Thirty years on from the Cartwright Inquiry and the changes it spurred, Teuila Fuatai assesses how far the doctor-patient relationship has really advanced
The sentiment that ‘doctor knows best’ has persisted through numerous medical botch-ups and poor decision-making over the years. Having the skills to fix people, developed over years of intense training and long hours, gives you a natural standing afforded to only a select few professions by the public.
But when does professional knowledge start to become a barrier for those who trust you with it?
Just a month after the 30th anniversary of the ground-breaking Cartwright Report, which spurred a major shift towards healthcare focused on patient rights, the answer still isn’t clear – at least in the case of surgical mesh implants for urogynaecological procedures.
This ongoing medical saga, spanning more than a decade, has unmistakable parallels to problems identified by the Cartwright inquiry and the 1987 Metro magazine expose which led to it.
Both the inquiry and media investigation showed how National Women’s Hospital doctors Herbert Green and Dennis Bonham chose to abstain from properly treating women with early signs of cervical cancer. The pair also withheld information about the severity of the cancer in their patients, blocking any real discussion on possible treatment options. Green and Bonham believed their behaviour was justified because they were studying how carcinoma in situ – the precursor to cervical cancer – progressed, and whether less invasive forms of treatment would work on it.
At the expense of their patients, the pair proved themselves wrong. Their research methods were also labelled highly unethical.
Fast forward nearly half-a-century and key aspects of how Green and Bonham conducted themselves seem to be replicated in the treatment of women implanted with surgical mesh for incontinence and pelvic organ prolapse.
Just yesterday, “strict new safeguards” overseeing the use of the plastic product in urogynaecological procedures were announced by the Government.
Bear in mind, it’s been 10 years since the first surgical mesh injuries were flagged with health authorities. These procedures have also taken place in New Zealand since at least the early 2000s.
The new safeguards included:
“Assessing surgeons undertaking urogynaecological surgical mesh work against credentialing guidance developed by the Australian Commission on Safety and Quality in Health Care.
“Ensuring rigorous informed consent processes that include understandings of the associated risk.”
Acting Associate Health Minister James Shaw also clarified that “only senior medical practitioners with the appropriate training, qualifications, experience and fitness to practice will be able to continue using surgical mesh in these surgeries”.
Shaw’s announcement followed a similar letter from Dr Ashley Bloomfield, director general at the Health Ministry, to district health boards. Bloomfield covered suspensions of urogynaecological procedures involving surgical mesh in England and Scotland, and had a stern message to DHBs about surgeons being up-to-scratch:
“If you are not satisfied that your services or surgeons meet these standards, surgeries involving surgical mesh should not take place,” he said.
In the Cartwright report, similar failings from Green and Bonham were articulated through recommendations around informed consent, as well as standard “treatment protocols for gynaecological disease”.
“Treatment protocols for gynaecological disease should be developed and maintained. These protocols will provide the basis for communicating information to various health professionals and for verbal communication with patients,” the report said.
For hundreds of women living with debilitating surgical mesh injuries (latest ACC figures show 1018 surgical mesh claims had been decided since 2005), last month’s apology from the Auckland District Health Board for the “events that led to the Cartwright Inquiry” – combined with the most recent round of announcements from those in charge of healthcare – will seem very close to home.
“Judge [Silvia] Cartwright identified long-standing failures in the ethical values and practices used by clinicians who were conducting research at the hospital, operated by the Auckland Hospital Board (now the Auckland District Health Board).
One of the most profound errors was the failure to respect patient consent, to respect the right all patients have to make informed choices about their medical treatment.On the occasion of this anniversary, as Chair of Auckland District Health Board, I formally apologise to the women whose lives were affected by these failures, which for many resulted in an early death.
These patients, including mothers, sisters, partners, daughters, friends and colleagues, whaea and tamahine, were failed by people they trusted to care for their health and wellbeing. We apologise to the women affected for these wrongs.
And to those who have been with them, their whānau, supporters and communities, we also apologise.
To learn from the mistakes of the past it is critical that we remember all aspects of our history, including this serious failure in our care.”
While any advance on the current status quo for New Zealand’s surgical mesh situation is heartening, ongoing problems around the informed consent process and properly qualified surgeons is a huge concern.
It shows that for all the years since the Cartwright Inquiry – and the then-revolutionary changes it led to like the appointment of the Health and Disability Commissioner – there are still major gaps in how patients are treated by doctors.
Calls to revisit just how true New Zealand has held to those 30-year-old recommendations in the form of an inquiry into surgical mesh should not be dismissed by authorities, and users of the health system – for it is obvious that within the medical fraternity, despite the roundtable efforts and announcements, understanding of fundamental principles like informed consent is still lacking.