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Ghost Marketing: Pharmaceutical Companies and Ghostwritten Journal Articles

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The use of ghostwriters by industry is subject to increasing public attention and scrutiny. This article addresses the practice and ethics of scientific ghostwriting. We focus on the type of ghostwriting that involves a pharmaceutical company hiring a medical education and communications company to write a paper favorable of their product, who then hires a well-known academic to publish it under his or her name without disclosing the paper's true origins. We argue that this practice is harmful both to the public and to the institutions of science and that it is not justified by an analogy to accepted scientific authorship practices. Finally, we consider ways to discourage the practice.
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Ghost Marketing
pharmaceutical companies and
ghostwritten journal articles
18
ABSTRACT The use of ghostwriters by industry is subject to increasing public
attention and scrutiny. This article addresses the practice and ethics of scientific ghost-
writing.We focus on the type of ghostwriting that involves a pharmaceutical company
hiring a medical education and communications company to write a paper favorable
of their product, who then hires a well-known academic to publish it under his or her
name without disclosing the paper’s true origins.We argue that this practice is harmful
both to the public and to the institutions of science and that it is not justified by an
analogy to accepted scientific authorship practices. Finally, we consider ways to dis-
courage the practice.
“W
HAT IS THE PURPOSE of publications?” asks the header on a Pfizer
sales document dated July 27, 2000. Publications have many pur-
poses, the document replies. Publications give the Pfizer sales force the tools to
drive prescriptions. They support regulatory requests. They improve Pfizer’s
relationships with potential speakers.The “purpose of data is to support, directly
or indirectly, the marketing of our product, states the document. “High qual-
ity and timely publications optimize our ability to sell Zoloft most effectively.
Center for Bioethics, University of Minnesota, Minneapolis.
Correspondence: Barton R. Moffatt, Center for Bioethics, N538 Boynton Health Service, 410
Church Street SE, Minneapolis, MN 55455.
E-mail: moff0022@umn.edu.
Perspectives in Biology and Medicine, volume 50, number 1 (winter 2007):18–31
© 2007 by The Johns Hopkins University Press
Barton Moffatt and Carl Elliott
One page sums up the message with the header:“Purpose of Publications:The
Bottom Line.
1
This view of publications is not unique to Pfizer. Publication strategy has be-
come a critically important element of pharmaceutical marketing. It is hardly an
accident that clinical trials sponsored and published by the pharmaceutical in-
dustry are overwhelmingly favorable to the sponsor’s product (Als-Nielsen et al.
2003; Bhandari et al. 2004; Lexchin et al. 2003; Melander et al. 2003; Smith
2005). Partly this is because the industry chooses not to publish unfavorable clin-
ical trials. But it is also because the trials the industry does publish are carefully
designed and presented to put the most favorable spin possible on the sponsor’s
drugs. So important has publication strategy become for pharmaceutical compa-
nies that it supports an entire cottage industry, medical education and commu-
nications companies (MECCs), which contract with pharmaceutical companies
to ensure that a company’s medical publications support its marketing plan (Rel-
man 2001).
One key element of publication strategy is the ghostwritten journal article.
Either a pharmaceutical company or an MECC will commission an academic
physician or researcher to “author” a journal article about a particular drug or
illness. Sometimes the academic is paid to write the article, which is then sub-
mitted to an academic journal, but more often the academic will be asked to col-
laborate with a medical writer—a ghostwriter. Some ghostwriters work full time
for an MECC or a medical public relations company, but many are freelancers.
The ghostwriter will typically produce an initial draft of the article, specified to
order by the pharmaceutical company, which the academic sham author is then
invited to review, revise, or simply to sign.When the article appears in press, the
academic appears as the author, while the contributions of the ghostwriter and
the pharmaceutical company remain hidden (Elliott 2004).
Ghostwriting is hardly a secret. It has been a topic of investigative reports in
media outlets such as ABC News, the Wall Street Journal, New York Times, Boston
Globe, Forbes, and the Guardian. Ghostwriting has been studied by academics, it
has been criticized by journal editors, and perhaps most significantly, it has at-
tracted the eager attention of lawyers suing the pharmaceutical industry. Ghost-
written journal articles have featured prominently in actions against Glaxo-
SmithKline in litigation concerning Paxil, against Parke-Davis in litigation
concerning Neurontin, against Wyeth in litigation concerning Fen-Phen, and
against Pfizer in litigation concerning Zoloft.
