I was surprised when the Canadian Medical Association Journal (CMAJ) asked me to write an analysis piece on Canada’s medical laboratories. My book, False Positive, clearly lays out my position that for-profit labs have no place in our health care system, which is at odds with the close, and profitable, relationship between the labs and many doctors. And I am a well-known critic of private health care delivery in general, a policy option that many doctors organizations have not supported.
Regardless, I was interested because an article in the CMAJ would reach a different audience than I had already reached with the book and spin-off speeches and articles. The CMAJ also wanted an international component. I know little about international laboratory services and was interested in learning. So I spent the summer investigating lab services in the United Kingdom and Australia.
When I submitted my first draft the editor said there was too much international content and what they really wanted was a focus onCanada’s services. Oh well, information and perspective gained, and the rewrite was easy, after all most of the data came from my own research.
The next draft was accepted for peer review. Two of the three reviews came back quite positive including comments such as, “a well written and researched paper. The results are interesting and worth disseminating.” The third reviewer felt that the article was too biased against for-profit labs, but provided nothing to refute the core evidence. A third draft was submitted based on the comments of the three reviewers.
So far the process had been fairly normal, but now it moved into the unusual. My rewrite, which met many of the concerns of the reviewers, was now deemed to be too biased by the editors but good enough to print as long as an article in favour of the private labs was included as well. They felt a need for balance. Again, they did not dispute the claims made in the article, including facts that have been used to support for-profit laboratories, only its perspective.
If the CMAJ is suggesting that to be publishable articles must incorporate more than one perspective almost none would be published. The research and analysis must be rigorous and defensible on peer review, criteria the article seemed to have met. The editors suggested, I guess to try and preserve some sense of integrity, that they would solicit another article supporting private labs and print both articles.
While I thought this was strange, I had no objection and agreed to this approach. Three months later I received a letter stating that the editors had, “not been able to attract the appropriate author to write [a paper in favour of private laboratories],” so my article was rejected. My first thought was that maybe they could not find an appropriate, I assume academic, author because there is a lack of credible evidence supporting the use of private labs. Those involved in the private laboratory industry would also not have agreed to engage in the debate because they prefer to “fly below the radar.” This is a political strategy that has been very profitable for them and it is a shame that the CMAJ would enable this lack of accountability.
As well as the organized medical profession’s intimate relationship with the private medical laboratories in four provinces the Canadian Medical Association (CMA) has been accused of trying to influence the CMAJ’s editorial policy. Five years ago the CMA relationship with the CMAJ came under intense international scrutiny after the firing of editors and resignations from the editorial board following allegations to this effect. Both the very unusual path my article took and the CMAJ’s history again call into question the journal’s independence.
My position that for-profit corporations should not be involved in the delivery of publicly funded health care is controversial but not unreasonable. It is defensible, has strong factual support and is part of an important debate on the future of our health care system. It is unfortunate if the CMAJ lets fears about upsetting the private interests of sections of the medical community override its mandate to present solid information and discussion on health care policy.