The vast majority of peer-reviewed scientific publications
have not yet moved into electronic publishing in spite of the tremendous
potential. Some of the major issues which remain unsolved include
questions of copyright, financial stability, and advertising. How
can journals be made available on the Internet and at the same time
protect their copyright to prevent unauthorized publication and
distribution of the journal which would undermine its financial
viability? How can electronic publication of journals be financed
to allow them to survive? Subscription revenue alone will not support
most journals, and currently advertising is not only critical to
their financial viability but is a useful source of information
for readers as well. Thus, advertising has been and will continue
to be necessary for the publication of the vast majority of high-quality peer-reviewed
scientific journals. However, advertising in an electronic medium
permits an interrelationship between the scientific material in
the journal and the advertisers that heretofore was not possible.
This creates potential and actual conflicts of interest.
Guidelines of Journal Advertising
The guidelines for handling advertisements vary from journal
to journal. Clinical Orthopaedics and Related Research manages
to survive in today’s marketplace without any advertising
revenue, relying entirely on its subscription revenue. The resultant
high subscription cost, however, limits its accessibility. The
Journal of Bone and Joint Surgery (JBJS) has a low subscription
cost and therefore relies in part on advertisements to remain financially
viable. JBJS separates advertisements from the
body of The Journal and places them in the pages
just before and after the scientific portion of The Journal.
This prevents any "connection" between peer-reviewed
publications and advertisements and maintains a high objective scientific
standard. However, advertising rates are determined not only by
the number of subscriptions but also by where the advertisements
are placed in The Journal. Much higher rates can
be charged when advertisements are placed among the scientific articles.
This is the standard for "throw-away" journals,
which come to your desk free of charge, as they are exclusively
supported by advertising.
Electronic publishing allows the intermixing of and access to
advertising materials in a way that is either not possible or not
as controllable as it is in hardcopy publishing. It is tempting,
for example, to sell advertising banners on a journal’s
home page, particularly if there is an article in that journal that
pertains to the advertiser’s product. How will this influence
the reader’s opinion of the validity of a scientific article
if there is a perception that the publication of the article may
have been influenced in some way by the payment for the banner ad?
If a scientific article concerns a particular drug or implant, is
it appropriate to allow a direct hyperlink to product information
on an advertiser’s web site? It might be convenient for
the reader to be able to click on the name of the generic item or
perhaps the brand-name item within the body of the scientific article
and be able to move directly to advertising materials. Potentially
more useful is supplementation of the written text with high-quality
videos of operations and other related information. However, production
of high-quality videos is very expensive and is usually supported
by manufacturers. It is possible to produce generic videotapes
demonstrating surgical techniques, but few manufacturers would do so
unless their product was featured in one way or another in the video.
These various links, while useful, permit the intermingling of advertising
bias with a strict peer-review process and thus create enormous potential
for conflicts of interest. How can we provide these enhanced learning
opportunities without threatening the integrity of our scientific
publications? It is a question important to all of us as the long-term
survival of our highest quality peer-reviewed scientific
journals appears to be threatened. The enormous advantages of electronic
publication mandate that our best journals take on the challenge
of electronic publishing, and in the long run, this will best serve
the needs of our patients.
Ethical Guidelines for Internet Publishing
The Journal of the American Medical Association (JAMA) has
developed guidelines for the publication of medical and health information
on the Internet1 (Table 1), in
recognition of the wide variation in the quality of content, the
potential for industry to influence the content, and the uncertainty
of preserving personal privacy. In this article, the American Medical Association
(AMA) proposes principles to guide the development and posting of
web site content, to govern the acquisition and posting of online
advertising and sponsorship, and to ensure site-visitors’ and patients’ rights
to confidentiality and privacy. At the same time, there are provisions
for secure and effective means of electronic commerce.
In 1995, the AMA published Principles Governing Advertising
in Publications of the American Medical Association2, and this was followed by an editorial
in JAMA proposing a set of quality standards for medical information
on the Internet3. These standards
included proper identification of contributors and authors; disclosure
of the ownership of web sites; policies for the disclosure of site
ownership; financing, advertising, and potential conflicts of interest;
and a requirement that dates of initial posting and updating of
content be recorded. The AMA and six other founding societies recently
launched Medem, a web site providing health-information
for the public, and it was in preparation for this launch that the guidelines
for the AMA web sites were developed by Winker et al.,1 members of an AMA staff committee.
Silberg, Lundberg and Musacchio3 have
previously warned web users about incomplete, misleading, and inaccurate
medical information available on the Internet. Although some web
sites and organizations have provided rating systems to evaluate
the quality of information available on the Internet, the criteria
used to assess quality are not often available nor is provision
of any means of assessing the reliability and validity of their
measures4,5,6. Silberg et al.
pointed out that assessing the quality of content in electronic
media requires the same information needed for print publications;
such assessment depends upon the quality and the integrity of the author’s
content, appropriate attribution, timeliness of publication, and
complete disclosure of funding and competing interests3.
Although less of a concern for professional readers, public access
to web sites permits tracking of the users’ reading habits,
with possibly improper disclosure of confidential information. A
survey by the California Health Care Foundation7 found
that preservation of personal privacy was the most important concern
of Internet users seeking medical information, and although many
Internet health-information web sites have policies regarding preservation
of privacy, most do not follow them8.
This concern about privacy is shared equally by the professional
users of a journal’s web site, where a reader’s
choices, whether they be scientific articles or advertisements,
should not inadvertently be made available to industrial interests
and advertisers without the reader’s knowledge and permission.