Critics of the pharmaceutical industry condemn ghostwriting as if it were
self-evidently unethical, yet the outrage that critics have hoped to provoke has
never generated any significant effort to stop the practice. Professional and reg-
ulatory bodies do not treat ghostwriting as academic misconduct or fraud. Uni-
Ghost Marketing
winter 2007 • volume 50, number 1
19
1
Document available from authors.This document emerged in Motus v. Pfizer and was made avail-
able to the authors on a non-confidential basis.
versities do not discipline faculty members who sign on to ghostwritten articles.
Journal editors do not sanction ghostwriters or sham authors. If ghostwriting is
a sin, it is apparently only a minor sin, at least in the eyes of those who are clos-
est to it.
Is there anything wrong with ghostwriting? As defenders of ghostwriting
point out, science is a collaborative enterprise. Jointly authored papers are the
rule in science, not the exception, and medical writers often produce clearer,
more readable papers than medical researchers themselves. If senior academic re-
searchers can sign onto articles written by a post-doc or a junior colleague, why
should they not be allowed to sign onto articles written by a medical writer, as
long as they agree with what they are signing? Nor is there anything wrong with
academics accepting fees for writing the articles, defenders of the practice argue.
Universities encourage researchers to collaborate with industry; even medical
journals are supported by revenue generated from pharmaceutical industry
advertisements and reprint fees. As Max Lagnado (2002), himself an occasional
ghostwriter, has pointed out, “If a financial relationship with a drug company
excludes you from sitting at the biomedical literature table, most seats would be
empty.
We believe that critics are right to condemn the production of ghostwritten
journal articles, a practice we believe to be unethical and dangerous.What those
critics have often failed to do, however, is articulate clearly just what is wrong
with ghostwriting. We will argue that the core of the problem with ghostwrit-
ing is not the collaboration of academics with medical writers per se, nor is it
the simple exchange of money (although both of these things are part of the
problem). Rather, the problem is the specific ways in which these collaborations
are disguised, manipulated, and used as tools for marketing drugs.
The Varieties of Ghostwriting
Academic whistleblowers have identified at least two different genres of ghost-
written articles: review articles or editorials and original research papers. Review
articles or editorials usually evaluate the current state of a particular issue, dis-
ease, or therapy (Brennan 1994).Adriane Fugh-Berman (2005), a professor of al-
ternative and complementary medicine at Georgetown University, has written
about an invitation that she received from Rx Communications, a British-based
MECC. Rx Communications invited her to write a review article on the poten-
tial of medicinal herbs and dietary supplements to interact with warfarin (Cou-
madin), a common anticoagulant.When Fugh-Berman asked for more informa-
tion, Rx Communications sent her a complete draft of an article, with the title,
“Interactions between dietary supplements and warfarin: the hazards of self-
administration, along with two suggestions for journals where she might sub-
mit the article.
Fugh-Berman said no to the offer, but later, by coincidence, she was asked by
20
Barton Moffatt and Carl Elliott
Perspectives in Biology and Medicine
the Journal of General Internal Medicine to referee an article on the same topic that
had been submitted to the journal. It turned out to be a version of the same arti-
cle she had been sent by Rx Communications, but signed by a different author.
What was the marketing purpose of the review article? According to Fugh-
Berman, Rx Communications was working for AstraZeneca, which was devel-
oping its own anticoagulant, Exanta (Herper 2005). Exanta’s only real competi-
tor, had it been approved by the FDA, would have been warfarin.Warfarin is the
only oral anticoagulant approved in the United States and is available generically.
But one drawback of warfarin is that it interacts with a number of foods and
dietary supplements.This drawback was expected to be a major selling point for
Exanta—hence the article that Fugh-Berman was invited to “author.
