Bad History....The Cartwright Report
With any historical material as a whole you have to rely that the account given by the historian is an accurate account and reflect the historical record fairly. In most cases, this is done and there have been many excellent writings on any particular topic. The problem is when they don't it can be difficult to tell with revisionist historical accounts which is the factual material and which isn't or whether the topic is represented fairly. This has happened with New Zealand material, particularly because our written history is fairly short and in some cases like with the claims about "Ancient Celtic New Zealand" it's wholly off base - there is no evidence of human habitation much prior to the Kaharoa eruption in 1314AD (+/- 12 years) that coincides with the arrival of the Maori people in New Zealand. The signs appear just before and just after. Getting on to more recent history, does anyone remember the Mason Report into Psychiatric care and hospitals in Auckland that came out in late 1988? That was probably more critical of the health care system and those administering it and was the subject of court injunctions and was published with portions redacted. The Hansard record is an interesting read.
The Cartwright Inquiry that also ran in 1988 wasn't half of it, while overall our health care system has worked well there have been times it's failed. In the case of the Cartwright Inquiry there was poor management of research projects, lack of informed consent for patients and a number of other problems besides. Those things needed to change and even now there are probably areas that could be improved. It wasn't until 1996 that there was a patient code of rights:
• The right to be treated with respect;
• The right to freedom from discrimination, coercion, harassment, and exploitation;
• The right to dignity and independence;
• The right to services of an appropriate standard;
• The right to effective communication;
• The right to be fully informed;
• The right to make an informed choice and give informed consent;
• The right to support;
• Rights in respect of teaching or research; and
• The right to complain.
This was a fair few years ago now and many people would have forgotten or maybe not even followed this in the first place. It's important to remember though that those patients in the system often had their rights disregarded. In the past, patients were meant to comply with health care professional’s directions (this could be termed the "Biomedical Model").
Today, it's patient centred care. The big flaw in the case of National Women's Hospital being there was a lack of informed consent, with patients being enrolled into research without their consent. "Consent" in general could mean that the doctor simply presented their preferred treatment and it was only if the patient objected that any further discussion was made of alternative options (often patients didn't feel they could object but that's another story). Often patients weren't given adequate explanation when undergoing treatment, with them only being told that they had such things as "odd cells". Clinical freedom or autonomy meant doctors were free to decide what they thought best with little or no interference, which in this case meant peer review failed despite attempts to address the issue.
The Cartwright Inquiry meant many changes, and there have been a number of articles which have been critical of the Inquiry over the years. Then in 2009 this book was published, causing debate to come up again: Confused offering adds little insight.
On reading the book there are statements like "...for clinical research it only required consent "if at all possible, consistent with patient psychology." (p67) and "Green did not breach the 1964 Declaration of Helsinki, which included a strong exemption for patient consent in therapeutic research." (p69)
In full this says: "If at all possible, consistent with patient psychology, the doctor should obtain the patient’s freely given consent after the patient has been given a full explanation. In case of legal incapacity, consent should also be procured from the legal guardian; in case of physical incapacity the permission of the legal guardian replaces that of the patient." I don't think that is a strong exemption at all, and certainly Green's patients were capable of understanding any reasonable explanation of their medical care and giving their consent to treatment or participate in research so there was no need to withhold from that from them. It has the effect of excusing the lack of consent, when it was clear it was required and it was only if it wasn't possible (i.e. the patient was incapacitated in some way) that it could be waived. This is an issue, as it appears that the treatment of the topic would lead the reader to see the situation in a particular way, and that would be what the author wishes to present rather than an unbiased assessment of the Inquiry. That isn't the only questionable part, and there has been quite some debate in various venues.
This has also been written about in NZ Skeptic, but the original article fails to look at whether those claims made in the book are valid. There are also some errors, like at the start it says it is considering "...whether or not the Inquiry made a fair and just assessment of the current (1988) internationally accepted management of carcinoma-in-situ of the cervix (CIN3) but the Inquiry spent a lot of time making an assessment of the internationally and local accepted management of CIS as it was in 1966. This has the unfortunate effect of implying that the standards of an different medical era applied during the Inquiry. In addition, the discussion of McCredie et al appears to be done from the abstract, and it's unfair to complain that terms weren't defined in that. Definitions of terms were in the full paper.
This lead me to write a response (unedited version). A response to the article was published in the next edition which was a bit of a surprise given that while the original article may have dealt with the book it wasn't mentioned in the article, although it was referenced. A response was written, but publication was refused with the suggestion that online publication be sought. It seems that the request to get it online has been done and I've received a brief statement from the author via the editor (who I'd asked to forward the article) but it's not readily available so here is the short version of "Orthodoxy? - revisiting The Cartwright Report (as submitted but with a correction and responses) and the long version, with extra material that was edited out for length before submission. I'm sure I've seen the comment before, but can't think of where I saw it but it seems to be that the author doesn't grasp the concept of preventative medicine, where early detection and intervention could prevent major problems down the track. That's probably why pathologists were positive about smear tests as they were part of an era where, for the first time, this could be instrumental in preventing both mortality and morbidity. Vaccines were part of that too.
I managed to get hold of a copy of Sandra Coney's book "The Unfortunate Experiment" on the topic, which was written before the results of the Cartwright enquiry were released. Green in the mid-sixties clearly had the belief that CIS was harmless, he is cited as saying to a GP in a letter that CIS and invasive cancer were two totally different diseases, and that "cases of invasive cancer appeared among women who had abnormal cervical cytology in much the same way as any large group of women followed because they had a broken leg." I'd forgotten about the "flying uterus" case. It's often been said that Green was trying to save women from hysterectomies, but in this case he didn't. Green, in his proposal, indicated that he already had patients being observed with persistent positive smears. In addition around 1960, at least 5 women or as many as 16 had hysterectomies based only on visual inspection and smear results with no biopsy being taken for confirmation. The book states that Green wrote that "serial section studies of lesions thus undisturbed by biopsy are being made." The intention being to observe intact lesions to study in the lab. This could have the effect of either over-treating and removing a healthy organ or alternatively if there was invasive cancer, the treatment could be more complicated and have more risks as this involved local irradiation and then hysterectomy and with the uterus removed the rods could not be inserted. Normally, tissue would be examined in the lab right after the surgery but in this case, some of the uteri went on a trip with Green to New York. Some months later a cable arrived reporting that one of them was an incidence of invasive cancer. This not only complicated treatment, but it delayed it and possibly could cause the spread of the original cancer. Despite further treatment the women died two years later at the age of 34. Then between 1963 and 1965 the rate of cone biopsy at the hospital markedly increased as Green did another special study aimed to correlate smear findings and histology. Some of the reports said there was only a finding of cervicitis (inflammation) that didn't require such radical treatment. The hospital policy of the time required that a series of abnormal smears was needed before proceeding with considering further treatment - either all A3 smears or three A2 smears. That, combined with the other studies that required repeated visits and interventions for follow-up purposes for many years didn't save anyone from anything. That they "saved" some women from a procedure or could treat cancer after it developed doesn't apply.