Ethical Authorship and the Ingelfinger Rule in the Digital Age
Authors: Peter A. Netland
Journal: Ophthalmology (2013)

Ophthalmology's Guide for Authors includes a policy regarding prior and repetitive publication that states: “The Journal will not consider manuscripts that have appeared, in part or in total, in other publications, except in special circumstances approved by the Editor-in-Chief.” This is the Ingelfinger rule,1Ingelfinger F. Definition of “sole contribution.”.N Engl J Med. 1969; 281: 676-677Crossref PubMed Scopus (66) Google Scholar which was written 44 years ago by Dr. Franz J. Ingelfinger and has been adopted widely by most peer-reviewed medical journals. The burden of ethical responsibility for upholding the Ingelfinger rule lies squarely on the shoulders of the authors, although editors and reviewers police this to the best of their ability. In recent years, compliance with this rule has become increasingly challenging for authors, with a flood of information about their work in the public domain, improved information-gathering methods for the non–peer-reviewed medical media, and evolution of new means for communicating scientific information. Ingelfinger himself articulated the reasons for the rule.1Ingelfinger F. Definition of “sole contribution.”.N Engl J Med. 1969; 281: 676-677Crossref PubMed Scopus (66) Google Scholar, 2Ingelfinger F.J. Shattuck Lecture. The general medical journal: for readers or repositories?.N Engl J Med. 1977; 296: 1258-1264Crossref PubMed Scopus (27) Google Scholar First, it protects the newsworthiness of the peer-reviewed journal, creating content for “readers” and not just for “repositories.” Second, it allows the peer-review process to occur before potentially misleading medical research results are released to the public and the profession. It also has been pointed out that journals have finite print and online page counts, and it is inefficient and unfair to other authors to use valuable space for previously published material.3Lichter P.R. Duplicate publication and copyright. The role of authors and reviewers.Ophthalmology. 1988; 95: 1601-1602Abstract Full Text PDF PubMed Scopus (9) Google Scholar The rule “drew the line in the sand,” creating a longstanding tension between the media and medical journals.4Altman L.K. The Ingelfinger rule, embargoes, and journal peer reviews.Lancet. 1996; 347 (1459–63): 1382-1386Abstract Full Text PDF PubMed Scopus (55) Google Scholar, 5Wilkes M.S. The public dissemination of medical research: problems and solutions.J Health Commun. 1997; 2: 3-15Crossref PubMed Scopus (22) Google Scholar The peer-review process is not perfect and can be inattentive or, worse, biased.6Lichter P.R. Scrutinizing peer review.Ophthalmology. 1989; 96: 929-930Abstract Full Text PDF PubMed Scopus (3) Google Scholar, 7Liesegang T.J. Albert D.M. Schachat A.P. Minckler D.S. The editorial process for medical journals: I. Introduction of a series and discussion of the responsibilities of editors, authors, and reviewers.Am J Ophthalmol. 2003; 136: 109-113Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar However, the principles of the rule have been accepted begrudgingly, even by prominent media writers.8Johnson T. Shattuck Lecture. Medicine and the media.N Engl J Med. 1998; 339: 87-92Crossref PubMed Scopus (111) Google Scholar Exceptions to the Ingelfinger rule are permissible, for instance, if information is of urgent concern for the public health. In his influential editorial on the topic, Dr. Arnold S. Relman cites the example of allowing prior publication during the period of rapidly developing information about toxic shock syndrome,9Relman R.S. The Ingelfinger rule.N Engl J Med. 1981; 305: 824-826Crossref PubMed Scopus (97) Google Scholar because the public health significance of the information superseded all other interests. However, exceptions to the rule would not likely be granted for authors who provide figures and tables to the non–peer-reviewed medical press, post a non–peer-reviewed version of results from their manuscript online, or commit other violations. The highest risk for violations of the rule occur as a consequence of medical news publications or press conferences held before publication,9Relman R.S. The Ingelfinger rule.N Engl J Med. 1981; 305: 824-826Crossref PubMed Scopus (97) Google Scholar allowing expression of bias and generating unwarranted enthusiasm for new findings. Medical news publications may provide coverage “that goes substantially beyond the information presented at the meeting, particularly if it includes additional data, illustrations, or tables that in effect duplicate the manuscript under consideration.”2Ingelfinger F.J. Shattuck Lecture. The general medical journal: for readers or repositories?.N Engl J Med. 1977; 296: 1258-1264Crossref PubMed Scopus (27) Google Scholar Presentation of research at scientific meetings is well accepted as a valuable process for authors and the physician audience, but the information is less protected when it moves into the public domain. For authors who present research at scientific meetings and are trying to avoid prior publication, a challenge is that information released from the meetings is increasingly accessible and detailed. Scientific posters and presentation slides may be uploaded for online access, with varying degrees of protection from subsequent dissemination. Daily news releases from meetings are sent by e-mails, blogs, or podcasts. Complete audio and video transcripts of the meetings are recorded and distributed online. Text messaging and social media postings may distribute information in real time. Digital distribution of material from the meeting through various electronic distribution outlets is viewed as a way to boost the profile of the meeting and to increase revenues. In most instances, this material is distributed before completion of the peer-review process. The increasingly accessible information from scientific meetings is available not only to physicians, but also to journalists. Shortly after meetings, before or during the peer-review process for journal publication, many authors are asked to approve public-domain articles, often written by journalists for medical news publications and often containing detailed information about their study. In recent meetings, authors may have refused consent to release figures from talks, but have been sent articles containing detailed quantitative results based on audio transcripts. This problem was anticipated several years ago,10Bressler N.M. Liesegang T.J. Schachat A.P. Albert D.M. Advantages and potential dangers of presentation before publication.Arch Ophthalmol. 