Summary of findings and recommendations from Cartwright Report

The Report of the Cervical Cancer Inquiry 1988 Judge Silvia Cartwright

A summary of the findings of the report by Sandra Coney for Fertility Action

Abbreviations:
Auckland Hospital Board (AHB);
National Women's Hospital (NWH);
Postgraduate School (PGS);
Carcinoma in situ (CIS)

Contents:
  • The 1966 Study of Cervical Carcinoma In Situ
  • Expressions of Concern about the Study
  • Adequacy of Treatment
  • Recall of Women
  • Medical Ethics
  • What the Women Knew
  • Patients' Rights
  • Improvements in Patients' Rights
  • Recommendations
  • The Relationship between the Academic and Clinical Units at NWH
  • Teaching
  • Cervical Screening

The 1966 Study of Cervical Carcinoma In Situ

  1. There was a study of the natural history of carcinoma in situ (CIS) at National Women's Hospital (NWH), officially commenced in 1966, even if it was poorly designed. (p69) The study was of little scientific value. (p55)
  2. By the early 1960s world medical opinion was that CIS was a precursor of invasive cancer. (p24)
  3. Normal adequate treatment at the time at NWH and elsewhere was hysterectomy or cone biopsy. (p24-25)
  4. The proposal was to prove Associate Professor Green's "personal belief' that CIS was "not a forerunner of invasive cancer." (p33)
  5. The biopsies to be taken under the 1966 proposal were for "diagnosis not treatment." They were to check invasive cancer was not present, rather than treat CIS. (p35)
  6. The study involved "no treatment or under-treatment of women with positive smears." (p35)
  7. The safeguards accepted by doctors approving the study were "illusory." (p37)
  8. There would be punch biopsy diagnosis of the most significant part of the lesion with minimal disturbance of it. (p39)
  9. Managing patients by punch biopsy alone was not adequate treatment. (p41)
  10. The cone biopsies performed by Green under the 1966 proposal (sometimes up to six on the same woman) were to check invasive cancer had not occurred rather than treat CIS. (p43)
  11. Multiple biopsies had unpleasant painful effects for the women - "there seemed to be little gained in repeatedly subjecting women to this procedure." (p46)
  12. The option of hysterectomy was usually not discussed with the women, even though many had completed their families. (P49)
  13. Dr Green ignored the "safeguards", "laboratory and clinical evidence suggesting the possibility of invasive cancer was overlooked or downplayed and warnings of progressive disease were dismissed or ignored." (p49)
  14. "Assiduous" follow-up of the patients "did not always result in treatment. Indeed, I have come to the view that Dr Green's care in this part of the Hospital's work resulted from his need to keep track of the condition of patients with positive cytology who were part of his 1966 study.... follow-up was not conducted for the purpose of monitoring and treating the patient where necessary, but to ensure that no data were lost which could be included in the study results." (p49 and pS l)
  15. By delaying treatment until invasion occurred "treatment is more radical and... live expectancy significantly endangered." (pSl)
  16. "Obvious symptoms of invasive disease were sometimes overlooked or downplayed." (pS2)
  17. By the end of 1969 three cases of invasion had occurred in patients. Green should have seen what he was doing was "unsafe," that his proposal was incapable of testing his hypothesis, and was therefore "scientifically unsound and dangerous to the patient." (p52).
  18. Green's study was carried out at enormous cost to the women and their families, and also at financial cost to the hospital, placing pressure on hospital resources. " (pS3)
  19. The understanding of a number of staff at NWH of the e natural history of CIS has been strongly influenced by Green's views. (p57)
  20. The findings of the 1984 paper by McIndoe, McLean, Jones ZE and Mullins reviewing Green's NWH cases are correct. "The criticisms do not stand up to examination." (p60)
  21. No consent to the trial was sought from the women. Only one of the 81 women interviewed by the judge knew she was part of research, (p67-68). "The fact that the women did not know they were in trial, were not informed that their treatment was not conventional and received little detail of the nature of their condition were grave omissions. The responsibility for these omissions extends to all those who having approved the trial, knew or ought to have known of its mounting consequences and its design faults and allowed it to continue." (p83)
  22. There was no need to conduct an experiment on replacing hysterectomy with cone biopsy as treatment of CIS as this was already happening at NWH and other parts of the world. (p83)
  23. There were also supplementary trials, that is the "baby smears" programme and the study of foetal cervices taken from aborted and stillborn infants. The baby smears study was formally approved; the foetal cervices trial was not. No formal consent was sought from parents to either trial. (p211)

