Primary Recounts

The relationship between doctor and patient, like any power relationship, is one which has long been subject to unfortunate exploitation and manipulation. In the 20th century- a time in which medical discovery was an area of enormous competition-, patients and their rights were often abandoned in favour of medical advancement. Such was arguably what drove Professor Herbert Green to oversee his contentious experiment in 1966.

Dr. Herbert Green was the Associate Professor of Obstetrics and Gynaecology at Auckland’s National Women’s Hospital. It was Green’s hypothesis that carcinoma in situ was not a pre-malignant disease [1], and he proposed an experiment which would prove this. He proposed punch biopsy as his method of interrogation, further stating that he would use a cone biopsy if ever he thought his patient was in danger of developing malignant cancer [2]. This idea was officially proposed by Green to the Medical Committee at the National Women’s Hospital, of which Dr. Algar Warren was the head. During this meeting it was decided that suitable patients would be sent to Dr. Green for further investigation and possibly treatment [3].

Before 1966,  carcinoma in situ was known as a condition without symptoms [4]. It was recognised as “a lesion which is found on the surface of the epithelium and which has not invaded or spread beneath that layer”, and by the 1960s most medical professionals in Europe, the United States of America and Australia believed that carcinoma in situ was a forerunner for invasive cervical cancer [5].

In 1955, eleven years before Green presented his study to the Medical Committee, the senior medical staff at the National Women’s Hospital discussed the possible formation of a research team, which would treat patients who tested positive for carcinoma in situ [6]. Dissimilar from Green’s idea however, was the proposed method of treatment. In this case, the treatment was to be hysterectomy, with exception given to those who wished to save their reproductive ability [7]. The loss of reproductive function, coupled with the risk of psychological trauma is what led Dr. Green to set out his project- aiming to establish a better way to treat carcinoma in situ [8].

According to 1966 proposal, Dr. Green stated that his aim was “to attempt to prove that carcinoma in situ is not invariably a premalignant disease” [9]. Commenting on this hypothesis, Professor David Skegg- Professor of Preventive and Social Medicine and Director of the Hugh Adam Cancer Epidemiology Unit at the University of Otago-, stated that “it would be an extraordinary thing to have embarked on this study if it were really believed that the purpose was to prove that this does not invariably progress… if he says the purpose was to show that carcinoma in situ does not invariably progress, that means that it was thought justified to prove that point, to withhold treatment from the proportion of women in whom it would progress, and in fact to prove that it does not invariably progress, one would have to go on until every single woman had developed invasive cancer” (10).

Such criticism is what lies at the crux of the Cartwright Inquiry. That Dr. Green had intentionally withheld necessary treatment in order to track the “invariable progress” of carcinoma in situ to invasive and often terminal cancer.It is claimed by many of Dr. Green’s patients, that he had falsely downplayed the severity of many of their conditions, using his status as a medical practitioner to falsify reality to suit his experiment’s needs. One of the patients maintained that Green told her “not to panic”, and that practitioners would intervene if “something goes wrong” [11]. Shockingly, she was further told by Green that essentially “all women are born with this cancer”, but being explained in inaccessible medical rhetoric, she was unable to understand exactly what he was implying [12].

Moreover, according to Clare Matheson (one of the most vocal patients at the centre of the Cartwright Inquiry), the ‘experiment’ was neither experimental nor unfortunate [13]. Whilst medical historians such as Linda Bryder advocated for Green’s ‘conservative approach’ -suggesting it limited a woman’s exposure to cone biopsies which could problematise fertility-, Green was simultaneously performing biopsies in order to detect invasive cancer which ultimately scarred Matheson’s cervix, smearing further pap smear test results [14]. For the duration of the inquiry, Green maintained his defence of ‘conservative treatment’, however his personal writings described the treatment as a research study used to test a theory regarding the treatment of carcinoma in situ [15]. In the Cartwright Inquiry report, Green eventually conceded his carcinoma in situ program was, indeed, a research program [16]. Judge Cartwright concurred, acknowledging his wilful intent to use patients as test-subjects [17]. Cartwright believed this experimental research highly unethical because it exposed patients to unnecessary and unacceptable risks. This risk was the manifestation of carcinoma in situ into invasive and malignant cancer [18]. Clare Matheson remains, to this day, an advocate for informed consent particularly in women’s health. She has written an autobiography,’Fate Cries Enough’, outlining her experiences as a victim of Dr. Green’s, and the catastrophic impact it had on her life.

References

  1. New Zealand. 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, p.21
  2. New Zealand, The report of the Committee of Inquiry, p.21
  3. New Zealand, The report of the Committee of Inquiry, p.22
  4. New Zealand, The report of the Committee of Inquiry, p.23
  5. New Zealand, The report of the Committee of Inquiry, p.23
  6. New Zealand, The report of the Committee of Inquiry, p.25
  7. New Zealand, The report of the Committee of Inquiry, p.25
  8. New Zealand, The report of the Committee of Inquiry, p.27
  9. New Zealand, The report of the Committee of Inquiry, p.32
  10. New Zealand, The report of the Committee of Inquiry, p.33
  11. New Zealand, The report of the Committee of Inquiry, p.33
  12. New Zealand, The report of the Committee of Inquiry, p.33
  13. Chris Barton, “An Unfortunate Revision”, NZ Herald, 2009.
  14. Barton, 2009.
  15. Barton, 2009.
  16. Barton, 2009.
  17. Barton, 2009.
  18. Barton, 2009.