are case studies or published guidelines regarding editorial decisions related to the topic informative? And 3) Are there historical perspectives that can or should inform editorial decisions?

Did the Lancet, meet the established codes of conduct in publishing the letter?

Four organizations have developed ethical guidelines for both editors and authors: the World Association of Medical Editors (WAME) (www.WAME.org); the Committee on Publication Ethics (COPE, www.pubicationethics.org); the Council of Science Editors (CSE, www.councilscienceeditors.org); and the International Committee of Medical Journal Editors (ICMJE, www.ICMJE.org). Although the guidelines created by these international groups do not directly address the issue of political treatise in medical journals, they present key principles that are of potential relevance to the present discussion: 1) the importance of peer review; 2) the need to disclose all conflicts of interest; and 3) the editor's responsibility to insure the integrity of the published record.

While only some journals request peer review for opinion pieces, commentaries and editorials, COPE guidelines note that editors that achieve best practices: 1) undertake peer review of all reports and reviews; 2) clearly identify sections or articles that are not peer‐reviewed; 3) publish a description of the peer review process; and 4) develop a transparent “policy to encourage maximum disclosure of the provenance of non‐research articles.” (www.publicationethics.org) The Lancet notes that: “Every Article, Case Report, Hypothesis, Seminar, and Review published in The Lancet has been peer reviewed,” but that: “Occasional contributions (eg, Essays) are accepted without peer review.” We cannot determine whether the article by Manduca underwent peer review.

A second important consideration in publishing a political commentary is whether potential or real conflicts of interest are accurately recorded. The WAME defines a conflict of interest as a “divergence between an individual's private interests and his or her responsibilities to scientific and publishing activities such that a reasonable observer might wonder if the individual's behavior or judgment was motivated by considerations of his or her competing interests.” (www.WAME.org) WAME also recognizes that a: “Strong commitment to a particular political view (e.g., political position, agenda, or party) or having a strong religious conviction may pose a conflict if those political or religious issues are affirmed or challenged in the publication.” The Lancet provides similar guidance to its authors in noting that: “conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course.” (www.thelancet.com)

As pointed out in a recent report by David Feifel, Manduca and her colleagues had substantive financial and intellectual conflicts of interest that would cause a reasonable observer to believe that the author's views were biased.3 For example, Manduca received funding and raised money for Interpal, a nongovernmental organization that was designated as a terrorist entity by the U.S. government.4, 5 Another author, Mads Gilbert, remarked in an interview with the Norwegian paper Dagbladet shortly after the attacks of 9/11 that: “If the U.S. government has a legitimate right to bomb and kill civilians in Iraq, the oppressed has a moral right to attack the U.S. with the weapons they may create as well. Dead civilians are the same whether they are Americans, Palestinians or Iraqis.”6

And, Derek Summerfield, noted in a 2004 article in the British Medical Journal; “that Israel is a morally malignant regime which capriciously murders Arabs with no justification.”7 The failure to acknowledge these obvious conflicts deprived the reader of crucial contextual information with which to judge the validity of the work.

Finally, editors are responsible for insuring the veracity of the published record. Manduca was clearly guilty of both the omission of verifiable information and inclusion of specious data. For example, her letter failed to mention the unceasing barrage of rockets and mortar shells on Israeli cities and its effects on their population and the complex tunnels exiting close to Israeli population centers that were created by diverting cement allocated for the construction of schools, hospitals and apartments. Manduca also failed to note that Israel has permitted essential supplies to be transferred daily from Israel to Gaza, that throughout the conflict, hundreds of Palestinians were treated in Israeli hospitals, and that Israel airlifted numerous wounded Gazans to trauma centers in Israel.8, 9 The editor of the Lancet also failed to question the veracity of the statement that 95% of Israeli physicians were “complicit in the massacre and destruction of Gaza” or the implicit suggestion that the Israeli Army used “gas.”