Expressions of Concern about the Study

  1. "I have been drawn inexorably to the conclusion that al- EEE though there was increasing opposition... both internationally and at NWH, there was no will to confront and resolve the difficult issues that emerged. For twenty years there was criticism, yet no special effort was made to ensure that patients' health did not suffer as a result of Dr Green's attempt to prove his hypothesis. Until the Auckland Hospital Board recommended the current Inquiry, no person or body with the power or responsibility to intervene took steps to deal decisively with its consequences. The medical profession failed in its basic duty to its patients." (p70)
  2. From 1969 at least Dr McIndoe voiced his concern (p74). At the inquiry, Green said he could not remember McIndoe's early memos and attempts to raise issues with him. The judge raises two possibilities for this: Dr McIndoe's at tempts "might simply be overlooked by a far more forceful personality such as Dr Green, in the way that a wasp is brushed from one's sleeve before it has stung." Secondly because Green was determined to prove his theory "any viewpoint contrary to his was simply ignored." (p74)
  3. When Dr McLean, McIndoe, and Dr Warren (medical superintendent NWH) took a formal complaint to the superintendent-in-chief of the Auckland Hospital Board (AHB) he did not consider the matter "urgent." The judge says "he ought to have retained a direct interest or control in the matter." Then the matter might have been resolved "with greater alacrity." (p77)
  4. The 1975 in-hospital Working Party Report was "extraordinary" (p85). It developed its own limited terms of reference: "It is astounding and of grave concern that the committee... chose to avoid the central issue: were patients at risk of developing invasive cancer or having the diagnosis of invasive cancer delayed as a result of the 1966 proposal." (p87)
    It did not "express any sense of alarm" or "critically assess the potential risks to patients in the 1966 trial. It seems to me that those risks were considered secondary to scientific inquiry." (p87)
    "Instead they... [followed] the time-honoured tradition of confusing etiquette with ethics in attempting to repair the relationships which had deteriorated in the hospital... " They chose "to avoid the real issue," if they had acted differently "I do not believe this inquiry would have been necessary."
  5. When McIndoe began writing the 1984 paper, he met opposition from Prof Bonham, head of the academic unit at NWH. (p92)
  6. There was "no noticeable reaction" to the 1984 paper "at NWH from the Hospital Medical Committee, the Ethical Committee or the Medical Superintendent. The Royal NZ College of Obstetricians ~ Gynaecologists took no steps to ensure that patients... were not at risk... " (p94). The Dean of the medical school had not even read the paper. (p101)
    "The publication of the 1984 and 1986 papers represented the medical profession's last opportunity to exercise its own assessment. It failed to do so." (p101)
    She has "disquiet" over the future of peer review when after "sustained, detailed and well documented statements of concern" the profession could not "confront issues squarely and resolve them."
  7. "I still have no evidence before me that the 1966 trial has been formally terminated." (plO2)
  8. Despite expressions of concern about the "baby smears" study, it was not stopped. (p211)

