CMS Analysis: Three Possible Lenses on the Case

Acknowledging that we can learn about multilevel conflict from this case, we now examine the impact of a law-based CMS on the conflict at NWH before turning to the potential effects of management-based and participation-based CMS.

The First Lens: A Law-Based System. The establishment of a commission of inquiry about the unfortunate experiment meant, de facto, the implementation of a law-based approach. We assess the outcomes of a law­based CMS using Hall and Fagan’s (1968) systems analysis. The objects of the system that fell within the terms of reference of the commission were primarily confined to individuals, organizational roles, and admin­istrative structures associated with NWH. In line with law-based CMS’ tendency to rely on expert third-party intervention, the Cartwright Report recommended that regional ethics committees, independent of hospitals, be established. Ironically, despite law-based systems’ claim to neutrality, the members of the commission became participant actors in the conflict and insisted that the hospital sys­tem in its current state, and medical practice more broadly, needed to be changed. Indeed, the inquiry was instrumental in drawing up new codes of practice (see http://www.hdc.org.nz∕the-act--code∕) combined with systemic change of practices around informed consent, patient rights, and external peer review.

The environment of extensive media cov­erage and public outcry that surrounded the inquiry meant that the attributes of the law-based system reinforced an ongoing win-lose rather than an integrative solution. The shift to the public arena amplified the desire to assign blame and responsibility for the deaths of those women who had already died (and those dying at the time). The choice of a semi-legal process—a commission of inquiry—as a conflict management strategy, reframed the conflict in terms of rights rather than interests: patients’ rights dur­ing medical research and women’s rights to make decisions about their own health and the medical profession’s rights to choose care and research interventions.

Unfortunately, since the groups involved were fighting about different issues, they failed to listen to each other. Some of Green’s concerns, however, such as loss of women’s fertility and the creation of needless fear of cancer in women with minor conditions, may have resonated with some feminist con­cerns about women’s health. Moreover, the creation of two adversarial groups obscured the needs of highly diverse members of the New Zealand medical profession and women who had been Green’s patients. While young doctors tended to validate the findings of the inquiry and embrace its emphasis on patient­centered care, many older doctors who had been “[serving] patients well for 40 years to the best of our abilities” (Pryor, 1990, p. 355) resented criticism of their practice. The possibility of a generational divide between women who accepted the word of the “god­like professor of medicine” (Brookes, 2009, p. 111) and those who would not also deserves investigation. However, a law-based CMS was unlikely to consider these nuances, since its narrow focus limited the scope to the orga­nization under investigation and privileged experts’ judgments about whose voices were more convincing.

The new set of internal relationships brought about by the commission of inquiry emphasized the importance of medical accountability and health consumers’ rights. Increased codification of policies and proce­dures aimed to meet both of these goals. The Auckland Area Health Board¹ responded to the inquiry’s recommendations by instituting a disciplinary policy for medical staff who did not comply with the informed consent guidelines, perhaps reinforcing the need for colleagues to blow the whistle to expose poor practice.

The case complexifies the notion of whether conflict will be negative or positive and for whom. Patients may seem to benefit from advocacy and the privileging of their perspectives within medical interactions and doctors might lose through lowered process and decision control (Ross & Conlon, 2000). However, we argue that both sides have lost due to lowered levels of trust. Patients assume that doctors may not act in their best interests and doctors fear complaints and public expo­sure. Law-based CMS’ rights focus downplays the possibility of identifying common interests and does not address the impact on relation­ships within the system. While participatory models of practice are still possible at an inter­personal or small-group level, rights-based conflict management processes ignore the role of interdependence.

