All the authors of rimonabant review articles held academic positions, many at prestigious institutions. They typified “medical opinion leaders” sought by pharmaceutical corporations to sign ghostwritten articles [48], [52], [53], [75]. Seven of eight rimonabant review articles appeared in journal supplements, which are non-peer-reviewed, usually industry-funded publications known to carry a high incidence of bias [19]. The Takhar bias instrument demonstrated bias in all eight articles (Table 3). The mean score was 3.08 (95% CI: 2.78 to 3.39), significantly greater than the 2.5 score that separates unbiased from biased publications [56]. In comparison, the mean score for 17 accredited CME events evaluated by Takhar and colleagues was 1.65 (95% CI: 1.32 to 1.99) [56]. An additional analysis of non-Sanofi-supported review articles would provide compelling data for comparison. But “absence of evidence is not evidence of absence”—to prove lack of Sanofi support would require much more than a Google search.

The RIO bias tally identified ten nearly-identical industry-friendly statements or inappropriate omissions in articles written by different authors (Table 3). These statements originally appeared in RIO publications, which acknowledged editorial assistance by Sanofi-Aventis (e.g., [7]), whereas the review articles did not. Nearly identical illustrations reappeared in several articles, and distinctive factual misrepresentations reappeared in articles by different authors. Replication of passages in a single author's work may indicate only carelessness, but replication of passages in articles by different authors raises the question of whether a common ghost author was involved. One rimonabant review article (not included in the analysis because we found no evidence that Sanofi funded its authors) listed the authors as “editors,” and the primary (ghost-) author was unidentified [55]. Of course, judgment regarding ghostwriting or plagiarism should be withheld until the candidate publications are appraised by an editorial board or ethics committee. The same proviso was made by Errami and Garner [76], who used a computational text-searching algorithm to identify “duplicate publications” and “plagiarism” in abstracts cited by PubMed. A search of their database (http://spore.swmed.edu/dejavu/) using the keyword “rimonabant” revealed seven pairs of duplicate publications (including one review article identified herein). The cases of suspected plagiarism repeatedly engaged in disease mongering, which expands the market for those who sell disease remedies. Disease mongering and “supersizing” of rimonabant's indications have been criticized [43], and satirized by a description of “indolebant,” a fictional CB₁ antagonist that treats “extreme laziness” [77].

Rationally choosing the best medication, like other sorts of clinical decision-making, has increasingly relied upon EBM. Thus whoever generates EBM, by funding RCTs, meta-analyses, and CME, may bias clinical decision-making regarding pharmaceuticals [78]. Industry-friendly bias is not unique to rimonabant publications. The discovery process in recent litigation has revealed that many pharmaceutical corporations recruit and train influential physicians for the purpose of manipulating their colleagues. These physicians sign biased ghostwritten articles without disclosing conflicts of interest [48], [52], [53], [75]. For participating in Parke-Davis promotional CME efforts, physicians received honoraria up to US$158,250, in addition to paid travel, lodging, and amenities at luxury resorts [53]. This behavior is not limited to MDs — a pharmaceutical marketing disclosure law in Vermont revealed that the third highest recipient in the state was an osteopathic physician who received $99,843 in 2007 [79]. Despite the fact that osteopathy began as an essentially drug-free school of medicine, the pharmaceutical industry now imparts significant financial leverage over that profession.

Financial conflicts of interest also bias clinical practice guidelines and FDA decisions. An analysis of 44 clinical guidelines revealed 87% of panelists received financial support from pharmaceutical companies, yet only two of the guidelines disclosed panelists' financial conflicts [80]. A larger investigation of over 200 guidelines revealed about 70% of guideline panels being affected [81]. In one guideline panel, every panel member was paid by a drug manufacturer, and that manufacturer's drug was recommended by the panel [81]. Members of FDA drug advisory committees have financial conflicts but rarely recluse themselves from voting, and they tend to vote in favor of corporations that sponsored them [82]. Ten of the 32 FDA panelists that voted in favor of rofecoxib and valdecoxib received fees from the makers of those drugs [83]. Had those financially conflicted panelists been reclused, the FDA would have voted against continued sales of rofecoxib and valdecoxib [83].

In summary, financial conflicts permeate the system and are by no means limited to corporations referenced in this article, such as Merck, Parke-Davis, Pfizer, Sanofi-Aventis, and Wyeth-Ayerst. On balance, pharmaceutical corporations do good work and aid in humanitarian efforts. For example Sanofi-Aventis provides artemisinin at cost to malaria-endemic countries [84]. Nevertheless, ghost authorship and the corrupting effects of covert financial support must cease. Only three of eight rimonabant review articles disclosed corporate sponsorship; two authors specifically denied conflicts. Lack of disclosure prevents readers from judging the credibility of an author. Medical journals should require stronger author disclosure procedures, and universities should discipline academics who sign ghostwritten articles. This behavior should be regarded as unethical misconduct [85]. More broadly, researchers with conflicts of interest should not be allowed to sit on guideline committees and regulatory boards. Corporate funding of CME programs and review articles should be abolished.