20 February 2006 may well be the day that marked the beginning of the decline of the CMAJ (Canadian Medical Association Journal) as a widely respected national and international journal. On that day John Hoey, Editor-in-Chief of the CMAJ for 10 years, and his Deputy Editor Anne Marie Todkill were summarily dismissed by Graham Morris, the president of CMA Media Inc which publishes the CMAJ.1 As to the reasons for the firings, Morris said, “I felt that after 10 years it was time for a fresh approach.”2 His rationale was greeted with disbelief and derision from leaders in the publishing field. Frank Davidoff, Editor Emeritus of the Annals of Internal Medicine was reported as saying, “Oh, come on! A summary firing without a cause? I mean, how naïve do they think people are?”, adding, “I think it could be the death knell of this Journal”.3

The dismissal of Hoey and Todkill provoked editorial comments in the Lancet4 and the British Medical Journal (BMJ),5 and condemnations from the Council of Science Editors, the World Association of Medical Editors and the International Committee of Medical Journal Editors — all parties called for the Canadian Medical Association (CMA) to respect editorial independence.4 Within 3 weeks, the CMAJ was reduced to a shell of its former self. The journal’s Acting Editor-in-Chief, Stephen Choi, resigned, along with its Editorial Fellow and a number of Associate Editors. Their resignations were provoked by the failure of the CMA to agree to Choi’s request that the publisher and the owner of the journal, CMA Holdings, a commercial subsidiary of the CMA, not interfere with editorial content.6 In dire straits, the CMA turned to Bruce Squires, the previous Editor-in-Chief, to resume this role in an acting capacity. Seventy-one-year-old Squires declined and urged the CMA to heed Choi’s request for editorial independence. Finally, 16 of the 19 members of the CMAJ editorial board resigned.6,7

There was dismay and disquiet in the Canadian medical community. Anger among academics, researchers and clinicians followed, with calls for a boycott of submissions to the CMAJ and the activation of a worldwide petition for editorial autonomy at the CMAJ, and the reinstatement of Hoey and Todkill. There was even talk of setting up an open-access journal in competition with the CMAJ.7,8

Caught in this imbroglio, the CMA desperately needed a circuit breaker. This came with two announcements. The first announced yet another Acting Editor, Noni MacDonald (a former Dean of Medicine), the assembly of a new editorial board, and the release by the CMA of nine interim principles for editorial governance, including editorial independence.9,10 The second was more striking, announcing the formation of a panel of eminent authorities to “review the Canadian Medical Association Journal’s (CMAJ) governance structure and to provide objective recommendations to further the CMAJ’s continued commitment to editorial independence and maintaining excellence in reporting on the science and art of medicine.”11 The review panel, chaired by Antonio Lamer, a former Chief Justice of the Canadian Supreme Court, is to report soon. Despite these measures, dissatisfaction remains. It is obvious the current turmoil was driven by matters other than the desire to seek new directions.2

What then was behind the sacking of Hoey and Todkill? During Hoey’s tenure, there were smouldering tensions between the CMAJ and CMA as to who should have control over the journal’s content, particularly if this was politically or commercially awkward for the CMA.6,7 These tensions reached a climax in the months immediately before the sackings, with two CMAJ news items — the Plan B story (a CMAJ investigation of over-the-counter dispensing of the newly approved emergency contraceptive pill by Canadian pharmacists) and the Tony Clement story (an article commenting on his appointment as Minister of Health in the Conservative Canadian Government, which was critical of his stance on privatisation of health services).12

In late 2005, reporters from the CMAJ began an investigation into the circumstances surrounding over-the-counter dispensing of the emergency contraceptive pill — the investigation became know as the Plan B story. They asked 13 women to purchase the pill and report the conditions for its procurement. They found that the women had been asked private and personal questions by pharmacists, in accordance with the guidelines of the Canadian Pharmacists Association (CPhA). On learning of the investigation, the CPhA complained to the CMA that the exercise was not investigative journalism, but research, and thus should have had ethical approval. They also objected to what they considered to be covert observation of pharmacists. Hoey was instructed by CMA executives to pull the article; he did not, but when it appeared, details of the personal questions had been expunged. This was tantamount to censorship.

After complaints by privacy commissioners following the publication of the story, the CPhA instructed its members to desist from extracting private information from consumers. However, the damage to CMAJ editorial independence had been done. This blatant breach was publicly exposed in a CMAJ editorial in December 2005, which noted that, “As a serious vehicle for science, news and opinion, CMAJ cannot avoid the discussion of contentious issues. It is not unexpected for tensions to arise between the association and the journal from time to time, for our mandates are not the same.”13

To bring the matter to a head, Hoey asked an ad hoc committee of the editorial board to review matters related to the handling of the Plan B story. During its deliberations, the committee’s attention was drawn to further instances of tampering with another news item — the Tony Clement story. This article, which was critical of Clement’s stance on privatisation of health services, was published electronically on 7 February 2006, but was subsequently removed from the website. It reappeared on 22 February 2006 as a different report, less critical of the Minister and more in harmony with the CMA stance on privatisation. The full texts of both versions are detailed in the final report of the ad hoc committee, chaired by Jerome Kassirer, the previous Editor-in-Chief of the New England Journal of Medicine, and with high-level individuals in medical publishing, journalism and academic medicine as members.12

After duly examining all relevant issues, the committee dismissed the complaints of the CPhA and reaffirmed the legitimacy of responsible journalism as an integral part of modern medical journals, drawing attention to this practice in the Lancet, BMJ, Science, Nature and the Journal of the American Medical Association. Significantly, it suggested that the CMA and CMA Holdings had a decision to make: either support editorial independence or run the risk of the CMAJ degenerating into “an association rag.” The committee also noted that, “Despite claims by the CMA, . . . the editorial autonomy [of the CMAJ] is to an important degree illusory” and that “Publishers have the option of dismissing an editor who exhibits a pattern of incompetence, misconduct or fiscal irresponsibility. As long as editors hold their position, however, they must be free to make editorial decisions independently of the ideological, strategic or commercial interests of the publisher. The editor’s conduct should be judged against the ideals of the medical profession and against standards of accuracy, precision and fairness. Editorial decisions should not be judged against the particular aims of the CMA.”12 In this context, the CMA President, Ruth Collins–Nakai, more recently revealed that “irreconcilable differences” between the editors and the publisher of the CMAJ were the real reasons for the sacking of Hoey and Todkill.14

Publishers and editors worldwide now await with interest the findings of the Lamer panel. Meanwhile, what can we learn from the CMAJ crisis? Editorial independence will only work if there is a clear understanding between owners and editors of journals as to a journal’s mission, and the empowerment of an editor or groups of editors to implement this mission and to be responsible for the cover-to-cover content of the journal. Essential to this process is the trust that editors will realise the stated ideals by making sound decisions and, at the same time, enjoy the freedom to publish controversial material, even when this is at odds with the purpose, politics and practices of the body owning the journal. In short, editorial independence is built on mutual respect, open communication and a clear understanding of boundaries.15 These appear to have been in short supply in the Hoey affair.