Sometimes, a seemingly run-of-the-mill retraction notice turns out to be much less straightforward.
Such was the case with a recent retraction of a 2016 paper in a journal published by the U.S. Centers for Disease Control and Prevention, apparently over permission to use an evaluation scale designed to test whether patients take their medications as prescribed. But when we looked into this story, we learned this retraction was only the tip of the iceberg – a representative of the evaluation scale (titled “Chief Investigator”) told us he has contacted hundreds of so-called “infringers” over the last year who used the scale without permission. The authors must then apply retroactively and show they’ve used it correctly, and may even have to pay fees. Or, in the case of the retraction we saw (and at least one other in 2016), pull the paper.
According to the chief investigator, Steve Trubow, who oversees licensing and use of the scale worldwide, for some uses, there is no fee – but depending on what the researchers are using the Morisky Medication Adherence Scale (MMAS-8) for, it can cost up to $100,000. Once they’ve used it without permission, there are fees for that, too, Trubow told us:
Retroactive license[s] cost $100 to $40,000…In the United States one large hospital system paid $40,000.00 in 2016.
He said thousands have licensed the MMAS, but too many don’t:
As the Chief Investigator one of my responsibilities is to protect the integrity of the MMAS from Infringers who misuse the MMAS…I have contacted hundreds of Infringers over the last year.
One such infringement led to the following retraction notice for “Health and Nutrition Literacy and Adherence to Treatment in Children, Adolescents, and Young Adults with Chronic Kidney Disease and Hypertension, North Carolina, 2015,” published by Preventing Chronic Disease:
Due to an unintentional error, the MMAS-8 scale in our article, “Health and Nutrition Literacy and Adherence to Treatment in Children, Adolescents, and Young Adults with Chronic Kidney Disease and Hypertension, North Carolina, 2015” (1), published on August 4, 2016, by Preventing Chronic Disease, was used without proper permission from Dr Donald E. Morisky and coauthors. We regret any problems our article may have caused, and we retract it from the literature.
When Trubow first came across Patel’s article in August, he contacted her to check whether she had received a license to administer and use MMAS scale. According to emails Trubow forwarded to us, Patel said that she had asked for permission in 2015 from Donald Morisky, a professor in the School of Public Health at the University of California in Los Angeles who created the scale — and forwarded the email to prove it. After not receiving a reply, however, she and her coauthors published the article using the MMAS scale, which she said they found online.
Trubow informed her that she could apply for a license retroactively. The license includes 13 questions about the authors, the study, and how the scale was administered, which Patel then answered.
As Trubow asked more questions about the scoring the researchers used in the paper, he and Morisky realized the researchers had applied the scoring incorrectly. In an email sent August 15, Morisky informed Patel that the scoring approach she and her coauthors used “will incorrectly identify individuals who are “highly adherent” as “low adherence” and vice versa…” This scoring approach, he continued, “will result in an inappropriate educational counseling intervention. This is a very serious misrepresentation of the validated MMAS-8. I am very concerned as to the repercussions of the inaccurate information you have published in a highly valued journal.”
Patel responded to Morisky the same day, apologizing and saying she had no intention of misusing the material.
On August 20, Trubow reached out to the journal’s editor-in-chief, Leonard Jack (and CC’ed Patel), to investigate the copyright infringement issue as well as the changes the authors made to the scale.
On December 21, Jack informed Morisky and Trubow of the journal’s final decision to retract the article:
After reviewing the information provided to us from the authors and from University of North Carolina’s institutional investigation, we recommended that the authors issue a retraction of the article. The authors have agreed with this recommendation, and a retraction will be published in PCD on Friday, December 23, 2016. Further, the retraction will be indexed in the literature according to AMA guidelines.
Jack also provided us with further context on the retraction:
The article was submitted for our annual Student Paper Research Contest and published on August 4, 2016, and used [Morisky’s] copyrighted survey instrument, the MMAS-8, without proper permission and was incorrectly scored. We promptly looked into these concerns and reached out to the authors for an explanation. Ultimately the authors decided to retract the article, and the retraction was published on December 23, 2016. To address any potential for a similar circumstance in the future, we have added survey instruments to the authorship statement of our manuscript submission system, which requires authors to acknowledge that the appropriate permissions have been obtained.
We reached out to the three study authors for comment, and have not yet heard back.
Regarding the unlicensed use of his scale, Morisky told us:
I have worked my entire career to protect the integrity of my intellectual property and unauthorized use is a serious infringement of international copyright laws.
Trubow forwarded us email correspondence that led to another recent retraction in the International Journal of Integrative Medical Sciences for a similar copyright infringement issue regarding unlicensed use of the MMAS scale. Here’s the retraction notice for “Prevalence of Patients Compliance among Hypertensive Patients and Its Associated Factors in Klinik Kesihatan Botanic Klang, Malaysia,” published in 2016:
The editor and Publisher regretfully retract the article  as per the request of the author’s, “upon the careful consideration of the issue”. We apologize to all affected parties for the inconvenience caused.
As part of that correspondence, the first author also apologized to Trubow for the use of the scale, saying the work was done by students who found the information online for free. The researcher answered the questions Trubow sent, then asked that the fee be waived, as the work was done without any grant. Trubow responded on December 28, 2016:
There will be a cost of $750.00 (USD).
This is a reduced fee for a corrective license.
The usual cost for serious infringements is $1000.00.
It costs us a lot of money to investigate and correct the infringements
If you don’t want to pay the fee, I will not prepare the license.
Let me know.
A few hours later, the author wrote back, saying they were no longer interested in using the scale, and had asked the journal to remove the paper.
Trubow stays busy — he forwarded us some emails he sent regarding a recent BMC Women’s Health paper, “Compliance and treatment satisfaction of postmenopausal women treated for osteoporosis. Compliance with osteoporosis treatment,” which he claimed violated the scale’s copyright. In this case, however, an assistant general counsel for GlaxoSmithKline (the company that funded the study) rejected Trubow’s claim that the article infringes on any copyright, also noting that the MMAS-4 questions and methodology are in the public domain. Trubow then contacted representatives of BioMed Central on January 14, saying:
Unless the BMC journal notifies us that it plans to remove the attached article, we will be forced to have our lawyer, Mr. Kenneth Gross use all legal means necessary to remove the article.
Trubow has licensed the scale to thousands of papers and many studies acknowledge that the Morisky scale is copyrighted material. For instance, according to a 2015 paper published in the Eastern Mediterranean Health Journal, a World Health Organization journal:
Use of the MMAS© is protected by United States copyright laws. Permission for use is required. A license agreement is available from Donald E. Morisky …
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