Cartwright Inquiry

The Cartwright Inquiry was a Commission of Inquiry held in New Zealand from 1987 - 1988. It was commissioned by the then Minister of Health, Michael Bassett to investigate the alleged malpractice of Associate Professor Herb Green, a gynaecology and obstetrics specialist. The inquiry was headed by then District Court Judge Silvia Cartwright, later High Court Justice, Dame, and Governor-General of New Zealand.

Background to the Inquiry

A 1984 medical paper ^[1] by a colposcopist, pathologist, gynaecologist and a statistician, described a study of 948 woman who had been diagnosed with carcinoma in situ (CIS) at New Zealand's The National Women's Hospital from 1966 onwards. This study involved withholding treatment of women with abnormal cervical smears, when these abnormalities could potentially lead to cervical cancer, the woman being divided into two groups based upon having negative or positive PAP smears for CIS after initial treatment. Two prominent women's health advocates and writers, Sandra Coney and Phillida Bunkle, had already heard rumours^[2] about this paper while they had been researching material about another matter. Coney and Bunkle published an expose in Metro Magazine in June 1987,^[3] titling it after a 1986 letter in the New Zealand Medical Journal by Professor David Skegg, a Public Health expert with a strong interest in screening condemning what he called the "Unfortunate Experiment".^[4] This led to widespread public outcry and the then Minister of Health, Michael Bassett calling an inquiry.

Green experiments

The inquiry was set up to examine whether Herb Green had been intentionally undertreating women with cervical cancer and experimenting on his patients without their consent or proper approval. Following the development of the Pap smear by Georgios Papanikolaou in 1928, there had been worldwide interest in developing screening programmes for cervical cancer, such as that begun in British Columbia, Canada in 1949 . Although Herb Green was an early proponent of cervical screening, by the mid-1960s he had formed a minority view that cervical dysplasia does not always progress to cervical cancer. In 1966 he submitted a proposal to the Hospital's Medical Committee to, in Coney's words:

'withhold conventional treatment of cone biopsy or hysterectomy in women under thirty-five years old'.^[2]

Inquiry

District Court Judge Sylvia Cartwright was appointed by warrant dated 10 June 1987 as a Committee of Inquiry to inquire into the treatment of cervical cancer at the National Women's Hospital and other matters. The terms of reference (below) contained many matters that were of general interest regarding patient care and research, in addition to being of particular importance at the National Women's Hospital.

Terms of Reference

The Terms of Reference for the Inquiry were to investigate whether (as alleged in the Metro Article):

1. If there was a failure to adequately to treat cervical cancer and the reasons for this
2. If a Research programme into the natural history of CIS was established
   1. Whether this had been approved
   2. Whether patients were aware they were in a research programme
   3. Whether any concerns were expressed at the time
3. Whether there was need to contact women involved
4. Whether the National Women's Hospital's procedures for research were adequate, especially regarding rights of patients
5. Whether the protection of patients undergoing research needs to be improved
6. Whether the patients at the National Women's Hospital were properly informed of the treatment and options available to them
7. What training is given to doctors regarding cervical cancer
8. What is the relationship between the academic and clinical units at the hospital
9. Any other matter which is relevant.^[5]

Parties to the Inquiry

The first preliminary hearing was held on the 18th June 1987. Three medical advisers were appointed, Professor E V MacKay, Professor of Obstetrics and Gynaecology at the University of Queensland, Dr Charlotte Paul, Epidemiologist, University of Otago Medical School and Dr Linda Holloway, Pathologist, University of Otago Wellington School of Medicine.

Overall 1200 patient files were reviewed. The Inquiry ran for seven months and experts were brought from around New Zealand as well as from Australia, United States and Norway, to comment on Green's work. They testified that Green's work varied significantly from what was considered good practice and put his patients at risk.

Results

The Inquiry confirmed the claims made by Coney and Bunkle and the ensuing report - The Report of the Cervical Cancer Inquiry (1988) ^[5] - led to sweeping changes in law and practice around health consumers' rights. The Office of Health And Disability Commissioner was established, with a Code of Health Consumers' Rights which enshrined informed consent. Teaching practice was changed at National Women's Hospital and Auckland Medical School to conform to international practice, independent health ethics committees were set up throughout New Zealand, and a national cervical screening programme was established.