Adequacy of Treatment

  1. Adequate treatment involves eradicating the disease. "A minority of patients have not received adequate treatment by generally accepted standards of time." (pl 19) "... a significant number were not managed by generally accepted standards over a period of years. For a minority of women, their management resulted in persisting disease, the development of invasive cancer and, in some cases, death." (p210) The main period for which the failure existed was the late sixties and early seventies but "there are still cases to be found where there is inadequate treatment or management." (p211)
  2. Women being examined vaginally "need a sympathetic understanding that the genital tract is a sacred part of a woman's body which should be treated with respect, examined in total privacy, and under conditions which enable the woman to respond... as an equal. If her consent is sought to any procedure or treatment... [it must be] freely given... If she is not offered these conditions, her management is not adequate." (pll6)
    "Any definition of adequate management for CIS of the genital tract implies adequacy from a broad viewpoint; one involving the cultural, emotional, family and social consequences of the disease. Specialist staff at NWH must clarify their scientific objectives in diagnosing and managing the disease and, of equal importance, come to terms with the personal problems encountered by patients diagnosed with this disease." (pll9)
  3. "Protocols for managing disease of the genital tract should be developed at NWH and reviewed from time to time." (pll9)
  4. Women should be given "accurate information concerning diagnosis, treatment and future management of the disease" and "the consequences of treatment and the impact that her treatment or management may have on her personally, on her family, working life and her mental health."
  5. "Counselling should always be freely available..." (p 120)

Recall of Women

  1. The judge got her medical advisers to review all cases down to the present time because "a number of patients whom I had interviewed privately demonstrated that there was cause for concern in more recent treatment and management procedures." (pl22) She was also concerned that some microinvasive (first stage invasion) cases were being managed the same as CIS cases when this was not safe.
  2. The judge gave the names of 140 women who should be recalled to the Minister of Health. The medical profession "have a special duty to these women." (pl23)
  3. There were broadly two categories of women recalled: women at high risk who need further treatment and women who "can no longer be located" who need to be told about their possibly inadequate treatment or follow-up who must be located and given this information so that they can "make decisions about their own health care." (pl23)
  4. "Some of these women may prefer to receive advice or treatment from gynaecologists who are not associate with NWH. If this is so, their requests must be honoured. More recent examples of delay in diagnosis and treatment of CIS and invasive cancer have led me to the view that independent review of treatment offered to these women at NWH must be put in place. I am not confident that the standard of management offered is always of the highest order." (p 124125) "The facilities must be independent of NWH, if that is what these women wish." (p217)
  5. The women and their GPs must be directly contacted and advised. Immediate colposcopy should be available. (pl25)
  6. Women's groups and Maori women should be asked to advise the minister on follow-up. Trained counsellors or medical social workers should be used to make initial personal contact and be available to women needing further advice and treatment. (pl25)
  7. The Commission and Minister hold lists of women whose cases have been reviewed and this information is available for women, or their relatives, in the case of women who died. (pl25)
  8. All women ever treated by NWH for CIS to receive written information about the nature of the condition and the need for follow-up smears. Women with micro" invasion should be told because they should know they had early invasive cancer. (pl26)

