A Statement of Principles for Health Care Journalists
by Gary Schwitzer
2004. The American Journal of Bioethics 4(4):W9

Many journalism organizations have published codes of ethics in recent years. The Association of Newspaper Editors, for example, lists 47 different codes on its website. But an organization of health care journalists felt that none of those codes addressed the unique challenges of covering complex health care topics. The Association of Health Care Journalists (AHCJ) is an independent, non-profit organization dedicated to advancing public understanding of health care issues. Its mission is to improve the quality, accuracy and visibility of health care reporting, writing and editing. AHCJ has written a statement of principles for its 750 members. In it, AHCJ states some of the unique challenges faced by journalists covering health care, and offers suggestions on how to face those challenges. Bioethicists are invited to comment on the statement, and to help generate continued discussion of the issues addressed therein.

BACKGROUND
In recent years, many journalists have been compelled to examine what they do, how they do it, and why. Many have gone on to publicly share these self-examinations. A group that calls itself the Committee of Concerned Journalists began such introspection seven years ago. About twenty-five influential journalists met at the Harvard Faculty club. The book, Elements of Journalism, reflects on that beginning: “They were there because they thought something was seriously wrong with their profession. They barely recognized what they considered journalism in much of the work of their colleagues. Instead of serving a larger public interest, they feared their profession was damaging it” (Kovach and Rosensteil 2001, 10).

Just three months earlier, a group of health care journalists met at a conference in Indiana. They were feeling the need to organize to address some of the challenges facing journalists on this specialized beat. It was the birth of the Association of Health Care Journalists (AHCJ), which now has 750 members in many types of media from several countries. AHCJ’s goals and objectives are:

1. Educating journalists about medicine and health care, including the business of health care, public policy, medical research and practice, consumer health issues, public health, health law and ethics.
2. Supporting the highest standards of reporting, writing, editing and broadcasting.
3. Enhancing understanding between journalists and health care experts to better inform the public about current and emerging issues in health care.
4. Rewarding excellence in medical and health care journalism.
5. Advocating for journalists by promoting access and the free flow of information and improvement of professional development opportunities.

At a meeting in San Francisco in March, 2003, the AHCJ board voted to explore the need for, and interest in, an Association code of ethics or statement of principles. Board members said they were being asked with increasing frequency to speak to groups or to write about the practice of health care journalism. For example, AHCJ members contributed articles to two special editions of Harvard’s Nieman Reports in 2003, devoted to health and medical reporting. The National Institutes of Health has begun offering annual “Medicine in the Media” workshops. The Mayo Clinic held a national conference on medicine and the media in September, 2002 (Lantz and Lanier 2002). The spring 2004 conference of the American Society for Bioethics and Humanities was entitled, “Medicine and Media: The Delicate Balance.” AHCJ board members were invited to speak at each of these sessions and other similar events.

For a year, the author studied other professional journalism organization’s codes of ethics and reflected on the ethical and professional questions posed daily by AHCJ members on the membership’s e-mail listserv. Concerns with sensationalism, commercialism, single-source stories, and interpretation of statistics and medical evidence were among the most frequently cited. Unbalanced, unquestioning coverage of new drugs has been a continuing concern. There is concern about conflicts of interest leading to troublesome entanglements of sponsors, researchers and journalists. Members were troubled by the quality and quantity of news coverage of the Raelian cloning claims. The Association led many journalism organizations in opposition to the U.S. Department of Health and Human Services’ distribution of video news releases featuring a paid spokesman posing as a reporter promoting the Administration’s Medicare legislation. The fact that some television stations actually used the video news releases is further evidence that some journalists need more guidance.

