A Systems Analysis of Conflict

We begin our analysis by detailing the objects, attributes, internal relationships, and external forces at work in NWH as a system. We then examine the implications of applying the three CMS to the case.

Objects. In a system, objects include the people involved; their roles, responsibilities, and authorities; the conflict management strat­egies employed; and the organizational structures. NWH was a system within the Auckland Hospital Board system with addi­tional relationships to another organization, the University of Auckland Medical School (the University). NWH was managed adminis­tratively by the Auckland Hospital Board, with Dr. Fred Moody as the medical superintendent­in-chief. Within NWH itself, the medical super­intendent, Dr. Algar Warren, was responsible for its management. The Auckland Hospital Board employed clinicians, while research and teaching staff were attached to the University’s medical school, which supervised postgradu­ate obstetrics and gynecology students. The University employed Professor Dennis Bonham, the head of NWH’s Post-Graduate School, and Associate Professor Herbert Green (MDs). NWH’s dual purpose heightened conflict about treatment and research goals and exacerbated relational tensions among medical professionals who perceived that others would prevent them from achieving their goals.

Coney (1988) claimed that within the hospi­tal, University staff enjoyed higher status than clinical staff. The composition of the NWH medical committee reflected this status differ­ential: Bonham chaired the committee, while Warren was only a member, along with Green, heads of clinical teams, the radiologist, and the head pathologist. Other significant mem­bers of staff were NWH colposcopist Dr. Bill McIndoe and pathologist Dr. Jock McLean, who both initially worked closely with Green. Green’s research relied on careful monitoring of women’s symptoms, and in this, the clinical services of McIndoe and McLean were piv­otal.

Attributes. Critical to the case was conflict about what counted as medical knowledge and whose views were privileged by the system. As a researcher during the medical trial, Green worked closely with pathologists and devel­oped histological as well as clinical experience. Consequently, he challenged and sometimes changed McIndoe and McLean’s diagnoses based on his knowledge of a case. Green’s inter­ference in his colleagues’ area of specialization was exacerbated by his forceful personality. The commission of inquiry report described him as strongly opinionated with total con­fidence in his own judgment and little toler­ance of criticism (Cartwright, 1988). McLean contested Green’s ability to interpret cytology results without “adequate training and back­ground” (Bryder, 2009, p. 79). Green (1985), however, framed results as opinions rather than facts. Certainly, neither man operated in an environment of medical “fact” as vigorous international debate about the relationship between CIS and invasive cancer continued throughout the 1970s and 1980s (Ostor, 1993).

Although McIndoe, McLean, and Green were professional peers, Green’s access to the international research literature and prestige as a graduate teacher-researcher contributed to his ability to continue with the medical trial. McLean recalled his isolation from other doctors who did not want to incur Green’s wrath by associating with McLean: “They feared I would open my mouth too wide. They have spoken behind Herb’s back, but they won’t confront him” (Coney & Bunkle, 1987, p. 58). The dissent, therefore, went largely underground, for while individuals questioned Green’s views, they remained unchallenged by the system. The system privileged medical research rather than medical care and framed dissent as a “personality issue” that interfered with the system’s purpose.

Internal Relationships. Even though NWH medical management was the responsibil­ity of the medical superintendent (Warren), University staff exerted significant influ­ence on clinical practice. Hospital structures afforded some opportunities for staff input into the decision-making process. Clinicians could bring up matters of concern at staff meetings, but the NWH medical committee, headed by Bonham, made final decisions. In response to Green’s proposal to carry out a longitudinal study on CIS, McIndoe presented a memo on June 20, 1966, stating that tissue diagnosis would be inadequate. Despite his concern, the medical committee approved Green’s study the same day. Peter Mullins, NWH statistician, claimed that McIndoe became “worried sick” about the research as he noticed the spread of CIS cells in some women from one diagnostic test to the next.

Another pathologist, Dr. Stephen Williams, noted that Green removed cases from his research series where CIS had progressed to invasion on the basis that invasive cancer had been present—and under-diagnosed—from the outset (Jones & Fitzgerald, 2004).

In 1971, the first acknowledged death of a woman in the research occurred from invasive cervical cancer. The interpersonal conflict became more serious. While Green was abroad in 1971, McLean attempted to make internal system changes by establish­ing the NWH “Tumour Panel,” where any staff member could introduce and openly dis­cuss difficult cases. McLean remembered that junior resident doctors attended the Tumour Panel, which was convened by McIndoe, to be “entertained” by hearing the three men “slugging it out” (Coney & Bunkle, 1987, pp. 53-54). McIndoe and McLean also attempted to shift the debate outside of the system. At an international pathologists’ conference in 1972, McIndoe mentioned that Green had unfairly reported the CIS results.

In a further attempt to make system changes, in 1973, McIndoe and McLean formally requested that Warren reappraise the CIS policy. Warren took the complaint to Moody, but the Auckland Hospital Board’s chief executive turned the decision back to NWH, and specifically the hospital medical committee, stating that the complaint required a clinical rather than an administrative deci­sion. This demarcation of responsibility meant that the medical subsystem continued without any major new inputs from the wider system.

The NWH medical committee responded by establishing an internal committee to verify if the current CIS treatment protocols aligned with the 1966 policy. The 1975 report stated that “all staff members... have acted with personal and professional integrity” and that those embroiled in the conflict needed to “[subjugate] their personality differences in the interests of scientific enquiry” (Bryder, 2009, p. 83). The report also blamed the 1971 death on a “colposcopic miss.” This action served to reinforce the medical dimen­sions of the conflict and suppressed it even further.

From 1974, however, individuals began to undermine the interdependence necessary for Green to continue his work. McIndoe refused to provide colposcopic services and McLean noted that doctors stopped trans­ferring patients, although neither Bonham nor Warren was clear when the trial actually finished. These individual actions sought to reclaim the organization’s health care goals over Green’s research agenda. Green retired in 1982, but concern about Green’s ongoing influence led McIndoe and McLean to publish the trial’s results (McIndoe et al., 1984).

External Forces at Work. Significantly, the conflict at NWH, which resulted from poorly articulated roles and an administrative struc­ture that deferred to medical expertise, was organizationally contained.

Extensive media coverage tended to sim­plify the issues surrounding complex medical science, administrative structures, individual choices, and interorganizational relationships. Two powerful interest groups emerged from the media debate, with Green and his support­ers on one side and feminist health advocates who took on the interests of the women under Green’s supervision on the other. In the polar­ized media environment, both parties claimed to be “right.”