COMMENTARY
Free Speech in Articles and Letters to the Editor in
The American Journal of Medicine
“. . . it is well understood that the right of free speech is
not absolute at all times and under all circumstances.
There are certain well-defined and narrowly limited clas-
ses of speech, the prevention and punishment of which
have never been thought to raise any Constitutional
problem. These include the lewd and obscene, the pro-
fane, the libelous, and the insulting or ‘fighting’ words—
those which by their very utterance inflict injury or tend
to incite an immediate breach of the peace. It has been
well observed that such utterances are no essential part
of any exposition of ideas and are of such slight social
value as a step to truth that any benefit that may be
derived from them is clearly outweighed by the social
interest in order and morality.” —Supreme Court Jus-
tice, Anthony M. Kennedy1
Recent instances questioning the boundaries of free
speech in academic publications have arisen, resulting in
heated conversations. These discussions should be taken
seriously because science cannot advance without raising
questions that are often contrary to previously held conclu-
sions. In medical journals, correspondence in the form of
letters to the editor frequently involve critiques of published
articles. Does that allow authors of letters to chastise
authors of publications? Are editors and publishers obli-
gated to publish any or all letters, no matter what their
content?
Vigorous debate continues in the United States concern-
ing what constitutes free speech, guaranteed in the Consti-
tution, and where the border lies across which one must not
tread. The first amendment to the Constitution says,
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors had access to the data and have participated
in the preparation of the manuscript. Joseph S. Alpert: Conceptualization,
Visualization, Writing − original draft, Writing − review & editing. Stuart
Chipkin: Conceptualization, Visualization, Writing − original draft,
Writing − review & editing.
Requests for reprints should be addressed to Joseph S. Alpert, MD,
Department of Medicine, University of Arizona College of Medicine,
1501 N. Campbell Avenue, Sarver Heart Center Room #5133, Tucson, AZ
85724-5037.
E-mail address: jalpert@shc.arizona.edu
0002-9343/© 2024 Published by Elsevier Inc.
https://doi.org/10.1016/j.amjmed.2024.02.026
“Congress shall make no law . . . abridging the freedom of
speech”.2 Does this mean that one can say anything they
want to whether or not it is true or whether bodily harm
might come to someone because of what was said? The
Supreme Court has ruled on this question several times.
The decisions are clear; one cannot say something that
might result in bodily harm to someone. The most quoted
example is an individual yelling “Fire!” in a crowded the-
ater when no fire exists. The resultant panic and rush for the
exits would almost certainly result in many serious injuries
and deaths. Thus, one may not exercise free speech that
might harm someone. Another area in which free speech is
not unconditional is during legal proceedings where one
has sworn to tell “the truth, the whole truth, and nothing but
the truth.” In that setting and when one is questioned by the
police, one may not lie, despite the principle of free speech.
Using a falsehood in the name of free speech can result in
incarceration and substantial fines. Other situations where
free speech is limited involve liability with false epithets
spoken or printed about someone. For example, publicly
announcing that another person is an “insane sociopath”
requires strong evidence that this description is true. If this
statement is not true, then one might be sued for falsely
slandering this individual, possibly resulting in a substantial
fine paid to the insulted person. However, private compa-
nies can set rules regarding what people using their services
or working for them are permitted to say. When, at the time
of employment, one clicks “I agree” to all the website terms
and conditions or when one signs an employment docu-
ment, there is invariably a statement in those documents
about what one is allowed to say. For example, if an indi-
vidual who is a strict vegan works in a non-vegan restaurant
and tells every customer who orders a steak that they are
evil baby cow murderers, they are not protected from losing
their job because of freedom of speech.
Having thus briefly reviewed the limits of free speech,
what is the policy of The American Journal of Medicine
(AJM) and American Journal of Medicine Open (AJM-O)
in letters to the editor where individuals express their agree-
ment or dissent involving something that has been
published in the journal? The AJM accepts and follows
Elsevier’s Principle of Ethics and the Reed/Elsevier
468
Editorial Policy (both listed below). Of course, we accept,
as do all other publications in the United States, the princi-
ple of the First Amendment to the Constitution as quoted
earlier in this commentary. However, the editorial board
also accepts Supreme Court Justice Kennedy’s amending
principle that “There are certain well-defined and narrowly
limited classes of speech, the prevention and punishment of
which have never been thought to raise any Constitutional
problem,” such as ” the lewd and obscene, the profane, the
libelous, and the insulting or ‘fighting’ words—those which
by their very utterance inflict injury or tend to incite an
immediate breach of the peace.”1 Such a breach of common
and decent dissent in letters to the editor have rarely been
seen during the present editorial board’s existence. How-
ever, we recognize that just because something has not
been seen before does not mean that it may not arise in the
future.
From our journals’ perspectives, there are 2 broad cate-
gories that might invoke questions related to freedom of
speech. The first involves the language used in a letter as it
relates to a publication in our journals. The second involves
the topic of politics. To be sure, we have received seriously
conceived and well-argued letters disagreeing with material
we have published, for example, concerning chronic Lyme
disease, potential harm in a high salt diet, and the value of
strict meritocracy in our nation. The AJM has always
published these letters, except in the rare case where they
contain personal invective. The use of language or its tone
that is (per Justice Kennedy) obscene, profane, libelous,
or insulting, is inappropriate and is not accepted for
publication.