It became clear that what the organization needed was a statement of principles—a guide to best practices in health care journalism. Draft statements were circulated to the twelve-member AHCJ Board of Directors, including journalists from Bloomberg News, the Charlotte Observer, Consumer Reports, the Los Angeles Times, the Philadelphia Inquirer, The Scientist, the Seattle

Times, the Spokane Spokesman Review, the Wisconsin State-Journal, two independent journalists and a university journalism faculty member. The last three had each worked for years in broadcast journalism at Cable News Network in Atlanta, and/or in Boston, Los Angeles, Milwaukee, and Portland, Ore.

Drafts were also sent for external review to: Arthur Caplan, PhD, of the University of Pennsylvania Center for Bioethics; Floyd J. Fowler, PhD, of the Foundation for Informed Medical Decision Making; Gary Hill of the Society of Professional Journalists ethics committee; Jeffrey Kahn, PhD, of the University of Minnesota Center for Bioethics; and Kelly McBride, Poynter Institute ethics faculty member. The document was presented at the Spring, 2004 conference of the American Society for Bioethics and Humanities, where feedback was solicited.

In March, 2004, a draft statement of principles was posted on the AHCJ website and members were invited to review and comment. The draft was presented at the AHCJ’s annual national conference in late March, 2004. Final editing of the first AHCJ statement of principles was completed in May, 2004.

Statement of Principles—Association of Health Care Journalists

Preamble
Members of the Association of Health Care Journalists believe journalists have a special responsibility in covering health and medical news. This responsibility is inherent in journalists’ role as watchdogs, holding the powerful accountable and giving voice to the voiceless. Association members know that readers and viewers may make important health care decisions based on the information provided in our stories. We embrace the code of ethics of the Society of Professional Journalists, with its emphasis on seeking truth, providing fair and comprehensive accounts of events and issues, minimizing harm, acting independently and being accountable. In this statement, we identify some unique challenges that health care reporters face and suggest how to meet those challenges. This effort is one sign of our organization’s commitment to help its members improve health journalism, to help them scrutinize their own efforts, and to encourage open discussion and debate on how health care news is reported and disseminated.

We further believe that well-balanced and thorough news coverage of health encompasses the determinants of health and not merely medical science or the provision of medical services. We suggest that news organizations scrutinize their role as health care news and information providers, commit to coverage of health care issues, and develop a strategy that meets the needs of their audiences.

PROFESSIONALISM, CONTENT, ACCURACY
Because our objectivity and credibility is paramount, health care journalists are bound by professional standards of truth, accuracy, and context in every report. To achieve this, health care journalists should:

• Be vigilant in selecting sources, asking about, weighing and disclosing relevant financial, advocacy, personal or other interests of those we interview as a routine part of story research and interviews.
• @@START_COMMENT Page W11 @@END_COMMENTInvestigate and report the possible links between sources of information (studies or experts) and those (such as the manufacturers) who promote a new idea or therapy. Investigate and report the possible links between researchers and private companies, researchers and public institutions, patient advocacy groups and their sponsors, celebrity spokespersons and their sponsors, non-profit health and professional organizations and their sponsors.
• Recognize that most stories involve a degree of nuance and complexity that no single source could provide. Journalists have a responsibility to present diverse viewpoints in context. In addition, anyone with knowledge of the health care industry, of medicine, and of the scientific community knows that many vested interests reside among government health spokespersons, researchers, universities, drug companies, device manufacturers, providers, insurers and so on. To reflect only one perspective of only one source is not wise. Most one-source stories lack depth and meaning. Avoid single-source stories.
• Understand the process of medical research in order to report accurately. Realize, for example, the distinction between Phases I, II, and III of drug trials. It is misleading to report bold or conclusive statements about efficacy in Phase I trials, since the primary goal of Phase I trials is to evaluate safety, not efficacy. (A simple guide is available at: http://www.cancer.gov/clinicaltrials/understanding/what-is-a-clinical-trial.) Be cautious in reporting results of preliminary studies, in vitro or animal studies. Give accurate portrayals of the status of investigational drugs, devices and procedures, including significant caveats and explanations of hurdles, unknowns and potential problems.
• Preserve journalistic independence by avoiding the use of video news releases or the use of quotes from printed news releases. Label and credit the source whenever a portion of a video or printed news release is used.
• Be judicious in the use of television library or file footage. The use of footage from the past may be inappropriate, misrepresentative, or embarrassing to individuals if used today. It may not even fit the topic of the day. Strive to ensure that your television station has policies on the use of health-related file footage by all news personnel.
• Recognize that gathering and reporting information may cause harm or discomfort. Use special sensitivity and understand legal limits when dealing with children, mentally handicapped people and inexperienced sources or subjects. Always consider alternatives that minimize harm while making accurate reporting possible.
• Show respect. Illness, disability and other health challenges facing individuals must not be exploited merely for dramatic effect.
• Remember that some sick people don’t like to be called “victims.” Be careful with the use of the term “patients.” This can contribute to the medicalization of normal states of health. Calling people in an experimental trial “patients” or referring to an experimental intervention as a “therapy” may contribute to the notion of therapeutic misconception, the implication that subjects in a research trial will certainly derive direct therapeutic benefit from what is actually an experiment with uncertain benefits and harms.
• Avoid vague, sensational language (cure, miracle, breakthrough, promising, dramatic, etc.)
• Make sure anecdotes are appropriately chosen to serve the interests of fairness and balance. Avoid the “tyranny of the anecdote.” Personal stories used as examples must be consistent with the larger body of evidence. Whenever possible, individuals who had both positive and negative outcomes should be included.
• Quantify the magnitude of the benefit or the risk in the story. Explain absolute risk or benefit, along with relative risk or benefit whenever possible. A 50 percent increase in relative risk may not mean much if the absolute numbers are small. Consider explaining the “number needed to treat”—the number of people you would have to treat with the experimental intervention (compared with the control) to prevent one event. (See http://www.cochrane-net.org/openlearning/HTML/mod11-6.htm.)
• Report the complete risks and benefits of any treatment, along with the possible outcomes of alternative approaches, including the choices of “watchful waiting.”
• Clearly identify and explain the meaning of results that indicate an association, rather than a causal link, between factors in a study. Remember: association is not cause.
• Clearly define and communicate areas of doubt and uncertainty. Explain what doctors don’t know as well as what they do know.
• @@START_COMMENT Page W12 @@END_COMMENTSeek out independent experts to scrutinize claims and evaluate the quality of evidence presented by sources. Apply the same scrutiny and skepticism that would be applied in any other news story. Avoid uncritical acceptance of official or expert pronouncements. Be skeptical about all emphatic claims, particularly about claims that an intervention has few or no adverse side effects.
• Strive to include information about cost and insurance coverage in any reporting of new ideas in medicine.
• Ensure that the total news package (headlines, teases, graphics, promotional material) does not oversimplify or misrepresent. Coach editors, photographers, producers, writers, graphic artists and copy editors to embrace these values in their work.
• Consider public interest the primary criterion when choosing which stories to report. Follow up on those stories that serve a wider public interest. In particular, followup stories on subsequent failures, negative findings or other reversals of fortune for investigational drugs, devices or procedures should receive coverage comparable to that given initial positive reports.
• Distinguish between advocacy and reporting. There are many sides in a health care story. It is not the job of the journalist to take sides, but to present an accurate, balanced and complete report.
• Be original. Plagiarism is untruthful and unacceptable.

INDEPENDENCE
We should strive to be independent from the agendas and timetables of journals, advocates, industry and government agencies. We should nourish and encourage original and analytical reporting that provides audiences/readers with context. Given that thousands of journal articles and conference presentations appear each year, and that relatively few are immediately relevant to our audiences/readers, health journalists have a responsibility to be selective so that significant news is not overwhelmed by a blizzard of trivial reports. We are the eyes and ears of our audiences/readers; we must not be mere mouthpieces for industry, government agencies, researchers or health care providers.

