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Ghostwriting: Research Misconduct, Plagiarism, or Fool's Gold?

  • Xavier Bosch
    Correspondence
    Requests for reprints should be addressed to Xavier Bosch, MD, PhD, Department of Internal Medicine, Hospital Clínic, University of Barcelona, Villarroel 170, 08036-Barcelona, Spain
    Affiliations
    Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain
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  • Joseph S. Ross
    Affiliations
    Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine and Center for Outcomes, Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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Published:February 03, 2012DOI:https://doi.org/10.1016/j.amjmed.2011.07.015
      Traditionally, personal integrity and professional accountability have guaranteed appropriate authorship of biomedical journal articles. However, recent controversies, including exposés of ghostwriting and guest authorship, have shown the fallibility of this trust.
      Ghostwriting, the practice whereby individuals make significant contributions to writing a manuscript but are not named as authors, invariably goes hand-in-hand with guest or honorary authorship, whereby named authors have not contributed sufficiently to a manuscript to merit authorship. Although ghostwriting and guest authorship are prevalent, and remain as common today as they were a decade ago,

      Wislar J, Flanagin A, Fontanarosa PB, DeAngelis CD. Prevalence of Honorary and Ghost Authorship in 6 General Medical Journals. Sixth International Congress on Peer Review and Biomedical Publication. September 10-12, 2009. Vancouver, British Columbia, Canada.

      the actual extent of ghostwriting in biomedical journals remains unknown.
      • Sismondo S.
      Ghosts in the machine: publication planning in the medical sciences.
      These practices are thought predominantly to occur when academic investigators collaborate with industry. However, they also occur within purely academic collaborations when, for example, senior academics supervising or supporting research are included as authors, regardless of their contributions, or when junior academics are asked to draft articles for senior academics, who are then listed as first author. Increasingly, academics also are using external medical writers to facilitate manuscript writing and preparation.
      • Korieth K.
      Demand for medical writing continues to rise.
      Nevertheless, more typically, an industry-employed or contracted writer prepares a complete draft of a review or research article for an academic partner, usually an expert in his or her field. The academic then submits the manuscript, perhaps after editing, and in turn receives an honorarium for his or her time and effort. Of note, the named academic authors rarely have access to actual clinical data for independent analysis and only participate once the manuscript has been drafted, after key decisions have already been made, including which analyses to conduct and which findings to disseminate.

      Why Ghostwrite?

      Many incentives can lead academic investigators, trial sponsors in industry and elsewhere, and medical writers to engage in ghostwriting and guest authorship. For professional medical writers, these practices mean employment and remuneration for services that, they argue, improve clarity, provide balance and objectivity, and reduce the time of manuscript production.
      AMWA position statement on the contribution of medical writers to scientific publications.
      For academic investigators, these practices are opportunities to enhance their professional standing. Not only does academic tenure frequently depend on multiple publications, preferably in high-impact journals as first or senior author, but also collaboration with industry in itself heightens prestige and often results in additional grant support.
      For industry sponsors, these practices are part of global publication strategies for product promotion. Strategically planned and placed ghostwritten manuscripts provide an aura of objectivity around clinical research and conceal conflict of interest.
      • Sismondo S.
      Ghosts in the machine: publication planning in the medical sciences.
      Such planning is notable not only because the broad ambition is to manage and shape the medical literature, but also because the narrow intention is for the article to convey a positive, promotional message. Litigation against several different companies has exposed these practices as part of larger efforts to develop relationships with academics, fight competition and build market share, and promote pharmaceutical products.

      Fool's Gold

      Although clearly economically profitable for all parties, ghostwriting flourishes because it is perceived as a slight, easily comprehensible moral failing, rather than as unethical.
      • Moffatt B.
      • Elliott C.
      Ghost marketing: pharmaceutical companies and ghostwritten journal articles.
      As one deputy editor of the Journal of the American Medical Association remarked: “They should be disgraced totally, but they aren't. People just think it's a bit naughty.”
      • Spears T.
      Drug companies get doctors to endorse tainted medical research.
      Furthermore, even those exposed for having engaged in these practices have, for the most part, suffered minimal shame or academic consequences.
      In this culture, ghostwriting and guest authorship are fool's gold, an unspoken permission to fatten curricula with redundant reviews and, predominantly, lower-impact clinical research studies. However, patients and physicians suffer from these practices, as the clinical research process and authorship integrity are devalued in an attempt to promote products. Even worse, the evidence-base for the practice medicine is distorted through the selective reporting of results
      • Sismondo S.
      Ghosts in the machine: publication planning in the medical sciences.
      • Hill K.P.
      • Ross J.S.
      • Egilman D.S.
      • Krumholz H.M.
      The ADVANTAGE seeding trial: a review of internal documents.
      and disease mongering
      • Moynihan R.
      • Cassels A.
      Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients.
      that often accompany ghostwritten articles.

      Plagiarism

      Fool's gold has a price, and in this case, occasionally those engaged in ghostwriting and guest authorship have been accused of plagiarism, a serious accusation. The Office of Research Integrity (ORI) considers plagiarism to include both the theft or misappropriation of intellectual property and the substantial, unattributed, textual copying of another's work, which materially misleads ordinary readers regarding author contributions.
      Guest authorship approximates plagiarism because an individual's naming implies credit for work done by others, but is the same true for ghostwriting? Both keep hidden the name of the actual author. However, a plagiarist copies text without consent, whereas a ghostwriter intentionally and willingly creates text for attribution to others. As such, ghostwriters appear not to be engaged in plagiarism.

