A collection of essays on lessons from the Cartwright inquiry became an examination of why some in the medical profession have refused to accept its findings. Chris Barton reviews the book
It's not often that professors will overtly criticise the standard of scholarship of another professor.
But that's the overriding theme in The Cartwright Papers where Auckland University historian professor Linda Bryder comes under sustained attack for her A History of the Unfortunate Experiment at National Women's Hospital published last year.
In the foreword, Otago University vice-chancellor Sir David Skegg leads the charge against Bryder's book.
"Its numerous references and its publication by a university press convey a superficial impression of academic rigour, yet the book is replete with factual errors and selective quotations."
History professor Barbara Brookes is similarly harsh. "... the book relies on selective evidence, misread sources, and makes no attempt to weigh the quality of the sources".
She is followed by Charlotte Paul, a professor in Otago University's Department of Preventative and Social Medicine.
"A failure to sift and weigh evidence in relation to her 'right' story has led Bryder into contradiction and incoherence, of which she appears unaware."
The Cartwright Papers was originally conceived as a record of a 2008 conference, "Twenty years after the Cartwright Report: What have we learned?".
But with the publication of Bryder's book it also became a rearguard action - damage control against Bryder's assertion that the Cartwright Report got it all wrong. Hence three extra chapters devoted to debunking Bryder's thesis.
For many of The Cartwright Papers' contributors this is familiar territory. Ever since the Cartwright Report's release in 1988, revisionists have been seeking to undermine and rewrite its findings.
The report was the culmination of a six-month judicial inquiry into allegations of unethical research begun in 1966 by Dr Herbert Green at Auckland's National Women's Hospital.
In a watershed event in New Zealand medicine, the inquiry found Green had indeed been engaged in experimental research that resulted in a number of women unnecessarily getting cancer, which in some cases led to death.
The question at the heart of The Cartwright Papers is why? Why has a segment of the medical profession in New Zealand steadfastly refused to accept Judge (now Dame) Silvia Cartwright's findings? And why would an academic like Bryder advocate for the disgruntled and put her reputation on the line defending the seemingly indefensible?
There is much to applaud in this book: Charlotte Paul's detailed unpicking of Bryder's partial quotations and misunderstanding of the medical science and statistics involved; Barbara Brookes' argument that to better understand this landmark event, any history written needs to properly assess all sides of the debate; Sandra Coney's forthright defence of feminism and against Bryder's attack on her as the prime instigator of a feminist plot; and Joanna Manning and Ron Paterson's account of what the Cartwright Inquiry delivered - New Zealand's Code of Patients' Rights.
But perhaps the most insightful essay comes from Dr Ron Jones, who lived through the experiment and was a junior co-author of the 1984 medical journal paper that blew the whistle on Green's practices. He says there is still no good explanation for why Green's research was approved or why it wasn't stopped when concerns were raised.
"To me, it remains a mystery (or a madness) that large sectors of the medical profession placed loyalty to colleagues above responsibility to patients, that the profession could not say, 'I'm sorry', and that even today some individuals continue to rail against the findings of the Cartwright Report."
Following Judge Cartwright's findings, Jones recounts how he and others proposed the hospital issue the following public apology: "The senior medical staff of the National Women's Hospital express their regret and sympathy to the patients and their families who Judge Cartwright described in the Report as a 'minority of women' whose management resulted in persistent disease, the development of invasive cancer and in some cases death." Initially the motion was carried, but following concerns by some senior medical staff it was decided no public statement would be issued.
Jones also explains how the revisionist story got under way just nine months after the inquiry through a reanalysis by Dr Graeme Overton, a senior obstetrician and gynaecologist at National Women's, of the data in the 1984 paper.
Even though Overton's re-analysis was faulty and never published in a scientific publication, Jones notes that it didn't seem to matter. Overton's view was seized on by many in the profession, including Dr Tony Baird, at the time chairman of the Auckland Division of Specialists in Obstetrics and Gynaecology, as a way to discredit the inquiry.
It also formed the basis of Jan Corbett's 1990 Metro article, "Second Thoughts on the Unfortunate Experiment", which in turn formed the basis of Bryder's book - a chain reaction of revisionism.
