Controversy concerning the Cartwright Report and the reforms that flowed from it continued following the 2010 publication of an international reprint of Professor Linda Bryder’s book. Republished in Britain as Linda Bryder, Women’s bodies and medical science: An inquiry into cervical cancer. London: Palgrave Macmillan (2010)
In 2011 the New Zealand Journal of History published a review by John Burrows of the Law Foundation, of The Cartwright Papers: Essays on the Cervical Cancer Inquiry 1987-88 published by Bridget Williams Books, Wellington, with support from the Law Foundation. This volume was edited by an Auckland University Associate Professor of Law, Joanna Manning. One third of the volume consisted of essays critical of Professor Linda Bryder’s book.
The review (1 below) compared the Bryder and Manning volumes.
In January 2012 Phillida Bunkle wrote a letter (2 below) to the editors of the New Zealand Journal of History in which she criticised this review for not tackling important errors of fact in the Bryder volume. Caroline Daley an editor of the journal replied on 24th January rejecting publication of Bunkle’s Letter (3 below) .
(2) Letter from Phillida Bunkle to the Editors of the New Zealand Journal of History, 11th January 2012. (3) Letter 1/24/2012 to Phillida Bunkle from Associate Professor Caroline Daley a member of the History Department Auckland University and an editor of the New Zealand Journal of History, rejecting publication of Bunkle’s letter.
In 2012 Cambridge Professor Robin Carrell published
(4) a review of Professor Bryder’s book in Notes and Records of the Royal Society. (5) Responses to the review from Associate Professor Manning of Auckland University and from (6) Phillida Bunkle were published in the same journal in July and August of that year.
New Zealand Journal of History, 45, 1 (2011)
The Cartwright Papers: Essays on the Cervical Cancer Inquiry of 1987–88. Edited by
Joanna Manning. Bridget Williams Books, Wellington, 2009. 224pp. NZ price: $39.99.
IN 1987 AND 1988 JUDGE SILVIA CARTWRIGHT conducted an inquiry into what has become known as the ‘Unfortunate Experiment at National Women’s Hospital’. In her report, justly famous, she found that Associate Professor Herbert Green had conducted research on women with carcinoma in situ (CIS) and that the research was unethical, in that it involved withholding conventional treatment in order to study the natural history of the disease. Judge Cartwright recommended some radical changes in the health system to ensure that such conduct could not happen again. The recommendations were swiftly implemented: a system of patient advocates; the appointment of a Health and Disability Commissioner; a code of patient rights; improvements in the constitution and performance of ethics committees; better teaching of ethics in the medical schools; and a national cervical screening programme. Some of those improvements would probably have happened anyway, but not as quickly or effectively. The inquiry resulted in a sea change in doctor–patient relations.
Some of the essays in this book originated as papers delivered at a conference held in 2008 at the University of Auckland to mark the 20th anniversary of the Cartwright Report. But others are responses to a book published earlier in 2009 by Professor Linda Bryder, A History of the ‘Unfortunate Experiment’ at National Women’s Hospital, in which sheargued that Green had been misunderstood. Rather than experimenting on the women, she said, he had adopted a conservative wait-and-watch approach to treatment, believing that most instances of CIS would not develop into invasive cancer, and that early radical treatment could be worse than the disease itself. This, Bryder claimed, was in line with much international practice.
The book under review commences with three introductory pieces: a foreword by Sir David Skegg, an introduction by Associate Professor Joanna Manning, in which she summarizes the essays which follow and comments on them, and a summary, also by Associate Professor Manning, of the Report and its aftermath.
Part One of the book contains four essays. Three of them might be described as personal stories. Clare Matheson was a patient of Professor Green who developed invasive cancer, and she gives an account of her ordeal. It is a sad story, and no reader could fail to be moved by it. Professor Ron Jones, an obstetrician and gynaecologist, describes his early scepticism about Green’s approach, and his contribution to a ground-breaking article (‘the 1984 article’) which put forward a very different view of CIS. In its way his story is poignant too— it shows the difficulty in breaking through the medical establishment, and his frustration at the reaction to the article.
Sandra Coney then describes the genesis of the famous Metro article she wrote with Phillida Bunkle, which led to the setting up of the inquiry. She details the research they undertook in the preparation of that article. Ms Coney reaches the troubling conclusion that it would be much more difficult to have such an article published today. For one thing, the 1980s were a decade where social action on many fronts — feminism, the Vietnam War, the Springbok rugby tour — was an accepted phenomenon. And the media were different then.
Today, newspapers, competing with the various forms of ‘new media’, have become more concerned with resources and the bottom line: journalism has become shallower and more risk-averse. These conclusions are of concern, but I fear Ms Coney is right. Risk-taking still happens — there is no better example than the Dominion Post’s breaking of the Louise Nicholas story; I even think the law of defamation may not be quite the restraint it once
was. But commercialism has certainly changed the nature of our media, and with occasional
welcome exceptions the depth and quality of their news and commentary is not what it once was. Let us exalt the exceptions when they happen. The media must remain one of our constitutional safeguards. Freedom of expression is undervalued if it is not well exercised.
