The mechanics of the ghostwriter’s job are fairly simple, David says. Early on, a medical-communications agency and its pharmaceutical-company sponsors will agree on a title for an article and a potential author, usually an academic physician with a reputation as a “thought leader.” The agency will ask the thought leader to “author” the article, sometimes in exchange for a fee. The ghostwriter will write the article, or perhaps an extended outline containing the message the company wants to transmit, and send it along to the physician, who may make some changes or simply sign it as written and submit it to a journal, usually scrubbed of any mention of the ghostwriter, the agency, or the pharmaceutical company. David says he rarely even sees the published articles he writes.
Every so often, the issue of ghostwriting moves out of medical schools, where it is generally tolerated or ignored, and into the wider public sphere, where it is treated as a moral scandal. The most recent burst of outrage came in July during an investigation by the U.S. Senate Finance Committee, which has been looking into whether GlaxoSmithKline tried to steer attention away from the cardiac risks of its diabetes drug Avandia (whose use was recently restricted by the Food and Drug Administration). The committee found not merely that GSK had “downplayed scientific findings” to minimize the apparent risks of Avandia, but that it had used a ghostwriting campaign for the drug. (The company had called the ghosting effort “Case Study Publication for Peer Review,” or CASPPER.)
Ghostwritten articles surface again and again in litigation (in cases concerning Vioxx, Fen-Phen, Zyprexa, Premarin, Neurontin, and Zoloft, to mention just a few). Years before the Avandia scandal, GlaxoSmithKline paid $2.5 million to the State of New York to settle a lawsuit alleging that it had concealed studies suggesting an increased risk of suicidal behavior in children and teenagers taking Paxil, most notoriously in an article “authored” by Dr. Martin Keller of Brown University. One 2003 study in The British Journal of Psychiatry found that ghostwriters working for a single medical-communications agency had produced more than half of all medical-journal articles published on Zoloft over a three-year period.
To many critics, the moral outrage of ghostwriting is like that of plagiarism: academic physicians are getting credit for articles they didn’t actually write. To David, letting someone else take the credit for his work is a minor humiliation. The real problem, of course, is much worse: spinning data perverts science. It also downplays risks that can lead to serious injuries, and deaths. As David puts it, “The moral crime I was being asked to commit was to do with truthfulness.”
In recent years, journals have strengthened their disclosure policies, but to little effect: most simply call for transparency (which can be dealt with by acknowledging the ghostwriter for “editorial assistance”), but allow the underlying moral crime to remain in place. In fact, the journal that published the notorious ghosted Paxil article, the Journal of the American Academy of Child and Adolescent Psychiatry, has not even retracted it. Doctors unfamiliar with the scandal have no reason to suspect the article is misleading.