Defenders of ghostwriting sometimes argue that ghostwritten articles do not
hype any specific drug—and that if they did, journal editors, referees, and
prospective “authors” would detect this right away. But as Fugh-Berman points
out, the purpose of industry-sponsored articles and lectures is usually more sub-
tle than outsiders suspect. Sometimes a sponsor wants to publicize a new disor-
der (social anxiety disorder, irritable bowel syndrome, restless leg syndrome, etc.)
that their drug is intended to treat. A sponsor may want to demonstrate that a
disorder is under-treated or that it is more common that physicians have sus-
pected. A sponsor may also want to show that a current treatment (for which
their drug is an alternative) has unsuspected problems, or that there are medical
alternatives to surgery, or that a drug is effective for off-label uses. The purpose
of such articles and lectures is not to hype the sponsor’s drug so much as to pre-
pare the ground for its marketing. Fugh-Berman (2005) compares such articles
to farming:“Weeds are removed, the soil prepared, perhaps a cover crop planted,
to be tilled under before seeds are sown in the receptive soil.
A second genre of ghostwritten article involves original research. Here aca-
demics collaborating with a drug company on a particular research program have
their names attached to original research papers they had little or no role in pre-
paring.This is what happened to Aubrey Blumsohn, a senior lecturer in the Bone
Metabolism Unit at Sheffield University. In 2002 Blumsohn and Richard Eastell,
a research dean at Sheffield, signed a $250,000 contract to perform research with
Proctor & Gamble (P&G), the manufacturer of the osteoporosis drug Actonel.
The purpose of the research was to see how Actonel affects women’s bones and
their susceptibility to fractures. P&G hoped that Actonel would compare favor-
ably to its chief competitor, Merck’s Fosamax (Baty 2005; Revill 2005;Washburn
2005).
Blumsohn eventually became convinced that P&G were skewing their data in
order to make Actonel look as if it had performed better than it really had. But
when he asked to see all of the raw data on which the Actonel studies were
based, P&G refused. In the meantime, Blumsohn was informed that a P&G
ghostwriter was writing up the Actonel studies for publication, and that Blum-
sohn and Eastell would be listed as authors. P&G also told him that they were
Ghost Marketing
winter 2007 • volume 50, number 1
21
writing up study results for him to present at the American Society of Bone and
Mineral Research in 2003. P&G emphasized that the ghostwriter was “familiar
with . . . our key messages” (Washburn 2005).
If Blumsohn’s experience is representative, the marketing purpose of original
ghostwritten articles is somewhat different from that of review articles. On the
most benign interpretation, a ghostwriter of original research will package the
message of the research paper so that it fits into the marketing plan for the drug.
The ghostwriter’s contribution is hidden because the study will look more cred-
ible coming solely from university researchers. On a more sinister level, however,
the ghostwriter may aid in orchestrating the various elements of the study so that
none of the contributors are actually aware of how the entire study fits together.
This makes it easier to spin the data in a way that is favorable to the sponsor.
Each contributor may be able to vouch for his or her own contribution, but only
the ghostwriter and company representatives can vouch for the study as a whole.
The Spread of Ghostwriting
How common is ghostwriting? It is hard to know, partly because ghostwriting
is hard to detect, and partly because it shades easily into other forms of ques-
tionable authorship practices. According to the Wall Street Journal, a poll of 71
freelance medical writers by the American Medical Writers Association found
that 80% had written at least one manuscript that failed to mention their con-
tributions (Mathews 2005). In a recent study published in Nature, 10.8% of all
early and mid-career scientists admitted to “inappropriately assigning authorship
credit” at least once in the past three years (Martinson, Anderson, and de Vries
2005). There are many forms of inappropriate authorship apart from taking
credit for a ghostwritten article, of course, such as crediting “honorary” authors
for work that they did not do, or failing to credit the contributions of junior col-
leagues. But the Nature study is consistent with older studies that suggest that a
conservative benchmark for ghostwriting of papers published in biomedical
journals is roughly 10%. A review of authorship practices in Cochrane reviews
found evidence of ghostwriting in 9% of the surveyed reviews and of honorary
authorship in 39% of the reviews (Mowatt et al. 2002). A widely cited JAMA
study found evidence of ghostwriting in 11% of papers in six leading journals
(Flanigan et al. 1998).
A more alarming figure emerged in a study by Healy and Cattell (2003), who
found that over half of all published articles on Pfizer’s antidepressant Zoloft over
a three-year period showed evidence of MECC authorship. Healy and Cattell
examined documents produced by Current Medical Directions, a New York–
based MECC, which had contracted with Pfizer to manage publications on
Zoloft.The documents had been produced in 1999 and were made public in lit-
igation against Pfizer.They listed all of the publications on Zoloft that Current
Medical Directions had produced for Pfizer, along with their topic, title,
22
Barton Moffatt and Carl Elliott
Perspectives in Biology and Medicine
“authors, and the journals or conferences to which they would be submitted.