The fourth essay in Part One is by Professor Charlotte Paul, a medical specialist. She was one of three medical advisers to the Cartwright inquiry. She outlines the relevant science, and describes three follow-up studies conducted on some of Professor Green’s patients. For me (a non-scientist) an interesting aspect of her essay is her comment that publicity about wrongdoing must take the greatest care to confine itself to the wrongdoers, and not tarnish a profession as a whole. How right she is. We members of the reading public are simple beings. We tend to construct our prototypes of the typical professional: the typical doctor, lawyer and journalist. Bad publicity about individuals in a profession can, unless it is carefully confined, all too easily affect that prototype. Unfortunately most publicity is bad — good behaviour does not attract much media attention — so the risks of misperception are high. Professor Paul points out that this attribution of the faults of a few to the whole profession in the Green affair caused resentment, and made change more difficult than it might otherwise have been.
Part Two of the book takes up the cudgels with Professor Bryder. Some of the essays elsewhere, like those by Sir David Skegg and Associate Professor Manning, introduce notes of disagreement, but Part Two constitutes the main rebuttal.
Sandra Coney takes issue with Professor Bryder’s methodology, saying she did not interview those involved in the inquiry, and did not pay enough attention to the history of the patients themselves. Professor Barbara Brookes, a medical historian, and Professor Paul undertake a close textual analysis of the Bryder book, and set out, sometimes in small detail, what they see as mistakes, misunderstandings, internal inconsistencies and nonsequiturs. Their conclusion is, quite simply, that Professor Bryder got it wrong.
I wonder why these contributors attack Professor Bryder’s work with such vehemence. (Vehemence is not too strong a word.) One might have thought that, 20 years after the event, a revisionist view should not matter quite so much. What the inquiry brought in its wake is unquestionably good, and there is not the slightest chance that it will be taken away from us as a result of Professor Bryder’s views. The reason for the reaction is to be found in a sentence from Joanna Manning’s introduction: ‘The story of the “unfortunate experiment at National Women’s Hospital” must be told and retold to successive generations, and the lessons learned reiterated and reinforced.’
The events which led to the Cartwright Report, in other words, have become an iconic example of medical misconduct. It is a teaching tool in the medical schools. It stands as our illustration of the sort of thing that must not be allowed to happen again. If the behaviour in question is now said not to have been unethical at all, where does that leave us? Is the importance of ethics diminished in some way?
In case it be thought improper for anyone to challenge the findings of an eminent judge, that is not the case. Inquiries usually have to confront a daunting amount of evidence; this one certainly did. They hear witnesses, some compelling, some not. They may hear conflicting opinions from experts. The judgements they have to make can be extremely difficult. Sometimes two minds can legitimately be persuaded by different pieces ofevidence and draw different conclusions. The history of inquiries shows that sometimes even governments do not accept their conclusions; there is no clearer example than Justice Peter Mahon’s report on the Erebus disaster. So while I agree with every complimentary comment about Judge Cartwright’s judicial acumen and her exemplary conduct of the inquiry, we live in a free country, and we are perfectly entitled to question her conclusions.
But there is a qualification: to do so we must have compelling evidence and arguments.
This is just what the contributors to this book say Professor Bryder does not have. I have read Professor Bryder’s book, and it gives every appearance of thorough research and command of the facts. As she explains in her introduction, in some cases she preferred to rely on the written record rather than re-interview people, but the book contains a remarkable amount of detail. International knowledge and practice are discussed at length.
The authors of the essays in Part Two set about rebutting Professor Bryder’s case. They have deep knowledge of the facts and the subject-matter. In making their case they are faced with three difficulties. First, much of the medical evidence is pretty much a closed book to members of the general public. The difference between a wedge biopsy, a cone biopsy and a punch biopsy; between CIN1, CIN2 and CIN3; between cytology and histology: this is for the cognoscenti.
Apparently it can matter, because Professor Paul alleges that Professor Bryder muddles the last two. There are also different ways of interpreting what was known internationally at the time. Such specialist argument makes it very difficult for the rest of us to judge who is right and who is wrong.
Secondly, New Zealand is a small country. Its professions are small by international standards, and specialities within those professions are even smaller. There are only two universities offering medical degrees. Everyone knows everyone else. This can cause difficulty; we have a powerful recent example of that in the legal community. It means not only that taking sides can be a painful business, but also that it can be difficult to obtain comment and opinion that looks truly objective. Some of the main contributors to this book — Professor Paul, Sir David Skegg, Ms Coney and Professor Jones in particular — were closely involved in the inquiry and the lead-up to it 20 years ago. Sir David was an expert witness at the inquiry, and Professor Paul was a medical adviser to Judge Cartwright.
The writings of Ms Coney and Professor Jones were instrumental in sparking the inquiry. So there will be those who say they are defending their own citadel, and that they are consequently less than truly objective. ‘What else would you expect them to say?’ That kind of comment is no doubt completely unfair, but there are those who will make it.
The third hurdle is of the contributors’ own making. Their criticism of Professor Bryder is at times very strong, and even personal. I was surprised by the tone of outrage in some of the essays. ‘It is not for me to speculate on her motives’; she ‘makes unnecessary mischief’; her account is ‘selective and negligent’; she has been captured by a small group of doctors at Auckland. I am afraid that, for me anyway, the strength of the language of the criticism diminishes its persuasive effect.
