Another Attempt to Rewrite History

It is not the intention of this article to debate the scientific merits (or absence of) of the research undertaken by Dr Herbert Green on women with cervical abnormalities and carcinoma in situ (CIS) at National Women’s Hospital in the 1960s and 70s.

The issue is the failure of some academics, health professionals and writers to accept that what he did was ethically wrong. For those people to persist in re-writing history in attempts to ‘beatify’ and honour the man is grossly offensive to the women upon whom he experimented – some of whom died – and their families, those of Green’s contemporaries who were horrified by his practices, the women who first shone a light on his ‘unfortunate experiment’, those who gave evidence at the Cartwright Inquiry into Allegations Concerning the Treatment of Cervical Cancer at National Women’s Hospital¹, and those who have worked since to protect and uphold the rights of patients.

Over the years there have been a number of attempts to “rewrite” history, to denigrate and dismiss the Cartwright Inquiry and its outcomes and recommendations, to discredit Sandra Coney and Phillida Bunkle who wrote the article ‘An Unfortunate Experiment at National Women’s’ published in Metro magazine in June 1987, and to posthumously restore Herbert Green’s reputation.

On each occasion these attempts have been met with a combination of outrage, disbelief, protest and condemnation. The disputing and defence of the Cartwright Inquiry, and of Green’s research are well documented in the medical literature, and a number of responses to the revisionist writings can be found on this website.

2020 Papers in the Journal of Clinical Epidemiology

The most recent of these revisionist writings are two papers published in the June 1, 2020, edition of the Journal of Clinical Epidemiology (JCE).^{2, 3} While this AWHC article doesn’t set out to discuss the merits or otherwise of Herbert Green’s science, both JCE papers also discuss the ethics of his experiment. The papers present the argument that the ethical principles acceptable in the 1960s cannot be measured against ethics acceptable in the 21^st century:

“Regarding 1960s research, university medical staff were expected to use their clinical practice to further medical science and the prevailing view was that doctors knew best. Research ethics committees were rare.”²

While that is strictly true, it is disingenuous to suggest that the environment was such that informed consent was a foreign concept. In 1966, when Green started his research at National Women’s the Nuremberg Code was 19 years old and the Declaration of Helsinki (see sidebar) two years into its influence on the ethics of medical research.

Raffle and Gray’s paper states that “The 1964 Declaration of Helsinki, which differs from the 1983 version, required patient consent ‘if at all possible, consistent with patient psychology,’ but consent did not need to be written.”²

For a man of Herbert Green’s supposed intellect and purported character, to suggest he was entirely unaware of the Nuremberg Code and Declaration of Helsinki seems somewhat incongruous. While it might not have required consent in writing as would be the case today, it is difficult to argue that the women that Green involved in his research were inadequately intellectually or psychologically equipped to provide informed consent, albeit verbally.

Raffle and Gray point out that “Evidence to the [Cartwright] Inquiry from patients and staff testified to the quality of Green’s care and to his kindness”; that “Dr Green was a person who cared intensely about his patients”.²

He has also been described as charming and charismatic, and some of his patients adored him,⁴ but charm and charisma do not absolve a medical researcher of the duty of care and obligation to inform patients of the fact that he was experimenting on them and obtain their consent to do so.

The second of the two papers in the Journal of Clinical Epidemiology, by Iain Chalmers,³ is written very much in the same vein as the Raffle and Gray paper. He engages in a semantic argument, that there was no ‘experiment’, however, there is no doubt that research was undertaken. It is well documented and directly quoted in Judge Silvia Cartwright’s Report from the Minutes of the Senior Medical Staff Meeting, using words such as “proposal” and stating that “his aim was to attempt to prove” his hypothesis.¹ That he had a theory or hypothesis to “prove” about the progression of cervical abnormalities to invasive cancer identifies his treatment (or lack thereof) as observational research or a form of experiment.

