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Political tensions about the goals of the American Medical Association, and their expression to the membership and the laity, have existed since the Association was founded in 1847. The most important is the tension between serving and self-serving. One could call oneself a doctor and practise as such about as easily and as legally as one can be a ‘therapist’ in California. Periodic attempts were made by state medical societies to elevate medical school standards, but they were half-hearted and unsuccessful. Financial anxiety, intellectual restlessness and patriotic competitiveness combined happily to inspire the membership to agree that a journal be founded. The redoubtable Nathan Davis, chairman of the Board of Trustees, sent out a mailing of 40, 000 describing the proposed new journal; he reported at the 1883 meeting that he had received some 2, 000 promises of support, which in addition to the projected advertising revenue should support the publication cost.

Scientific misconduct is now widely recognized as a genuine and significant problem for contemporary science, but too often the participants in the research system—and those outside who are affected by it-suffer from lack of clarity about what constitutes scientific misconduct. Examples are presented in which questions of professional discourtesy, methodological disagreement, and political struggle are misunderstood as questions of honesty.

IN RECENT years, scientists and editors of scientific journals have often noted how few hard data exist on the workings of editorial peer review. Although pressures from inside and out increasingly encourage journals to be more explicit about their practices and more inclined to question their own habits, there is still a good deal of truth in the sardonic observation made 5 years ago that "the arbiters of rigor, quality, and innovativeness in publishing scientific work do not apply to their own work the standards they apply in judging the work of others." 1 This paradox inspired The First International Congress on Peer Review in Biomedical Publication, with its goal of encouraging the systematic and empirical study of journals. Of course, data and rigorous methods are not enough to make a science. The systematic study of peer review is even more deficient in theory than it is in data. Some

STAGES 197 Moral Development: Kohlberg and Some Critics 197 Other Cognitive-Developmental Sequences •......... 200 Development of Ego or Self 202 Structural Models 204 Cross-Cultural Applicability • 205 TRAITS 206 Trait Approaches to Morality 206 Consistency of Personality 208 SELF AND EGO 210 PSYCHOANALYTIC PERSONALITY THEORY 213 CONCLUSION 216

For Darwinism to succeed as a general theory of the development of life, it had to account for at least the rudiments of all human characteristics. Thus Darwin and his colleague G. J. Romanes had to make "mental evolution" the basis for scientific psychology. F. Max Muller, Oxford's professor of comparative philology, drew on Kant's work, Romantic Naturphilosophie, and his views on the history of language and the relation of language to thought to maintain that language showed a difference not in degree but in kind between man and the lower primates. In his debate with Romanes, he argued that the study of language, not Darwinist natural history, should be the basis for a science of human psychology. However, the two authors had such different definitions of the key terms in their discussion that their differences were not only unresolved but irresolvable.

To the Editor. — After months of widely publicized investigation, psychologist Stephen Breuning has admitted recently (in court) to having invented a great deal of data supporting the use of methylphenidate (Ritalin) to control hyperactivity in severely retarded children. 1 Robert Sprague, the former colleague of Breuning who first discovered and reported the fraud, calculated that between 1979 and 1983 Breuning's publications accounted for slightly more than one third of the published research in the psychopharmacology of mental retardation. 2 Several states depended largely on his publications in setting regulations for the treatment of the institutionalized mentally retarded. 1 The October 21 issue of JAMA contains one letter to the editor and two articles on the possibly excessive use of medication—particularly methylphenidate hydrochloride—in the treatment of attention-deficit hyperactivity disorder. 3-5 Understandably, since specialists in attention-deficit hyperactivity disorder know of Breuning's fraud, none of the articles cited Breuning. Granted, they did

Any editor rapidly learns that the authors who submit manuscripts have widely differing ideas about the process of selecting articles for publication. He also soon discovers that the readers have an even wider range of views on the subject. Though trained to take a neutral and objective position when judging manuscripts, when it comes to journal business, the editor is naturally disposed to imagine that all views that do not coincide with his own are wrong. It is useful, then, to list what are reasonable expectations for author, journal editor, and reader and then to examine them to see what we really know about them and how often, if at all, they are realized. The author expects that his manuscript will be handled promptly and fast; that it will be judged by several unbiased, expert reviewers whose comments will be passed along to enhance any revision; that the editors will