Time, it is said, is a great healer. Not always. There are certain big controversies where time heals nothing, and where even greater wounds open when the matter is revisited. Usually these matters are ones which involve personal and human issues as well as intellectual ones. They engage the heart as well as the mind. The Christchurch Crèche case involving (or not involving?) Peter Ellis is one such. The Herbert Green affair is obviously another.
So, who is right, Linda Bryder or her detractors? I am sorry to say that, having read both books, I simply do not know. I am not ‘copping out’. To make a confident judgement I would need to study the Report, the literature and as much evidence as was available to me; I would need expert advice. I simply do not have the months, or even years, it would take to do it properly. I can only leave it to every reader of the two books to form their own judgement. And they need to read both books. However, whoever is right and whoever is wrong, we are a better society if people are allowed to challenge the views of others. If, after careful study, someone believes aninjustice has been suffered, they should be able to say so. That is as true of Linda Bryder in 2009 as it was of Sandra Coney and Phillida Bunkle in 1987.
Part Three of the book enters calmer waters. It is about the ethical aftermath of Cartwright. Former Health and Disability Commissioner Ron Paterson, and Joanna Manning, write about the Code of Patient Rights. They extol its virtues — not without justification. It is clear and simple. It is not detailed, but consists of a series of brief principles. It is easy for patients to understand, and is flexible enough to serve in the future as well as the present. A disadvantage of drafting like that is that it leaves room for thejudgement of the commissioner when interpreting the code, and different commissioners may have different ideas. But provided a system of precedent is developed, and guidelines are issued based on the precedents, one probably gets the best of all worlds. By all accounts that is what is happening.
The Code reflects the rebalancing of the doctor–patient relationship which the Cartwright Report required. No longer do we tolerate the doctor-god who told his patients nothing. Yet, as a first-time reader of the Code (am I unusual in that?) I was surprised to see how far the pendulum has swung. Perhaps I read it incorrectly, but I wonder if its words, taken at face value, quite capture the essence of the relationship. It seems to say that thatrelationship is centred entirely on the patient, who is firmly in the driver’s seat. The patient has the choices, and makes the decisions. The doctor’s role is one of explanation: to provide information about the treatment options, and the risks involved in each. Missing, at least in the words of the Code, is the very thing I want from my doctor, namely clear advice on what is the best option for me. But I imagine that good sense prevails, and that in practice it usually works out fine. Yet the shift of focus, as I say, is quite marked. Good communication is the essence of it.
The final two essays are about the new processes for ensuring ethical conduct, in particular ethics committees. They ask the question ‘Could it happen again?’ Associate Professor Jan Crosthwaite examines the New Zealand system, and concludes that while it could happen again, that will be a rare occurrence. I hope she is right. One can never entirely eliminate unethical behaviour. Simply ‘having systems in place’ is not alone enough; those systems have to be observed and applied. Heavy workloads resulting from lack of resources, coupled with tight deadlines, can sometimes lead to corners being cut. More seriously, the flush of enthusiasm generated by ground-breaking research with exciting but unknown potential can sometimes blind the researcher to the ethical implications. But the current processes are thorough, and more importantly, have engendered a culture and awareness that means things will usually be done properly. So, overall, I share the author’s optimism.
It may be different in the international sphere, though, as the final essay by Alistair Campbell, Voo Teuk Chuan and Jacqueline Chin demonstrates. When research is sponsored by large corporates in developing countries, the host country may lack the facilities or expertise, in both medicine and process, to do a good job. Proper vigilance becomes a responsibility of the partners in the enterprise. Ethical behaviour must not stop at our back door.
So, in summary, this is an interesting and stimulating book. It reaches a wide audience or, rather, different bits of it reach different audiences. Some of the content is for everyone; some is for historians; some is for medical specialists; some is of real interest to lawyers like me. However, in the end, it is the debate about the Bryder book which overshadows the rest. It is that which makes this collection part of a controversy.
- ‘Trial by Media’,
NOTES AND RECORDS OF THE ROYAL SOCIETY
Vol. 66 No. 63
Robin W. Carrell*
Trinity College, University of Cambridge, Cambridge CB2 1TQ, UK: firstname.lastname@example.org
If a professor … neglects research, lets controversy rest, He’s but a petty tradesman at best.Kãlidãsa (Sanskrit poet, ca. fifth century a.d.)The incorporation of advances in medical science into clinical practice is led by the great teaching hospitals of the world. Not only are these found in the predictable clusters of Boston, London and Paris but they are also dotted in unexpected places throughout the globe. New Zealand had one such centre of excellence, the National Women’s Hospital in Auckland. It was an acknowledged international leader in the medical care of mother and newborn, the specialties known as obstetrics and gynaecology. Its reputation was built on the quality of its teaching and patient care together with the constant research and questioning that is the mark of a teaching hospital. The index of its greatness comes from the way in which this openness to new ideas led to two outstanding medical advances: the introduction of intrauterine blood transfusion by William Liley and the demonstration by Mont Liggins that corticosteroids promoted the maturation of the lungs in the developing fetus. Together these two discoveries by clinicians at the National Women’s Hospital have saved the lives of many thousands of newborns. The contributions of Liley and Liggins were recognized by distinguished awards, and both were elected FRSNZ, with Liggins subsequently also being elected FRS. The Women’s Hospital became a source of national pride, a beacon for young medical graduates in New Zealand, showing what could be achieved within its shores. Yet in 1987, within a matter of months, a catastrophe struck that ended up destroying the hospital, dishonouring its staff, and in the longer term undermining academic medicine as a whole in New Zealand.