2004; 122: 1045-1048Crossref PubMed Scopus (5) Google Scholar but has become increasingly difficult for authors trying to uphold their ethical responsibility to avoid publication before peer review. Another challenge is the open-access initiative in scientific and biomedical publishing, offering full-text articles.11Liesegang T.J. Schachat A.P. Albert D.M. The open access initiative in scientific and biomedical publishing: fourth in the series on editorship.Am J Ophthalmol. 2005; 139: 156-167Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar More broadly speaking, e-journals and electronic serials may or may not require a subscription fee and provide varying types of digital content, including video, images, and full-text articles. According to Ulrichsweb.com (accessed January 11, 2013), in 2003, there were more than 43 500 scholarly or refereed online publications, including more than 21 000 active refereed periodicals. China Online Journals produced approximately 7320 full-text journals as of April 2012. Although online, non–peer-reviewed, open-access articles are cited less frequently compared with peer-reviewed articles, the number of non–peer-reviewed or minimally peer-reviewed online journals continues to proliferate. Authors receive almost daily e-mail solicitations for manuscripts, often from journals outside of their fields of expertise. Online publication is tempting for authors as a way to publish their material rapidly without the delays of the peer-review process, and they provide another avenue for duplicate publication. Most readers understand the weaknesses of online non–peer-reviewed information, including bias and lack of accuracy. The current online entry in Wikipedia (accessed January 11, 2013) for the Ingelfinger rule briefly states that the rule “has been seen as having the aim of preventing authors from performing double publications which would unduly inflate their publication record. On the other hand it has also been stated that the real reason for the Ingelfinger rule is to protect the journals' revenue stream.” Most scholars would consider the entry superficial, misleading, and poorly referenced, with most of the citations from other online non–peer-reviewed sources. Although the true extent of duplicate publication in online journals, medical news publications, or the lay press is not well understood, the recent availability of software for detecting redundancy and plagiarism has allowed estimation of the rates of duplicate publication in the peer-reviewed literature. According to one report, in the ophthalmology literature, duplicate publication occurred in approximately 1.4% of publications.12Mojon-Azzi S.M. Jiang X. Wagner U. Mojon D.S. Redundant publications in scientific ophthalmologic journals: the tip of the iceberg?.Ophthalmology. 2004; 111: 863-866Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In the peer-reviewed otolaryngology and urology literature, the rates of redundancy were similar, occurring in 1.8% of original articles in both fields.13Bailey B.J. Duplicate publication in the field of otolaryngology-head and neck surgery.Otolaryngol Head Neck Surg. 2002; 126: 211-216Crossref PubMed Scopus (72) Google Scholar, 14Hennessey K.K. Williams A.R. Afshar K. Macneily A.E. Duplicate publications: a sample of redundancy in the Journal of Urology.Can Urol Assoc J. 2012; 6: 177-180Crossref PubMed Scopus (14) Google Scholar Authors and editors who were raised on the Ingelfinger rule are being replaced by a new generation. Interesting descriptions of the characteristics and values of the future ophthalmologist have appeared,15Mets M.B. Brown A. Doan A.P. et al.The ophthalmologist of the future.Arch Ophthalmol. 2012; 130: 1190-1194Crossref PubMed Scopus (7) Google Scholar and cautious optimism has been expressed about their fit in the workplace.16Bartley G.B. The ophthalmologist and ophthalmic practice of the future.Arch Ophthalmol. 2012; 130: 1203-1204Crossref PubMed Scopus (1) Google Scholar Generations Y (Millennials) and Z, as the upcoming generations have been called, are digital “natives” who are skilled at managing the flood of information about medical research and the seemingly endless outlets for publication. With an estimated corpus of more than 10 trillion words accessible on the Internet and more than 50 trillion e-mails sent per year (royal.pingdom.com; accessed January 26, 2013), the volume of written communication is greater than at any other time in history. Having been raised in this environment, generations Y and Z are excellent written communicators and are more adept than any other generation at tailoring their communication to their audience. How will future generations manage the peer-review process and the issue of prior publication? Because new generations usually vary from their predecessors, we expect change. Perhaps the perceived flaws of the peer-review process, which may be time consuming and may be marred by occasional inappropriate or biased reviews, will encourage the use of non–peer-reviewed and rapid online publication. Authors and editors who see many manuscripts recognize that authors often believe their work is perfect when submitted, but then, through peer review, discover the flaws that can be observed only by others. Prolific authors can probably think of few, if any, of their published manuscripts that were not improved in some way by the peer-review process. Many authors are grateful for having been saved the embarrassment of publishing a flawed piece of information. We do not know whether future generations will continue to embrace the peer-review process. However, because of the dramatic increase in outlets for communication of medical information, it is certain that ethical questions related to publication are unlikely to abate. Adherence to the Ingelfinger rule is an ethical responsibility for authors submitting manuscripts to this and other journals. The rule applies during the peer-review process and, if the manuscript is accepted, until the work appears in the online e-publication queue or the journal releases copyright. Improved efficiency of the peer-review process and contraction of the time to online publication have made it easier to comply with the rule. However, the increasing volume and speed of myriad medical communications have introduced new challenges. Authors must be increasingly vigilant to maintain their ethical duty to avoid supporting, consenting to, or providing detailed information before completion of the peer-review process.