Medical Ethics

  1. Clinical freedom: "Now the patient must be involved in decisions concerning her management and medical colleagues must intervene if there is a risk to the patient for any reason. The doctor is no longer wholly autonomous. Clinical freedom has been proved worthless at NWH when patients' safety or the rigorous testing of a new treatment protocol were at stake." (pl29)
  2. Peer Review: "When it came to evaluating or reviewing the 1966 trial, Dr Green's peers failed him. Twenty-one years after the first oral and written challenge to the proposal, an article in a non-medical magazine achieved in a few days what his colleagues could not." The concerns raised by McIndoe, McLean, Warren and Jones through the superintendent-in-chief, a world authority and the HMC - "all this counted for nothing." The publication of the 1984 and 1986 papers "hardly seemed to cause a ripple among the staff at NWH," the women were not recalled and reviewed. "Of even graver concern is the fact that the AHB took no steps to ensure that patients' welfare was not at risk even though it had known of the risks, through its medical superintendent, since 1975....I believe that unless the profession can establish adequate peer review and adequate systems to cope with the inevitable mistakes or problems caused by incompetence, then there will a continuing succession of inquiries of this nature." (pl31-137) At NWH, peerreview "is almost non-existent except at an informal level." (p212)
  3. Informed Consent: As a consequence of the Accident Compensation Act 1972, "the law in New Zealand relating to informed consent may need to be spelled out specifically." The patient has the right to "all relevant information... The focus should be centred on the patient, and not on the doctor." If the women in the 1966 study had been informed "then it is my firm view that fewer patients' carcinoma in situ would have progressed to invasion. The investigator should have sought the patients' consent... These are principles which have been clearly enunciated throughout the period that the 1966 trial has been in operation, but which were breached from the outset." (pl36-137) Consent, however, would not have freed the investigator from responsibility because the study was "flawed in design." The patient must freely give consent to all treatment and research. There must be full disclosure. The doctor has an obligation to understand cultural perspectives and where "yes" might be just a desire to please. There should be more written information for patients. (pl37)
  4. Research: The NWH Ethical Committee had no established procedures for evaluating research, for independent assessment, referees, or reviewing the science. It has no formal guidelines and no written principles or special application forms to guide researchers such as those used by the Auckland Hospital Ethical Committee. (pl 39-144) Most projects "appear not to have received adequate scientific assessment in all cases..." (p212)
    The judge reviewed ten years working of the committee, leaving her with "serious reservations." Consent forms were rarely included in proposals. Prof Bonham as head of department and post-grad school, chaired ali meetings and never stepped down. Most of the proposals came from his department, even from himself. Thus the committee lacked independence. (pl45) No existing research projects were reviewed, the publication of results is "not encouraged or enforced" (p212), the sole lay member was male, a retired pharmacist and deputy coroner.
    The NWH Ethical Committee had not always achieved the objective of ensuring that unethical practices do not occur. These inadequacies "pose a serious risk to patients' rights." (p212)
    The judge specifically criticised the reply of Prof Bonham to a letter to the Ethical Committee about the 1966 study written by Phillida Bunkle. (pl49-151)
    The judge decided the ethical committee "has demonstrated no sense of responsibility to the public in providing accurate information when it is sought and on at least one occasion suppressed information in case of public reaction. It lacked independence and impartiality during the period covered by the minutes I have seen. Lay representation has been inadequate." The AHB has shown little interest in it. "I have come to the conclusion that NWH is too small an institution and too closely associated with the Postgraduate School to be entrusted with the critical task of evaluating scientific and ethical content of in-house research proposals." (p151) She recommends it be disbanded and a more "detached" ethical committee should be established. The AHB under the supervision of the Director-General of Health should develop "one or more ethical committees for assessment of all projects in its institutions." (p212)

What the Women Knew

Of the women the judge interviewed, only one knew she was being studied. "I disagree with the suggestion of one witness that many patients lack the intelligence to grasp essential information. In general, the level of information received by the patients I met was poor. It is disturbing that on occasions patients felt confident they had had full and accurate information when in fact that had not been the case." (plS6) "Only a minority of women or relations of patients who spoke to me had grievances about their treatment, about NWH or about any member of the medical staff. After reading their files and listening to their experiences I could only conclude that the vast majority of the people I talked to had so little knowledge of the nature of the condition for which they or their relatives were being monitored, that they had no basis from which to formulate a complaint." (plS7)

