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Robert T Mathie research development adviser, Competing interests: Most signatories of this letter are British Homeopathic Association, Luton LU1 3BE health professionals who incorporate homoeopathy and y [email protected] other forms of complementary into their practice. alam Peter Fisher clinical director, Royal London Homoeopathic 1 Colquhoun D. Secret remedies: 100 years on. BMJ Hospital, London WC1N 3HR 2009;339:b5432. (15 December.) Competing interests: None declared. 2 Science and Technology Subcommittee. Evidence check: . Witnesses. 30 Nov 2009. www. 1 O’Dowd A. Government says public backs homoeopathy parliamentlive.tv/Main/Player.aspx?meetingId=5257. y/ photograph despite lack of evidence. BMJ 2009;339:b5234. y y Cite this as: BMJ 2010;340:c594

ga (2 December.) 2 O’Dowd A. Giving homoeopathy on the NHS is unethical and unreliable, MPs are told. BMJ 2009;339:b5080. y garr y (27 November.) uncomplementary debate 3 Science and Technology Committee. Evidence check and : 2: homeopathy. 30 Nov 2009. www.parliament.uk/ parliamentary_committees/science_technology/s_t_ protecting patients What parliamentary witnesses homeopathy_inquiry.cfm. also said about homoeopathy Cite this as: BMJ 2010;340:c592 ’s editorial makes unfounded assertions about the Department of Health Adrian O’Dowd’s two articles about the steering group and its recommendations.1 Science and Technology Committee’s Editorial ignores evidence Given that a public consultation has only evidence check on homoeopathy failed to The BMJ’s coverage of homoeopathy is biased recently closed, his views should not be seen mention several key responses made by and systematically ignores the evidence. We are as representative. witnesses at the parliamentary hearings1‑3— astonished that the BMJ commissioned David He states, as before,2 that decisions for example: Colquhoun’s polemical rant as an editorial.1 are needed on whether disciplines being • There are 24 condition based systematic He attacks the minister, the Department of considered for statutory regulation are reviews of randomised controlled trials Health’s chief scientist, the chief executive “nonsense” or sufficiently grounded in (RCTs) of homoeopathy, of which nine are of the and Healthcare Products science and evidence based practice to positive, five negative, and 10 inconclusive Regulatory Agency, and others who do not share justify regulation. If acupuncture and herbal (question 112 in transcript). his opinions, insulting them by describing their medicine are nonsense, he thinks that • Of 87 placebo controlled RCTs (efficacy considered replies at the recent Commons regulation may officially endorse treatments trials) in peer reviewed literature, Science and Technology Committee hearings on with no proper evidence base. Colquhoun 37 provide positive evidence for homoeopathy as “pure comedy gold.” wrongly asserts that the steering group and homoeopathy; the remainder are mostly A recording of the entire proceedings is the Department of Health lost this important non-conclusive (Q145). available online to those who prefer to make point. The report states clearly that NHS • Not all homoeopathic medicines are up their own minds, but we don’t recommend it funding should be available to complementary diluted beyond the point where no for a laugh.2 Colquhoun’s glossary is no doubt medicine only if there is evidence of efficacy, molecules of original substance are left in intended to be humorous, but the definitions safety, and quality assurance,3 and it reviewed solution (Q123). he gives of acupuncture, herbal medicine, how best to implement meaningful research. • The minister for health services, Mike and homoeopathy bear no relation to the true Statutory regulation and the quest for O’Brien, considered homoeopathy worth definitions and belie any pretence that this is a evidence should proceed together, and in further clinical research (Q199), and he serious contribution. the interests of patient safety, the second stated that government should not stop Despite the subtitle calling for a look at point should not be an absolute prerequisite NHS funding for homoeopathy (Q245-246). efficacy there is not a word about evidence. for the first.4 Many conventional treatments • On medical practitioners of homoeopathy, All attempts to inject evidence into this prove ineffective as research proceeds, Mr O’Brien stated, “There is a significant debate have come from those who believe but to protect patients, practitioners are lobby of clinicians who are quite capable homoeopathy deserves proper investigation regulated while they practise according to of looking at data and who take the view (previous letter). current evidence. Lastly, as many as 10.6% that [homoeopathy] works . . . There is an The only independent and contemporary of adults in England have accessed the more illiberality in saying that personal choice in citation Colquhoun offers in support of his established therapies, so regulation to protect an area of significant medical controversy views is from the Sun. It would be lamentable the public is a priority. should be completely denied” (Q248). if the BMJ’s level of discourse emulated that Robert M Pittilo university vice-chancellor and principal, • And on patient choice he said, “We should publication. Robert Gordon University, Aberdeen AB10 1FR not take the view that patients should not [email protected] Peter A Fisher clinical director, Royal London Homoeopathic be able to have homoeopathic medicine Hospital, London WC1N 3HR [email protected] Competing interests: RMP was chair of the Department when they want it” (Q248). on behalf of Robert T Mathie, David Owen, Anita E Davies, of Health steering group on the statutory regulation of acupuncture, herbal medicine, traditional Chinese medicine, It is important to reflect on these facts when Jeremy Swayne, Tom Whitmarsh, Gary J Smyth, Noel Thomas, Boris Morrice, , Saul Berkovitz, and other traditional medicine systems practised in the UK. forming a balanced judgment of contributions Sosie Kassab, David Peters, Joyce Frye, Mike Cummings, He has also served as a trustee of the Prince’s Foundation for made at the committee hearings. Menachem Oberbaum, and seven others Integrated Health.

