Giving up the Ghost: Unmasking Unethical Ghostwriting in Medical Publications

You’ve probably heard the term ‘ghostwriting’ before, maybe while discussing how most politicians have entire teams of speech writers or how many celebrities don’t actually write their own autobiographies. You may not have heard, however, that ghostwriting is also quietly rampant throughout academia, with a wide array of implications and potential dangers.

How Does Academic Ghostwriting Work?

When we talk about ghostwriting in academia, there are two distinct concepts that often become conflated. Though the difference between them is nuanced, each carries its own implications and threats.

Ghost/gift/guest/honorary authorship

As you can tell, this form of ghostwriting goes by many names. ‘Ghost’, ‘gift’, ‘guest’, or ‘honorary’ authorship defines a serious ethical violation in which an author that hasn’t adequately contributed to a manuscript—standardly defined by meeting the International Committee of Medical Journal Editors’ (ICMJE’s) 4 requirements for authorship—is still attributed as an author on a manuscript. This is an incredibly widespread practice; in fact, a 2020 study published in the journal Accountability in Research found that researchers perceive this to be the “most prevalent” form of research misconduct.

Unattributed authors

This definition of ghostwriting more closely aligns with the traditional, non-academic version and is becoming increasingly exposed in scholarly publishing. In a sense, this is essentially the opposite of the above definition: rather than an author who didn’t make substantial contributions being included as an author on a paper, unattributed authorship ghostwriting entails someone who has made a significant contribution to the paper being excluded from the author list, without any acknowledgment. As the scholarly publishing resource American Journal Experts (AJE) explains, the intentions of this practice can be benign (e.g., an author hiring a medical writer to write their paper with insufficient attribution) or malicious (e.g., a hidden industry sponsor intentionally obfuscating its involvement in a research study).

Why is Ghostwriting Dangerous?

Though ghostwriting comes with an array of concerns, there are a few primary dangers associated with this practice.

  • The unattributed authorship form of ghostwriting poses a major public health risk, as the ghostwriters may unintentionally miscommunicate or, in the most malicious cases, overstate or outright lie about results. These papers then influence physicians’ clinical decision-making and treatment recommendations. This is especially worrisome when considering how some drug manufacturers have been found to misrepresent their research in order to improve physicians’ opinion of a drug or product, also called ‘spinning’ their results.
  • Ghost/guest/gift/honorary authorship improperly confers academic respect or credit onto individuals, and job positions or promotions could be granted in part because of their false authorship credits. These physicians may be consulted on clinical cases related to the literature they’ve ‘published’ on, but they may not actually have the relevant specialist knowledge.
  • There’s an argument to be made that ghostwriting may be a form of plagiarism, though this is an active debate in the scholarly publishing community.
  • Especially with paper mills, authorship has become a black-market trade, with some sites being specifically designed to buy and sell authorship. For example, Retraction Watch has called public attention to the Latvian website Science Publisher Company in September 2021; over a year later, their website still explicitly states that they provide “ready-made articles on a wide variety of topics,” ranging from medicine to architecture or law.

Steps Forward: How to Address Ghostwriting

Unfortunately, there’s no singular solution that can entirely erase the ghostwriting problem. However, there are several smaller steps that can be implemented to confront it.

  1. Prioritize thorough, data-driven research on ghostwriting. Due to the inherently secretive nature of ghostwriting, we don’t have a comprehensive modern understanding of how widespread the problem is. In a 2019 meta-analysis, DeTora et al. found that most research on this topic is conducted with small sample sizes or are opinion-based, resulting in prevalence metrics ranging from <1% to 91%. To help understand the current state of the problem, we need to establish a more universally-accepted definition of ghostwriting, clarify indexing terms, and promote systematic and evidence-based research on the topic.
  2. Strengthen journals’ authorship evaluations. The practice of journals identifying ghostwriters, also referred to as ‘ghostbusting’, is gaining traction with some publishers. For example, editors at PLoS Medicine have called for increasingly stringent requirements for author contribution statements, disclosures of industry involvement, and “enforceable sanctions” of retracting published articles that have retroactively been found to involve ghostwriters.
  3. Increase efforts to eliminate paper mills and malicious ghostwriting firms. Thankfully, exposure of these practices is already increasing, to the point that a 2022 United States congressional hearing was called exclusively to discuss the dangers of and responses to paper mills.
  4. Educate authors on the dangers of ghostwriting. This solution is designed to address benign or unintentional cases of ghostwriting. Landmark studies have found that researchers, especially in low- or middle-income countries, don’t receive sufficient education on research/publication ethics; further training is vital for avoiding inadvertent or nonmalicious ghostwriting.
  5. Reduce the publication pressure that researchers face. It’s an unignorable undercurrent of the ghostwriting problem. The current academic environment places immense, unsustainable pressure on researchers to publish their research, and unfortunately, many authors are beginning to see ghostwriting or paper mills as their best chance at a successful research career.

Overall, a focus on prevention and halting the problem before it snowballs will be critical in order to substantially reduce ghostwriting in academic publications.