Issues in Medical Ethics is in now in its tenth year of publication. It has been years of voluntary effort and the commitment of a few, on a shoestring budget, that have seen the journal through. Bringing out each issue has been demanding. The editorial board is still voluntary and there is no full time staff. We still share an administrative office and our income is mainly from subscriptions. Things haven’t got easier over the years. We have been helped by the occasional grant from an institutional donor. Overall, it has been an uphill struggle all the way.

We wrote to 12 editors in this field around the world to find out how they survived financially. They are:
Robert Veatch, Director, Kennedy Institute of Ethics Journal, USA,
Gregory Kaebnick, Editor, Hastings Center Report, USA,
Bette-Jane Crigger, Editor, IRB: Ethics & Human Research (a Hastings Center publication), USA,
Udo Schuklenck, Co-Editor Bioethics and Developing World Bioethics, South Africa,
Julian Savulescu, Editor, Journal of Medical Ethics, UK ,
Richard Nicholson, Editor, Bulletin of Medical Ethics, UK,
Arthur Caplan, Center for Bioethics, University of Pennsylvania, USA,
Leslie LeBlanc Executive Editor, The Journal of Clinical Ethics, USA,
Darryl Macer, EUBIOS Journal of Asian and International Bioethics, Japan,
Lynley Anderson, Editor, New Zealand Bioethics Journal, New Zealand,
Merle Spriggs, Editor, Monash Bioethics Review, Australia, and
Deborah Zion, Editor, Monash Bioethics Review, Australia.

We asked them questions on the general structure of funding available to the journal, the nature of academic affiliation, their attitude towards advertising and raising non-subscription funds, the strategies they adopted to increase circulation, and how they handled potential conflicts of interest. On another note, we asked about their experiences and financial fallouts of putting up journal content on line . A collation of responses of the nine editors who replied is detailed below.

Sources of funding and associated ethical dilemmas

1. Journal subscriptions: These alone accounted for the major chunk of the income of the medical ethics journals.
2. Contribution and grants: Individuals, private philanthropic organizations made these contributions along with a limited number of corporations some of which were health related. Mechanisms suggested to avoid conflict of interest were:
   1. Editorial staff should not be involved in fund raising;
   2. Funders should not have any control over the content of the publication, and
   3. Industry funding should make up only a small portion of overall revenues.
3. Advertising in journals: If journals carry advertising these must not be allowed to influence editorial decisions. Editors must have full responsibility for advertising policy and must ensure that existing standards for advertisements are enforced. Journals should not be dominated by advertising but editors should be careful about publishing advertisements from only one or two advertisers.

Funding problems

The usual sources of funds were subscriptions, grants (institutional or industry), and advertisements. Resources were usually available in terms of administrative space and support, and in voluntary work in peer reviewing articles, etc.

Subscriptions alone accounted for the major chunk of the income of medical ethics journals. The Kennedy Institute of Ethics journal and The Journal of Clinical Ethics derived all their income from subscriptions. They did not accept advertising. Gregory Kaebnick writes that Hastings Center Report does get non-subscription funds: “The shortfall is managed through unrestricted charitable contributions. Individuals, private philanthropic foundations, make those contributions, along with a limited number of corporations, some of which are health-care related. A small percentage of funders come from industry, and they are periodically lost because of material published in the journals.” This raises important concerns about conflicts of interest that accompany large contributions or grants. Each journal’s way of coping with this problem is described below.

The editorial board of Issues in Medical Ethics recently reexamined their own attitudes towards advertising and conflicts of interest. A pharmaceutical company offered to distribute a CD containing all volumes of Issues in Medical Ethics produced between 1993 and 2000. It would have the right to distribute the CD to any doctor around the country without changing its format or jewel case.

Eighteen editorial board members were asked to vote. Eleven members voted for the offer, four against, one preferred to remain neutral and two did not vote.

An important argument in support of the offer was that if a product had been produced for sale, and someone wanted to buy it (be it a pharmaceutical or anyone) and in turn distribute it to a target audience of physicians, the product could not be withheld, because it was produced to be sold.

The arguments against accepting the offer were: any association with a pharmaceutical firm amounted to promoting the company as the latter was piggy-backing on the journal’s credibility; it was like taking an advertisement.

This exercise brought to the fore the difficulties of accepting or denying associations, whether overt or implied. It made us aware that a pure ‘black or white’ stand was unacceptable. The most appropriate ethical stand needed to be defined and periodically redefined together by the editorial board, readers and publishers.

