Intellectual freedom: an endangered basic requirement of scientific publishing

Giovanni A. Fava1

1Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, Usa.

Summary. The intellectual capital of medicine is the creativity linking clinical practice and research. Intellectual freedom, that allows the emergence of new paradigms, is the basic component of scientific progress in medicine. There have been major threats to intellectual freedom in the past decades: financial conflicts of interest that allowed the drug industry to gain control of scientific societies, clinical practice guidelines and reporting investigations in meetings and journals; special interest groups suppressing the pluralism of viewpoints; financial thresholds for investigators reporting their data and views (open access journals); the totalitarian derive of Evidence-Based Medicine. Further, there have been growing attacks of publishers to the independence of editors and editorial boards, with the ensuing resignations of editors and members of the editorial boards. Such events recently occurred in a journal, Psychotherapy and Psychosomatics, that was a symbol of independent thinking, pluralism and innovations.

Key words. Censorship, conflicts of interest, intellectual freedom, medical journals, open access publications.

Libertà intellettuale: un requisito fondamentale dell’editoria scientifica a rischio.

Riassunto. Il capitale intellettuale della medicina è la creatività che lega la pratica clinica alla ricerca. La libertà intellettuale che fa emergere nuovi paradigmi scientifici è la componente essenziale del progresso in medicina. Negli ultimi decenni ci sono state importanti minacce alla libertà intellettuale: i conflitti di interesse finanziari che hanno permesso all’industria farmaceutica di acquisire il controllo delle società scientifiche, delle linee guida e delle modalità di riportare la ricerca nei convegni e nelle riviste; i gruppi di interesse speciali con il compito di sopprimere il pluralismo in ambito scientifico; le soglie finanziarie per pubblicare dati e opinioni nelle riviste caratterizzate da “open access”; la deriva totalitaria della medicina basata sulle evidenze. Inoltre, ci sono stati crescenti attacchi alla indipendenza delle riviste scientifiche, con conseguenti dimissioni di direttori e comitati editoriali. Un esempio di questi attacchi è quanto è successo recentemente a Psychotherapy and Psychosomatics, un simbolo di indipendenza, pluralismo e innovazioni.

Parole chiave. Censura, conflitti di interesse, libertà intellettuale, pubblicazioni open access, riviste mediche.

Introduction

For three decades (1992-2022) I was editor-in-chief of a medical journal, Psychotherapy and Psychosomatics, that over the years achieved a specific connotation in fostering innovations and critical thinking at the interface between behavioral and medical sciences1. It became a top journal in psychiatry and psychology. In 2022, when the publication reached the Impact Factor of 25.62, I thought that it was time for me to leave my position in Psychotherapy and Psychosomatics and to hand the baton to the two associate editors. Upon their request, I remained as honorary editor, acting as consultant in special cases.

On Dec 11, 2024, the editors and assistant editors of Psychotherapy and Psychosomatics were suddenly replaced by a managing editor, an employee of the publishing house (Karger) of the journal. The stated reason communicated to one of the editors was that it was “time for the journal to take a new direction”, despite its international standing. The decision was taken without consulting the honorary editor and the editorial board. As a result, the honorary editor, the statistical consultants and the vast majority of the members of the editorial board resigned from their positions. There were hundreds of protests, from all over the world, against the editorial demise of the publication. What happened to Psychotherapy and Psychosomatics was astonishing in view of the journal’s reputation and scientific standards, that could not be assured by a managing editor. The event was however in line with the growing attacks of publishers to the independence of editors and editorial boards, with the ensuing resignations of editors and members of the editorial boards that have occurred in recent years2. On May 1, 2025 an editor-in-chief was added to the managing editor and the small group of members of the editorial board who had decided to stay. In June 2025, the new journal’s impact factor was released; it was concerned with the citations Psychotherapy and Psychosomatics received in 2024 for the papers published in 2022 and 2023. The journal’s ranking (third both in psychology and psychiatry) was in sharp contrast with the Karger’s decision to start a new editorial line.

I have realized that my journey as an editor and what happened more recently reflect the many changes that have taken place in scientific publishing in medicine in the past decades. In this editorial I will share the insights that I have progressively gained, with particular reference to the decline of intellectual freedom.

Increasing threats to intellectual freedom

From the beginning of my tenure, I realized that being a clinician, a researcher and an editor were inextricably linked. As a clinician I could discern whether a study made any sense and contained clinical implications. As a researcher I could evaluate the methodological structure of an investigation. My appraisal not only complemented that of the reviewers, but was also a key factor in interpreting the quality and unavoidable biases of their judgments. I could not understand (and still wonder) how one could run a journal without having first-hand experience of the topics that it covers and of the practical difficulties in performing research. Kuhn reminds us that novelty in science emerges with difficulty, against a background of strong resistance3. The intellectual capital of medicine is the creativity linking clinical practice and research. The development of models and innovations that may provide better explanations of clinical phenomena strictly depends on this interaction. I decided that the journal’s mission was to foster innovative thinking and research, and such mission had total intellectual freedom as a basic requirement2. In all cases we were open to host (and did publish) dissenting views.