Ever since Dr Leonard Bailey transplanted the heart of a young baboon into a human newborn with fatal hypoplastic left heart syndrome, there has been great public concern about the ethical issues involved in the highly experimental surgery. Among the many questions asked were: How much was known about this procedure? How much did the parents understand and how was their permission obtained? In the particular area of informed consent, the report by the investigative team of the National Institutes of Health (NIH) answers some questions but raises new ones. 1 In December 1984 members of the NIH's Office of Protection From Research Risks, an NIH legal adviser, and two nongovernmental consultants accepted Loma Linda University's (LLU) invitation to examine the university's decision to attempt the xenograft. After two days of discussions, the site visitors concluded that the review of the proposed procedure— which had included participation by the hospital

Original research studies and case reports, personal essays, and discussions of specialized fields: the articles inThe Journalhave traveled widely by the time they are published. All submissions are read by the editors; most are sent to reviewers in the relevant fields for consultation; and some (11.0% of unsolicited manuscripts in 1984) are accepted for publication. They are then copy edited and sent to the authors for approval; a layout is designed; and the final copy is set in type, ready for timely publication. The manuscript is seen by many eyes during this process; its tables, illustrations, and references may be examined dozens of times atThe Journaland outside it. The ease of every task from review to production is significantly affected by the way in which the manuscript has been prepared by the authors. Missing tables, blurry photographs, or tiny margins in which copy editors cannot make

Over the past three months,The Journalhas published several articles dealing with human torture, from ancient times to the present day. Some of the information was so detailed and graphic that it caused some readers extreme discomfort. Some documentation was not as rigorous as that which we require for our usual scientific and clinical articles, but studies of abuses such as state-sponsored cruelty cannot be subjected to the same standards as controlled laboratory experiments. We believe that the evidence from various sources, published here and elsewhere, demonstrates conclusively that physicians have played many roles in the torture and systematic abuse on which too many of the world's governments rely to maintain their power. 1-4 The great importance of the subject to those within and outside the medical community requires that responsible reports be widely disseminated. The Journalhas a great ethical heritage and prides itself on its broad consideration

Excerpt As medicine has grown, it has become clear that no one person could encompass all its expanding fields, and so the twentieth century has been the age of the specialist. Editors of specialty...

"Only connect," E. M. Forster advised his readers.The Journalis about to follow his suggestion in four new ways, starting with its format and design and continuing with new ways of looking at the various aspects of medicine. We begin by improving our connection to our readers with a revised design. This format is intended to giveThe Journalan uncluttered look and bring stylistic consistency to all sections. The new design is practical as well as attractive: it makesThe Journal's many kinds of articles easier to find and easier to read. Along with this streamlined design, we begin three new features in this issue. OSLERIANA, JAMA 100 YEARS AGO, and THE EXCHANGE, different as they are, will each be a way to make connections—between the science of medicine and the humanities, between contemporary research and the history of medicine, and betweenThe Journaland the future

In Reply.— Drs Howard and Young are, of course, entirely right about my muddled corn terminology. The error is all the more embarrassing because my roots are in loam: I am a native of Nebraska. Although I did not grow up on a farm, I certainly know the difference between corn husks, ears of corn, and corn cobs. My family's discovery that I was capable of such an elementary goof will only confirm their view that my education was seriously marred by my neglect of Cornhusker football games and other patriotically instructive rituals. Fortunately, my mother has reassured me that I will still be allowed to come home for Christmas. One can't argue with Dr Young's suggestion that the elderly man in the painting could be the little boy's father: this is not a portrait of real individuals, after all. That we who are several generations removed from 19th-century rural

"Peer review" has a variety of meanings for physicians. All physicians are accustomed to surveillance of their use of hospital beds or of the records they keep about the patients in those beds by utilization review and quality assurance committees made up of their peers. Physicians face yet more peer review when they double as investigators, put their proposals before institutional review boards, and have their grant applications assessed by expert panels of their peers. Finally, the product of all this—the manuscript that embodies their scientific brainchild and carries their hopes of fame and promotion—is subjected by journal editors to yet another round of peer review. Understandably, it is this last version that tends to interest journal editors the most. However, the workings of the editorial peer review system are of vital concern to every scientist and ultimately to all physicians and patients because all the important advances in science

Announcements of new journals arrive on physicians' desks every week, if not every day, along with all the existing journals that still clamor to be read. It has been estimated, for instance, that the ratio of faculty positions in internal medicine to internal medicine journals is about 15 to 1,1suggesting to the innocent mind that more people publish in some journals than read them. The cataloging creativity of librarians and the memory of readers are ever more tested by the proliferation of medical journals. So is the patience of authors, since every journal has its own editorial style, spelled out in small print in Instructions for Authors or in a formal style manual. The fact that articles that are published in medical journals frequently acknowledge the contributions of secretaries as well as those of professional colleagues is a reminder of the sheer technical effort involved in getting a