The level of concern about conflicts of interest in medical literature is at an all-time high. A recent Neurology editorial¹ and American Academy of Neurology (AAN) position statement² focus on financial conflicts of interest in the patient care setting, in academic institutions, and for members of AAN committees and AAN office holders. Equally important conflicts of interest pertain to the publishing of Neurology.

A conflict of interest exists when an individual (e.g., an author, reviewer, or editor) must make a judgment concerning a primary interest (publishing high-quality research), but is unduly influenced by secondary interests (such as financial gain or personal relationship to an author or others).³ In Thompson's view of conflict-of-interest situations,³ the secondary interest is usually legitimate and may be a necessary and desirable part of the life of the professional who must make such judgments. Thus, the secondary interests only become an issue when they are given sufficient weight to perhaps inappropriately influence judgment, whether or not the judgment is altered. Because a conflict of interest may impair the integrity of judgment, or cause reasonable persons to believe that the judgment has been improperly influenced,^3-4 conflict-of-interest situations are usually regulated to prevent this actual or perceived impairment of judgment. The two main features of regulation are disclosure that a conflict of interest exists and prohibition or avoidance of certain conflicts of interest. The decision to prohibit certain conflicts of interest is based on the likelihood that professional judgment will be influenced, or appear to be influenced, and that this could lead to serious harm.

Secondary interests are typically financial relationships, but academic competition, intellectual passion, personal relationships, and political and religious beliefs are also important. Financial conflicts of interest are particularly important, and are both objective and potentially amenable to mitigation. According to the International Committee of Medical Journal Editors, authors are responsible for "recognizing and disclosing financial and other conflicts of interest that might bias their work."⁴ By acknowledging all financial support and other financial or personal connections to the work, authors take the minimum step necessary in mitigating potential financial conflicts of interest. The readership is able to judge for themselves what level of skepticism may be appropriate for the given degree of conflict.²

Mandatory disclosure of conflict of interest for authors is only effective if all authors are named. Honorary authorship has received considerable attention⁵ (e.g., listing of authors who do not fulfill criteria for authorship), but is not a major problem in terms of conflict of interest. The opposite situation, ghost authorship, poses major problems. Ghost authorship is the intentional omission of an individual from the list of authors, despite the fact that the person qualifies for authorship and may have played an important role in drafting the manuscript and "shaping" its message. Ghost authorship is frequent in review articles⁵ and there is a perception that these individuals are often employees or representatives of pharmaceutical companies.⁶ By omitting such "ghosts" from an authorship list, the authors and sponsors avoid the need to disclose their conflicts of interest. The International Committee of Medical Journal Editors' Guidelines indicate that credit for authorship should be based on substantial contributions to conception and design or analysis and interpretation of data, drafting the article or revising it critically, and final approval of the version to be published. Therefore, in all submissions to Neurology (including supplements to Neurology), the corresponding author must list all individuals qualifying for authorship and verify that all those individuals are listed as authors. If an individual other than one of the authors listed was responsible for the initial draft of the manuscript, the corresponding author must tell the editors who that person was and give an explanation for why that individual is not listed as an author.

The International Committee of Medical Journal Editors' Guidelines state that all financial relationships that may pose a conflict of interest must be listed on the title page of the submitted manuscript.⁷ Neurology requires authors to disclose financial conflicts of interest. Specifically, the authors should identify the following relationships with commercial sponsors: research grant or contract support administered through an academic or research institution; personal compensation (as opposed to institutional salary support) through contracts, grants, honoraria, fees or salary and whether this is less than or in excess of $10,000 per year, and personal financial investment including ownership, and equity or other financial holdings; and whether this is less than or in excess of $10,000. Although disclosure helps to mitigate the effects of these conflicts of interest, the Editors will continue to consider whether certain conflicts of interest are serious enough (e.g., equity ownership) to prohibit authorship.

Reviewers are subject to the same conflicts of interest as authors. Financial conflicts of interest and academic rivalry are the most common. Current standards require that reviewers disclose to editors any conflict of interest that may bias their opinions and they should voluntarily disqualify themselves from reviewing specific manuscripts if they believe it appropriate.⁴ The reviewers must make sufficient disclosure of financial (and other) conflicts of interest so that the editors are able to judge whether the reviewers should be disqualified. Written disclosure has not been required of Neurology's external reviewers, but we have required that they report conflicts of interest, financial and otherwise. We will now ask our reviewers to disclose conflicts of interest as a written part of their confidential comments to the editor. In general, anyone with a personal financial conflict in excess of $10,000 should not review a paper.

Editors are subject to similar conflicts of interest. Current guidelines state that editors should have no personal financial involvement in any issues where they are able to make final decisions.⁴ Editors are thus in a difficult position of deciding for themselves when a personal financial conflict of interest exists, as well as assessing the seriousness of conflicts of interest on the parts of reviewers and authors. There are few mechanisms for oversight of such editorial decisions. One means of addressing this that has been successful is the appointment of an ombudsperson whose task is to receive and address complaints about the editorial process.⁸ The editors of Neurology along with the AAN will consider the feasibility of such a process for this journal. Some oversight of Neurology is provided by the AAN and its Board of Directors. Currently, concerns about inappropriate editorial processes or action can be addressed to the Academy President and the Board. In addition, the Editors are required to disclose conflicts of interest to the AAN, and will categorize those conflicts as outlined. Although the Academy guidelines do not specify dollar amounts,¹ we will abide by a $10,000 limit for annual personal compensation from any industrial or commercial sources.

From the editors' perspective, the primary interest of the journal Neurology is to publish high-quality medical research. Another potentially competing interest is providing educational services, and publishing supplements to Neurology supports that interest. Studies of the medical literature have shown that articles published in journal supplements are often of lower quality and more likely to have product promotional material than articles that are published in the parent journal.^9-10 In an effort to avoid this situation with Neurology, in addition to the guidelines published previously,¹¹ we are asking authors to comply with the following:

1. Manuscripts submitted for supplements must explicitly state who produced the original draft of the manuscript.
2. The manuscript must explicitly state whether the authors received personal financial compensation for their authorship.
3. If the supplement is a report of a symposium, the manuscripts must state whether the presenters received personal compensation for their presentation at the symposium.

References

1. Bernat JL, Goldstein ML, Ringel SP. Conflicts of interest in neurology. Neurology 1998;50:327-331.
2. Ethics and Humanities Subcommittee. American Academy of Neurology Policy on Conflicts of Interest. Neurology 1998;50:332-334.
3. Thompson DF. Understanding financial conflicts of interest. N Engl J Med 1993;8:573-576.
4. International Committee of Medical Journal Editors. Conflict of interest. Lancet 1993;341:742-743.
5. Flanagin A, Carey LA, Fontanarosa PB, et al. Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals. JAMA 1998;280:222-224.
6. Rennie D, Flanagin A. Authorship! Authorship! Guests, ghosts, grafters, and the two-sided coin. JAMA 1994;271:469-471.
7. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. JAMA 1993;269:2282-2286.
8. Horton R. The journal ombudsperson. A step toward scientific press oversight. JAMA 1998;280:298-299.
9. Rochon PA, Gurwitz JH, Cheung M, Hayes JA, Chalmers TC. Evaluating the quality of articles published in journal supplements compared with the quality of those published in the parent journal. JAMA 1994;272:108-113.
10. Bero LA, Galbraith A, Rennie D. The publication of sponsored symposiums in medical journals. N Engl J Med 1992;327:1135-1140.
11. Kieburtz K. Policies on reporting clinical trials and publishing supplements. Neurology 1997;49:2-3.