I write to respond Professor Iain Chalmers' letter in the 30 July 2010 issue of theJournal. Chalmers is critical of the medical advisers to the Inquiry for not seeking ‘systematically analysed and published evidence of (i) international consistency of gynaecological practice in ... respect [of the treatment of carcinoma in situ]; and (ii) empirical research evidence justifying such consistency.'Chalmers suffers from the misunderstanding that I was one of the medical advisers to the Inquiry. I took no part in the Inquiry. I am an academic medical lawyer and the editor of The Cartwright Papers.Chalmers is very critical of the medical advisors to the Cervical Cancer Inquiry, who incidentally included Professor Eric MacKay, gynaecologist and Professor Linda Holloway, pathologist as well as Professor Charlotte Paul, epidemiologist, for the fact that Judge Cartwright relied on expert evidence to form an opinion about conventionaltreatment. Chalmers' criticism betrays a fundamental misunderstanding of the judicial process.First, the Judge's terms of reference charged her with determining whether ‘there was a failure adequately to treat cervical CIS at NWH, and if so, the reasons for that failure and the period in which the failure existed'. In order to do so, she was required to determine what constituted ‘adequate' treatment for CIS in 1966 and thereafter during the period of Green's study. Hence the evidence Judge Cartwright sought was a definition of adequate treatment. Chalmers cites pages in the Report where the evidence for conventional treatment is summarised, complaining that ‘[t]hese short passages do not cite scientific articles, but simply quote the opinions of four witnesses (and one interviewee).'Prompted by Professor Jones' criticism, Chalmers has apparently ‘now consulted the Cartwright Report.' Clearly, he has still not read the whole Report. It is tempting to dismiss him as unqualified to participate knowledgeably in these debates until he has done so. In any event his reading was clearly only ‘in search of the evidence [he] needed' of a definition of conventional treatment for CIS, for he misses the whole chapter called ‘Adequate management of CIS' (page 103 and following).Chalmers states he ‘felt sure that [Paul] would have pointed [him] to the relevant parts of the Cartwright Report if it contained the evidence [he] sought from her.' I am happy to refer him now to the relevant part of the Report he missed. On page 106 the Judge concluded, on the basis of expert advice from eight world leaders in the gynaecological field and consideration of other views canvassed during the Inquiry, that: ‘the appropriate treatment of CIS, if invasive cancer is to be avoided, is to remove the lesion. The patient must then be monitored so that further treatment can be offered if there is persisting disease or a recurrence, as evidenced by positive cytology.' (See also page 107, under the heading ‘The aim of treatment').Secondly, a judge relies on the advice of experts who can be cross-examined. It is they who cite the published evidence for their opinions. The Judge stated: ‘Their evidence was derived from an examination of the medical literature, a review of research projects and personal experience in practice at various periods from the early 1950s.' (page 106) Even if the Judge had asked the experts called to give evidence to conduct a systematic review, as Chalmers thinks ought to have been done, he produces no evidence that it would have been different from the advice of the experts and the conclusion of the Judge (page 107)—that all treatments at that time were aimed at eradicating the lesion, be they by local destructive treatments, local excision, conization or hysterectomy. What Green was doing was not treating.Chalmers criticises Paul for using uses the term ‘current best practice' without defining it in The Cartwright Papers. He omitted to notice that Paul was quoting Bryder's view of what Green was doing, that the 1966 proposal was for ‘conservative treatment that was ‘current best practice'' (pages 23-24 of History). Paul disagreed with this characterisation by Bryder of Green's 1966 proposal (pages 121-122 of The Cartwright Papers).Far from being an ‘intemperate attack', Paul's careful analysis is based on an unimpeachable grasp of the scientific evidence. I urge the Journal's readers to read it for a full understanding of the true scale and seriousness of Bryder's errors in herHistory, rather than to rely on Chalmers' misunderstandings both of the Report and of the proper way evidence is gathered and factual findings are made on the basis of it in judicial inquiries. Joanna Manning Associate Professor in Health Law and Policy Faculty of Law, The University of Auckland