The Second Lens: A Management-Based System. Management-based CMS aim to pre­vent, minimize, and resolve conflict. In this section, we suggest how a management-based CMS could have been implemented and iden­tify its possible outcomes. As the interpersonal and professional relationships between these two groups were central to the conflict, the objects within the management-based CMS are likely to have included the clinical staff employed by NWH as well as the teaching and research staff employed by the University. We propose that private, mandatory mediation could have been used to clarify their respective roles and responsibilities, as some organiza­tional members such as Green and Bonham dealt with the conflict by ignoring opposition and may have refused to participate volun­tarily. In this case, we suggest that two organi­zationally neutral mediators would be needed.

The a ttributes of a management-based sys­tem frame conflict in terms of apparently incompatible interests. Management-based processes, such as mediation, aim to help parties find points of convergence so as to maintain productivity and work performance. For example, the mediator may have shifted the discussion from disagreement about what did or did not constitute evidence of CIS to discussion of appropriate scientific design, reporting, and evaluation of medical research. Another key area may have involved negotiat­ing ethical guidelines. Nonetheless, although mediation may have democratized intraorga- nizational decision making, the CMS might not have explicitly considered criticisms by stakeholders from outside the bounds of the organizational system.

Consequently, we speculate that the media­tion process may not have integrated patient advocates into the system as they fell out­side the immediate organizational boundar­ies. Although individuals such as McIndoe, McLean, and other non-NWH medical com­mittee doctors outside the “Herb Green camp” emphasized health over research out­comes, the conflict was still framed as an interest-based dispute between doctors who disagreed about what was best for patients. Hence, strategies involved peer review within the hospital and the international research community without reference to (or interfer­ence by) broader society and the issues that might concern people if they knew.

The internal relationships that result from a management-based CMS increase organi­zational control of its members. Review and clarification of the obligations and roles of employees and subsequent reorganization of hierarchical reporting lines and ethics com­mittee membership and the establishment of guidelines for questions relating to medical ethics would all be mechanisms that give man­agers greater levels of control over the behav­ior of individual clinicians. Increased internal accountability would likely maintain the health system’s status quo: The medical profession would maintain its reputation and medical trials deemed by doctors to have therapeutic benefit would continue with informed consent.

The Third Lens: A Participation-Based System. The commission of inquiry may have involved a broad range of stakeholders, but we argue that this was not participation. Although the commission opened NWH’s organizational system to public critique, the CMS was not participatory as the relationship between par­ties to the inquiry tended to be adversarial rather than cooperative. In fact, relationship conflict was so entrenched that implementing a participatory strategy could have amplified the negative impacts rather than moderat­ing the conflict (Jehn & Bendersky, 2003). A participation-based CMS also needs to pro­vide appropriate mechanisms for feedback/ input that are legitimized by the system itself. NWH, however, did not legitimate any form of feedback from external sources, so when the media weighed in, breaking all the rules, people took sides without engaging the other.

The objects within an effective partici­pation-based CMS have the broadest scope of any CMS. Relevant stakeholders would include all the parties affected by the events at NWH and power differentials in health provi­sion more generally. For example, women’s health groups, women who were happy with the treatment they received, and women who had never been to the hospital would need to be included.

The key attribute of participation-based CMS is the development of ongoing rela­tionships. Before these stakeholders could discuss their perspectives on the events at NWH, facilitators would need to encourage participation and repair relationships among some of these groups. A facilitator would be vital to monitor progress and establish goals since this process could easily derail over to the long time period needed to (re)build trust. Since dialogic models that aim to encourage participants to express their own opinions and views can fail without appropriate guidance, group leaders would also need to ensure that participants could confidently and skilfully articulate their perspectives and experiences without feeling overwhelmed by the complex science involved in the case.

The internal relationships of participation­based CMS would give rise to outcomes that reflect the composition of and relationships within the group. A community panel might contain medical representatives and layper­sons of various ethnicities and professional backgrounds. The outcomes are also likely to be adaptable as the environmental conditions and members’ needs change. However, we sug­gest that the implementation of diverse forms of patient advocacy and the introduction of a medical ethics committee would be likely outcomes of ongoing community consultation.