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1 Colquhoun D. Secret remedies: 100 years on. BMJ surrounding the subject. That is why the 2009;339:b5432. (15 December 2009.) 2 Colquhoun D. Complementary medicine. A very bad Department of Health’s policy towards Author’s reply to report on regulating complementary medicine. BMJ complementary and alternative medicines is the minister 2008;337:a591. neutral. 3 Department of Health Steering Group on the Statutory Regulation of Acupuncture, Herbal Medicine, Whether I personally think homoeopathy I think the minister (fifth letter) is wrong in two Traditional Chinese Medicine and Other Traditional is nonsense or not is beside the point. As a ways, one relatively trivial but one very important. Medicine Systems Practised in the UK. Report to minister, I do not decide the correct treatment Firstly, he is wrong to refer to homoeopathy ministers. 2008. http://hdl.handle.net/10059/176. 4 Pittilo RM. Complementary medicine. Regulating for patients. Doctors do that. I do not propose as controversial. It is not. It is quite the daftest herbal medicine and acupuncture: Author’s reply. BMJ on this occasion to interfere in the doctor- of the common forms of magic medicine and 2008;337:a590. patient relationship. essentially no informed person believes a word Cite this as: BMJ 2010;340:c595 Mike O’Brien minister of state for health services, of it. Of course, as minister, he is free to ignore 410 Richmond House, 79 Whitehall, Westminster, London scientific advice. But he should admit that that SW1A 2NS [email protected] is what he is doing, and not hide behind the Protecting patients? Competing interests: None declared. (imagined) controversy. 1 Colquhoun D. Secret remedies: 100 years on. BMJ In his letter (previous page) Pittilo states that 2009;339:b5432. (15 December 2009.) Secondly, and far more importantly, he is in conventional medicine, many treatments Cite this as: BMJ 2010;340:c617 wrong to say I was mistaken to claim that “you prove ineffective as research proceeds. cannot start to think about a sensible form of True! Sorting out the wheat from the chaff regulation unless you first decide whether or not is precisely what evidence based medicine Lead, follow, or get out of the way the thing you are trying to regulate is nonsense.” aims to achieve. All statutory regulations If it were irrelevant that the subject you are trying of UK healthcare professions include an In the previous letter Mike O’Brien, minister to regulate was nonsense then why not have obligation to practise evidence based of state for health services, made a statement statutory regulation of voodoo and astrology? The medicine. But the proposed regulation of that cannot be allowed to stand without Pittilo proposals would involve giving honours herbal, traditional Chinese medicine, and exposing its fallacies and cynicism: degrees in nonsense1 if one took the minister’s acupuncture practitioners does not include Further research into the efficacy of view that it doesn’t matter whether the subjects such an obligation. Why? Making sure that therapies such as homoeopathy is unlikely are nonsense or not. Surely he isn’t advocating NHS funding is available to complementary to settle the debate, such is the controversy that? medicine only where evidence exists is not surrounding the subject. That is why the The minister is also wrong to suppose that the same as obliging practitioners to practise Department of Health’s policy towards regulation, in the form proposed by Pittilo, would evidence based medicine. The omission complementary and alternative medicines do anything to help patient safety. Indeed, a of such an obligation is nothing short of is neutral. good case can be made that it would endanger establishing double standards in health care, As a Queen’s counsel, can Mr O’Brien patients2: the main danger is patients being and double standards do not protect patients. imagine a judge telling a jury: “Don’t bother given “remedies” that don’t work. The proposed Edzard Ernst professor of complementary medicine, to assess the truth, accuracy, and validity of regulatory body, the Health Professions Council Peninsula Medical School, Universities of Exeter and the evidence and arguments submitted by the (HPC), has already declared that it is not Plymouth, Exeter EX2 4NT [email protected] prosecution and defence; just decide not to interested in whether the treatments work or Competing interests: None declared. make a decision”? not. That in itself endangers patients. In the case Cite this as: BMJ 2010;340:c597 