Healy and Cattell compared the Current Medical Directions documents with
the published literature to see what had happened to the articles in the years
since the report was put together.
In the three years that Healy and Cattell examined, approximately 57% (55 of
96) of all published articles on Zoloft in the peer-reviewed medical literature had
originated from Current Medical Directions. Not only did the articles from
Current Medical Directions outnumber the traditionally authored articles, they
appeared in higher-impact journals. Perhaps most significantly, the citation rate
for the articles produced by Current Medical Directions was over five times
higher than the citation rate for the traditionally authored articles.This statistic
suggests that ghostwritten articles may have an even greater influence than their
numbers suggest.
As the study by Healy and Cattell suggests, litigation against pharmaceutical
companies has provided the most revealing window into the practice of corpo-
rate ghostwriting. In Dispensing with the Truth,Alicia Mundy (2002) describes the
evidence of medical ghostwriting turned up by the lawsuits regarding Fen-Phen.
Recovered documents show that the pharmaceutical company Wyeth hired the
MECC Excerpta/Medica to produce several scientific papers on the dangers of
obesity and on obesity treatment as part of their marketing strategy for Fen-
Phen. Mundy documents that Wyeth paid between $15,000 to $20,000 for Ex-
cerpta to prepare each article, of which $1,500 would go to the “named author”
as an honorarium. Some completed papers, simply listed as “author to be deter-
mined, lacked a “named author, while others had made their way in to print
or were under review. One doctor, Dr. Richard Atkinson, was so pleased with
the arrangement for “Therapeutic Effects of Dexfenfluramine: A Review” that
he wrote a thank you note to Excerpta/Medica saying,“Let me congratulate you
and your writer....Perhaps I can get you to write all of my papers for me”
(Mundy 2002, p. 164).
Similar revelations emerged in a whistleblower lawsuit against Parke-Davis
(now part of Pfizer) for its off-label marketing of its drug Neurontin. Neurontin,
which had been approved by the FDA for treating seizures, was illegally mar-
keted by Parke-Davis for a range of conditions for which there was no evidence
that the drug worked, from bipolar disorder and attention deficit disorder to rest-
less leg syndrome and migraine headaches. Among the marketing strategies
employed by Parke-Davis was the production of ghostwritten articles on the
drug’s off-label uses. In 1996, Parke-Davis retained two MECCs, Adelphi Ltd.
and Medical Education Systems, to produce 20 articles for placement in medical
journals.The MECCs recruited recognized Neurontin prescribers and paid them
$1,000 each to lend their names to the articles. Some articles eventually appeared
in high-profile journals such as JAMA and the Annals of Internal Medicine under
the names of academic physicians. In a 1997 memo, for example, Medical Edu-
cation Systems told Parke-Davis that it was trying to track down Dr. John
Ghost Marketing
winter 2007 • volume 50, number 1
23
Pellock of the Medical College of Virginia for an article about pediatric seizure
disorders.The memo said,“Author interested; still playing phone tag. MES HAS
DRAFT COMPLETED,WE JUST NEED AN AUTHOR.
2
The figures cited in such litigation appear consistent with other published ac-
counts.According to the Wall Street Journal, an MECC may charge a pharmaceu-
tical company upwards of $30,000 to have a team of writers and editors put to-
gether an article for publication (Mathews 2005).The academics invited to sign
on usually disclose getting somewhere between $1,000 and $2,000 per article
(Petersen 2002). Freelance ghostwriters, who often have backgrounds in science,
are typically paid $90 to $120 per hour by an MECC for their work (Mathews
2005).
Arguments Against Ghostwriting
Why is ghostwriting wrong? First of all, and most importantly, it is harmful to
the public health.Although relatively little is known about the details of corpo-
rate ghostwriting, the glimpses that we get of it through anonymous surveys and
lawsuits suggest that the reason pharmaceutical companies go through the trou-
ble and expense of shaping medical opinion about the safety and efficacy of their
products is that it is highly profitable. Marketing campaigns seek to influence the
prescribing practices of doctors. Ghostwritten articles may mislead doctors about
the actual risks and benefits associated with medical treatments. Medical misin-
formation of this sort has the risk of harming a large number of people. The
potential for harm is amplified by the fact that ghostwritten articles usually bear
the name of a highly respected researcher who appears to have no financial stake
in the issue at hand.
