An editorial on editorials

How well do our lead editorials in CMAJ reflect the opinions and sentiments of Canadian physicians? Judging from the feedback we receive, sometimes well, sometimes poorly — assuming that medicine can be fairly represented by any one, cohesive view. Is it our job to represent the filtered view of the majority? We don't believe that it behooves journalists in any guise to say things merely for the sake of being provoking. At the same time, if our commentaries caused no discomfort to anyone (including ourselves) we would worry even more than we usually do about how well we are doing our job.

And discomfort does arise, from time to time. Some have taken offence that their journal, published by their association, prints commentary that appears unsupportive, harsh, or simply out of touch. Some readers feel that any criticism of the actions of physicians, especially in these beleaguered times, is misplaced in a journal published by their national association. We constantly remind journalists, and take this opportunity to remind our readers, of the arm's-length relationship that CMAJ has enjoyed with the CMA, a policy of editorial independence formally endorsed by the International Committee of Medical Journal Editors,1 of which CMAJ is a founding member, that assures the autonomy of the journal and safeguards its credibility.

Some readers have expressed the view that any comment on international politics is inappropriate in our journal: the medical profession, or medical journal editors at the very least, they argue, should stay out of political debate. For our part, we fail to see how health can be viewed as apolitical, or how medicine can be practised in an ideologic vacuum. Even though medicine strives toward humanitarian ideals that it perceives as universal, all human action occurs in social and political contexts. Political circumstances and events have important consequences for health, and physicians need to be aware of issues such as trends in international aid, the destruction of health infrastructures as a consequence of war, the impact of international trade agreements on health services, the Kyoto protocol, and more local matters such as health care restructuring, drug postmarketing surveillance or government intervention in the staffing of emergency departments.

Medicine is an intellectually robust profession with a long history of self-examination and self-critique. Much of that critique has been scientific. The randomized controlled trial (RCT), that exemplar of objective assessment, is largely medicine's child. Nor has the RCT itself been exempt from critique, as the Cochrane collaboration and the consensus-building rigours of evidence-based medicine show. And the scrutiny of methods and practice does not end there, for the limitations of evidence-based medicine itself are also debated.

Medicine's self-examination also extends into a humanistic concern with improving the quality and the character of the physician–patient relationship. Some of this self-questioning is a response to the double message that physicians seem to be receiving from an increasingly well- informed and dissatisfied public: that doctors should be infallible; that doctors have too much power. The white coat of healing is a heavy garment, and the responsibility it represents has engendered a long tradition of ethical self-examination in medical practice, and in medical journals.

In 1837 Thomas Wakley, a London physician and founding editor of The Lancet, vehemently criticized John Snow (the physician famous for removing the handle of the Broad Street pump) for taking the side (and money) of industry in a public debate in Parliament on the harm being done to human health by factories in London:

These bills have encountered formidable opposition from a host of “vested interests” in the production of pestilent vapours, miasms, and loathsome abominations of every kind. These unsavory persons, trembling for the conservation of their right to fatten upon the injury of their neighbours, came in a crowd, reeking with putrid grease, redolent of stinking bones, fresh from seething heaps of stercoraceous deposits to lay their “case” before the Committee.2

The Lancet has to this day continued to publish comment and editorial opinion on an exceedingly broad range of what we now call the “determinants of health” and has not hesitated to be critical of the medical profession itself. Other medical journals, especially those owned by medical associations, were slower to enter into public debate. However, in the 1940s and 50s, the British Medical Journal (now BMJ) began to do so, particularly during the editorships first of Ernest Hart and later Hugh Clegg, who were challenged by their publishers, the British Medical Association, for publishing articles of which the association disapproved.3 We found ourselves in a similar position at a meeting of the CMA's General Council in Quebec City in August 2001, when some council members challenged the independence of CMAJ's editors in selecting articles that were critical of the medical profession and in publishing opinion on matters of public policy that was at odds with stated policies of the CMA.4 More recently the CMA has objected to our comments on the public and moral responsibilities of physicians even when faced with repressive legislation — Quebec's Bill 114.5

These are trying times for the medical profession — so trying, that any criticism from within may be seen as treasonable. Caught between the unrealistic expectations of their high calling and an apparent desire of governments (and perhaps patients) to transform clinicians into biddable service providers, physicians find themselves between a rock and a hard place. As doctors and their representative bodies know, medicine is not just about seeing patients and treating them. The practice of medicine and the ethical and moral responsibilities of physicians and their professional associations do not end at the front door of hospitals and offices. The CMA and the Canadian provincial medical associations have all taken public positions on a variety of important issues, opinions often critical of government policy. These associations have also been outspoken and foresighted in defining and defending the rights of patients and the ethical and moral responsibilities of doctors.

With our editorial autonomy comes a duty to be responsive to our readers, to hold a mirror up to the range of opinion both within the profession and outside it and to allow the open exchange of conflicting views in our letters column, our commentary section, and indeed throughout the journal. The integrity of CMAJ rests on the intellectual rigour of our contributors, the thoughtful comments of peer reviewers, the advice of our editorial board, the diligence of our copyeditors and the efforts of our news writers and content editors to achieve balance in the presentation of information, ideas and events.

We take the hopeful view that the profession has the resilience and the honesty to persist with its longstanding habit of introspection on matters such as privilege and responsibility and the obligations of trust, power and professionalism. The process of self-scrutiny is multilayered, complex, dialectical, sometimes painful, and unending. It is a process that, ultimately, can only be constructive.