Does he imagine that it is neither possible of traditional Chinese medicine, there is also a nor desirable to decide how best to spend the danger to patients from contaminated medicines. Regulation means patient safety taxpayer’s money on NHS patients? Or, is he The HPC is not competent to deal with that either. looking to some lobby? It is the job of the Medicines and Healthcare I am glad that David Colquhoun was The Department of Health cannot take a products Regulatory Agency (MHRA) or the entertained by my appearance before the neutral stance to funding complementary and Trading Standards Institute, or both. There are Health Select Committee on Homoeopathy.1 . Either it funds it (ignoring much better methods of ensuring patient safety But he is mistaken when he says, “you the scientific evidence) or it takes account of than those proposed by Pittilo. cannot start to think about a sensible form critically appraised evidence. To see the harm that can result from premature of regulation unless you first decide whether Mr O’Brien’s “neutral policy” amounts to a statutory regulation, it is necessary only to look at or not the thing you are trying to regulate is decision not to make a decision and to continue the General Chiropractic Council (GCC). Attention nonsense.” to waste taxpayers’ money and patients’ time was focused on chiropractic when the British Regulation is about patient safety. and health. I would like to remind him of some Chiropractic Association decided to sue Simon Acupuncture, herbal medicine, and traditional remarks made by Thomas Paine: Singh for defamation. That led to close inspection Chinese medicine involve piercing the skin or It is error only, and not truth, that shrinks of the strength of the evidence for its claims the ingestion of potentially harmful substances from inquiry. to benefit conditions such as infant colic and and present a possible risk to patients. Lead, follow, or get out of the way. asthma. The evidence turned out to be pathetic.3 The Pittilo Report recommends statutory When men yield up the privilege of thinking, At the same time something like 600 complaints regulation and we have recently held a public the last shadow of liberty quits the horizon. were made to the GCC (including two by me consultation on whether this is a sensible way Michael Power medical practitioner, Newcastle upon Tyne against practices run by the chair of the GCC forward. NE1 2ES [email protected] himself, complaints which are being defended). Further research into the efficacy of Competing interests: MP is a taxpayer and consumer The processing of these complaints continues, treatments such as homoeopathy is unlikely of NHS services. but what is absolutely clear is that the statutory to settle the debate, such is the controversy Cite this as: BMJ 2010;340:c598 regulatory body, the GCC, fell foul of the

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Advertising Standards Authority and the Trading other than flu. If the number of deaths is small, flu occurs every year during the winter months in Standards Institute for making false claims itself. the estimate may be zero. the UK. It affects 10-15% of the UK population, There is no doubt that the HPC would be similarly The HPA is currently reporting excess deaths causing around 12 000 deaths every year.”4 An engulfed in complaints if the Pittilo proposals weekly. At 17 December 2009, no excess deaths information page reported, “Even during a winter went ahead. had been seen since February 2009. Had we where the incidence of flu is low, 3000-4000 It is one thing to say that the government relied solely on this measure, we would not deaths may be attributed to flu; this can rise chooses to pay for things like homoeopathy, have been aware of any deaths due to A/H1N1 much higher in epidemic years, for example there despite it being known that they are only influenza so far. Our study has value in filling were an estimated 13 000 deaths in 1993 which placebos, because some patients like them. It this gap. were attributable to flu and 29 000 in 1989/90.”4 is quite another thing to endanger patient safety A second estimate of flu deaths is found in How can Donaldson et al explain the apparent by advocating government endorsement, in the the annual mortality statistics produced by the distortion of policy based on claims of thousands form of statutory regulation, of treatments that Office for National Statistics. These statistics of deaths from flu every year when their records don’t work. record the underlying cause of death. The show an average of no more than 33 deaths a I would be very happy to meet the minister number of deaths for England and Wales with an year for the past four years? to discuss the problems involved in ensuring underlying cause of influenza for the four recent John Stone contributing editor, Age of Autism, London N22 patient safety. He has seen herbalists and others calendar years are: 39 (2008), 31 (2007), 17 [email protected] with vested interests. He has been lobbied by the (2006), and 44 (2005). Many more deaths are Competing interests: None declared. 