Dr Tree Cocks
Doctors in Denial by Ron Jones is a meticulously researched and perceptive account of the “unfortunate experiment” entailing non-treatment of cervical carcinoma in situ that occasioned The Cartwright Inquiry. It is an account of two cancers really, one physical and the other moral.
Jones has gathered together an enormous amount of detailed information from the 1920s to the present day. Because his research has tapped many sources and because he is interested in human dynamics, the chronology sometimes takes a complex route. I found it a multifaceted detective story, to uncover the why and how of the tragedy.
Ron Jones looks at the backgrounds of the main players, the power relationships and social systems common to all institutions (then and now). This allows him to meet the challenge of keeping the patients in focus as well as holding on to a deeply uncomfortable identification with those doctors most responsible for the experiment. He understands that without acknowledgement of errors of commission and omission, nothing will be learned. It was only at the launch of his book in February 2017, nearly thirty years after the Cartwright Report, that the New Zealand Committee of the Royal Australian & New Zealand College of Obstetrics and Gynaecology (RANZCOG) issued an apology to the women and their families.
I recall when the article in Metro magazine came out in 1987 (21 years after Green was given the go-ahead for his experiment in 1966), I knew enough about medical hierarchies to know that what feminist friends were saying could well be distressingly true. I did not read the Metro article for some weeks, but when I did, I was keenly aware that every word would have been carefully vetted by Metro’s lawyers and yet it still reduced me to tears. One obvious aspect, not explicitly mentioned but especially relevant at a time when most consultants were men, is that the specialty of obstetrics and gynaecology is unique in that all the patients are women and it largely involves the “sensitivity and to some, the sacredness of a woman’s genital area”. The vulnerability and power imbalance is stark. Working as a GP, women often remark to me that if men had to have the equivalent of smear tests or go through labour, the world might be different.
Jones concedes that the action started in a different era, over half a century ago, when clinical freedom was more important than scientific evidence and medical etiquette more important than ethics and sexism was common-place. (As late as 1979, the chairman of the Auckland Hospital Board said women “had a moral obligation to allow their bodies to be used for teaching purposes” p.170.)
New Zealand had sought a “teacher of empire standing” to head National Women’s Hospital (NWH) in 1952. In 1963, Bonham (Cambridge University) was appointed as the 3rd post-graduate professor, passing over Green, the local man. Perhaps inevitably, they had an uneasy working relationship.
Jones’ descriptions of the main players shows an understanding of the nuances of personal, social and medical politics crucially at play:
Bonham: the London man, an outsider to some extent and a bully.
Green: a big man physically, from a conservative Southland farming background; not a team player, stubborn and a bully.
McIndoe: son of a “tradesman engineer” who had been an apprentice electrician before doing medicine; reserved but strongly principled.
McLean: from a working-class background; unpretentious, eccentric but meticulous in his work.
Jones: the son of a freezing worker, distracted in 1985 by his wife’s battle with breast cancer.
Jones was “town” not “gown”, so recognised his lower position in the rigid hierarchy at NWH, along with the lower status of pathologists and colposcopists – mere technicians. “Town vs gown” also affected the hospital/University interface at NWH, particularly where approval for and mounting concerns about Green’s “research” took place. With his grasp of the bigger picture, I sense Jones would have made an excellent GP, a specialty still considered pretty low in the medical hierarchy.
Jones reflects on the tension between the practice of clinical medicine and academia, which, even then, had some degree of “publish or perish”. He points out that the results of Green’s research on untreated women at NWH and the results of a forty year experiment on untreated syphilis in African Americans at Tuskegee, USA in the 1930s were both published regularly in medical journals, so anyone reading these articles might have seen how unethical they were. In both cases it took the involvement of the media to stop the studies. Green’s teaching also had a wider impact: a whole generation of junior doctors were erroneously told that cervical screening was not effective.
The Hippocratic Oath has been modified over time, but the one Jones quotes surprised me with its emphasis on loyalty to one’s colleagues, which is a persistent theme through this book, still taking precedence over what happened to women patients. Jones points out that there has never been a legal challenge to the findings of the Cartwright Inquiry and yet there continues to be support for a revisionist account of the experiment. So, Jones sadly acknowledges that it could happen again, even today. Jones has written an account of his battle for truth.
It made me reflect on the common Latin root of inequality and iniquity and the need for self-critical vigilance in practice, lest one become too trusting of one’s own perceived virtue.
Dr Tree Cocks is a GP in Dunedin, New Zealand.
Also on Corpus by Tree Cocks: Doctoring Fabric: an After-hours Affliction
I fear we may soon be needing another book “Surgeon’s in Denial” about the use of surgical mesh transvaginally.
A valuable account of an extremely important book. I wonder if women doctors would have had the same sense of town/gown hierarchy, or the same misplaced loyalty to their colleagues rather than their women patients. Leaves me with a great deal to ponder.