How wrong was the reanalysis? Jones asserts in his essay that Overton "failed to appreciate" the difference between adequate and inadequate treatment received by the two groups of women analysed.
"He ought to have known also that no one should be discussing death in the context of the management of carcinoma in situ, since nobody should die of the disease."
Jones points out, too, that even if one combined the adequate and inadequate treated groups, as Overton proposed, the hospital "still ended up with the world's worst figures of approximately one woman in 20 developing cancer".
Jones puzzles over the fact that the 1984 paper "has received more detailed examination, misrepresentation and criticism than any other scientific paper emanating for New Zealand" - and yet it said nothing new or controversial.
It simply confirmed what everyone, except perhaps Green, knew - that carcinoma in situ of the cervix if left untreated progresses to invasive cancer.
So why the controversy? Because it revealed the truth about Green's "unfortunate experiment" which was to leave women with the condition untreated because, in his own words, he thought it was "probably benign in the great majority of cases".
Jones says the paper delivered a truth that none of the senior medical staff at National Women's wanted to hear: "The paper explicitly stated the number of women who had developed cancer and related this to the adequacy of treatment."
Jones then returns to the question of why - when all the evidence pointed to Green being wrong - did no one stand up and sort it out? He suggests many reasons: that it was someone else's problem; loyalty to colleagues and teachers; "a belief that the issue would miraculously disappear"; a disbelief that anything untoward could be happening in "our hospital"; a natural reluctance to interfere in another clinician's cases; and university and hospital hierarchies "which are powerful and can be intimidating".
Jones' lament is that though all doctors hear the dictum primum non nocere - "first do no harm" - hundreds of times during their career, it did not feature in the thinking and actions of the senior medical staff at the hospital during the course of the unfortunate experiment.
The only ones who did make "expressions of concern" were Dr William McIndoe and Dr Malcom McLean, the lead authors of the 1984 paper. "All, with the exception of Green, considered carcinoma in situ a cancer precursor," says Jones of the senior medical staff.
"All recognised the risks to the women in Green's experiment. Their failure to stand up to the power of the senior academic staff in the 1960s and 1970s was unquestionably at the root of the disaster."
Jones' essay speculates whether Green ultimately considered he may have been wrong, noting that having published a paper a year between 1962 and 1974 on the natural history of carcinoma in situ, he suddenly stopped publishing.
"Green was an intelligent man, and by the mid-1970s he had witnessed many women in his study developing cancer, so one must assume he recognised that his experiment had failed."
In her essay Could it Happen Again? Jan Crosthwaite argues that motives behind unethical research "involve moral blindness more often than malevolence".
It's a view that finds favour with Skegg: "Green was far from being the devil incarnate, as some would portray him." But what Skegg can't accept is what Green did when some of the women in his study developed invasive cancer - his re-examination of their original slides and reinterpretation that the women had cancer from the outset, and could therefore be removed from the study and not reported on in his publications.
"How do we explain this manipulation of results, which must be regarded as scientific misconduct?", asks Skegg in the book's foreword. Rather than describe it as dishonest or a deliberate attempt to cover his tracks, Skegg believes it was Green's "stubborn and unshakeable conviction" that carcinoma in situ was not a premalignant disease.
"He simply could not believe his theory was wrong, and had to find an alternative explanation."
As to whether it could happen again, Jones concludes that it could; that the ethics committee approval process now in place wouldn't always be a safeguard. As he points out once a research project is under way, it is not closely monitored by independent experts. A case in point is Bryder's own research which gained a $345,000 Marsden Fund grant.
The question Brookes asks in her essay is why, when Bryder chose to write the history that she did, she didn't personally interview key players like Ron Jones about the 1984 paper, or David Skegg, an expert witness at the inquiry. Brookes argues when researching controversial events in living memory, historians have a duty to try to remain dispassionate.
"At the very least, they should detail why they have chosen to speak to some people (and what they have asked them) and not to others."
The end result for a reader of The Cartwright Papers is a sense of dedicated people trying to move forward from a terrible wrong. But it's also a story of a battle with revisionists which produces a sense of disquiet, and concerns about how some research is undertaken and published in our university system.
The Cartwright Papers: Essays on the Cervical Cancer Inquiry 1987-88; Edited by Joanna Manning, Bridget Williams Books; $39.99