The potential harm of ghostwriting was made evident in litigation surround-
ing Fen-Phen, which showed how Wyeth marketed the diet drug by ghostwrit-
ing articles exaggerating the dangers of obesity and the effectiveness of its drug,
while downplaying the potential side-effects. Fen-Phen was eventually with-
drawn from the market after being linked to primary pulmonary hypertension
and valvular heart disease (Mundy 2002). In the case of Zoloft, Healy and Cattell
(2003) found that the articles produced for Pfizer by Current Medical Directions
articles gave Zoloft a more positive side-effect profile than did the traditionally
authored articles. For example, the articles prepared by Current Medical Direc-
tions on pediatric psychopharmacology failed to mention five children taking
Zoloft who took action towards committing suicide.
Second, ghostwritten journal articles always contain undisclosed conflicts of
interest.The failure to disclose conflicts occurs on many levels.The “named au-
thor” fails to disclose that he or she has received payment for agreeing to pub-
lish the paper under his or her name.The MECC fails to disclose that it has re-
24
Barton Moffatt and Carl Elliott
Perspectives in Biology and Medicine
2
Document available from authors.
ceived a substantial amount of money to prepare the article and find a “named
author. And the sponsoring company fails to disclose that it has a direct finan-
cial stake in the drug or product in question.
There is no way around the problem of non-disclosure. If the “named au-
thors” were to disclose the relevant financial facts—that someone else wrote the
paper, that a third party gave them an honorarium for signing the paper, and that
a pharmaceutical company provided the third party with the money for the
honorarium—then the paper would no longer be ghostwritten. Disclosure
makes the ghosts visible; there is no way to reveal the actual and potential con-
flicts of interest without also revealing obscured authorship and funding details.
Defenders of ghostwriting sometimes claim that the conflicts of interest in-
volved in ghostwriting are no different from other forms of conflict of interest
that arise in academic-industry collaborations. But academics collaborating with
industry have an obligation to disclose their funding sources; undisclosed finan-
cial ties by researchers are generally considered a violation of research ethics. In
the case of ghostwriting, the financial involvement of the sponsoring company
cannot be disclosed, because the very purpose of ghostwriting is to make the
article appear as if it came from the academic rather than the corporate sponsor.
Some defenders of ghostwriting draw a parallel between ghostwriting prac-
tices and accepted scientific authorship practices.They claim that there is no rel-
evant difference between the practice of ghostwriting and authorship practices
in a large laboratory setting. Harry Sweeney (2005), the head of a medical com-
munications company, outlines his version of the development of ghostwriting
in a letter to the Hastings Center Report: “As research articles became more for-
mulaic and less prosy, busy department heads used students and postdocs to draft
their reports or formed medical writing groups to grind out the grants and pub-
lish-or-perish materials. So long as the putative ‘author’ reviews and edits a draft
document, I find it difficult to see the problem.
Does the analogy between ghostwriting and lab authorship practices hold?
The analogy trades on a legitimate distinction between the ordinary usage of the
word author and the relevant notion of “scientific authorship. In ordinary usage,
to author an article is to write it. But in science, the standard for authorship is
often merely that a person has made a substantial intellectual contribution to a
given paper. Thus a scientific paper may have many named scientific authors,
each of which has made some intellectual contribution to the paper, but who
may not have actually drafted any part of the paper itself. For example, one study
found that only 41% of authors had actually participated in writing the first draft
of a paper (Goodman et al. 1998).
But in the case when a senior researcher does not actually draft a paper yet
legitimately remains an author because of the fact that he or she has provided a
substantial intellectual contribution, the paper will either acknowledge the per-
son who has actually drafted the paper or list that person as a named author.
There is no counterpart to the hidden ghostwriter. For example, when a senior
Ghost Marketing
winter 2007 volume 50, number 1
25
researcher assigns a problem to a postdoc who does the research and writes up
the initial draft of the results, with the understanding that the senior researcher
will be one of the paper’s “scientific authors, the postdoc has also earned credit
as a “scientific author. If the case of lab authorship were truly analogous to the
ghostwriting case, the contribution of the postdoc would not be mentioned.