4 1 Donaldson LJ, Rutter PD, Ellis BM, Greaves FEC, Mytton Prince of Wales. Perhaps it is time he listened to attributed to pneumonia, some of which will be OT, Pebody RG, et al. Comparisons with recent flu the views of scientists too. secondary to influenza. mortality. BMJ 2010;340:c612. (1 February.) 2 BBC News. At risk urged to get flu shot. 2007 September David Colquhoun research professor, Department of Our study includes any death with pandemic 27. http://news.bbc.co.uk/1/hi/health/7016172.stm. , University College London, London WC1E 6BT flu (or synonym) mentioned anywhere on the 3 Stone J. Some published UK data [electronic [email protected] response to Jefferson T. Influenza vaccination: policy Detailed critiques of the points made by Fisher and colleagues death certificate and any death with a laboratory versus evidence]. BMJ 2007. www.bmj.com/cgi/ and Pittilo are available on bmj.com at www.bmj.com/cgi/ positive swab for pandemic flu, irrespective of eletters/333/7574/912#146323. eletters/339/dec15_1/b5432#228877. the reported cause of death. Our method has 4 Department of Health. Explaining pandemic flu: a Competing interests: None declared. guide from the chief medical officer. 2005. www. also rapidly captured information on underlying dh.gov.uk/en/Publicationsandstatistics/Publications/ 1 Report to Ministers from the DH Steering Group on the illness patterns. While absolute numbers PublicationsPolicyAndGuidance/DH_4121751. Statutory Regulation of Practitioners of Acupuncture, Cite this as: BMJ 2010;340:c613 Herbal Medicine, Traditional Chinese Medicine and of deaths may not be out of the ordinary, other Traditional Medicine Systems Practised in the a relatively large number have occurred in UK. 2009. www.dh.gov.uk/prod_consum_dh/groups/ WHO surgical checklist dh_digitalassets/@dh/@en/documents/digitalasset/ children and young adults. dh_086358.pdf. Liam J Donaldson chief medical officer for England 2 McLachlan JC. Response to the Consultation on the [email protected] Customise by specialty Report to Ministers from the DH Steering Group on the Paul D Rutter clinical adviser Statutory Regulation of Practitioners of Acupuncture, Benjamin M Ellis clinical adviser The widespread use of the WHO surgical checklist Herbal Medicine, Traditional Chinese Medicine and Other Felix E C Greaves clinical adviser will undoubtedly bring about improved safety, Traditional Medicine Systems Practised in the UK. Available Oliver T Mytton clinical adviser making existing safety systems increasingly at: www.dcscience.net/Pittilo-consultation-JMc.pdf. Iain E Yardley clinical adviser, Department of Health, 3 Ernst E. Chiropractic for paediatric conditions: substantial Richmond House, London SW1A 2NS redundant and building a team approach with evidence? BMJ 2009;339:b2766. (9 July.) Richard G Pebody consultant medical epidemiologist, shared responsibility in operating theatres.1 The 4 Walker T. Prince Charles lobbies Andy Burnham on Health Protection Agency, Colindale, London complementary medicine for NHS. Telegraph 31 Oct universal use of the WHO checklist, however, 2009. www.telegraph.co.uk/news/newstopics/ Competing interests: Full details are available in the original 2 risks endangering patients if the checklist items mandrake/6474595/Prince-Charles-lobbies-Andy- article, www.bmj.com/cgi/content/full/339/dec10_1/b5213. Burnham-on-complementary-medicine-for-NHS.html 1 Delamothe T. Deaths attributed to influenza in previous are not relevant to the surgical specialty. Cite this as: BMJ 2010;340:c640 years. [electronic response to Donaldson LJ, et al. Mortality Many months ago we trialled the NHS version from pandemic A/H1N1 2009 influenza in England: public of the WHO checklist in cardiac surgical practice health surveillance study]. BMJ 2009. www.bmj.com/cgi/ English mortality from A/H1N1 eletters/339/dec10_1/b5213#227728. in our institution. We found immediately that the 2 Donaldson LJ, Rutter PD, Ellis BM, Greaves FEC, Mytton checklist omitted many important safety checks