In those years I gave intellectual freedom for granted and I underestimated a number of threatening phenomena which started occurring in the Nineties.

Conflicts of interest

One saturday afternoon, I was browsing magazines in a bookstore in the United States. I found an article dealing with financial conflicts of interest in medicine. I did not know much of the topic; the journalist mentioned a study that looked very interesting, but I was unable to track it in the usual databases. I wrote to the Author of the investigation and he explained to me that it was not retrievable because no journal wanted to publish it. For the first time the investigation indicated that one out of 3 articles in major journals had at least one author with substantial conflicts of interest. I invited him to submit the paper to us and, after peer review, it was published4. Three years later, the same group reported on the lack of effectiveness of disclosure policies in medical journals5. Also, in view of those publications4,5, the issue of financial conflicts of interest in medicine could no longer be ignored6,7. Researchers with major financial conflicts of interest were not simply the easily recognizable prodigal experts who moved from one meeting to another to illustrate the wonderful properties of the drugs to be launched, who had their slides prepared and checked by the companies, and who signed ghostwritten papers8. They became also the gatekeepers of corporate interest in scientific information. They acted as editors, reviewers and consultants to medical journal, scientific meetings and non-profit research organizations, with the task of systematically preventing dissemination of data which may be in conflict with the financial interests they represent6,7. Progressively, the drug industry gained control of scientific societies, clinical practice guidelines and reporting investigations in meetings and journals. Censorship is a major component of such control and may take different forms: direct suppression of information by individuals who act as editors and reviewers or make choices in scientific programs; careful selection of the literature in a biased direction and manipulated interpretation of clinical trials (including those supported by public sources); self-censorship (when an investigator omits of raising questions and criticism for the fear of retaliation)6,7. Determining whether censorship occurs may be difficult in scientific publishing, particularly in the case of journals that have a very low acceptance rate (for instance, in the journal I edited around 15% of submitted papers). Was a specific paper rejected because of low quality, similar papers in the journal, lack of space or for other reasons? It is difficult to establish. However, when a journal never publishes any paper dealing with specific topics (e.g., side effects of medications) the suspicion of censorship arises. Pursuing intellectual freedom, I decided to host topics that could not find room in other journals, such as the withdrawal reactions ensuing with antidepressant medications1, that were masked as discontinuation syndromes by the industry9.

In the first decade of the new millennium the reactions to the devastating effects of financial conflicts of interest were mainly in the lay press. However, such reactions subsequently faded. Recently I was asked to review a paper submitted to a pharmacology journal by well-known investigators. The paper was conceived by the company which owned the drug patent, written by a medical writer and simply approved by those who appeared as authors, who had a start-up dealing with the products that were discussed. When I raised these problems to the editor, together with highly questionable and unsubstantiated statements in the text, her response was that “everything had been duly disclosed”. The paper was then published, despite my suggestion to reject it. Current trends as to financial conflicts of interest thus suggest transparency on the surface, but business as usual underneath.

Special interest groups

Corporate interests result in special interest groups, that, by virtue of their financial power and close ties with other members of the group, have the task of systematically preventing dissemination of data which may be in conflict with their interests6. Their target is to undermine the critical individual judgment of the clinician. Such groups include also researchers who may not receive direct financial incentives for their participation, but may benefit from power and visibility they would not otherwise enjoy, which may explain how mediocre scientists may get important positions10. Mediocrity supports the power structure, which, in turn rewards it adequately10. As a result, the number of authors of papers has dramatically expanded and one could easily identify the same group of investigators who simply rotate in the order of authorship of papers (particularly reviews). Authors are looking for increasing their h index and these collective papers, that entail the considerable the support of self-citation by an influential group, seem to be perfect for achieving this goal. Those who do not subscribe to these totalitarian views are likely to be emarginated, particularly the young investigators who, because of their questioning that may lead to new discoveries, are the lifeblood of science11. Typical reviews today appear to be rigorously ghost-written, with as many key-opinion leaders as possible as authors (better if they do not even remember or realize what they have signed, as I had the opportunity to verify in many cases by casual chats), and the general conclusion is that more studies are needed.