Linda Bryder tells in a scholarly and definitive way the story of how this calamity came about. It is a chilling and gripping account. Read it. Although the story relates to a crisis in New Zealand, it bears a grim message for all who endeavour to advance medical science. The societies we live in are not always rational. Bryder records in referenced sequence the events that built up to the implosion of 1987. This arose from what is one of the most contentious issues in medical practice—the assessment of the use of screening procedures for the detection of cancer. The underlying dilemmas are seen in the current questioning of the long-established programmes to detect breast cancer, as well as with the more recently proposed screening tests for cancer of the prostate and for bladder tumours. There is a double quandary: the detection systems used merely give an indication and not a certainty of the presence of a cancerous change, and there is now an increasing awareness that even if confirmed such changes can regress or grow so slowly as not to threaten the well-being of the individual. Yet once a screening programme is established it becomes difficult to question it. Epidemiologists and Health Authorities love the statistics ‘40 000 screened and 200 cancers prevented’. It seems churlish to raise the possibility that a significant proportion of the 200 who have had radical surgery and are rejoicing in a clean bill of health might not, after all, have had a life-threatening tumour. The lesson is that before instituting a mass screening programme there need to be careful and documented studies of the significance and reliability of the screening procedure and of the natural history of the progression of detected lesions. It was the institution of such studies and the asking of these questions that led to the downfall of the National Women’s Hospital in 1987. The studies began in the 1960s and centred on the newly introduced screening test for cervical cancer, the Papanicolaou smear.
The changes in the microscopic appearance of cells present in a scraped smear provide a powerful method for the early detection of one of the most common tumours in women, cancer of the cervix of the uterus. There was agreement by all that the detection of cancer by this method should be promptly followed by surgical removal, usually involving the excision of the whole uterus—hysterectomy. The questions arose from the much more frequent identification in the smears of cellular changes indicating a precancerous state, collectively labelled carcinoma in situ. How many of the carcinomas in situ progress to malignancy? How many will regress to give subsequent normal smears? If the carcinoma in situ is followed by repeated examinations, is it feasible to detect the focal development of malignant changes? Can this be achieved early enough to allow a local excision that does not mar the future of a young woman? These were the questions addressed by an academic clinician at the National Women’s Hospital, Herbert Green. He set up a proper and recorded study to follow by repeated examinations the changes in cervical cytology in individual patients, with surgical intervention if malignant changes became evident. To do this he became expert in the interpretation of the cellular changes in cervical smears under the tutelage of a specialist cytopathologist. This commendable study needed to be done, and Auckland as a centre of excellence in academic obstetrics was a place where it should be done. There was international recognition of the study. Liley quoted in 1975 the comment of a distinguished US expert in the field: ‘I think Green’s work on the natural history of carcinoma in situ is just as important as your [Liley’s] work on haemolytic disease or Liggins’s work on fetal endocrinology. He has saved a lot of young women from mutilating surgery.’ This was praise indeed, but it was not universal.
For anyone who has worked in a major teaching hospital Bryder’s account captures a familiar milieu. In the best of circumstances there is a seamless merging of academic and service medicine, but even so there are underlying tensions. The academics question and innovate; the health service doctors just get on with it and practise in the hospital and in their private clinics the medicine they were taught in their first postgraduate years. In the worst case there is a resentment of the perceived ivory-tower existence of the professors and a resistance to change and to new ideas. Such tensions surfaced in Auckland with the appointment of a new histopathologist who clearly resented Green’s independent assessment of cervical smears. He joined with a gynaecologist in writing a critical review of the management of carcinoma in situ in the Women’s Hospital with particular regard to the outcome of Green’s study. The review was a retrospective account in 1984 of procedures set in motion nearly 20 years beforehand. The field in general and procedures in Auckland had changed in the interim, but nevertheless it was right that such a review should take place. Unfortunately the authors presented their findings in a way that was consistently misinterpreted. Their division of the patients into two groups with very different outcomes was made on the basis of the cervical cytology, whereas it was repeatedly presented to the public in subsequent proceedings as a callous division into treated and untreated cohorts. It was to no avail that Green’s colleagues, including Liggins, later protested, ‘the charges against Herb Green that he divided the patients into 2 groups and treated them differently, was then, and still is, entirely false.’
Green faced further opposition arising from his view at the start of his study that carcinoma in situ might regress, and hence he was sceptical of the benefits of a mass cervical screening programme. This put him at odds with public health epidemiologists in the other and older medical school in the south of New Zealand. They were commendably advocating the introduction of mass screening, but this commendation carries with it the obligation that there should also have been at least an encouragement to perform accompanying studies to check the assumptions on which the screening programme is based. Such clinical studies are the most arduous and least applauded of all forms of medical research. They require, as Liley said in praise of Green’s work, ‘dogged long-term data collection’. It was the right of the epidemiologists to criticize the assumptions and procedures of Green’s study, but for an academic to describe in 1986 such a careful and open clinical study as ‘an unfortunate experiment’ was ill-considered. It was these three words, whether taken out of context or not, that fed the irrationality that went on to cripple academic medicine in New Zealand. The label ‘unfortunate experiment’ was readily linked in the media and the public mind to ‘Auschwitz’.