There have been some journals that have published
articles and editorials on political topics. At times, political
issues have implications for health care, for example, when
a topic impacts patient concerns or public health. The
AJM’s approach has been only to publish political or cur-
rent events material where it clearly and directly pertains to
the practice of medicine.3 AJM Open adheres to this
approach. The AJM and AJM-O are medical journals and
that is all we publish. We have always felt that letters
reflecting current events or local/national/international poli-
tics make much more sense on the op-ed pages of newspa-
pers such as The New York Times, The Washington Post,
The Los Angeles Times, The Wall Street Journal, The Chi-
cago Tribune, and many others.
As always, we look forward to hearing from readers about
this commentary or any other that we have written. Contact
us at jalpert@arizona.edu and schipkin@umass.edu.
ELSEVIER PRINCIPLE OF EDITORIAL
INDEPENDENCE
 We believe strongly in ensuring that we keep the editorial
decision-making processes of our publications completely
separate from our commercial interests.
 Safeguarding this editorial independence requires that all
editorial decisions, or concerns or complaints, about
The American Journal of Medicine, Vol 137, No 6, June 2024
editorial decisions are dealt with strictly within the edito-
rial structures of a publication.
 These structures typically include editors, editors-in-
chief, editorial boards, or review boards, and ombudsmen
or analogous structures for the editorial governance of
any given publication.
 It further requires that no one on the commercial or exec-
utive side of the business can get involved in, interfere
with, or even comment on editorial decisions under any
circumstances.
 To deviate from the rigorous application of this principle
in any individual situation would ultimately serve to
undermine the integrity of the principle of editorial inde-
pendence altogether.
THE RELX EDITORIAL POLICY
The RELX (RELX plc [pronounced "Rel-ex"] a Reed/Elsev-
ier British multinational information and analytics company
headquartered in London) Code of Ethics and Business Con-
duct makes clear our commitment to excellence and our obli-
gation to uphold ethical standards in all our corporate
activities. Accordingly, the RELX Editorial Policy
(“Policy”) outlines principles underlying our products and
services, including but not limited to data, books, journals,
magazines, websites, blogs, marketing, apps, and other
mobile content and community sites. We have a responsibil-
ity to all stakeholders, including our authors, editors,
reviewers, customers, and employees, to produce informa-
tion of the highest quality, which is reliable, comprehensible,
and timely; which avoids bias, defamation, discrimination,
conflict of interest or plagiarism; which makes a clear dis-
tinction between fact and opinion; and which clearly identi-
fies editorial, advertising, user-generated, or other content.
We respect human rights. We encourage dialogue on our
content, including through responsible use of social media.
We encourage pluralism of sources, ideas, and contributors
and aim to advance informed decision-making. We are com-
mitted to universal, sustainable access to information. We do
not allow threats or inducements to influence our manage-
ment, handling, or publication of information. We have a
responsibility not to take personal advantage of information
gained in the course of our duties before that information
becomes public knowledge. To foster a free exchange of
ideas, we allow our authors, editors, and reviewers indepen-
dence in their decision-making and freedom from internal
and external pressure. For parts of the business where appro-
priate, we verify content, cite supporting materials, and use
methods such as peer review to ensure impartiality and bal-
ance. We respect privacy, including the data privacy and
security of our customers and those with whom we work and
engage. We uphold copyright laws. We are committed to
using artificial intelligence responsibly. RELX employees
have the right to refuse an assignment or be identified as the
author of editorial content that violates the letter or spirit of
this Policy. We ensure awareness of our editorial standards
Alpert and Chipkin Free Speech in Articles and Letters to the Editor in AJM
by employees and relevant stakeholders. We are transparent
and provide clear instruction for corrections, retractions, or
withdrawals, and provide mechanisms for reader and cus-
tomer feedback and for registering any concerns or com-
plaints. Employees should report breaches of the Policy to a
company lawyer or a compliance committee member.
Breaches may result in disciplinary action after appropriate
investigation. We share and require adherence to this Policy
with relevant suppliers.
Joseph S. Alpert, MDa
Stuart Chipkin, MDb
a 2. Congress.gov. The Constitution of the United States: First Amendment.
University of Arizona School of
Medicine, Tucson,
Editor in Chief,
The American Journal of Medicine
469
b
School of Public Health and Health
Sciences, University of
Massachusetts Amherst,
Editor in Chief,
The American Journal of
Medicine Open
References
1. National Constitution Center. Constitution 101 Resources:10.4 First
Amendment quotes. Available at: https://constitutioncenter.org/educa-
tion/classroom-resource-library/classroom/10.4-primary-source-quotes-
from-free-speech-cases. Accessed February 8, 2024.
Available at: https://constitution.congress.gov/constitution/amendment-
1/#:»:text=Congress%20shall%20make%20no%20law,for%20a%
20redress%20of%20grievances. Accessed March 3, 2024.
3. Alpert JS. Medicine, yes; politics, no!. Am J Med 2015;128(3):211–2.