The Cartwright Inquiry And The Reform Of Patients Rights & Medical Ethics

In June 1987 Phillida Bunkle and Sandra Coney published an article ‘An “Unfortunate Experiment” at National Women’s Hospital’, Metro magazine. The article described unethical research conducted at Auckland University’s prestigious Post-Graduate School of Obstetrics and Gynaecology. The School was located at National Women’s Hospital which was New Zealand’s leading teaching hospital in Obstetrics and Gynaecology.

The results of this research into the ‘natural history’ of CIS of the cervix had been published in 1984 in the prestigious medical journal Obstetrics and Gynaecology in an article by Mcindoe, Mclean, Jones and Mullins. The authors provided an retrospective anlysis of the results for groups of women who had been addequately treated and their leisions eliminted and those who had been followed with continuing evidence of disease.

The 1987 Metro article by Bunkle and Coney explained that women with precancerous carcinoma in situ of the cervix (CIS), and some with micro invasive cancer of the cervix or vaginal vault had, without their knowledge, received repeated diagnostic biopsies and cervical smears, but had been left untreated or undertreated in order to study the extent to which these lesions developed into invasive cancer. The result was that many developed invasive cancer and some died. The article revolved around the experiences and case notes of patient Clare Matheson, known then as patient ‘Ruth’, who developed invasive cancer after initially having only diagnostic biopsies.

The article provided evidence that in 1966 the study of CIS had been formalised into a research programme, which had never been formally ended. Even when, in the early 1970’s, deaths occurred and the dangers had become apparent, the institution did not act to save the remaining patients, and marginalised critics of the programme within the hospital. The Board, senior clinicians and professors of Auckland University, particularly its head, Professor Bonham were implicated

The government responded by setting up a judicial inquiry entitled the ‘Committee of Inquiry into Allegations Concerning the Treatment of Cervical Cancer at National Women’s Hospital and into Other Related Matters’. The processes and evidential rules of a judicial inquiry are those of a court of law, but with additional powers of independent of investigation. Headed by District Court Judge Silvia Cartwright in became known as the Cartwright Inquiry.

The findings and recommendations of the Inquiry were published by the Government on 5th August 1988 in what has become known as the Cartwright Report. The Report found that the allegations made in the original Unfortunate Experiment article were largely correct.

Cartwright was critical of the objectification of patients and the connection this implied to inhuman treatment. The Cartwright reforms were based on four important and related innovations:

An understanding of ‘treatment’, which went beyond medical procedures and included respect for the patient’s human dignity, including their right to effective communication and informed consent.
A human rights approach to patient’s rights.
The development of a legislated Code of Patients Rights.
An independent Health Commissioner, external to the medical professions, charged with adjudicating medical providers conformity to the Code and enforcing its provisions and compensating victims.

This system of accountability to patients external to the medical profession remains unique but is usually seen as a substantial reform of the health system.

The recommended changes also included the implementation of a successful population based, free-to-user, national cervical screening programme with provision of ethnically appropriate community-based lay smear takers, and
the establishment of independent ethics committees focused on protecting patients composed of half lay membership and chaired by a layperson.

The Judge also recommended an independent recall and review of cases where the women might still be at risk. This was resisted by the Hospital. The independent recall identified an additional death and another case of invasive cancer while one quarter of the affected women needed further follow up.

The development of a patient-centred health system also led to the participation of consumer representatives, including Maori and Pacific Islands women, at many levels of health policy decision making.

CONTINUING CONTROVERSY

The Cartwright Report located responsibility within the structures of power within the hospital and university in which important differences of professional opinion became personalized.

Following investigation the Medical Council of New Zealand upheld professional charges against Professor Bonham, Professor Seddon and Dr. Bruce Faris. The charges against Associate Professor Green were not heard because he was unfit.

An application for judicial review of the Inquiry by Valarie Smith, a friend and neighbour of Professor Green, and Dr. Faris, a gynaecologist , was struck out by the High Court.

