SURGICAL ETHICS CHALLENGES James W. Jones, MD, PhD, MHA, Section Editor
Is a gift authorship really a grift authorship? James W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex A senior resident wrote an innovative paper comparing several different endovascular techniques. Working closely with his faculty mentor, he designed the study, got permission from the Institutional Review Board, collected the data, and wrote the paper. A faculty mentor supervised the study, allowing his patients to be included, and made design suggestions. A departmental statistician analyzed the data. Now that the paper is ready for submission, the mentor suggests that he, the statistician, another widely published senior faculty member, and especially the chair, be included as co-authors. The reasoning is that the resident will benefit from the good will of the senior faculty member and chair and likely will be incorporated on the included faculty’s bylines as well. He was told: “It is a widely accepted practice and will certainly thicken your CV.” The resident should: A. Cite as authors only himself and the faculty member who served as his mentor. B. Include as authors his mentor, the surgeon who operated on the study patients, and the statistician. C. Include his mentor, the surgeon who operated on the study patients, the widely published senior faculty member, and the chair. D. List only himself as the paper’s author. E. Include as authors his mentor, the statistician, and the senior Faculty member.
I have often noticed that a bribe has that effect – it changes a relation. The man who offers a bribe gives away a little of his own importance. dGraham Greene
There generally is little confusion about who wrote nonscientific articles and books but a team does much of medical research and bylines reflect that approach. Someone has done the bulk of the work and occupies the first author position (although not always). Someone may have mentored the first author and occupies the last or senior author position (although not always). Others have done less and may have earned co-authorship and unfortunately some are included who have done nothing. “The inclusion on publication bylines of colleagues who have done little or no work in the conceptualization or development of a scientific project has been called ‘gift authorship,’ ‘guest authorship,’ ‘honorary authorship,’ ‘gratuitous authorship,’ ‘ghost authorship’ and more.”1 From The Center for Medical Ethics and Health Policy, Baylor College of Medicine. Author conflict of interest: none. Reprint requests: James W. Jones, MD, PhD, MHA, 31 La Costa Dr, Montgomery, TX 77356 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:1092-3 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.02.006
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The fact that none of the designations for the practice is pejorative indicates wide acceptance. After all, if the research has merit, the experimental design is correct, and the data are properly reported, what is wrong about doctoring the byline? A Web-based, self-administered survey found that 39% of papers had honorary authors, 9% included ghost authors, and 2% had both, for a staggering total of 50%.2 According to the International Committee of Medical Journal Editors (ICMJE) criteria for authorship, the overall rates of honorary authors varied according to the journal reaching 60% in the Annals of Internal Medicine to a low of 4% in JAMA.3 In addition, those with honorary listings had fewer publications than legitimate authors. Perhaps those more published were trying to help colleagues meet the “publish or perish” threat. Chairs of departments seem often to be included as last or senior authors. Cultivating good will with the boss is wise, indeed. Co-authorship is the academic coin of the realm; it builds good will that can manifest in a variety of ways: reciprocation; maintaining patient referrals; obtaining laboratory usage; support for academic advancement; funds for travel; and other perks. Shulkin et al looked at the phenomenon and found that chairs seemed to grow satiated from senior authorship because those whose tenure was over a decade had significantly fewer coauthored publications.4 Is the practice of “gift authorship” within the acceptable ethics of medical professionalism? It certainly does not sink to the level of data falsification or otherwise pollute or misdirect medical science. On the other hand,
JOURNAL OF VASCULAR SURGERY Volume 61, Number 4
does it? The Oxford Dictionary defines plagiarism as: “The practice of taking someone else’s work or ideas and passing them off as one’s own.” Is being included as a contributor when one is undeserving actually plagiarism? It is felony, not misdemeanor, plagiarism because the gift author egregiously represents as his or her own work that which is completely the product of others. Should we not apply the same standards to ourselves as we apply to our students and residents? What would happen if one caught a trainee plagiarizing on an assigned paper? Of course, one would be required to discipline him or her and would consider seriously whether his or her character was flawed, perhaps enough to exclude that individual from our profession. Unearned authorship violates the well-understood standards that we impose on our students and