Further proof of the experimental or research nature of Green’s work is his tests on healthy newborn baby girls (see sidebar). Chalmers doesn’t discuss this aspect of Green’s research, either because he isn’t aware of that part of Green’s history, or chooses to ignore it no doubt because it would not fit with his narrative of a brilliant clinician with only patients’ best interests at heart. Chalmers claims that Green’s work was not experimental, merely ‘conservative management’ of women with ‘cervical cytological abnormalities’.³ How then, would Chalmers justify the taking of vaginal swabs from newborn baby girls on the basis of it being acceptable medical management? How is that not research; how is it not experimental?

One of the Terms of Reference of Judge Cartwright’s inquiry into the treatment of cervical cancer at national Women’s Hospital was to answer the question, “Was there a research programme?”¹

Judge Cartwright wrote in her report that witnesses in the proceedings varied in their views: “Some took the view that it was not a research proposal but a move to treat patients more conservatively. Others were clearly of the view that it was a research proposal, albeit a poorly designed one.”¹

Nine pages of the Cartwright report are devoted to the question of whether Green’s work was research (Chapter 3, pages 61-69). Judge Cartwright concluded:

“It was an attempt to prove a theory that lacked scientific validity and little attention was given to ethical considerations. From 1966 and throughout the period of the 1966 trial, there were clear guidelines against which a doctor’s moral and professional right to include patients in research trials could be measured. I can think of no reason for gynaecologists who practised at National Women’s Hospital or in other parts of New Zealand, or administrators whose responsibility it was to be familiar with ethical principles, to overlook the basic ethical and scientific information that was then available.”¹

In his paper, Chalmers goes further than Raffle and Gray with his ongoing criticism of Sandra Coney and Phillida Bunkle, the Cartwright Inquiry and many of the academics and epidemiologists and doctors who gave evidence (David Skegg, Charlotte Paul, Ron Jones, et al.) in that inquiry.

In his conclusion, Chalmers writes that “a public apology to Herbert Green is long overdue” over “unsubstantiated allegations that his practice in the 1960s was unethical.”³

He goes on to suggest that Herbert Green be honoured with the establishment of an international Herb Green Prize, “preferably jointly by epidemiologists in New Zealand and individuals who owe their very existence to conservative management of ‘‘cervical carcinoma in situ’’ at National Women’s Hospital.”³

This proposal must be especially galling to the surviving women and the families of those women who died as a result of inadequately treated cervical abnormalities.

The Response to the 2020 Journal of Clinical Epidemiology Papers

The responses to the Raffle and Gray, and Chalmers papers in JCE, subsequently published in that journal, are divided between those in full support of and those disputing the conclusions of those papers. To cover these responses in detail here would be longwinded and run the risk of descending into a “he said, she said” style of discussion.

However, it is worth noting a few comments from those defending the Cartwright Inquiry and its conclusions and outcomes:

Sandra Coney and Phillida Bunkle respond to criticisms by pointing out that they, and their legal counsel and medical adviser, had access to the women’s medical files and over 80 interviews of patients, and conducted many interviews with most of the personnel involved, including Green and his superior Professor Denis Bonham, which Raffle and Gray, and Chalmers did not.⁷

They point out that the legacy of the cervical cancer inquiry is not as Raffle and Gray claim “a climate of mistrust between patients and health professionals” but change that has “led to informed consent enshrined in law, ethical oversight of research, and a cervical screening programme that has reduced the incidence of cervical cancer by over 50 percent.” They say that “by and large health providers and their colleges embraced the need for change.”⁷

Ron Jones describes how he was “a young colleague of Herbert Green… I have first-hand experience, sadly, of the harms caused by Green withholding treatment. I was also a co-author of the paper that initially exposed the truth about Green’s experiment (this paper is completely misunderstood by Chalmers, as his thesis is based on conservative treatment and Green’s experiment was based on no treatment).”⁸

Ron Jones goes on to point out an uncomfortable truth: “The introduction of screening was delayed in New Zealand because of Green’s implacable opposition. If as had been suggested in 1959 by Dr George Weid, a national screening program had been introduced, rather than in 1991, about 3,200 New Zealand women would have been prevented developing cervical cancer.”⁸