The women’s movement in New Zealand has a proud record. In 1893 New Zealand was the first independent country to grant the franchise to women, an advance preceded in 1877 by its being the first country in the British Empire to grant a woman a BA degree and then in 1891, much to its credit, petitioning the University of Cambridge to award degrees to women! But years later, in the 1970s, as Bryder describes, a more aggressive anti-male stance developed, with the new women’s health movement proclaiming its intent ‘to attack medical authority and reclaim women’s bodies and autonomy over their lives’. Strident attacks were made on the medical staff of the National Women’s Hospital: on Professor Liley and Professor Green for their attitude to abortion, on the head of the Department of Obstetrics, Professor Bonham, for his support for hospitalized births, and eventually on Liggins for his research on hormone contraceptives. The vehemence of the two leading feminists climaxed with the publication in 1987 in a national magazine of an article entitled ‘An unfortunate experiment at National Women’s’. This set the scene with a damning misinterpretation of the 1984 review of Green’s work and the implication that the academics of the National Womens Hospital had callously allowed patients to develop cancers of the cervix as part of an ‘unfortunate experiment’. The response was a national uproar of indignation. Wisdom and insight at this stage should have immediately questioned this repugnant charge. The greatest of all courts is that of common sense. The list of professors at the Women’s Hospital reads like a roll of honour—Liley, Liggins, Bonham, Green, Seddon—these were all people of exceptional and proven ability. It goes against common sense that these would together take part in, or be bystanders to, dubious—let alone unethical—practices. There was of course one almost inevitable truth: all the professors were male and all the patients with changes in cervical cytology were female.
The timing of the feminists’ article coincided with a new government’s taking power with a feminine agenda. The Minister of Women’s Affairs was the niece of the disgruntled pathologist who authored the 1984 review, and the militant feminists were allowed direct access to the government at all levels. Once the political decision was made to hold a formal Inquiry, these militants were consulted before the appointment of a female judge to head the Inquiry, and their closeness to influence was evident on the day that the Inquiry issued its report, when they shared a champagne celebration with the Minister of Health in his office. Even more inappropriately, and in breach of natural justice, the government took advice from the senior epidemiologist who led the opposition to the Auckland study and appointed a member of his department to the key post, as the judge’s technical advisor. Both Green and Bonham approached the Inquiry naively confident in their record and unaware that what would start as an inquiry would degenerate into an inquisition. From Bryder’s account, the judge, Silvia Cartwright, did try to maintain fairness and keep the proceedings in the format of an inquiry. However the combination of an aggressive advocate for the feminists, together with the accompanying press furore, turned the process into an adversarial trial. Disgracefully, Herbert Green, at the age of 71 years, ill, and after a lifetime of distinguished medical service, was publicly humiliated and Professor Bonham was harassed. Contrary to the feminist and press clamour, both were caring and thoughtful clinicians, but the feminists’ counsel disparagingly dismissed as ‘fan mail’ the many letters of support from their patients. The predictably devastating final report of the Inquiry is dissected by Linda Bryder, and the doyen of the field, Sir Iain Chalmers, has from Oxford issued in the New Zealand Medical Journal an unanswered challenge to the central point of the report’s findings. In the words of Mont (Sir Graham) Liggins FRS:the famous 1984 article … on which the Metro article which stimulated the cervical cancer enquiry was based, was misinterpreted by the authors of the Metro article and by the judge. Once rolling, such minor matters became irrelevant to the course of the juridical inquiry which allowed its brief to encompass every possible area of medical practice about which there was public concern.Liggins’s conclusion was simply that there was no unfortunate experiment at National Women’s. But that was beside the point; the Inquiry had become a Trial By Media.
The merit of the Inquiry can be judged from its outcome, a mixture of farce and tragedy. The report was received with an extraordinary wave of media approbation and public applause. The prosecutors became instant celebrities. Weirdly, the judge, Silvia Cartwright, appeared in the company of the militant feminists at a victory celebration and in doing so immediately placed her objectivity in question. Her career nevertheless accelerated from district to high court judge and then in nearly a decade to Governor General of New Zealand. No doubt this was justifiable in her own right, as certainly was the advancement of the senior epidemiologist to be Vice-Chancellor of the southern university. But compare and contrast that with the fate of the academics whose lifetimes of work had built in New Zealand a world-acclaimed medical centre for women. Liley was by this time dead, and Green in retirement was universally denigrated. Liggins was scarred. The feminists arrogant in their victory had pressured Bonham, the head of the Women’s Hospital, into retirement, and then cowed the University of Auckland into denying him emeritus status. But worse was yet to come.
How does an enlightened nation descend into irrationality and allow witch-hunts to destroy the lives of decent people? This reviewer remembers being in the Paris office of a prosecuting magistrate in the 1990s, at the time of the persecution in France of blood transfusionists. A Cambridge professor faced imprisonment and the magistrate had narrowed the accusations against him to just seven patients. One by one we went through their folders and one by one she conceded each to be baseless or irrelevant. In the end there was no case. When asked why then was she going ahead with the prosecution she answered wearily, hands outstretched and looking beyond the room, ‘But you do not understand. There is such anger out there.’ Similarly in New Zealand a senior medical authority, when challenged on the way in which Professor Green and Professor Bonham were treated, replied, ‘public opinion would accept no other outcome’!
