It is also difficult to publish articles documenting that the status quo in a medical specialty is harmful for the patients even though such articles should be warmly welcomed. Particularly in psychiatry, it has been amply documented that guild interests are far more important than the patients' survival and well-being.1,2
For top general medical journals, e.g. Lancet and New England Journal of Medicine, the conflicts of interest are obvious, as the revenue from drugs ads and selling reprints of trial reports constitutes a substantial proportion of their income.3 Top specialty journals have similar conflicts. In addition, they usually have part-time editors who are keen to protect the specialty's guild interests and prevailing dogmas.
Another problem is the threat of litigation. The BMJ has an insurance that mandates the editors to adhere to their lawyers' advice; otherwise, the insurance won't cover the costs of a libel lawsuit.