OT, Pebody RG, et al. Mortality from pandemic A/H1N1 Comparisons with recent 2009 influenza in England: public health surveillance crucial to the safe conduct of cardiac operations, study. BMJ 2009;339:b5213. (10 December.) such as checks on perfusion equipment and flu mortality Cite this as: BMJ 2010;340:c612 preparations for postoperative intensive care. How do the number of deaths from pandemic The Society for Cardiothoracic Surgery in the A/H1N1 compare with influenza related United Kingdom and Ireland subsequently 1 2 Discrepancies in published data mortality in recent years? developed a specific checklist for cardiac surgery, The official estimate of influenza mortality A BBC report with which Sir Liam Donaldson1 is produced by the Health Protection Agency was associated in September 2007 stated: (HPA). It is derived from excess (above “According to Department of Health figures, “expected” level) all cause death registrations flu contributes to over 25 000 excess winter in the winter. The estimates for the past five deaths every year and thousands of people are years in England and Wales are: 1965 (2004-5 hospitalised due to serious complications.”2 winter season), 0 (2005-6), 0 (2006-7), 426 In 2006 I downloaded from the Department (2007-8), and 10 351 (2008-9). The highest of Health website other statements about estimate in recent years (21 497) was for the flu mortality that were not only mutually spl 1999-2000 flu season. This method has its contradictory but also out of line with the present / limitations. It does not examine causation disclosure1 or, indeed, the BBC report.3 Another photo

directly, so excess deaths may have causes of Sir Donaldson’s publications stated, “Ordinary aj

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which has now been approved by the National Frank W Arnold doctor, London [email protected] Patient Safety Agency for use in all cardiac Competing interests: FA was reported to the General Medical Council by the management of a privately run operations in the UK and will be available on the immigration detention centre after giving potentially life Society for Cardiothoracic Surgery’s web site saving medical advice to three detainees. He experienced (www.scts.org). considerable anxiety during the months it took for the Surgical specialties should adapt the checklist GMC to decide that there was no evidence to support the allegations made against him and that he had done nothing to maximise safety in their patient population. that violated his duties as a doctor. Only when checklists are specific to the 1 Delamothe T. Gagging for it. BMJ 2009;339:b4444. environment and developed by the surgeons (29 October.) 2 Gornall J. Whistleblowing: the price of silence. BMJ who will use them will safety be fully improved. 2009;339:b3202. (27 October.) Stephen Clark consultant cardiothoracic surgeon 3 Cassidy J. Falling foul of gagging clauses. BMJ [email protected] 2009;339:b4203. (27 October.) Leslie Hamilton consultant cardiothoracic surgeon, 4 Secretary of State for Health. MISC (97)65: Freedom Freeman Hospital, Newcastle upon Tyne NE7 7DN of speech in the NHS. 1997. www.dh.gov.uk/en/ men could remain healthy on as little as 10 mg Competing interests: None declared. Publicationsandstatistics/Lettersandcirculars/ ascorbic acid a day for at least a year. 1 Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K. Miscellaneousletters/DH_4018033. Of the 20 young male volunteers, three were Practical challenges of introducing WHO surgical checklist: 5 Rusbridger A. Trafigura: anatomy of a super-injunction. UK pilot experience. BMJ 2010;340:b5433. (13 January.) Guardian 2009 October 20. www.guardian.co.uk/ given a diet containing 70 mg ascorbic acid a day, Cite this as: BMJ 2010;340:c589 media/2009/oct/20/trafigura-anatomy-super-injunction. seven a diet containing 10 mg a day, and 10 a diet Cite this as: BMJ 2010;340:c601 providing no food containing vitamin C. All 10 of Gagging and duty those in the last group developed clinical scurvy Administrative accountability after four to seven months. None of those in the What of outsourced two other groups developed any signs of scurvy or Paul Galea’s letter eloquently makes the case for any illness which could be attributed to scurvy. settings? a mechanism within the NHS for employees to Choh and colleagues mention the occurrence Tony Delamothe’s editor’s choice highlighted complain about administrative incompetence or of follicular hyperkeratosis as an early sign of articles by Jonathan Gornall and Jane Cassidy misconduct.1 scurvy. In our 10 