Patients' Rights

  1. Consent: All treatments under anaesthetic must have written consent. The consent form must specify what the patient has been told and to what she has consented. "In the light of the evidence I have heard, the Hospital should consider providing the patient with a written summary of possible risks. I consider it is insufficient... "to make a general statement that the nature, effects and risks of a treatment have been explained. The consent form should name the doctor. (plS8)
  2. Translators: "It is inappropriate for relatives or members of the hospital staff who are not in a confidential relationship with the patient to undertake this task." (plS8) "The AHB should urgently consider employing and training interpreters who would be bound by the rules of patient confidentiality. They would be available to help explain treatment or procedures and ensure that the woman's consent is freely given... These services should be publicised throughout the hospital and a woman should have easy access to an interpreter's help. Health professionals proficient in the patient's language may often be the most appropriate to manage that case. Other hospital workers, relatives, and friends should not be relied on as interpreters." (pl59)
  3. Patients' Rights Code: The judge was concerned about the manner of its distribution, that it was kept in wardrobes. She said this was "inadequate." "It may be that the staff place little emphasis or importance on the provision of the document. I was informed by Dr Collison that this Code of Rights could be handed to each patient as she was admitted to hospital. I believe it ought to be freely available to out-patients as well." (pl59)
  4. Women are entitled to privacy and modesty. She should be able to meet her consultant fully dressed and change for examination. Gowns must be available in all sizes. Patients should not be able to be overheard. (plS9)
  5. Consent to teaching: Permission should always be sought for students to be present "before they enter her cubic or room." (plS9-160)
  6. Colposcopy should be private, a female staff member should be present or available, she should be able to have a relative or friend with her, she should be able to see what the colposcopist is doing. (pl60)
  7. Out-patients: Waiting periods must be reduced: "The principle should be that hospital care is for the patient, and not for the convenience of the doctors and other staff. (pl60) Consideration should be given to decentralising out-patient clinics.
  8. Attitudes: The judge relayed a recent experience of a patient at an out-patient clinic. The woman was kept waiting hours, had a rough and painful examination, and was told it was all in her mind: "The type of experience has been described on several occasions during patient interviews. I was concerned, however, that even while the Inquiry was still sitting, patients were being treated in this manner." (pl61)
    The judge also detailed the experience of a woman being treated for invasive cancer between 1984 and 1987 and concluded: "To be made to feel a nagger, a nuisance and a person with a poor attitude is extraordinarily insensitive. If the staff at NWH cannot cope with women who are seriously ill, the' other health professionals such as social workers must be introduced to the system urgently, to assist with communication, reassurance and support, both for the patient and he family." (pl62-167)
  9. Consent to Research: There must be full information and consent given freely. She must not be in a dependent relationship to the researcher, must not feel under any obligation, must have a good grasp of English and have time to decide and consult family and friends: "These rules have seldom been observed in clinical trials at NWH.' (pl67)
    The judge discovered that some women had been included in several trials without their consent.

Improvements in Patients' Rights

"There are still signs that some (albeit few) patients are no being managed adequately by currently accepted standards. There is a basic lack of understanding of the ethical importance of providing information to patients, be it about the nature of her condition and its management, or inclusion in a clinical trial. Communication with patients can be poor and occasionally attitudes are punitive."

"I had fully expected that most doctors, and other health workers or administrators, who have been the focus of attention during this Inquiry would have demonstrated changed attitudes and updated their knowledge of the scientific and ethical issues that have been discussed. Some obviously have done this. But there has been a pervading atmosphere of defensiveness and even arrogance which, while understandable at a human level, does not bode well for the future care of patients at NWH." (pl71)

She decided she concluded she could not leave "the encouragement of new habits and practices to the medical profession alone."

The judge makes these specific criticisms:
  1. With one exception, no administrator or gynaecologist listened to the evidence of patients given to the judge "in' camera" Dr Collison was the only staff member who has read most of the patient interviews. (pl71)
  2. Prof Bonham had responsibility for research and for the clinical work of his staff, but "he did not intervene to ensure that the 1966 trial was formally terminated and the patients involved were treated." (pl72)
  3. "Nurses who most appropriately should be the advocates for the patient, feel sufficiently intimidated by the medical staff' (who do not hire or fire them) that even today they fail or refuse to confront openly the issues arising from the 1966' trial." (pl72)
  4. Professor Colin Mantell (now head of the Department of Obstetrics and Gynaecology at NWH) and Dr Tony Baird, chairman of the New Zealand Medical Association and former Acting Superintendent of NWH "both gave incorrect information to the public outside the Inquiry. " They claimed the vaginal smears of babies were to check for infection and a normal part of child care (Mantell). The "baby smear" programme was in fact a study of Green's. (p172)
  5. Baird, Bonham, the AHB and Collison had all known about anaesthetised women being used to teach IUD insertions and vaginal examinations without consent. "...there is evidence to suggest that these practices may have continued up until the time of this Inquiry." (pl72)
    "Quite obviously old habits and attitudes provide a sense of security for many who have been buffeted by the cold winds of this Inquiry. Gynaecologists, administrators, and health professionals need to listen to their patients, communicate with them, protect them, offer them the best health care within their resources, and bravely confront colleagues if standards slip. If this does not happen, then the kind of events disclosed during this Inquiry may well occur again.
    "With some regret I have concluded that I cannot leave the encouragement of new habits and practices to the medical profession alone. In Auckland, in many parts of New Zealand, and even overseas, the problems arising out of the 1966 trial were known but not confronted and resolved. Peer review failed and patients suffered. Moreover, some teaching practices revealed mediocre standards." (pl72)
    "The focus of attention must shift from the doctor to the patient." (pl76)