trainees. This is a result of the distinctive feature of moral standards: they are universal in that they apply to all relevantly similar circumstances. “Our deception is more consequential than that of a plagiarizing trainee, because it is not done in the context of a training exercise; it’s an actual contribution to the professional literature. It lacerates integrity by asserting authority for people who have no authority, and by misplacement of trust, without which we would regress to the cultural status of medieval barber surgeons from which we mutated. The crime is not victimless.”1 Is the inclusion of patients in the analysis enough to warrant true authorship? If one has not contributed to the intellectual content of the paper, especially if the data contribution is in the control side, it should not count. Intellectual integrity in science is the sustained commitment to intellectual excellence in science: adherence to the highest standards of the design, conduct, analysis, interpretation, and reporting of laboratory or clinical investigation. In the absence of intellectual integrity, the scientific enterprise fails, with deleterious consequences for all who have a stake in it. This includes, especially, patients in the case of biomedical research. Violating the test of the universality of a moral standard for authorship results from absence of intellectual integrity in science, which is not permissible. Doing so out of self-interest violates the intellectual integrity of the individual scientist, which is a moral calamity in science, for the medical profession, for patients, and for society. The Journal of Vascular Surgery was among the first to recognize that the practice of “gift authorship” was wrong. A decade ago, the Journal concluded: “Conceptually, identifying the authors of a scientific article is straightforward. They are those who have made substantial intellectual contributions to a published study. However, scientific authorship has important academic and financial implications that have often resulted in the inappropriate inclusion of ‘honorary’ authors.”5 Option A, including only the resident and mentor as authors, excludes those who are substantial contributors, such as the statistician, who have therefore earned
Jones and McCullough 1093
co-authorship. The statistician is always an integral member of a scientific study and should be named. Failure to do so may be read by others as a claim that the listed authors may be capable of using statistics in the design, analysis, and interpretation of a study. When, in fact, that is not the case, the kind of plagiarism described above occurs. Option A violates intellectual integrity. Option C includes additional “guest authors” who are positioned to benefit the resident author by advancing his self-interest but who have not contributed to the present paper. Such inclusion is often not an isolated event but a pattern in which those who have not earned authorship reciprocate by adding the first author to their papers. In itself and in the dangerous pattern it promotes, option C must be avoided as an unacceptable violation of and threat to intellectual integrity. Option D would be the worst professional choice of a young resident’s career because it is an egregious error and invites the hypothesis that it was done out of unbridled ego. Moreover, it is imprudent because it jeopardizes self-interest: he has been mentored through a study and to exclude a faculty mentor would almost certainly create a powerful, life-long adversary. A female scorned is not comparable to a mentor scorned. Avoid D at all costs, to protect intellectual integrity and prevent reckless disregard of legitimate self-interest. Once again, E offers an unprofessional choice. Giving credit where credit is undue violates professional integrity and honesty because of the resulting plagiarism. A person’s ethical worth is calculable directly to for what they will sell their principles. Option B passes muster. All those listed as authors have earned their authorship. Leaders in academic surgery e chairs, program directors, fellowship directors, and clerkship directors e should take a preventive ethics approach to violations of intellectual integrity in authorship. These leaders should create clear policies and then enforce them without exception, keeping in mind a fundamental concept of professional leadership: what one permits, one promotes. Leaders in academic surgery should never promote violations of intellectual integrity. They should then create an organizational culture of professional excellent that never permits violations of intellectual integrity. REFERENCES 1. Jones JW, McCullough LB, Richman BW. The ethics of bylines: would the real authors please stand up? J Vasc Surg 2005;42:816-8. 2. Mowatt G, Shirran L, Grimshaw JM, Rennie D, Flanagin A, Yank V, et al. Prevalence of honorary and ghost authorship in Cochrane reviews. JAMA 2002;287:2769-71. 3. Bates T, Anic A, Marusic M, Marusic A. Authorship criteria and disclosure of contributions: comparison of 3 general medical journals with different author contribution forms. JAMA 2004;292:86-8. 4. Shulkin DJ, Goin JE, Rennie D. Patterns of authorship among chairmen of departments of medicine. Acad Med 1993;68:688-92. 5. Cronenwett JL, Seeger J. Criteria for authorship. J Vasc Surg 2005;42:599.