Another defense of ghostwriting centers on the idea that the only significant
parts of a scientific paper are the arguments and data. According to this line of
reasoning, the origins of a particular paper are irrelevant as long as the named
author accepts responsibility for the scientific content of the paper. For example,
Max Lagnado (2002) dismisses the view that paid medical writers working for
pharmaceutical companies might obscure the reporting of scientific truth, argu-
ing that “this view conveniently overlooks the fact that the report belongs to the
authors, not the individual who provides writing assistance.
But what does it mean for a paper to “belong” to the named authors and not
the person who has written it? We understand Lagnado to mean that the named
authors have taken responsibility for the integrity of the data and the quality of
the argument.According to this argument, it is only the soundness of the data and
arguments that are at issue, not a paper’s origins.Assessing data or arguments based
on the personal circumstances of the author amounts to an ad hominem attack.
Yet there is something obviously disingenuous about using this argument as a
defense of ghostwriting. If authorship details do not matter, why do pharmaceu-
tical companies go to such lengths to obscure the real authorship of the papers in
question? Why do they hire leading academics to sign on? The company could
simply commission medical communication companies to submit papers under
the names of their actual authors along with the statement that the company in
question commissioned the paper. But they do not do this, for obvious reasons.
In any case, it is by no means clear that named authors are in any position to
claim responsibility for the soundness of a paper they did not write. If the named
authors have not actually done the research for the paper—whether it is origi-
nal research, a literature review, or an opinion piece—then it is not clear that
they have access to all relevant data or literature, or even whether they know
what questions ought to be addressed.
This point is made forcefully in a recent article by Richard Smith (2005), the
former editor of the British Medical Journal, who has written that medical jour-
nals have essentially become a marketing arm of the pharmaceutical industry. If
a drug company publishes a large, favorable clinical trial in a major journal, it can
hire an expensive public relations firm to promote it and ensure that the trial re-
ceives media attention around the world. So valuable is such a trial, Smith writes,
that a drug company may spend over a million dollars on journal reprints, which
are then distributed to doctors by the company sales force. Doctors may not
actually read the reprints, but they will be impressed by the journal in which the
study has appeared. As Smith puts it, “The quality of the journal will bless the
quality of the drug” (p. e138).
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Barton Moffatt and Carl Elliott
Perspectives in Biology and Medicine
The advertising value of these studies makes their results critically important.
Drug companies get the results they want not by outright fraud or manipulation
of data, Smith suggests, which might be detectable by peer reviewers, but by ask-
ing the right questions. For example, a company might conduct a trial of its drug
against a treatment known to be inferior, or against too low a dose of a com-
petitor drug (making their drug appear more effective), or against too high a
dose of the competitor (making their drug appear less toxic). A company might
conduct multi-center trials and select results only from centers that are favorable,
or conduct subgroup analyses and select only those that are favorable for publi-
cation. Smith writes, “There are many ways to hugely increase the chance of
producing favourable results, and there are many hired guns who will think up
new ways and stay one jump ahead of peer reviewers” (p. e138).And while these
ways of producing favorable results may be obvious to the people who analyze
the data and write up the results, they will not always be obvious to the named
author who is being asked to sign on to the paper.
Undermining Science
Ghostwritten articles are useful as marketing tools precisely because they appear
to come from a disinterested source. In fact, the entire program of ghostwriting
is designed to give articles written by people with a direct financial interest in
promoting a product the appearance of disinterestedness. Because there is so
much evidence showing that industry-sponsored articles are more favorable to a
sponsor’s product than non-industry-sponsored articles, accurate information
about authorship details is in fact essential for an accurate assessment of the sci-
entific content of a given paper.
The harm done by ghostwriting is compounded by the fact that the system
of scientific communication is a key aspect of scientific objectivity. One ap-
proach to scientific objectivity holds that science is objective because of its pro-
cedures. According to this view, the foundation of scientific objectivity rests in
the way scientists communicate and contest results. Helen Longino (2001)
argues that scientific communities are objective insofar as their communication
procedures are open and contestable. But ghostwritten papers conceal the inter-
ests of authors and sponsors in a way that makes it difficult to assess and contest
the scientific data, which undermines the objectivity of science itself.