Recommendations:

  1. Patients' Rights Legislation: In the absence of a Bill of Rights and "where the financial accountability of the medical profession has been distorted by no-fault Accident Compensation legislation..." she recommends legislation "to codify principles and be a rule against which ethical and medical standards can be measured." (pl72) The Human Rights Commission Act to be amended to include a statement of patient rights. (pl76)
  2. Patient Advocates: She recommends a patient advocate at NWH "independent of the University of Auckland and the AHB... [but] will keep the board and university fully informed of her work and consult with them when appropriate." "Patients would have one person to whom their immediate grievances could be addressed." She would have "a voice at ethical committee level. " She would have a voice in the "development and dissemination of information about treatment protocols." She would "heighten awareness" of patient needs "when teaching or patient examination techniques were implemented."
    The person must have "the power to work side-by-side with administrators, researcher, nurses and doctors," have "excellent communication skills," be "familiar with Maori culture and language" (pl73). She should have the power to refer complaints to the disciplinary bodies, the Health Commissioner or AHB on behalf of a patient or class of patients. (p214)
  3. There should be formal independent audit "of treatment and management procedures at the hospital" to ensure treatment is of the highest standard. (pl73-174)
  4. Health Commissioner: Because existing structures within the hospital and AHB and the present system for disciplinary procedures have not responded adequately, there should be a Health Commissioner, attached to the Human Rights Commission, to whom grievances can be addressed. It has procedures already in place for negotiation, mediation and education. Cases could go to the Equal Opportunities Tribunal on behalf of a patient or class of patient (pl74) The commissioner would also work to heighten professionals understanding of patients' rights. (p214)
  5. Medical disciplinary procedures must be put in place in consultation with community health groups and those representing different cultural perspectives.
  6. Elected hospital board members should take greater responsibility for patient welfare and should ensure that the administration and the academic unit make the patients' health their primary consideration. There should be a committee of elected board members to which patients can take grievance. A sub-committee of elected representatives should have the power to seek further information from the ethical committee where appropriate. (pl75)
  7. The Director General should monitor progress and improvements in ethical standards at NWH. The DG should ensure the patient advocate role is developed and that her independence is maintained at all times. He should ensure that half the ethical committee are lay members and should encourage better procedures within that committee. (pl76)
  8. The university should improve the teaching, of ethical principles and teaching skills at all levels during medical school training and encourage community debate on medical-ethical topics. (pl76)