Other related findings

Other unethical practices exposed at the Inquiry were Green's 'baby smears' experiment in which cervical smears were taken from newborn baby girls without their parents' consent, all part of Green's theory that some women were born with abnormal cervical cells and that these were not linked to cervical cancer. Also exposed was the hospital's practice of teaching vaginal examinations and IUD insertions on unconsenting women anaesthetised for operations.

Public interest in the process

There was widespread public interest in and condemnation of both Green's actions, and the ethos of the hospital itself which allowed these practices to continue. The Inquiry revealed that several doctors in the hospital had tried to stop Green's studies but the hospital and hospital board hierarchy had declined to take action.

Perspectives on the Inquiry

Feminist perspectives

There can be no doubt that the Inquiry marks one of the most major leaps forwards in Women's rights in New Zealand. In her book, Coney says "There was a danger that this significant event would go down as something to do with doctors and lawyers and that the women who initiated it and saw it through would be, like so many of their foremothers, written out of history." ^[6]

The events surrounding the Committee of Inquiry into Allegations Concerning the Treatment of Cervical Cancer at National Women's Hospital and into Other Related Matters in Auckland, New Zealand between August 1987 and March 1988 have international importance as an example of a feminist challenge to patriarchal medical structures^[7]

Medical perspectives

Although Coney and Bunkle rightly deserve credit for the popular groundswell of opinion that led to the Inquiry, medically the introduction of the cervical screening programme marks the end of long-standing work by large numbers of researchers and campaigners over decades. The medical schools now emphasize ethical training, research and evidence as fundamentals in medical training.

Patient perspectives

The reforms started by the changes in ethics committees recommended by the Inquiry and cemented in the role of the Health and Disability Commissioner

New looks at the Inquiry

There have been many articles over time in the lay and academic press over the last twenty years, some are accused of taking a 'revisionist' view of the Unfortunate Experiment.^[8] Some (such as Heslop^[9]), have claimed that lack of ethical and research training left Herb Green ill-equipped to design or carry out a better experiment. Others such as Linda Bryder^[10] repeat Green's claims to the Inquiry that there was no experiment.

Numbers harmed

Sandra Coney claimed in her book that "His way was too slow for the twenty-six women who died".^[11] In the 1996 Listener Article written by Coney she referred to '26 lives wasted'.^[12] Tony Baird wrote to the Director-General of Health, George Salmond, to inquire where this figure had come from; he was told that it was a 'commonly used figure' rather than an 'official figure'.^[13] There was no 'official figure'. Sixteen years later, the director of the Women's Health Council, Lynda Williams, published an article in the New Zealand Medical Journal stating that 'we must not forget that over 30 women died as a result'.^[14] Baird responded; claiming that the figure 'cannot be substantiated; he referred to appendix 12 of the Cartwright Report listing 24 women who died between 1973 and 1987, pointing out that in only eight of them was cancer of the cervix recorded as the cause of death and there is no way of knowing whether or not those women were part of the study of Associate Professor Green'.^[15]

Outcomes

Green was never brought before medical disciplinary authorities because he was deemed to be too frail to be charged [citation needed]. His superior and head of the hospital, Professor Denis Bonham, was found to have engaged in disgraceful conduct by the Medical Council. Eventually 19 women who took legal action received compensation in an out-of-court settlement [citation needed].

References

Further reading

• Coney, Sandra (Ed.) 1993 Unfinished Business: What happened to the Cartwright Report? Women's Health Action Trust, ISBN 0-473-02018-1
• Bryder, Linda 2009 "A History of the 'Unfortunate Experiment' at National Women's Hospital" ISBN 9781869404352
• Heslop, Barbara: "All about research’—looking back at the 1987 Cervical Cancer Inquiry" Journal of the New Zealand Medical Association, 06-August-2004, Vol 117 No 1199

External links

• Time-line of events and links
• Cartwright Inquiry Website