Publishers’ greed

When I started being an editor, the vast majority of journals were subscription based. Publishers derived their income by subscriptions, reprints, and advertisements. All editorial correspondence took place by mail. My contact with the publisher occurred only when I sent the accepted papers. In the publishing house accepted papers were re-typed and, quite surprisingly, the outcomes (proofs) were more accurate than what occurs today with computer files. The publisher had no track of what had been submitted and rejected. The editor’s freedom was complete. When publishers, however, realized that the subscription potential of libraries was getting less and less, the open access formula was invented: with the excuse of making the articles available without any paywall authors had to pay for their publication. This meant limiting the opportunity to publish to authors whose work is supported by grants and/or to those who are loaded with conflicts of interest and have private firms behind them, and/or those who work in institutions that may pick up the bill12. Truly innovative research, however, is unlikely to be funded, also by public sources. Further, the reporting of side effects which may occur serendipitously is also unlikely to be funded. From the author’s perspective open access publications are like a restaurant in which the customers cook the meal and then pay the bill13. Setting a financial threshold for publishing thus became a major threat to intellectual freedom12. Creative investigators, particularly in their initial phase, may encounter difficulties in communicating their insights and pilot data that are likely to trigger changes in paradigms, as Kuhn suggested3. Further, open access triggered another change in the structure and aims of publishing houses: the search for additional sources of income. Max Weber’s notion of greed14 may describe these trends. At the beginning of my career as an editor there was a clear distinction (with mutual respect) between editing and publishing; such differentiation became blurred. Publishers hired employees with a doctorate, but no academic experience, who thought they had a saying about running journals and make them more profitable. The role of managing editor is a common expression of the direct influence of the publisher on the journal’s editorial work and choices. While I was able to protect Psychotherapy and Psychosomatics from becoming open access, I experienced increasing pressures on shaping the aims of the journal on lucrative business, while the publishing house did not seem to be particularly concerned about the quality deterioration of the production process. I missed the typists of the Nineties, their care and brightness, so much.

The decline of pluralism and the intellectual crisis of medicine

Thomas Kuhn3 clarified that scientific revolutions are initially restricted to a small segment of the scientific community, but progressively lead to a more general awareness that a paradigm, previously leding the way, has ceased to function adequately. Conflicts of interest, whether of financial or non-financial nature7, special interest groups6, and setting financial thresholds to publishing12 are major threats to the preservation of intellectual freedom in medical research.

Beliefs and practice contrary to the orthodox doctrine, to what is normally accepted and maintained, may be a valuable source of conceptual progress3. If we silence heretics (according to the Greek root of the word, people who make their own choices), we are condemned to intellectual stagnation15. Such stagnation is ultimately likely to produce harm also to the industry.

A single pathophysiological model or therapeutic strategy is unlikely to entail solution to all clinical situations that occur under the umbrella of a single diagnosis16. As one of the founders of Evidence-Based Medicine (EBM) remarked17, there is no single right decision in a specific clinical situation and one should evaluate the potential harms and risks of each therapeutic act. Indeed, the model of EBM was originally articulated in a way that highlighted the many sources of knowledge and how they could be integrated with judgment in the shared decisions for the care of the whole person18. However, in the following years, vested interests and lack of familiarity with clinical issues conveyed the message that there is only one option for treatment of a specific condition. The totalitarian derive of EBM clearly emerges when dissenting views are expressed. Meta-analyses are geared to the average patient and to highlight only benefits16,19. Commercial interests may further drive this tendency. The net result is the production of authoritarian guidelines, with the suppression of pluralism. In such guidelines, endorsed by scientific societies liable to conflicts of interest7, the prescribing clinician is driven by an overestimated consideration of potential benefits, paying little attention to the likelihood of responsiveness and to potential vulnerabilities in relation to the adverse effects of treatment16. Preservation of and support to pluralism are thus key to addressing the increasing challenges of current clinical research15,20.

The majority of what gets published in clinical journals nowadays does not seem to convey any clinical implication15. Influential randomized trials are generally done by and for the benefits of the industry; guidelines serve vested interests; national and federal research funds are unable to address basic clinical questions; reviews are very generic and their frequent conclusion is that the evidence is too limited and further studies are needed21,22. In addition to lack of familiarity of researchers with clinical practice who are unable to elaborate adequate research questions15,23, the decline of pluralism and a clear avoidance of issues that may raise questions about prescription practices are responsible for the current intellectual crisis of clinical research24.

Halstead R. Holman, in a paper published in 1976 which anticipated some developments in health care of the following decades, observed that «[…] the medical establishment is not primarily engaged in the disinterested pursuit of knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power. The concept of excellence is a component of the ideological justification of that role»25(p.11). Holman identified a decline in intellectual freedom as a major source of the “excellence deception”, which perpetuates prevailing practices, deflects criticism, and insulates the profession from alternative views and social relations that would illuminate and improve health care25.

Conclusions

In recent years there have been many cases of attacks of publishers to the independence of editors and editorial board, with the ensuing resignations of editors and members of the editorial board2. What happened to Psychotherapy and Psychosomatics, with a new course of the journal that has very little to do with its orientation in the past three decades, is particularly serious, since it involved a publication that had become a symbol of independent and innovative thinking. Intellectual freedom is the basic component of scientific progress in medicine. All types of threat should be a source of reflection and call for action. If medical knowledge is the cumulative experience of human history, «a legacy from those who have gone before to those who live today»25(p.21), we will be speaking of ourselves and the moral and intellectual values we share.

Conflict of interests: the author has no conflict of interests to declare.

References

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