Are case studies or published guidelines regarding editorial decisions related to the topic of mixing politics and medicine informative?

There is a paucity of literature focused on the topic of mixing politics and medicine/science in a medical/scientific journal. The Canadian Medical Association Journal established a goal of publishing a ratio of nonscientific to scientific content of 1:3 over 30 years ago.10 The decision was based on the increased importance of the business of medicine after the birth of national health insurance. However, the editor was transparent in justifying the inclusion of nonmedical articles in the journal. He noted that articles about practice structure, financial management, politics, history, ethics, and public policy increased both the journal's readership and its advertising.

In 2004, Dr. Kamran Abbasi, the acting editor of the British Medical Journal addressed the question in an editorial entitled: “Should journals mix medicine and politics?”11 The editorial was written to respond to his receipt of over 1,000 letters responding to a commentary by Derek Summerfield on the public health effects of Israel's security wall in the West Bank. Although Abbasi noted that there were a number of letters that suggested that the conflict between Israel and its neighbors could be resolved through dialogue, a review of the responses that the Journal received, many of which were published on line within 24 hours of submission, found that they were largely biased and inflammatory on both sides.12 Indeed, even Abbasi recognized that “in a state of conflict [those] views will be sometime abrasive and unpalatable.”

Most recently, the Lancet justified its decision to publish the Manduca letter by noting that: “It is surely the duty of doctors to have informed views, even strong views, about these matters, to give a voice to those who have no voice, and to invite society to address the actions and injustices that have led to this conflict. Our responsibility is to promote an open and diverse discussion about the effects of this war on civilian health.”13 Taken in isolation, this statement by the Lancet appears reasonable. However, like the letter from Manduca and her colleagues, the Lancet editorial focused exclusively on the hardships suffered by the people of Gaza and did not mention a single effect of the conflict on the civilian health of the people of Israel. The Lancet would have better served their readership if they had published two companion articles—each having a different perspective on the conflict if their aim was to promote an open discussion. However, it is unlikely that such reports could be written objectively in the midst of conflict.

The only recorded case study was an issue that was brought by an editor to the forum of COPE in order to ascertain whether the editor had been biased in electing to publish a cross‐sectional survey of Palestinian refugees.14 The paper was sent to two reviewers and although the study provided a Palestinian perspective, the editor felt that the paper's bias did not detract from the findings and that because the author's affiliations were obvious, the readers could draw their own conclusions. Letters attacking the review process and suggesting that the paper was politically motivated arrived shortly after publication and the editor asked the forum to decide whether the journal had allowed political bias to affect their editorial decisions. The COPE forum determined that there was no evidence of political bias, but that the editor might have sought more extensive peer review because of the strong political context surrounding the study.14

Are there historical perspectives that can or should inform decisions regarding the publication of political treatise in medical journals?

Any discussion of the propriety of a medical journal linking medicine and politics must be looked at relative to the eugenics movement that actually began in the U.S. in the early part of the 20^th century. In 1921, the Section of Opthalmology of the American Medical Association proposed that hereditary blindness could be eliminated if a law was enacted that: “When a man and woman contemplate marriage, if a visual defect exists in one or both of the contracting parties, or in the family of either, so apparent that any taxpayer fears that the children of such a union are liable to become public charges, for which that taxpayer would probably be assessed, then such taxpayer on guaranteeing the legal costs may apply to the County Judge for an injunction against the marriage.”15 Indeed, in 1924, an editorial in the New England Journal of Medicine entitled “Feeblemindedness and the future” noted that: “The burden to society resulting from this increase of feeblemindedness is tremendous. For one thing, persons with subnormal intelligence are always potential criminals: ….the financial loss to the country is appalling…Sterilization of defectives, which is practiced extensively in California, may be advisable in a limited number of cases, but this measure will by no means solve the problem….We should at least recognize this danger that threatens to replace our population with a race of feeble‐minded; we must study its causes and the sources form which it springs.”16 This was followed in 1934 by an editorial in the New England Journal of Medicine that noted that: “Germany is perhaps the most progressive nation in restricting fecundity among the unfit, for that country provides that the treatment is compulsory when ordered by district courts, which consist of a judge, an official medical officer of health, and another doctor who is a recognized expert in hereditary diseases.”17 Indeed, Deutsches Arzteblatt, the preeminent medical journal in Germany, published Hitler's intentions for cleansing the nation of foreign influences and alien races and supported the “The Physician and Genetic Improvement” act which sought to identify children “whose life was deemed less worthy” because of genetic or psychiatric disease.18 By the late 1930s, Deutsches Arzteblatt was publishing a regular column called “Solving the Jewish Question.”19 Thus, prestigious journals supported the early adopters of the field of eugenics in the U.S., and the later policies of ethnic cleansing in Germany.