On a practical level, it is easy to see how the widespread practice of corpo-
rate ghostwriting would undermine scientific objectivity. If the majority of sci-
entific papers were secretly written as marketing tools based on proprietary raw
data by corporations that have an economic stake in the issues at hand, trust in
scientific information and institutions would decline. This trust is based on the
assumption that scientists are engaging in a good-faith search for scientific truth
and are disclosing any relevant financial interests. Without it, science cannot
flourish.
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27
Why Ghostwriting Persists
Perhaps the most interesting aspect of ghostwriting is that the practice persists
despite the fact that it has been so widely reported and condemned. Partly this
is because the production of ghostwritten articles is economically advantageous
for so many different parties. But it is also because those who engage in the prac-
tice (unlike those who write about it in the press) do not see it as outrageously
unethical. Medical researchers see the lending of one’s name to an article as a
minor, easily understandable moral failing. Drummond Rennie, the deputy edi-
tor of JAMA, once commented about academics who sign ghosted papers:“They
should be disgraced totally, but they aren’t. People just think it’s a bit naughty”
(Spears 2003).
Why merely “naughty” instead of “outrageous?” Part of the explanation is a
difference in the perceived value of writing. For those people who see ghost-
written journal articles as outrageous (especially journalists and scholars in the
humanities), writing is an important creative act. When they talk about their
work, they are essentially referring to their writing—the work of writing his-
tory, literary criticism, philosophy, or journalism.The act of writing itself is a cru-
cial part of the value of what they do. But for scientists and physicians, writing
is different.The act of writing is seen as almost incidental to the work of scien-
tific research. The important part of their work is designing a study, collecting
the data, doing the conceptual work, and so on.Writing is the “mere” commu-
nication of results. Thus scientific researchers tend to see writing as more of a
technical task. And if this is the case, then what does it matter if someone else
actually does the writing? On this view (which we believe to be deeply mis-
taken), complaining about ghost authorship is like complaining that the named
authors did not do some mundane piece of scut work.
Another reason the practice of ghostwriting persists may simply be the name
“ghostwriting, which implicitly identifies the medical writers as the wrongdo-
ers. But in the end, the real culprits are not the ghostwriters.Writers are simply
selling their skills to help corporate scientists produce more readable papers.
Their ethical failing is in allowing their skills to be used improperly. And while
ghostwriting itself is unethical, the more serious ethical problem is a larger
one—the production of ghostwritten articles for purposes of marketing.The real
culprits are the pharmaceutical companies who commission ghostwritten papers
and the academics who sign them.The pharmaceutical companies are manipu-
lating the good-faith system of scientific communication in order to market
their drugs.The academics who sign on to ghosted papers are taking advantage
of the same system in order to get money and academic credit for papers they
did not actually write. It is this larger problem that threatens to undermine our
entire system of scientific communication.
28
Barton Moffatt and Carl Elliott
Perspectives in Biology and Medicine
How Can Ghostwriting Be Eliminated?
Would the ethical problems presented by ghostwritten journal articles be solved
if medical writers were acknowledged as authors? Acknowledgement would
help, but it would not solve the problem, because the presence of sham “named
authors” on the article would still lend the articles a patina of undeserved aca-
demic credibility. Would the problem be solved if the named authors were not
allowed to accept payment for allowing their names on the articles? Again, this
would help, but many academics would still sign on in the absence of payment.
They would still get academic credit for “authoring” the articles, which they
could then translate into promotion, tenure, grants, and so on. Payment to aca-
demic “authors” and the failure to acknowledge medical writers are each part of
the problem, but the larger and more serious problem is the way that the con-
ventions of scientific communication are perverted for purposes of marketing.
We believe that discouraging the production of ghostwritten journal articles
will require a number of different strategies and mechanisms. First, universities
need to treat the practice of signing on to ghostwritten journal articles as a case
of academic misconduct. They need to institute rules to prevent faculty mem-
bers from lending their names to papers they did not write, and when they dis-
cover cases where faculty members have engaged in the practice, they need to
have mechanisms in place to sanction them.