When irrationality overwhelms any society it reveals the existence of a sizeable group of people, often in posts of influence, who sense and respond to the public mood. They are called different names in different countries—placemen, apparatchiks, or in Britain safe pairs of hands. So it was in New Zealand. In actions that seem beyond belief, another tribunal found not only Professor Bonham but each of the remaining members of the ethics committee of the National Women’s Hospital at the time of Green’s research, 20 years previously, including Professor Seddon, guilty of conduct unbecoming of a medical practitioner. Professor Bonham in his role as head of the Postgraduate School of Obstetrics and Gynaecology was additionally found guilty of disgraceful conduct. All were fined. Their medical careers and standing were effectively ruined. It was indeed a witch-hunt. Some of the leaders in medicine in New Zealand spoke out on Bonham’s behalf, but in the prevailing mood it took courage to do so. A national magazine that exceptionally did question the Cartwright Report and its aftermath met the full force of the feminist zealots including an intimidating threat to write to the publishers of the magazine and separately to each of its 24 advertisers. At times of irrationality and militancy such as this, is there any safeguard left? One answer comes from the Paris blood transfusion trials. When the Professor of Transfusion Medicine at the University of Cambridge was sentenced to imprisonment for two years in France, a wise Regius Professor advised that what mattered in the university’s response was the verdict of history. Cambridge, to its everlasting credit, continued the professorship with all the official mail (to the chagrin of the French activists!) being addressed to the Professor of Transfusion Medicine at the prison and moreover with the university continuing to pay his full professorial salary throughout. If the Council of the University of Auckland had been reminded in 1990 that they would later be judged by history, would they have made the shameful decision to deny emeritus status to Professor Bonham—a decision that now mars the academic repute of the university?
The verdict of history does matter. Linda Bryder’s book, in putting the record straight, provides an outstanding example of the beneficial function of the medical historian. Her authoritative documentation of the events before and after 1987 now brings a redeeming distinction to the University of Auckland and with it an opportunity for New Zealand to begin to right the injustices of that time. Feeble attempts by the feminists to label her as ‘a self-proclaimed medical historian’, or patronizingly by the epidemiologists as ‘a social historian … misunderstanding scientific evidence’, only compound their unwillingness to take responsibility for the consequences of their interventions. Those consequences have been dire. As Bryder details, the feminist zealots were on the crest of a wave and set about aggressively reorganizing on their terms the fragile infrastructures and interactions that integrate academic and service medicine. It was a disaster. The mood of the zealots is seen in the boast of their leader, with respect to her gardening, ‘There’s something very satisfying about hacking and slashing gorse bushes. I pretend they are doctors’!
And now? The monument to the heritage of Cartwright and the militant feminists can be seen in Auckland, in the shell of all that remains of what was once, under Liley, Liggins, Bonham and Green, one of the great clinical medical centres of the world—the National Women’s Hospital.
- The medical facts and the unfortunate experiment, Joanna M Manning,
Associate Professor of Law
Faculty of Law,
The University of Auckland
Dr Robin Carrell’s review in Notes & Records praises Linda Bryder’s Women’s Bodies and Medical Science: an inquiry into cervical cancer for ‘putting the record straight’. That was clearly Bryder’s mission, but her claims do not withstand scrutiny nor merit the breathless enthusiasm of her apologists. For detailed critiques of Bryder’s scholarship and the shortcomings of her account of Dr Herbert Green’s ‘unfortunate experiment’ at National Women’s Hospital, readers should refer to The Cartwright Papers. This collection of essays was a response to original Bryder’s book, published in New Zealand under a different title.3 Readers are also referred to the official account of the findings of the judicial inquiry: The Cervical Cancer Report.4
Details of the adverse outcomes for patients as a result of Green’s study of the natural history of carcinoma in situ of the cervix are included in the Cervical Cancer Report, Appendix 3 (though not in Bryder’s account) and in two recent publications based on a re-examination of all the data.5,6 One of these papers5 reported the direct outcome for patients of having treatment of curative intent withheld. In Green’s ‘core group’ (women diagnosed in 1965-1974, who were initially managed by punch or wedge biopsy alone) the cancer risk was ten times higher than in women initially treated with curative intent. The authors concluded that, during Green’s study, women underwent numerous interventions that were aimed to observe rather than treat their condition, their risk of cancer was substantially increased, and that nearly all the deaths from cervical and vaginal vault cancer occurred in the core group.
The acquisition of new knowledge at the expense of the safety of patients has long been regarded as unethical. As the Declaration of Helsinki in 1964 stated: “The doctor can combine clinical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that clinical research is justified by its therapeutic value for the patient.”
