Case Summary

The NWH case is somewhat unique in that data are available from all the key play­ers within the system as well as external sources. Sources include Coney and Bunkle's (1987) interviews with hospital staff and patients, statements from the commission of inquiry (Cartwright, 1988), published medical research articles (e.g., McCredie et al., 2008), opinion pieces in professional journals (e.g., Cameron, 2008), and extensive media report­ing from 1987 onward.

Background. The environment within which this case took place changed from the 1950s-1960s to 1987 when the case became public—a period of considerable social change. Postwar policy in New Zealand focused on family health, full employment, and economic growth. Women worked pri­marily within the home and local community. The welfare system provided free medical care to New Zealand citizens, and the medical profession was generally held in high regard. Consistent with international standards of the time, however, no hospital in New Zealand had an ethics committee. It was not until 1964 that the World Medical Association Declaration of Helsinki (1964/1975) stated the need for informed consent and then too only for medical trials with no therapeutic benefit. In 1974, the New Zealand Accident Compensation Commission Act introduced a no-fault medical system that precluded individuals and institutions suing for medical misadventure, negligence, or malpractice.

Key Events. Associate Professor Herbert Green was head of the cervical cancer team at NWH from 1956 to 1982. He believed that women whose clinical results showed abnormal carcinoma in situ (CIS) cells would not later develop invasive cervical cancer. Green considered that the standard treatment of the time, a hysterectomy, was unnecessary “mutilating surgery” and so began to limit his interventions to cone biopsies to verify that malignant tissues had been removed.

The early success of less invasive proce­dures in managing CIS impelled Green to begin a longitudinal clinical trial in 1966 to document its “natural history” without treatment. Consequently, Green left lesions untreated, delayed the removal of abnor­mal tissue, and withheld biopsies for women below 35 with a “clear conscience” because he was convinced that the two diseases were distinct (Coney, 1988). Green proposed to use various diagnostic tests to satisfy himself that the women did not have invasive cancer from the outset. Although the experiment received the approval of the NWH medical committee in 1966, Green never requested or obtained patient consent.

Up until 1976, 131 women (of 948 in total) presented with persistent equivocal or abnormal cytology. Later analysis found that these women were 24.8 times more likely to develop cancer than those who received prompt treatment (McIndoe, McLean, Jones, & Mullins, 1984). By 1984, 8 of these women had died of invasive cervical cancer, as well as 4 more from the remaining 817 (McIndoe et al., 1984). Although McIndoe, McLean, and members of the NWH cytology department raised concerns about the trial, the hospital’s management reaffirmed Green’s assertion that the treatment plan would be discontinued if it posed significant risks to the women involved.

Subsequently, four clinicians engaged in a discrete whistle-blowing attempt within professional circles by publishing the clinical results in an international medical journal (McIndoe et al., 1984). Response was minimal until two health advocates stumbled across the article in 1987. After interviewing the key players, they ran the story in a national magazine, Metro, creating widespread public outrage (Coney & Bunkle, 1987). Two weeks later, the government initiated a commission of inquiry to investigate the CIS trial.

The commission (Cartwright, 1988) con­demned Green’s treatment as inadequate and the hospital management’s lack of ethical oversight as negligent. It also called for a rigorous ethics approval process, legislated patient rights, the provision of patient advo­cates to remedy power imbalances in doctor­patient relationships, and the establishment of a health and disability commissioner to handle patient complaints about medical treatments.

Twenty-five years after the commission released its findings, this case remains con­tentious: Interpretations of the medical data and the commission’s castigation of the medical profession have been criticized for reducing staff morale and damaging patient­clinician relationships (Overton, 2010; Paterson, 2010). Yet the outcomes resulting from the commission of inquiry have also been applauded for bringing long-term ben­efits to health consumers.