Second, lawyers should start naming ghostwriters and sham authors as defen-
dants in litigation against the pharmaceutical industry. As things stand now, only
pharmaceutical companies are financially punished for fraud, and since their
pockets are so deep, the threat of litigation is not sufficient to deter them from
commissioning ghosted articles. But the threat of litigation would probably deter
those with more limited financial resources. Litigation could serve as a dramatic
way of making ghostwriters, sham authors, and medical communications com-
panies directly culpable for the harm caused by their fraudulent activity.
3
Third, there needs to be a standing committee, task force, or office with an
established institutional home whose job is to gather information about poten-
tial cases of ghostwriting, to sanction authors who have been determined to par-
ticipate in ghostwriting, and to disseminate information about ghostwritten
papers to the public. One major difficulty in identifying ghostwritten articles is
the fact that journal editors are often reluctant to identify suspected or known
ghostwriters publicly. A committee to counter ghostwriting could be housed in
a professional body or in a governmental institution, such as the Office of Re-
search Integrity (ORI). Alternatively, it could be hosted in a university or a
watchdog organization.
Ghost Marketing
winter 2007 volume 50, number 1
29
3
The U.S. attorney’s office in Brooklyn recently indicted a physician on criminal charges for mar-
keting a narcolepsy drug off-label in paid speeches and seminars for Jazz Pharmaceuticals (Berenson
2006).
Finally, there needs to be an effective strategy for identifying and discourag-
ing ghostwriting. To achieve this end, we propose an amnesty program where
people who report their own involvement in the production of ghostwritten
journal articles are offered immunity from sanction in exchange for a detailed
description of their involvement. People involved with the production of ghost-
written articles but who have not reported their involvement, on the other hand,
would, if discovered, receive sanctions. In the case of academic sham authors, for
example, such sanctions might include restrictions on receiving federal funds for
research and the forwarding of the academic misconduct case to the university
of the researcher in question. The benefit of the amnesty approach is that it
would offer incentives for authors to come forward and would identify previ-
ously ghostwritten papers, while also discouraging the production of ghostwrit-
ten papers in the future.
We acknowledge that these recommendations might sound harsh, but they
are necessary to combat fraudulent authorship practices.The financial incentives
for pharmaceutical companies are too great to expect this problem to go away
without some form of sanction for those scientists who fraudulently lend their
scientific reputation to marketing campaigns. Standard scientific checks are pow-
erless against this kind of misconduct. Other forms of scientific misconduct, like
fabrication of data, can be uncovered by standard scientific processes. But ghost-
writing is harmful precisely because it involves deliberately hiding information
necessary for the mechanisms of scientific evaluation to work.
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... For example, a freelancer sponsored by a pharmaceutical company may approach life scientists with a biased bundle of articles and ask them to write a research paper based on it [48], hoping the paper will promote the official approval, and/or boost the sales, of a drug. As the freelancers do not receive authorship (and thus are ghost authors), the monetary commitment of the firm stays secret [49]. ...
... Nevertheless, the results are in line with prior work that indicated deviations from the ICMJE standards within the life sciences [19,46]. Interestingly, the social scientists in our study report more honorary authorship but less ghost authorship than life scientists [49,78], using ICMJE criteria as the point of reference. ...
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... " [13,63] Proven fraudulent "ghostwritten" articles sponsored by pharmaceutical giants have appeared regularly in top clinical journals, such as JAMA, and New England Journal of Medicine-never to be removed despite proven scientific abuse and manipulation of data. [49,63] Ghostwritten articles involve using planning companies whose job it is to design articles containing manipulated data to support a pharmaceutical product and then have these articles accepted by high-impact clinical journals, that is, the journals most likely to affect clinical decision making of doctors. Further, they supply doctors in clinical practice with free reprints of these manipulated articles. ...
... These academic researchers and the journalists they talk with are allowed to promote the future product to the public sector, as it concerns public health. As long as the product is off-label, not officially tested and approved, the private commercial sector is not allowed to do this type of promotion (Moffatt et al. 2007), although the above named networks do 'hidden marketing'. The process of innovation (R&D) is increasingly blurred with the process of marketing, and often reaches mainly institutional public sector clients that are 'seduced' to fund the research. ...
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... Regarding the ghostwriting, it is ethically anathema in most academic research (PLoS Medicine Editors 2009;Leo, Lacasse, and Cimino 2011;Lacasse and Leo 2010;Moffatt and Elliot 2007). Among political actors though, ghostwriting is common. ...
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