      Research Misconduct

      Although plagiarism is classified unreservedly as research misconduct by the ORI, what should we make of ghostwriting and guest authorship? Ghostwriting meets neither the strict definition of plagiarism nor the current definitions of fabrication and falsification. Fabrication is limited to “making up data or results and recording or reporting them,” and falsification is limited to “manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record.” The ORI further broadens these definitions to include fabrication or falsification of credentials, but limits the scope to degrees and positions, rather than to naming of authors and authorship contributions.
      Office of Research Integrity
      Handling Misconduct–Inquiry Issues, ORI Responses to Issues Arising from Inquiries and Investigations.
      Although both ghostwriting and guest authorship clearly perpetuate a fraud on an unsuspecting public and profession, ghostwriting currently seems to lie outside ORI jurisdiction, despite recent condemnation by the director of the National Institutes of Health after discovering ghostwriting among National Institutes of Health grantees.
      Francis Collins' response to Paul Thacker (Project on Government Oversight).

      Cleaning Out the Attic

      Ghostwriting and guest authorship are acts of research misconduct and deserve such widespread indignation because they entail maintaining secrecy, falsifying credentials, and fabricating the attribution of writing to another, representing an intentional and significant departure from accepted practices within the research community. The ORI should further broaden its definition of fabrication and falsification of credentials, and thus of research misconduct, to explicitly include ghostwriting and guest authorship. This action would signal a change of professional culture that investigators would increasingly abide by as the norm. In addition, the ORI actions against individuals, and their affiliated institutions, have significant potential to effect change. Conviction can lead to exclusion from receiving federal funds through grants and contracts, prohibition from serving on Public Health Service advisory and peer-review committees, imposition of supervision by the institution, and requirements for retraction of published articles. Furthermore, both the individual and the institution face a more severe loss to their reputation when an inquiry or charge of misconduct is made by the ORI, larger than any that would be expected from a similar charge made by a journal editor. The challenge remains that for the ORI, any allegation must be proven by a preponderance of evidence, and evidence of ghostwriting and guest authorship is deliberately hidden, suggesting large investments of time and effort to establish cases against investigators.
      Furthermore, because the ORI rules were created to protect Federal research dollars, and industry-employed researchers are the least likely to come under the ORI's auspices, additional strategies also are needed. For instance, non-federal research institutions, including industry, should strongly enforce policies for research and employee misconduct that emulate the ORI's. In addition, the National Institutes of Health and academic centers could similarly announce the seriousness with which they intend to examine future allegations and the ramifications of convictions. The profession, our institutions, and medical journal editors must remain increasingly vigilant, enforcing the highest ethical standards to protect the integrity of clinical research, improve care for patients, and restore trust in the medical profession.

      References

      1. Wislar J, Flanagin A, Fontanarosa PB, DeAngelis CD. Prevalence of Honorary and Ghost Authorship in 6 General Medical Journals. Sixth International Congress on Peer Review and Biomedical Publication. September 10-12, 2009. Vancouver, British Columbia, Canada.

        • Sismondo S.
        Ghosts in the machine: publication planning in the medical sciences.
        Soc Stud Sci. 2009; 39: 171-198
        • Korieth K.
        Demand for medical writing continues to rise.
        The Centerwatch Monthly. 2008; (Vol. 15. Issue 12) (Accessed July 12, 2011)
      2. AMWA position statement on the contribution of medical writers to scientific publications.
        (Accessed July 12, 2011)
        • Moffatt B.
        • Elliott C.
        Ghost marketing: pharmaceutical companies and ghostwritten journal articles.
        Perspect Biol Med. 2007; 50: 18-31
        • Spears T.
        Drug companies get doctors to endorse tainted medical research.
        Victoria Times. December 1, 2003; (Accessed July 12, 2011)
        • Hill K.P.
        • Ross J.S.
        • Egilman D.S.
        • Krumholz H.M.
        The ADVANTAGE seeding trial: a review of internal documents.
        Ann Intern Med. 2008; 149: 251-258
        • Moynihan R.
        • Cassels A.
        Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients.
        Nation Books, New York2005
        • Office of Research Integrity
        Handling Misconduct–Inquiry Issues, ORI Responses to Issues Arising from Inquiries and Investigations.
        (Accessed July 12, 2011)
      3. Francis Collins' response to Paul Thacker (Project on Government Oversight).
        (Accessed July 12, 2011)

      Linked Article

      • Ghostwriting: An Existing Problem
        The American Journal of MedicineVol. 125Issue 10
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          The recent publication on ghostwriting is interesting.1 I would like to share my experience with this subject. Indeed, ghostwriting may be a common problem that is rarely mentioned. In a recent report, Wislar et al2 state that “21% of articles published in major medical journals” might pose the problem of ghost authorship. Although it is accepted that ghost authorship is unethical in medical literature, it is still prevalent for many reasons.3 The high rate of the problem should be discussed. In many cultures, especially in developing countries in Asia, honorary giving as ghost authorship is practiced commonly.
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      • Don't Be a Fool—Don't Use Fool's Gold
        The American Journal of MedicineVol. 125Issue 10
        • Preview
          When ghostwriting and legitimate professional medical writing are conflated, many are fooled. Professional medical writers are not ghostwriters, but your readers may not appreciate this distinction after reading the article “Ghostwriting: Research Misconduct, Plagiarism, or Fool's Gold?” by Bosch and Ross.1
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