deprived subjects thousands that show the dangers of employers gagging General practitioners within the NHS, while of very small (1-2 mm) haemorrhages around doctors from raising serious concerns about not strictly speaking employees, labour under the bases of the hair follicles were the first most patient safety.1‑3 He observed that “George Orwell the same deficiency. Sadly, the Department of obvious clinical sign.2 This sign and a careful would have savoured the designation of these Health does not recognise this as a problem. We dietary history should make it possible to [employing authorities] as ‘trusts’.” recently wrote to the secretary of state for health diagnose scurvy before serious haemorrhages as The two articles show trusts behaving as “big on this matter, having exhausted every avenue described occur. brothers,” by silencing those who would speak within the NHS. The authors state that adults require 40 mg of the truth to protect senior managers’ reputations, The initial response was that the appropriate vitamin C daily. We found that seven young men bonuses, and jobs.2 3 Within the NHS, doctors authority was our local strategic health authority remained healthy for at least a year on only 10 mg can rely on the flimsy protection of ministerial (NHS London). Once we had confirmed it was daily, but we suggested 30 mg daily to provide a statements that confidentiality clauses on NHS outside their remit, the department replied that margin of safety. employment contracts contravene NHS executive “the only recourse is to settle the dispute with John Pemberton emeritus professor of social and preventive policy and staff’s rights to bring unacceptable legal action” and that this “reflects [their] policy medicine, Queen’s University, Belfast [email protected] practices into the open.4 In outsourced health regarding such matters.” Competing interests: None declared. care the situation is worse. Here, incentives to This could better be described as the absence 1 Choh CTP, Rai S, Abdelhamid M, Lester W, Vohra RK. abuse legal muzzles are fortified by “shareholder of a policy, and the department is not persuaded Unrecognised scurvy. BMJ 2009;339:b3580. value,” and rights of commercial confidentiality that there is a problem that needs solving. In the (17 September.) 2 Medical Research Council. Vitamin C requirement of may be so sanctified in law as to be virtually meantime, precious NHS resources are wasted by human adults. 1953. (Special Report Series No 280.) unchallengeable. primary care trusts defending themselves in court, Cite this as: BMJ 2010;340:c590 Outsourcing is occurring in community care with the blessing of the Department of Health. (out of hours work, walk-in clinics, commercial Brian J Golden GP principal, Ravenscroft Medical Centre, Risk money for trial volunteers practices), secondary care (independent surgical London NW11 8BB [email protected] treatment centres), and custodial settings Competing interests: None declared. Not payment, but compensation (privatised prisons and immigration detention 1 Galea P. Gagging and duties. BMJ 2010;340:c148. centres). Does ministerial prohibition of gags in (13 January.) We should not treat participation in medical Cite this as: BMJ 2010;340:c602 NHS bodies apply to these commercial entities? Or trials as if it were a gladiatorial performance, will they be allowed to apply clinical equivalents with participants paid for their bravery.1 of super-injunctions?5 Concerned clinicians may Unrecognised scurvy However, all participants in trials should be able to rely on the General Medical Council’s be provided with adequate insurance policies Duties of a Doctor for support if they speak out in Vitamin C requirements against the risk of adverse reactions. such a situation. Or they may not. In their article on unrecognised scurvy, Choh Joseph More retired, Winthrop, MA 02453, USA We urgently need enforceable legal protection and colleagues1 do not refer to the important [email protected] for employees of commercial organisations human experiment on the effects of vitamin Competing interests: None declared. 1 Saunders J. Should healthy volunteers in clinical trials contracted to provide state responsibilities for C deprivation on conscientious objectors in be paid according to risk? No. BMJ 2009;339:b4145. health care where their ethical duties require Sheffield in 1942.2 This study demonstrated the (22 October.) them to speak out. earliest signs of scurvy and showed that young Cite this as: BMJ 2010;340:c587

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