In 1948 the World Medical Association (WMA) adopted the Declaration of Geneva to attest to the rejection of the politicization and corruption of medicine that had occurred in Nazi Germany and to modernize the Oath of Hippocrates.... The Declaration established the “health of my patient” as the primary responsibility of a physician, committed the physician “to maintain the honor and the noble traditions of the medical profession,” and “to consecrate their life to the service of humanity.” The Declaration specifically forbids a physician to discriminate on the basis of “age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor.”20 Implicit in this explicit rejection of discrimination and the affirmation that “my colleagues will be my sisters and brothers” is the separation of politics and medicine. The WMA council took an additional step in 2009 in response to conflicts in Gaza, Sri Lanka, Darfur and the Democratic Republic of Congo, by passing the Preservation of International Standards of Medical Neutrality resolution.9 This resolution commits physicians to provide health care in times of conflict without a pre‐condition of the achievement of peace, thereby further separating the delivery of care from the politics of the conflict itself.

Conclusion

The letter by Manduca and her colleagues provides a case study of the potential consequences of mixing politics and medicine in a medical/science journal. First, I believe that the editor of Lancet breached the fundamental ethics of responsible publishing by failing to acknowledge the substantive conflicts of the authors and allowing unsubstantiated and inflammatory claims to be posited. At a time when wars are occurring throughout the world, the publication of a diatribe that is focused on a single country must raise serious issues of motivation and bias. It is fine to write about the impact of war on civilian health, but only if the studies meet high scientific standards and are peer reviewed by those without a conflict of interest.

The larger issue is whether a medical journal should publish articles focused on geopolitical issues regardless of context. It could be argued that physicians and scientists should not stand by idly while injustices occur that harm human health; however, the Lancet letter illustrates how difficult it is for a medical or scientific journal to be the repository for a commentary about a highly politicized topic when there are few impartial stakeholders, undertones of religious and ethnic bias, enormous vitriol, and inadequate opportunities for an editor or reviewer to validate claims. Indeed, the numerous letters published by the Lancet that were submitted in response to the Manduca letter could be viewed as being equally biased and many of their comments either in opposition to or in support of the Manduca article could engender the exact same criticisms as did the initial letter. While the lay press can take advantage of skilled and unbiased reporters on site and a team of researchers to fact check, a medical journal is dependent on authors of commentaries to provide the information and the journal must then try and verify the information—a task that is often problematic. This puts journals at the continuing risk of publishing specious information. Finally, guidelines from the WMA implicitly separate politics and medicine even in the context of armed confrontations. Therefore, in aggregate, the existing data would suggest that a medical/scientific journal should take great care in trying to bridge the chasm that exists between politics and medicine or science.

This journal has neither the resources nor the desire to undertake the appropriate level of due diligence required to publish political commentary that is outside the scope and expertise of its editorial board. Therefore, we will continue to publish commentaries related to Federal and state laws and policies, decisions by regulatory agencies and university policies that directly influence the ability of its readership to effectively and efficiently undertake clinical and translational research. However, we will not publish letters or commentaries that discuss geopolitical topics or issues.