Is a gift authorship really a grift authorship? James W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex A senior resident wrote an innovative paper comparing several different endovascular techniques. Working closely with his faculty mentor, he designed the study, got permission from the Institutional Review Board, collected the data, and wrote the paper. A faculty mentor supervised the study, allowing his patients to be included, and made design suggestions. A departmental statistician analyzed the data. Now that the paper is ready for submission, the mentor suggests that he, the statistician, another widely published senior faculty member, and especially the chair, be included as co-authors. The reasoning is that the resident will benefit from the good will of the senior faculty member and chair and likely will be incorporated on the included faculty’s bylines as well. He was told: “It is a widely accepted practice and will certainly thicken your CV.” The resident should: A. Cite as authors only himself and the faculty member who served as his mentor. B. Include as authors his mentor, the surgeon who operated on the study patients, and the statistician. C. Include his mentor, the surgeon who operated on the study patients, the widely published senior faculty member, and the chair. D. List only himself as the paper’s author. E. Include as authors his mentor, the statistician, and the senior Faculty member.
I have often noticed that a bribe has that effect – it changes a relation. The man who offers a bribe gives away a little of his own importance. dGraham Greene
There generally is little confusion about who wrote nonscientific articles and books but a team does much of medical research and bylines reflect that approach. Someone has done the bulk of the work and occupies the first author position (although not always). Someone may have mentored the first author and occupies the last or senior author position (although not always). Others have done less and may have earned co-authorship and unfortunately some are included who have done nothing. “The inclusion on publication bylines of colleagues who have done little or no work in the conceptualization or development of a scientific project has been called ‘gift authorship,’ ‘guest authorship,’ ‘honorary authorship,’ ‘gratuitous authorship,’ ‘ghost authorship’ and more.”1 From The Center for Medical Ethics and Health Policy, Baylor College of Medicine. Author conflict of interest: none. Reprint requests: James W. Jones, MD, PhD, MHA, 31 La Costa Dr, Montgomery, TX 77356 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;61:1092-3 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2015.02.006
1092
The fact that none of the designations for the practice is pejorative indicates wide acceptance. After all, if the research has merit, the experimental design is correct, and the data are properly reported, what is wrong about doctoring the byline? A Web-based, self-administered survey found that 39% of papers had honorary authors, 9% included ghost authors, and 2% had both, for a staggering total of 50%.2 According to the International Committee of Medical Journal Editors (ICMJE) criteria for authorship, the overall rates of honorary authors varied according to the journal reaching 60% in the Annals of Internal Medicine to a low of 4% in JAMA.3 In addition, those with honorary listings had fewer publications than legitimate authors. Perhaps those more published were trying to help colleagues meet the “publish or perish” threat. Chairs of departments seem often to be included as last or senior authors. Cultivating good will with the boss is wise, indeed. Co-authorship is the academic coin of the realm; it builds good will that can manifest in a variety of ways: reciprocation; maintaining patient referrals; obtaining laboratory usage; support for academic advancement; funds for travel; and other perks. Shulkin et al looked at the phenomenon and found that chairs seemed to grow satiated from senior authorship because those whose tenure was over a decade had significantly fewer coauthored publications.4 Is the practice of “gift authorship” within the acceptable ethics of medical professionalism? It certainly does not sink to the level of data falsification or otherwise pollute or misdirect medical science. On the other hand,
JOURNAL OF VASCULAR SURGERY Volume 61, Number 4
does it? The Oxford Dictionary defines plagiarism as: “The practice of taking someone else’s work or ideas and passing them off as one’s own.” Is being included as a contributor when one is undeserving actually plagiarism? It is felony, not misdemeanor, plagiarism because the gift author egregiously represents as his or her own work that which is completely the product of others. Should we not apply the same standards to ourselves as we apply to our students and residents? What would happen if one caught a trainee plagiarizing on an assigned paper? Of course, one would be required to discipline him or her and would consider seriously whether his or her character was flawed, perhaps enough to exclude that individual from our profession. Unearned authorship violates the well-understood standards that we impose on our students and trainees. This is a result of the distinctive feature of moral