There have been a number of public media challenges to the conduct of the Inquiry and the content of the Report. These include in March 1989 claims the Inquiry was ‘based on a scam’ in the Dominion Sunday Times by Dr Graeme Overton, a National Women’s gynecologist. This was followed in November 1989 by an article ‘Trial In Error’ in the New Zealand Listener; in which Wellington GP Dr Erich Geiringer attacked the Cartwright Inquiry as ‘unbalanced’ because the matter was raised by feminists. Finally a July 1990 Metro article by Jan Corbett entitled ‘Second Thoughts on the Unfortunate Experiment at National Women’s Hospital’ repeated accusations that the inquiry was a ‘radical feminist witch-hunt’.

The Government officially replied to these allegations and continued to support the Report.

RECENT REVISIONISM

These challenges have however been reinvigorated by further controversy from within Auckland University. A history of the ‘Unfortunate Experiment’ at National Women’s Hospital by history Professor Linda Bryder, published by Auckland University Press in 2009 and internationally in 2010 questions the reality of the ‘experiment’ and the findings of the Cartwright Inquiry. Professor Bryder also argues that there were no adverse effects on the women involved and that the recommendations for reform made little contribution to changes already underway within medicine and patients rights.

Professor Bryder’s claims have been refuted in a number of academic publications. In 2008, Dr Margret McCredie, Professor Charlotte Paul and others had published a paper in The Lancet Oncology which examined cases in the hospital from 1955-1976 and provided convincing support for the Inquiry’s findings about the risks to women who received only diagnostic biopsies compared to those in whom lesions were removed and successfully followed up to ensure they had been eliminated. The study showed that women who initially had their lesions fully removed had a progression rate of 0.7% at 30 years while those having only diagnostic procedures had a progression rate of 31.3%. Of these women, the rate of invasion in those who also had evidence of continuing abnormalities two years after diagnosis was 50.3%. Delays in treatment of curative intent were thus shown to be dangerous.

Following the Publication of Professor Bryder’s book, an Auckland law professor Jo Manning, edited a collection entitled The Cartwright papers: essays on the cervical cancer inquiry 1987-88 which reviewed the Cartwright legacy generally positively and offered a variety of criticism of Professor Bryder’s book. Professor Ronald Jones, writing in the New Zealand Medical Journal has asked ‘Why did so many women develop cancer?’ during the research period.

The most important medical refutation of Linda Bryder’s thesis was by Margret McCredie, Professor Charlotte Paul, Professor Ron Jones and others writing in the Australian and New Zealand Journal of Obstetrics and Gynaecology, 2010, contrasting the medical experiences of the women in the study decade with those in the periods before and after. Analysis of the case notes and a review of the original slides and smears showed that Associate Professor Green was not saving women from invasive surgery because cone biopsy had already replaced hysterectomy for the treatment of CIN3 before the study began, and that the women who initially had only diagnostic biopsies eventually had far more procedures, including repeated surgery, than those whose lesions were initially removed. The paper also showed that ‘ women initially managed by punch or wedge biopsies alone had a cancer risk ten times higher than women initially treated with curative intent’.

Finally in early 2011 an interchange of views on Cartwright in the New Zealand Medical Journal displayed significant differences between those who support Professor Bryder’s position and others who seek a more patient-centred reconsideration of the lessons learned from the Unfortunate Experiment.

Recent exchanges have focused once again on the scientific misconduct which invalidated Associate Professor Green’s results. The Inquiry heard, and subsequent analyses confirmed, that he removed cases where invasive cancer developed from his study series. A document by Professor Charlotte Paul explaining the implications of accepting these fraudulent results for Professor Bryder’s thesis is made public on this site for the first time.

Meanwhile the three original protagonists, Clare Matheson, Phillida Bunkle and Sandra Coney have written complaints to Auckland University about serious inaccuracies concerning them in Professor Bryder’s book. These complaints have been dismissed by the University of Auckland. These documents are made public on this site for the first time.

The Purpose Of www.cartwrightinquiry.com

This site aims to provide the original texts of the key documents concerning the Cartwright Inquiry and the implementation of its recommendations, along with subsequent research findings which have supported its conclusions.

It is hoped that the provision of these texts will allow readers to identify the weaknesses in recent criticism of the Cartwright Inquiry and the important reforms which followed. It concludes with the texts of the hitherto unpublished responses of the University of Auckland to concerns raised about these errors.