I write to respond Professor Iain Chalmers' letter in the 30 July 2010 issue of theJournal. Chalmers is critical of the medical advisers to the Inquiry for not seeking ‘systematically analysed and published evidence of (i) international consistency of gynaecological practice in ... respect [of the treatment of carcinoma in situ]; and (ii) empirical research evidence justifying such consistency.'Chalmers suffers from the misunderstanding that I was one of the medical advisers to the Inquiry. I took no part in the Inquiry. I am an academic medical lawyer and the editor of The Cartwright Papers.Chalmers is very critical of the medical advisors to the Cervical Cancer Inquiry, who incidentally included Professor Eric MacKay, gynaecologist and Professor Linda Holloway, pathologist as well as Professor Charlotte Paul, epidemiologist, for the fact that Judge Cartwright relied on expert evidence to form an opinion about conventionaltreatment. Chalmers' criticism betrays a fundamental misunderstanding of the judicial process.First, the Judge's terms of reference charged her with determining whether ‘there was a failure adequately to treat cervical CIS at NWH, and if so, the reasons for that failure and the period in which the failure existed'. In order to do so, she was required to determine what constituted ‘adequate' treatment for CIS in 1966 and thereafter during the period of Green's study. Hence the evidence Judge Cartwright sought was a definition of adequate treatment. Chalmers cites pages in the Report where the evidence for conventional treatment is summarised, complaining that ‘[t]hese short passages do not cite scientific articles, but simply quote the opinions of four witnesses (and one interviewee).'Prompted by Professor Jones' criticism, Chalmers has apparently ‘now consulted the Cartwright Report.' Clearly, he has still not read the whole Report. It is tempting to dismiss him as unqualified to participate knowledgeably in these debates until he has done so. In any event his reading was clearly only ‘in search of the evidence [he] needed' of a definition of conventional treatment for CIS, for he misses the whole chapter called ‘Adequate management of CIS' (page 103 and following).Chalmers states he ‘felt sure that [Paul] would have pointed [him] to the relevant parts of the Cartwright Report if it contained the evidence [he] sought from her.' I am happy to refer him now to the relevant part of the Report he missed. On page 106 the Judge concluded, on the basis of expert advice from eight world leaders in the gynaecological field and consideration of other views canvassed during the Inquiry, that: ‘the appropriate treatment of CIS, if invasive cancer is to be avoided, is to remove the lesion. The patient must then be monitored so that further treatment can be offered if there is persisting disease or a recurrence, as evidenced by positive cytology.' (See also page 107, under the heading ‘The aim of treatment').Secondly, a judge relies on the advice of experts who can be cross-examined. It is they who cite the published evidence for their opinions. The Judge stated: ‘Their evidence was derived from an examination of the medical literature, a review of research projects and personal experience in practice at various periods from the early 1950s.' (page 106) Even if the Judge had asked the experts called to give evidence to conduct a systematic review, as Chalmers thinks ought to have been done, he produces no evidence that it would have been different from the advice of the experts and the conclusion of the Judge (page 107)—that all treatments at that time were aimed at eradicating the lesion, be they by local destructive treatments, local excision, conization or hysterectomy. What Green was doing was not treating.Chalmers criticises Paul for using uses the term ‘current best practice' without defining it in The Cartwright Papers. He omitted to notice that Paul was quoting Bryder's view of what Green was doing, that the 1966 proposal was for ‘conservative treatment that was ‘current best practice'' (pages 23-24 of History). Paul disagreed with this characterisation by Bryder of Green's 1966 proposal (pages 121-122 of The Cartwright Papers).Far from being an ‘intemperate attack', Paul's careful analysis is based on an unimpeachable grasp of the scientific evidence. I urge the Journal's readers to read it for a full understanding of the true scale and seriousness of Bryder's errors in herHistory, rather than to rely on Chalmers' misunderstandings both of the Report and of the proper way evidence is gathered and factual findings are made on the basis of it in judicial inquiries. Joanna Manning Associate Professor in Health Law and Policy Faculty of Law, The University of Auckland