standards: they are universal in that they apply to all relevantly similar circumstances. “Our deception is more consequential than that of a plagiarizing trainee, because it is not done in the context of a training exercise; it’s an actual contribution to the professional literature. It lacerates integrity by asserting authority for people who have no authority, and by misplacement of trust, without which we would regress to the cultural status of medieval barber surgeons from which we mutated. The crime is not victimless.”1 Is the inclusion of patients in the analysis enough to warrant true authorship? If one has not contributed to the intellectual content of the paper, especially if the data contribution is in the control side, it should not count. Intellectual integrity in science is the sustained commitment to intellectual excellence in science: adherence to the highest standards of the design, conduct, analysis, interpretation, and reporting of laboratory or clinical investigation. In the absence of intellectual integrity, the scientific enterprise fails, with deleterious consequences for all who have a stake in it. This includes, especially, patients in the case of biomedical research. Violating the test of the universality of a moral standard for authorship results from absence of intellectual integrity in science, which is not permissible. Doing so out of self-interest violates the intellectual integrity of the individual scientist, which is a moral calamity in science, for the medical profession, for patients, and for society. The Journal of Vascular Surgery was among the first to recognize that the practice of “gift authorship” was wrong. A decade ago, the Journal concluded: “Conceptually, identifying the authors of a scientific article is straightforward. They are those who have made substantial intellectual contributions to a published study. However, scientific authorship has important academic and financial implications that have often resulted in the inappropriate inclusion of ‘honorary’ authors.”5 Option A, including only the resident and mentor as authors, excludes those who are substantial contributors, such as the statistician, who have therefore earned
Jones and McCullough 1093
co-authorship. The statistician is always an integral member of a scientific study and should be named. Failure to do so may be read by others as a claim that the listed authors may be capable of using statistics in the design, analysis, and interpretation of a study. When, in fact, that is not the case, the kind of plagiarism described above occurs. Option A violates intellectual integrity. Option C includes additional “guest authors” who are positioned to benefit the resident author by advancing his self-interest but who have not contributed to the present paper. Such inclusion is often not an isolated event but a pattern in which those who have not earned authorship reciprocate by adding the first author to their papers. In itself and in the dangerous pattern it promotes, option C must be avoided as an unacceptable violation of and threat to intellectual integrity. Option D would be the worst professional choice of a young resident’s career because it is an egregious error and invites the hypothesis that it was done out of unbridled ego. Moreover, it is imprudent because it jeopardizes self-interest: he has been mentored through a study and to exclude a faculty mentor would almost certainly create a powerful, life-long adversary. A female scorned is not comparable to a mentor scorned. Avoid D at all costs, to protect intellectual integrity and prevent reckless disregard of legitimate self-interest. Once again, E offers an unprofessional choice. Giving credit where credit is undue violates professional integrity and honesty because of the resulting plagiarism. A person’s ethical worth is calculable directly to for what they will sell their principles. Option B passes muster. All those listed as authors have earned their authorship. Leaders in academic surgery e chairs, program directors, fellowship directors, and clerkship directors e should take a preventive ethics approach to violations of intellectual integrity in authorship. These leaders should create clear policies and then enforce them without exception, keeping in mind a fundamental concept of professional leadership: what one permits, one promotes. Leaders in academic surgery should never promote violations of intellectual integrity. They should then create an organizational culture of professional excellent that never permits violations of intellectual integrity. REFERENCES 1. Jones JW, McCullough LB, Richman BW. The ethics of bylines: would the real authors please stand up? J Vasc Surg 2005;42:816-8. 2. Mowatt G, Shirran L, Grimshaw JM, Rennie D, Flanagin A, Yank V, et al. Prevalence of honorary and ghost authorship in Cochrane reviews. JAMA 2002;287:2769-71. 3. Bates T, Anic A, Marusic M, Marusic A. Authorship criteria and disclosure of contributions: comparison of 3 general medical journals with different author contribution forms. JAMA 2004;292:86-8. 4. Shulkin DJ, Goin JE, Rennie D. Patterns of authorship among chairmen of departments of medicine. Acad Med 1993;68:688-92. 5. Cronenwett JL, Seeger J. Criteria for authorship. J Vasc Surg 2005;42:599.