On a similar note, Leslie LeBlanc writes: “here in the US, there is still discussion regarding who ‘owns’ medical ethics, and to align ourselves with one institution rather than another might constrain us in ways that we don’t want.”

Other strategies and resources

Udo Schuklenk suggests that circulation can be improved by consciously marketing the journal to western institutional subscribers and charging them a substantially higher fee. Other suggested strategies are to sell bulk subscriptions to members of ethics committees, offering a budget price for subscriptions of large groups, and special issues for special audiences.

At IME, we have tried giving free sample copies for two or so issues — in the hope they get converted to paid subscriptions — with limited success.

Deborah Zion suggests that if a publisher takes over the journal, this might provide some funding.

Lynley Anderson of New Zealand Bioethics Journal says “We are fortunate enough to be based at the University of Otago and the work of all four members of the editorial board of the Journal is funded by their departments so that helps keep our costs down.” Similarly the Hastings Center has full-time staff available to work on the journals though their editorial board members are volunteers.

About content going online

There has been a lot of debate on the pros and cons of making IME’s content available free on the Internet. On the upside, this leads to increased readership, easy searching and retrieval of articles. On the downside, there are concerns that the online edition could cannibalise the already small print subscriber base, and fears of copyright violations. We launched our website on www.medicalethicsindia.org with hesitation and caveats. We find these thoughts reflected around the world.

One person who is clearly thinking digital is Darryl Macer of the University of Tsukuba, Japan, who has put all of EJAIB’s content on-line and has done so for six years. He admits to losing sales as a result, but believes that being on-line has the maximum impact on readership.

Lynley Anderson of New Zealand Bioethics Journal plans to put the journal’s contents pages and an article index on the web, but not the articles themselves. To access to the articles, the reader would still have to subscribe. Gregory E. Kaebnick, of The Hastings Center Report, writes: “We do not now make the Report available online, but we have been considering the possibility of going online. If we do, we will either make the Report available online only some time after the print version is out, or restrict access to the online Report to subscribers. I am not aware of any online publication that makes money.”

Bette-Jane Crigger of the Hastings Center has similar views: “It’s difficult to know whether making full text available online helps or hurts small publications—finding data on the question has proven very difficult. But we are wondering the same thing, since we are preparing to put both journals of the Hastings Center online over the next two years or so. One idea we are discussing is to make abstracts freely available, but restrict access to full text to paying subscribers. We are thinking through the logistics of just how to do that and what implications it may have for the hardcopy publications. Now, full text of most articles is available online through commercial services with which we have contracts. They provide modest royalties every time an article is downloaded.”

Leslie LeBlanc of The Journal of Clinical Ethics plans an interesting variation: “Overseas subscribers would pay a reduced fee and receive only the password (that is, no paper copies of the journal) for that fee, saving shipping time and shipping costs. This way, we would be making our journal more available to those overseas who might not otherwise be able to afford it, either because of limited budgets (in third-world countries) or because the added shipping costs make the price hard to justify.”

Further, she has articulated some peculiar ethical problems with the internet: “Many subscribers understand that it is ethically and legally inappropriate to photocopy journal articles and to distribute them or use them for classes unless they pay a copyright fee; but because there is a perception that “everything on the Web is free,” many otherwise sophisticated and ethical individuals believe it is completely appropriate to print articles from the Web and distribute them, sometimes without attribution, in ways that they would never think appropriate with a printed journal.” She adds that in the US, many journals sell their mailing lists of subscribers to any individual or organization that is willing to pay for them. She believes this is counterproductive and unethical, and her centre does not sell or trade subscriber lists even though it may be profitable.

Finally Robert Veatch gives some hope; they do make some money after all: “Our journal is technically owned by Johns Hopkins University Press so they set all our policies about Internet access. We have not considered making our journal available on line free, but many universities have subscriptions to the entire package of Johns Hopkins journals and we get some income from those fees.”

In conclusion, there seems to be no clear consensus or panacea for funding issues or about going online. The issues of logistics and the dynamics of the print production process seem to vary with geography and economy. While the developed world does enjoy better access to resources, and more institutional and overseas subscribers, the problems and dilemmas they face are similar to those in the developing world. For a developing country journal of medical ethics, the choices are harder. Since these journals provide the only platform for ethical thought and debate, it is vital that they be kept alive. But at what cost?