Ethics Journal Corrects Record, Reveals Conflicts of Interest

The American Journal of Bioethics has published what has to be one of the longest corrections ever for an academic journal.

And yet it manages to beg more questions than it answers.

Since the correction appeared in the August edition of the journal, I have tried to answer some of these begged questions, but, as you will see, I have been stymied on multiple fronts. This gets quite complex. There are a lot of names, dates and drug companies involved. So shout if you get lost. (I’ve found myself doing a lot of shouting.)

In May, I wrote that the journal had published several articles that made the case for broader use of pain medications without disclosing that some of the authors had ties to the pharmaceutical industry. For example, I wrote about Myra Christopher, former president of The Center for Practical Bioethics:

What I found troubling, however, is that neither Christopher nor the journal noted in the article that the center had received substantial gifts from Purdue Pharma. Since writing that 2011 piece, Christopher's position at the center has received funding from Purdue Pharma's endowment.

The Center for Practical Bioethics, until recently, was the home for the ethics journal, and Christopher is a member of the editorial board for the journal. Earlier this year, the U.S. Senate Finance Committee started probing the center and other institutions to see whether some groups have worked as messengers for the pharmaceutical industry, putting an academic sheen on subtle – and sometimes not-so-subtle – marketing for painkillers and other drugs.

So it makes sense that the ethics journal would want to clarify its record of disclosing conflicts by authors who have published there.

The journal’s editors said as much in a blog post in May 2012:

The editors have taken note of the recent letter from members of the Senate Finance Committee inquiring as to certain parties’ relationships with opioid manufacturers. We have asked all contributors who have written on pain in AJOB to revisit their conflict of interest disclosures. The responses to our request will be shared with the AJOB Conflict of Interest committee, per our policy, and that committee will recommend any appropriate action on the part of AJOB.

Now, the editors wrote this in the August edition of the journal:

The editors regret that the journal failed to include the following possible conflict of interest disclosures in the November 2010 issue of The American Journal of Bioethics.

The correction goes on for more than 900 words listing various conflicts that should have been disclosed two years ago to readers. But it fails to actually name any of the articles where these conflicts should have been disclosed in the first place. Most of the conflicts appear to have been connected to one article, “A Rose by Any Other Name: Pain Contracts/Agreements,” a piece critical of pain management contracts, the agreements that pain care physicians often have their patients sign to let them know up front that they will be on the lookout for any abuse of pain medications. The article says:

In the absence of good evidence about diversion of nonprescribed drugs (diverted before being prescribed) versus actually prescribed drugs, there is a risk of shifting the brunt of the diversion problem in the system writ large onto pain patients (Inciardi et al. 2007). These same medications provide relief and help restore function for more than 10 million people living with pain.

This article was highlighted in May by Alan Bavley at The Kansas City Star, who wrote about the U.S. Senate inquiry. The senior author in that paper was Christopher. The journal’s editors write in the correction:

Myra Christopher, President and CEO of The Center for Practical Bioethics, disclosed no personal conflicts but reported that: “Although I do not own stock or hold stock options; act as a consultant to, serve as an officer or on the board of a company; have not provided expert testimony, been employed by or performed contract work for the organization in the past five years; received honoraria, royalties, reimbursement or other forms of payment from ANY of the following, the Center for Practical Bioethics has in the past five years accepted grants, contributions, and travel reimbursement or held contracts with the following which relate to the topic of this article: American Academy of Family Physicians; American Academy of Pain Management; American Academy of Pain Medicine; American Hospital Association–Circle of Life Awards Committee; Center for Disease Control–Center for Aging Studies; Drug Enforcement Administration–Diversion Division, Administrator’s Office; Federation of State Medical Boards Foundation; Greenwall Foundation; Headache and Pain Center of Kansas City; King Pharmaceuticals; Mayday Fund; National Association of Attorneys General Foundation; Pfizer Pharmaceuticals; PriCara (Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc.); Purdue Pharma, LLC; Robert Wood Johnson Foundation SJ Pain Associates, Inc.; St. Luke’s Pain Care Center–Kansas City; TEVA Neuroscience[;] United Health Foundation; United Health Group; William T. Kemper Foundation."

Are you shouting? It’s easy to lose track. But it appears that Christopher acknowledged that the Center for Practical Bioethics had received funding from five pharmaceutical companies, including the makers of many of the major opioids on the market.

Christopher makes a distinction between funding she personally has received and funding the center has received. She says that she has received no funding from any of the pharmaceutical companies, physician groups, government agencies or other organizations on her list. This might be an important distinction to make. But the disclosure doesn’t really explain why that distinction is being made. Christopher works for the Center for Practical Bioethics, and the center did receive funding from pharmaceutical companies and others. Christopher also was on the editorial board for the journal, and, as of 2010, the editorial offices for the journal were at the center.

A more important disclosure would be an explanation of what – if any – of this funding to the center was tapped for Christopher’s work on pain management issues. Academic centers often have complicated financial structures that channel specific grants to specific work, and it’s quite possible that Christopher did all of her research for the November 2010 article without any help from drug company funding. A clear statement to that effect would be helpful.

Another thing that is unclear from this correction is who is at fault. At first read, it appears that Christopher and the other authors mentioned disclosed quite a list of possible conflicts to the journal before the November 2010 article was published.

But look at the language: “[T]he journal failed to include the following possible conflict of interest disclosures.” What exactly does that mean? Did these authors fill out conflict of interest forms that were then ignored by the journal? Did the journal ask for conflicts and then the authors ignored those requests?

I asked Christopher in an email about what prompted this correction in the August issue. To be clear, she is on the editorial board but the day-to-day responsibilities of editing the journal fall to two co-editors-in-chief. (One of the peculiarities of the journal is that it does not provide any information about its editorial board online.) She wrote in the email:

I want to clarify for you that prior to the article, “A Rose by Any Other Name: Pain Contracts/Agreements” being published in the Nov. 2010 issue of the American Journal of Bioethics, I signed and returned AJOB’s usual disclosure form to their editors and attached to it a statement which included the information published in the Editors’ Notes in August 2012.  I also emailed the additional statement to the editors. 

So, it seems Christopher did what was asked of her and perhaps went above and beyond. Why the journal did not publish any of this information and feels that it should set the record straight now remains a mystery.

Only one of the journal’s co-editors-in-chief has ever responded to my questions, David Magnus at Stanford. So I asked Magnus about the chain of events that led to this correction. I did not receive a response.

Also, remember that the ethics journal editors said in May that they were asking “all contributors who have written on pain in AJOB to revisit their conflict of interest disclosures.” The August correction says nothing about whether Christopher made accurate disclosures in other instances. Nothing is said, for example, about the 2011 article I referenced, "It's time for bioethics to see chronic pain as an ethical issue." Presumably, all of the conflicts outline above from this month’s Editor’s Note would have applied in 2011, too.

I’ll write more about the other disclosures that went undisclosed and questions yet to be answered in my next post.