The Relationship between the Academic and Clinical Units at NWH

  1. The line of responsibility for academics involved in research or clinical work involving patients is through Professor Bonham, head of the Postgraduate School and Department of O and G, to the dean, and back to the medical superintendent and superintendent-in-chief of the Auckland Hospital Board. The university is responsible for teaching and administration. (pl77-178)
  2. The judge called the relationship between the academic unit and the hospital "sometimes fiery" which has caused "grave difficulties in administration." "There have been many occasions over the years when members of the Postgraduate School and clinicians have clashed on matters of interpretation."(pl78)
  3. The judge documents efforts by Professor Bonham, head of the PG School to also be medical superintendent (pl79) as well as the objections of the non-academic unit. The medical superintendent in 1976 wrote to the AHB about the "rift" in the hospital. The cause, he said, was the "outspoken, hectoring manner of the Head of the University Department. This unfortunate attitude has been tolerated for a number of years but I can now see that the obstetrical and gynaecological staff are not prepared to endure it any longer... The antipathy of the part-time staff... is directed mainly at the Head of the Department whose manner and conduct has not won their respect... Quite frankly they have lost confidence in him; and do not want him in any position of influence in this hospital which will affect them..." (pl80)
  4. This "atmosphere," says the judge, partly explains why the criticisms of Green's work "were seen by Dr Green as an attack on him personally" and why Bonham "chose not to intervene and ensure that the 1966 trial was terminated." (pl81)
  5. She concluded that "there are still rivalries which must be confronted and resolved in the interests of patients' welfare and the future reputation of the Hospital itself. Effective peer review cannot operate in this atmosphere." (pl82)

Teaching

  1. Professor Green had responsibilities for teaching on CIS. His teaching papers gave inaccurate information about CIS and screening. They were written in the late 1960s but were still being handed out at the PGS in the 1980s, by which time they were 17 and 20 years out-of-date. (p 183) This, she concluded, "displays intellectual impoverishment." (pl84)
  2. A textbook published by the PGS in 1983 repeated Green's views. (pl84)
  3. The message that Green "repeatedly" gave general practitioners over the years, downplayed the significance of a diagnosis of CIS and positive smears. (pl85)
  4. The PGS has decried cervical cancer screening and this has had an influence "right up until the present day. I suspect they are one reason why the Health Department has sidestepped the allocating of funds to a nationwide screening programme on the grounds that the profession in New Zealand is not united in the need for one. It is of great concern that the members of the Department (PGS) have failed to analyse accurately the available material and publicly continue to attempt to influence the profession and undergraduates with their unorthodox views. There has been a tendency to make inaccurate use of recent information on CIS, its incidence and causes." (pl86) She cites a letter to the New Zealand Medical Journal by Dr Murray Jamieson (1985) and an editorial in the Australian and New Zealand Journal of Obstetrics and Gynaecology in mid1987 co-authored by Green, Bonham and Prof Liggins.
    "The views of some members of the academic unit at National Women's Hospital have demonstrated an apparent unwillingness to accept up-to-date information and incorporate it in teaching both students and general practitioners."
  5. The PGS have failed to convey information about the "male factor" in CIS, wrongly giving the impression to women that promiscuity causes CIS.
  6. The Royal College of Obstetricians and Gynaecologists should review teaching of general practitioners at NWH to "reassure the public and the medical profession that any mediocrity in the teaching programme is confronted..." (pl90)
  7. The judge outlined examples of anaesthetised women being used to teach vaginal examination and IUD insertion without their consent. These practises had been criticised in the 1970s and 1980s and were know to AHB, academic unit and hospital authorities. Women entering a teaching hospital "cannot be taken as acquiescing to teaching procedures." "The implications for patients who, without their prior consent, are teaching subjects while anaesthetised extends beyond NWH. It may well be that the time has come for professional ethics to prohibit such a practice, and for legislation to be clarified to ensure that this does not recur. I regret to say I cannot rely on the assurances that have been given me." (pl90-191)
  8. Vaginal examinations under anaesthetic: "not more than two students... should undertake the procedure. The woman's written consent to the precise procedure and names of those actively participating must be sought well before she is prepared for her anaesthetic..." (pl92)
  9. Vaginal examinations of conscious patients also demand consent be sought in the same way. "Normal courtesies, including the introduction of the students, maximum privacy and respect for the patient must be observed." (pl92)
  10. The PGS and nursing associations should "consult representatives of their consumers, in particular women's health groups, the Ministry of Women's Affairs and other interested bodies, to establish a scheme for teaching examination techniques which will be acceptable for patients." (pl92)
  11. "No person who is an employee of a hospital, or who might be known to the teaching staff and students, should be invited to take part in any teaching programme." (pl92) (Female staff were used to demonstrate equipment such as colposcopy to visiting students and doctors).
  12. The judge suggests a study of patients' interviews and evidence given by consumer groups and the Ministry of Women's Affairs to be used for teaching "to help [students] understand the views of women..." (pl93) "This report" …should "be accessible to all health professionals in training." (p216)
  13. She suggests use of expert material used at the commission on disease, research and ethics for teaching. (pl93)
  14. "The Head of Department is due to retire shortly. A replacement of world class would do much to invigorate the Department's image and morale." (pl93)
  15. Academic staff should be encouraged "to participate in programmes or research relevant to their specialities." (p 194)
  16. The Royal College of O and Gs has offered to disseminate information on CIS. However, the judge stresses that other lessons besides scientific ones need to be learned. She suggests articles and comment in medical and nursing journals, regional seminars to discuss ethical issues and screening, television and radio debates and comment, as well as "special attention to these issues in undergraduate and postgraduate lectures during the next two or three years." (pl94)
  17. There is little or no formal teaching on ethics at the Auckland School of Medicine... The Auckland School should consider a similar course [to Otago], stimulated perhaps by the involvement of members of the public (including patients), recognised ethicists and health consumer groups." (pl94)
    "The public does not see medicine purely as a scientific pursuit. Increasingly, it is demanding evidence that doctors think through the many dilemmas which surround its practice and they involve the public in ethical decisions." (pl94)
  18. The information from the inquiry, including patients' vievvs should be disseminated to previous trainees. General practitioners should be informed about generally accepted vievvs about CIS and the importance of offering smear testing. The Royal College of O and Gs and the Royal New Zealand College of General Practitioners have a responsibility to do this. (p216)