Emeritus Professor Charlotte Paul writes that Raffle and Gray “rely uncritically on Professor Linda Bryder’s A History of the ‘Unfortunate Experiment’ at National Women’s Hospital, 2009.”⁹ She goes on to say that “scholarly integrity insists that Raffle and Gray should have evaluated the detailed critiques of Bryder’s work before deciding whether to rely on her,” specifically recommending The Cartwright Papers (ed. J Manning, 2009) and Doctors in Denial (2017) by Ron Jones.⁹

Prof Paul writes that she corresponded with Chalmers some ten years prior, writing “This is not just an academic dispute. I care about the harms that patients suffered. I care about medicine owning up to its mistakes. I reckon people need to be brave and speak out in this circumstance. If this continues to bring denigration on me, so be it. Matters more important than my reputation are at stake.”⁹

This is precisely what it is all about – the harms that patients suffer, accepting and owning up to mistakes, and speaking out where necessary to ensure that patients and their rights are protected and that lessons are learned. This a large part of what drives the Auckland Women’s Health Council and many other NGOs. Matters more important than reputations are at stake.

In Conclusion

Scientific debate always continues – medical science and understanding is not fixed and immutable, it is always changing. For the AWHC the main issue is one of informed consent and patient rights. The right to informed consent should remain a constant and unassailable truth. Sandra Coney and Phillida Bunkle’s article in Metro magazine led directly to the Cartwright Inquiry, and from Judge Silvia Cartwright’s recommendations the Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996 was enacted in New Zealand.

Regular readers of the AWHC Newsletter will know that those rights are not always adequately applied; breaches of those rights are regularly the subject of complaints to the Health and Disability Commissioner, and it seems that some health practitioners and organisations providing health services feel that rights of informed consent can be dispensed with. But no-one in the health sector can justifiably claim that they do not know that patients have these rights, or that the onus is on practitioners to obtain fully informed consent from patients. This is the legacy of the Cartwright Inquiry and possibly the only upside to the suffering of the women who were involved in Herbert Green’s research without their knowledge or consent.

References

1. Cartwright SR, 1988: The Report of the Committee of Inquiry into Allegations Concerning the Treatment of Cervical Cancer at National Women’s Hospital and into Other Related Matters, 1988, Government Printing Office
2. Raffle AE and Gray JAM, 2020: The 1960s cervical screening incident at National Women’s Hospital, Auckland, New Zealand: insights for screening research, policy making, and practice, Journal of Clinical Epidemiology, 2020 Jun;122:A8-A13, accessible at https://www.jclinepi.com/article/S0895-4356(20)30161-X/fulltext
3. Chalmers I, 2020: The ‘‘unfortunate experiment’’ that was not, and the indebtedness of women and children to Herbert (‘‘Herb’’) Green (1916-2001), Journal of Clinical Epidemiology, 2020 Jun;122:A13-A19.
4. Comm., J Warren August 2017.
5. Jones RW. Doctors in Denial. The forgotten women in the ‘unfortunate experiment’. Dunedin: Otago University Press; 2017.
6. Comm. Ron Jones August 2017.
7. Coney S and Bunkle P, 2020: Letter to the editor: Women’s experience of ‘the unfortunate experiment’ at National Women’s Hospital, New Zealand, Journal of Clinical Epidemiology 127 (2020) 232e234.
8. Jones R, 2020: Letter to the editor: A clinician’s perspective of the ‘unfortunate experiment’, Journal of Clinical Epidemiology 127 (2020) 229e230.
9. Paul C, 2020: Letter to the editor, Journal of Clinical Epidemiology 127 (2020) 225e227.
10. Annas GJ and Grodin MA, 2018: Reflections on the 70th Anniversary of the Nuremberg Doctors’ Trial, American Journal of Public Health, 2018 Jan;108(1):10-12.
11. NIH: The Nuremberg Code, Office of NIH History and Stetten Museum, accessed at https://history.nih.gov/display/history/Nuremberg+Code
12. Shuster E, Fifty Years Later: The Significance of the Nuremberg Code, New England Journal of Medicine, 1997 Nov 13;337(20):1436-40.
13. WMA, 2013: World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, JAMA, 2013;310(20):2191-2194.
14. WMA, 1964: Declaration of Helsinki 1964, World Medical Association, accessed at https://www.wma.net/wp-content/uploads/2016/11/DoH-Jun1964.pdf