Joanna Manning Associate Professor Faculty of Law The University of Auckland
1 Palgrave MacMillan, Basingstoke: 2010. 2 Manning J. The Cartwright Papers. Bridget Williams Books, Wellington: 2009. 3 Bryder L. A History of the ‘unfortunate experiment’ at National Women’s Hospital. Auckland University Press, Auckland: 2009. 4 Government Printer, Wellington, 1988, now on line at: http://www.health.govt.nz/publication/cartwright-inquiry-1988 5 McCredie MRE, Paul C, Sharples KJ, Baranyai J, Medley G, Skegg DCG, Jones RW. Consequences in women of participating in a study of the natural history of cervical intraepithelial neoplasia 3. Aust & N Z J Obstet & Gynaecol. 2010, 50: 363-370. 6 McCredie MRE, Sharples KJ, Paul C, et al. Natural history of cervical neoplasia and risk of invasive cancer in women diagnosed with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008; 9: 425-434.
Conflict of Interest:
Published August 3, 2012
- ’Trial By Media’
49, Schermerhorn St. Brooklyn, New York USA.
July 25th 2012
The Editor, Notes and Records of the Royal Society, The Royal Society, London
Dear Sir, Re; Trial by Media
Notes and Records of the Royal Society has recently published a review by Robin Carrell of Trinity College Cambridge of Linda Bryder’s Women’s Bodies and Medical Science an Inquiry into Cervical Cancer, published in London in 2010.
Carrell’s review uncritically amplifies Bryder’s ad hominem argument that the Cartwright Inquiry into cervical cancer, which took place in New Zealand in 1987-88, rested on errors perpetrated by feminists primarily motivated by personal hostility to male doctors. Ad hominem arguments lend themselves to conflation. Conflation gives exaggerated significance to insignificant or co-incidental events and leads towards a conspiratorial view of the influence and motivation of protagonists. This tendency makes it particularly important that the Royal Society lives up to its role in carefully identifying the factual basis for such personal allegations.
The Cartwright Inquiry was a judicial inquiry. Its findings were accepted by the New Zealand government in 1988 and its recommendations were substantially implemented in the decade which followed.
The findings of the Inquiry were independent of the allegations of the feminists involved. The evidence upon which the Inquiry formulated its findings was its own examination and analysis of the evidence contained in the clinical case notes primarily of the cervical cancer clinic at New Zealand’s National Women’s Hospital. The greatest weakness of Professor Linda Bryder’s thesis is that she did not access this critical evidence and misunderstood the medical implications of the two cases reported in full in Judge Cartwright’s Report.
The findings of the Inquiry have since been confirmed in scientific articles based on a re-examination of the original pathological specimens by an independent laboratory in Australia and analysed by a team of researchers at Otago University . Unfortunately, Bryder dismisses this scientific evidence once again on ad hominum grounds. She argues that this evidence can be dismissed because one of the authors, Professor Charlotte Paul, was an expert medical advisor to the Inquiry who assisted in the original analysis of the cases for the Inquiry. The implication that Paul’s involvement invalidated the science is not only a serious allegation against a reputable scientist but against the team at Otago University of which she was a member.
Bryder can only dismiss the scientific evidence which formed the basis of the Cartwright Inquiry by ignoring the facts contained in the case notes. The case notes clearly showed that the abnormal cells of a significant numbers of women with In Situ, miroinvasive, or frankly invasive cancers of the cervix, vagina or labia were left intact or only partially removed for months and frequently years after these abnormalities had been diagnosed by smears and biopsies.
All the experts who examined these case notes at the Inquiry gave evidence condemning what they found there. Bryder can only suggest otherwise through the use of highly selective quotations.
The important issues under review should not be personal but factual. Carrell’s review accepts the facts as presented in the Bryder book without examining their validity. The validity of the findings and subsequent recommendations of the Cartwright Inquiry rest on a factual, scientifically-verified basis independent of the particular personalities involved.
Science should carefully distinguish the two types of argument. If Carrell had separated ad hominem from factually-based argument he would have been critically alerted to the way in which Bryder attempts to use popular dislike of feminism to discredit the foundations of the Inquiry. However, Carrell accepts the pejorative description of the motivation and action of the feminists without taking the precaution of evaluating the accuracy of Bryder’s statements about them. He, therefore, reinforces prejudiced belief to the detriment of science and ultimately also to its place, and the place of well-informed community opinion, in the formation of public policy; not to mention injustice to those whose statements were ultimately vindicated by science.
I remain, Yours faithfully,
Conflict of Interest:
I am one of the people criticised in the work under review
- Letter from Phillida Bunkle to the Editors New Zealand Journal of History, 11.01.2012
18 Mount Pleasant Avenue, Nelson, New Zealand
January 11th 2012
New Zealand Journal of History,
Re: Response to a review of The Cartwright Papers: essays on the Cervical Cancer Inquiry of 1987-88 edited by Joanna Manning Bridget Williams Books, Wellington 2009 in the New Zealand Journal of History, 45, 1, (2011) by John Burrows of the Law Commission.
In reviewing The Cartwright Papers John Burrows of the Law Commission focuses on those sections of the book which contest the assertions made by Professor Linda Bryder in A History of the ‘Unfortunate Experiment’ at National Women’s Hospital’ , 2009
John Burrows writes ‘who is right, Linda Bryder or her detractors? ….. having read both books, I simply do not know’. He therefore welcomes both books as contributions to valid democratic debate.