INTEGRITY
Those who cover health care will encounter many different interest groups including government, academic medicine and research, medical centers, providers, purchasers, advocacy groups, pharmaceutical companies and device manufacturers. Health care journalists should remember that their loyalties reside with the truth and with the needs of the community.

We must:

• Preserve a dispassionate relationship with sources, avoiding conflicts of interest, real or perceived.
• Avoid any personal or financial interest in any company in any field related to what is being covered. This includes actual and potential competitors of subjects about whom we report. It is not wise to own stock in health care companies. We must not profit from, nor allow others to profit from, non-public information, including, but not limited to, results in embargoed journal articles and meeting abstracts.
• Remember that journalists face other potential conflicts of interest. Think about questions such as: Were you a patient at a particular hospital? Do you have a relative with a specific disease that could unduly influence your handling of a story? Does this insurance company cover employees in your newsroom? It is the journalist’s responsibility to recognize these conflicts and prevent them from influencing stories or story choices. The best way to do this is by constant, open and honest discussion with other reporters, editors or producers.
• Deny favored treatment to advertisers and special interests and resist their pressure to influence news coverage.
• Refuse gifts, favors, and special treatment. Refuse meals from drug companies and device manufacturers and refuse to accept unsolicited product samples sent in the mail.
• Weigh the potential benefits involved in accepting fees, honoraria, free travel, paid expenses from organizers of conferences or events against the desire to preserve our credibility with the audience and the need to avoid even the appearance of a conflict of interest.
• @@START_COMMENT Page W13 @@END_COMMENTAlso weigh the potential benefits of accepting awards from organizations sponsored by an entity with a vested interest in health care against our need for credibility.
• Weigh the potential conflict in accepting support from public, private, or foundation sources.

RESPONSIBILITY
We must improve our coverage of the structural, institutional, political, financial and ethical issues in health, medicine and health care.

We have a responsibility to encourage editors to pay as much attention to health stories as to medical stories. It is our responsibility to understand the difference between the two types of stories, and to help our editors maintain an appropriate balance.

We know the significance of stories on health policy and public health. We know they are relevant and important for our readers and viewers. We have to work harder to make them interesting.

We must work harder within our newsrooms to keep health care coverage comprehensive and proportional.

While brevity and immediacy are touchstones of news reporting, health and medical reporting must include sufficient context, background and perspective in order to be understandable and useful to audiences/readers.

Stories that fail to explain how new results or other announcements fit within the broader body of evidence do not serve the interests of the public.

Finally, it is our responsibility to lobby our editors to raise the standards of health reporting. Our beats can be viewed as health, medicine, business, health policy, research, science, finance, politics and other specialized areas of news. We must ensure that our beats don’t become so super-specialized that we let important health issues fall through the gaps of our finely-defined beats. We must work with editors to ensure that our specialized knowledge, training, expertise and instincts have a voice in the broader editorial decision-making of our publication or broadcast or website.

CONCLUSION
As with most professional journalism codes or statements, the Association of Health Care Journalists statement of principles contains no provisions for enforcement. With a small staff and a volunteer Board of Directors, the Association believes that enforcement is not practical; nor is it desirable. Rather, this statement takes the form of a best practices guide for those covering health care news, with some suggestions for ethical journalistic practice. As suggested in the final paragraph of the statement, AHCJ hopes to influence not only producers, reporters and writers, but editors and news directors, who often assign inexperienced journalists to cover health care stories, and who decide what is ultimately published or broadcast. Further, AHCJ hopes to influence the management of journalism organizations, so that employees will be given the training needed to cover these complex topics. Finally, it is hoped that publication of this statement may influence some of the disseminators of health care news and information—government officials, researchers, providers, medical centers, insurers, pharmaceutical companies and device manufacturers—to examine their own communications practices. We also believe that letting consumers know about our concerns for best practices can help them become smarter consumers of news and of health care.

COMPETING INTERESTS STATEMENT
The author declares that he has no competing financial interests.