By design, American Family Physician (AFP) covers a comprehensive array of topics in family medicine. Given the diversity of our readers, some topics are inevitably controversial because of viewpoints stemming from social, political, religious, or moral convictions. The concept of an editorial on the ethics of controversial topics emerged from discussions at AFP’s annual editors meeting, where we acknowledged the role of the COVID-19 pandemic in amplifying debates in medicine and generating more comments from readers. We then identified article topics that have generated the most feedback and conflicting viewpoints. In acknowledging these differing views, our intent was to create a policy that ensures that controversial topics are addressed in a thoughtful, proactive manner and that authors can produce evidence-based content “devoid of overt commercial, religious, political, or philosophical rhetoric,” as Drs. Tunzi, Ventres, Day, and Satin describe in an editorial on page 12 in this issue of AFP.1
What does it mean to be thoughtful and proactive about topic selection? First, the topic should be relevant to our readership and be consistent with AFP’s mission: “To empower family physicians to improve the health of patients and communities as the leading source of medical information while advancing science and health equity.”2 Authorship and publication should be consistent with our policies on publication ethics.3 Also, all manuscripts undergo a rigorous peer review and editorial review process, designed to ensure scientific accuracy and to minimize bias in the presentation.
Another step in thoughtfully producing content, including controversial content, is to be transparent about our processes. AFP solicits most of our articles based on a curriculum of approximately 650 topics, and we do our best to routinely update the top 200. We cover additional article topics through author proposals. Proposals go through an approval process that includes review by the editor-in-chief and sometimes a team of medical editors, especially if the topic could be perceived as controversial, with roughly 11% of all proposals getting approved.4
We also pay attention to author selection. Potential authors are required to complete a conflict of interest form and an author credentialing form, which are found in our Authors’ Guide.5 Information about an author’s clinical background, writing experience, and proficiency in evidence-based medicine is requested on the credentialing form. In addition to our strict conflict of interest policy, we strive to select authors who do not have strong advocacy commitments on the topic, leading to what could be called advocacy bias.6 The goal is to select objective authors who actively seek to cover the evidence behind topics in a way that is less subject to such bias. This is not an easy task because we have all been influenced by our lived experiences and “there is no philosophical ‘view from nowhere,’” as our colleagues with expertise in ethics have stated.1
Understandably, our policies cannot address all readers’ concerns, and they do not capture all the nuances of managing controversial topics. These nuances include deciding when an opposing or different viewpoint is needed, when an editor’s note should be added, and when an author who may not have direct financial conflicts has another agenda (sometimes unknown to them) that introduces unintended bias into an article. There is no cookie-cutter formula that applies to every scenario; each controversial topic is addressed on a case-by-case basis, usually in consultation with a team of medical editors. Our goal is to provide practical information to readers who desire to learn about a particular subject, while providing information to readers with differing views who may encounter this in practice. Some readers have mentioned that this approach lacks an honest, intellectual discussion of controversial topics; however, it is not clear how to acknowledge these differing views in a way that is satisfactory to our diverse readership, when some readers would prefer that some topics not be covered at all and others believe we need more coverage. Our intention is not to tell readers how to practice medicine, but rather to provide the best available knowledge that they can then apply, as appropriate, to their own practice and patient population.
But, we ask a genuine question: How can we do better? We encourage readers to provide constructive feedback and dialogue by posting a comment online; emailing us at firstname.lastname@example.org; sending a letter to the editor to email@example.com; or following us on social media (Twitter [@AFPJournal], Facebook [@AFPJournal]). AFP has excelled because of dedicated authors, readers, reviewers, and editors. We are thankful for this and look forward to a continuing evolution of the journal based on productive feedback and dialogue.
Editor's Note: Dr. Sexton is editor-in-chief of AFP.