Cervical Screening

Internationally, the value of screening has been long accepted and established. Further study is not needed to evaluate the need fora screening programme (pl98 and201)

The PGS at NWH has opposed and undermined the value of cervical screening (pl97-198) NWH believed it was "right and the rest of the world was wrong... " (pl99). NWH opponents of screening have argued it has failed because the death rate from cervical cancer in NZ has not declined. The conservative attitude to treatment ot this disease promoted by NWH may have resulted in in situ lesions being not properly treated. Thus the death rate may have been affected.(pl99)

Screening in New Zealand has been opportunistic, that is, women have had a smear test when attending doctors for other reasons. As a result, large sections of at risk women have not had smears, eg. older women who no longer have babies or use contraception.

The judge said it was of "great concern" that cost deters many women and that many general practitioners were not offering smear tests. (p203)

The recommendations of the Skegg Report (three-yearly screening) for a nationwide population-based cervical cancer screening programme should be implemented urgently. (p201)

Other health workers and nurses should be able to take smears and pilot studies made to evaluate how they are trained. Women would prefer a choice of site for screening - work based clinics, marae clinics, mobile clinics, well E women's centres. This is especially true of low -paid women, Maori and Pacific Island women. "Many women would prefer a woman to take the cervical smear." (p206-208)

The programme must be centrally organised so that it is coordinated and women can move from one region to another. Leadership from national level is important to success. There must be coordination of educational material and publicity. (p207-208)

Patient recall must be linked to all laboratories, possibly by a centralised records register. (p208) A common nomenclature should be developed for all labs; training for cytotechnologists should be developed, as should quality assurance programmes. (p218)

A central register based on a regionalised network is ideal. It must ensure privacy and confidentiality and be under the Departmentof Health. It could be computerised with efficient recall systems. (p208)

The method of recall must be culturally appropriate. Women must get their smear results. Where possible recall should be staffed by women. "as must the smear taking procedure itself." 'Qf the screening service is intimidating, embarrassing or extremely uncomfortable, many women will not take advantage of it."~(p209

The Minister of Health should establish "a group representative of consumers and health professionals to evaluate procedures, advise on resource allocation and implement... a population-based cervical screening programme..." (p209) Maori women must be consulted. (p217)

Colposcopy services should be urgently expanded throughout New Zealand. (p218)

More pathologists will need to be trained to cope with the demand. (p218)