10th September 2010, Volume 123 Number 1322

Iain Chalmers

Judging the adequacy of any treatment in health care should result from comparing treatments actually given or withheld with a generally accepted treatment standard—‘conventional treatment’. Although ‘conventional treatments’ should be based on empirical evidence that they are more likely to help than to harm patients, patients have quite often suffered because they have not been.
For more than 20 years1 Professor Charlotte Paul has claimed that ‘conventional treatment’ for cervical carcinoma in situ was withheld from women treated at the National Women’s Hospital in Auckland—most recently in an article co-authored with Professor Linda Holloway2– and the claim has recently been reiterated by Professor Jo Manning.3
I have challenged4,5 Professors Paul and Manning to justify their use of the term ‘conventional treatment’ by documenting the implied international agreement on an accepted treatment standard, and referring to the reliable empirical evidence on which it was based. Neither of them has taken advantage of several opportunities to respond to this challenge, so I have now assumed that they are unable to do so.
In her recent letter published in the NZMJ Professor Manning suggests that the definition of ‘conventional treatment’ is contained in a section of the Cartwright Report entitled ‘Adequate management of CIS’.6 It is not to be found there, or anywhere else in the Report.
Other defendants of the Cartwright Inquiry7,8 have tried to deflect the challenge to define ‘conventional treatment’, for example, by suggesting (wrongly) that I had blamed Professor Paul for “not providing the Inquiry (my emphasis) with a definition of conventional treatment”,7 and with interpretations of the views and alleged proposals of Professor Archie Cochrane on cervical screening.7,8 None of these attempted diversions can alter the fact that ‘conventional treatment’ for cervical carcinoma in situ—the standard against which the adequacy of its treatment should be judged—remains undefined by these defenders of the Cartwright Inquiry.
Some people reading the NZMJ in the hot-house atmosphere of New Zealand name-calling may wonder why an ‘outsider’ like me should spend so much time investigating and commenting on this affair.
My interest is longstanding. Twenty years ago, in a letter published in the BMJ,9 I noted that two gynaecologists at the National Women’s Hospital had been charged by the New Zealand Medical Council with “disgraceful misconduct” because treatment had been withheld from “women with carcinoma of the cervix after convincing evidence had emerged that such treatment could be expected to do more good than harm”.
I went on to observe that it was a sad irony that “it was at the National Women’s Hospital that evidence was first produced showing that giving corticosteroids to women who were expected to give birth before term reduced the chances that their babies would die... yet many obstetricians continued to withhold this life saving form of care.” I asked what fair-minded people were supposed to make of these apparent double standards.9
In retrospect, I was wrong to take on trust the assertion that treatment that could be expected to do more good than harm had been withheld from women with “carcinoma of the cervix (sic)”. First, I had understood, incorrectly, that the focus of the Cartwright Inquiry had been the treatment of cervical cancer, when in fact the focus was the management of cervical carcinoma in situ. Second, I had assumed, also incorrectly, that the findings of the Cartwright Inquiry were trustworthy.
The factors that have recently led me to judge the Inquiry to be untrustworthy are (i) the findings of Professor Bryder’s research10; (ii) correspondence with Professor Charlotte Paul5; (iii) my search in vain for any definition of adequate treatment of cervical carcinoma in situ in the Cartwright Report itself; and (iv) reading Göran Larsson’s 1983 report demonstrating dramatically wide international variations in the ways cervical carcinoma in situ was being treated during the era concerned.11
Some New Zealanders may assume that the reliability of the conclusions of the Cartwright Inquiry are of only parochial concern. This would be a mistake. The international prominence given to assertions that effective treatment had been withheld from women with cancer at the National Women’s Hospital in Auckland has led the so-called ‘unfortunate experiment’ there to be referred to in the same breath as the scandalous long term study of untreated syphilis in poor black sharecroppers in Tuskegee, Alabama. It is clear that this is a totally unjustified slur on the treatment of patients in Auckland.
People with substantial vested interests in believing that the findings of the Cartwright Inquiry are unchallengeable have not addressed the fundamental and irresponsible deficiency in their positions. The implication of their inability to define the components of the ‘conventional treatment’ that they allege was withheld from women treated at the National Women’s Hospital is that the Inquiry’s judgements about the adequacy of treatment remain unfounded in reliable evidence.
Challenges to define the evidential basis for judging treatment of cervical carcinoma in situ at the National Women’s Hospital to have been inadequate will not be deflected by bluster about ‘the judicial process’,6 references to ‘expert advice from world leaders’,6attempts to divert attention from the challenge by irrelevant displacement activity,7,8 andad personam attacks on those people impertinent enough to have raised important questions about the validity of the conclusions of the Cartwright Report.7,8,12
The Inquiry should have based its judgements about the adequacy of treatment for cervical carcinoma in situ using comparisons of treatments actually given or withheld at the National Women’s Hospital with explicit, generally accepted treatment standards, founded on reliable empirical evidence. It is clear that the Inquiry’s judgements were not based on such evidence.
Note: The NZMJ does not hold itself responsible for statements made by any of its contributors. Statements or opinions expressed in the NZMJ via this letter and any other submissions reflect the views of the author(s) and do not reflect official policy of the New Zealand Medical Association unless stated as such.
Iain Chalmers
Editor, James Lind Library
Oxford, UK
Email: ichalmers@jameslindlibrary.org

Author Information

Iain Chalmers, Editor, James Lind Library, Oxford, UK

Correspondence Email

ichalmers@jameslindlibrary.org

References

  1. Paul C. The unfortunate experiment. BMJ 1988;297:533-39.
  2. Paul C, Holloway L. Scientific facts and the unfortunate experiment. The New Zealand Listener, 12 September 2009, pp 31-33.
  3. Manning J. Letters. The New Zealand Listener 2009, 22 August, p 6.
  4. Chalmers I. Cancer scandal. The New Zealand Listener, 12 September 2009, p 6.
  5. Chalmers I. Why won’t defenders of the Cartwright Inquiry provide evidence to justify their use of the term ‘conventional treatment’ for carcinoma in situ. New Zealand Medical Journal 2010;123:109-112.
  6. Manning J. The Unfortunate Experiment debate: Manning response to Chalmers. New Zealand Medical Journal 2010;123:113-114.
  7. Bunkle P. Reassessing Cartwright – understanding the factual record. New Zealand Medical Journal 2010;123:88-94.
  8. Matheson C. A patient’s response to recent criticisms of the findings in the report of the Cervical Cancer Inquiry 1988. New Zealand Medical Journal 2010;123:95-101.
  9. Chalmers I. NZ medicine after Cartwright. BMJ 1990;300:1199.
  10. Bryder L. A history of the ‘Unfortunate Experiment’ at National Women’s Hospital. Auckland: Auckland University Press, 2009.
  11. Larsson G. Conization and preinvasive and early invasive carcinoma of the uterine cervix. Acta Obstetrica et Gynecologica Scandinavica. Supplement 114, Lund, 1983.
  12. Paul C. Medicine in context: a response to Linda Bryder’s arguments. In: Manning J (ed.). The Cartwright Papers: Essays on the Cervical Cancer Inquiry of 1987-88. Wellington: Bridget Williams Books, 2009, pp 119-138.