John Burrows notes that Professor Bryder’s book conforms to the appearance of scholarly norms, while commenting adversely on the adversarial style of protagonists in the Manning volume. Mr Burrows concedes that lacking expertise in medicine, evaluating the factual content of both books is beyond his scope. He conceptualizes the controversy not as issues of fact and error but of competing interpretation of the facts and welcomes the contest of such interpretations as a mark of an ‘open society’.
Mr. Burrow’s position is entirely understandable; however there are passages in the text of Professor Bryder’s book which might alert him as a lawyer to errors so substantial as to invalidate Professor Bryder’s position. Take for example a passage on page 158 which reads:
“Valerie Smith did, however, attempt to challenge the findings of the Inquiry in the High Court and Dr Farris joined her at the last moment. In the event, the case was withdrawn because of her lack of status in relation to the Committee of Inquiry and because of Faris’s delay in initiating proceedings. Solicitor-General John McGrath, while agreeing that Coney, Bunkle and Cartwright had misinterpreted the McIndoe paper, explained that he was disallowing it because of the time lapse since the Inquiry findings in August 1988. [footnote 48]. He also commented that too much money and effort had been spent on implementing the findings of the report for these to be challenged as invalid. That expenditure included plans and discussions for government legislation to establish a health commissioner, patient advocates and ethics committees, and $14 million to launch a nationwide cervical screening programme – ‘we have to face the fact that the world has moved on,’ he said. [Footnote 49]. At least, Smith observed, the Solicitor-General did acknowledge that the McIndoe paper, which was central to the Inquiry, did not describe a prospective division of patients into two differently treated groups, as the original Metro article had claimed. [Reference 50]”.
The reader would conclude from this passage that
that the legal challenge (an application for judicial review) by Smith and Faris was withdrawn that it was disallowed by the Solicitor-General of New Zealand that the Solicitor-General agreed that the 1984 McIndoe paper was central to the inquiry that the Solicitor-General had found that Coney, Bunkle and Judge Cartwright had misinterpreted the McIndoe paper that the Solicitor-General agreed that the McIndoe paper did not describe a prospective trial and that this was a central claim in the original Bunkle and Coney Metro article
The reader might also consider that the reasons for dismissal of the judicial challenge were comparatively insignificant compared to the seriousness of the Solicitor-General’s findings, thus casting doubt on the integrity of the judicial process.
If true these assertions would add very substantial support to Professor Bryder’s argument and pose a very serious blow to the credibility of the Cartwright Report; however none of these assertions are true.
Firstly a lawyer familiar with the institutional structure of New Zealand might be alerted to the fact that the Solicitor-General does not dismiss cases in the High or any other court. New Zealand has a separation of powers. The Solicitor-General is a public servant, his minister is the Attorney-General, and he acts as the government’s most senior lawyer. Thus in this instance he was arguing on behalf of the government that the application for judicial review be rejected. What is presented here as parts of the findings of the court in support of Smith and Faris are actually part of the Solicitor-General’s arguments to the court against Smith and Faris.
Had the reviewer been alerted to this misunderstanding he might have examined the record of the court or the account of the action provided by the Auckland Law Society. Had he done so he would have found that the application for judicial review was not ‘withdrawn’ or ‘dismissed’ it was ‘struck out’ by the judge. Furthermore it was struck out with the consent of Smith and Faris.
The legal record would further show that far from the Solicitor-General agreeing that ‘Coney, Bunkle and Cartwright had misinterpreted the McIndoe paper’; in fact Smith acting through her counsel acknowledged that she had been mistaken in these assertions. Therefore it was not true that the Solicitor-General had acknowledged these important errors, for indeed such errors had not been made. No official of the New Zealand government, or judiciary has ever found that they were.
The court record shows that the facts are therefore exactly opposite to those asserted by Professor Bryder. The professional historian must therefore ask how these errors have come to be made?
The assertions depend on the use of two secondary sources in the Auckland Star. Such sources need to be approached with caution. Inspection of them however shows that that they do indeed make the assertions quoted, however in the newspaper they are correctly attributed to the appropriate persons. They are the views of Smith which she acknowledged to the court were in mistaken.
Both newspaper articles contain an accurate account of events. The erroneous impressions have been constructed by selecting part of the first Auckland Star account while omitting those parts which contradict Professor Bryder’s assertions. The selected portion is then juxtaposed with partial selections from the second Star article. Read appropriately it becomes clear that the Solicitor-General did not find that the Cartwright inquiry rested on error but neither did the Auckland Star report that it did.
This specific example is indicative of the construction of other serious errors in the text. It is in the interests of professional historians and particularly their professional academic journals to provide detailed examinations of claims which have significant impacts on the public perception of their profession the legal, judicial, and medical professions, the public service and specific individuals.
- Letter from Caroline Daley, editor, New Zealand Journal of History to Phillida Bunkle 24.01.2012
Thank you for writing to us in our capacity as editors of the New Zealand Journal of History. The issues you raise in your letter are more to do with Linda Bryder’s book than the review we published by John Burrows. The Burrows review was, of course, not of Bryder’s book but of The Cartwright Papers. Given this, we will not be publishing your letter in the NZJH.
Associate Professor Caroline Daley
Dean of Graduate Studies
The University of Auckland
+64 9 3737599 extn 87819