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Women and power: How can we change the system? Phillida Bunkle BA(hons), AM
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Women's Studies Department , Victoria University , Wellington, New Zealand Published online: 14 Aug 2009.
To cite this article: Phillida Bunkle BA(hons), AM (1991) Women and power: How can we change the system?, Health Care for Women International, 12:4, 379-391, DOI: 10.1080/07399339109515962 To link to this article: http://dx.doi.org/10.1080/07399339109515962
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WOMEN AND POWER: HOW CAN WE CHANGE THE SYSTEM? Phillida Bunkle, BA(hons), AM
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Women's Studies Department, Victoria University, Wellington, New Zealand
In 1988 a judicial Committee of Inquiry was commissioned to investigate allegations concerning research undertaken at National Women's Hospital in Auckland, New Zealand, on women with cervical abnormalities. The inquiry found mat this and other research had been undertaken and that senior academic and clinical staff had known but that the women had rarely been informed. Their report found that many women had been undertreated and some had died. The findings stimulated widespread public debate on issues of medical ethics. The report made recommendations for reform, but few have been implemented. These events and an analysis of the resistance to reform, especially on issues concerning patient rights and medical ethics, are the focus of this article.
New Zealand has a unique no-fault system for dealing with medical misadventure that stands at the opposite extreme to the litigious excesses of the United States. The Accident Compensation Act came into effect in 1974. It established the Accident Compensation Corporation, which was responsible for compensating the victims of accidents on a no-fault basis. If a medical misadventure is accepted by the corporation as an accident, then it is compensated from this scheme, but with the exception of earnings-related compensation this is set at an extremely low level. Some jurists maintain that if medical misadventure is not accepted as accidental, then the patient could bring an action under common law for negligence, but no one has successfully brought such an action since the introduction of the act. In effect, the concept of malpractice has ceased to have legal meaning, giving the medical profession a practical immunity from suit.*
*This, however, is currently being challenged by Clare Matheson and other survivors of the "unfortunate experiment." Health Care for Women International, 12:379-391, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Some jurists maintain that the right to consent to medical treatment is protected under English common law, although once again no one in New Zealand has successfully brought an action for a violation of informed consent. English law uses the criterion of what a reasonable doctor would tell a reasonable patient, in effect leaving judgments about what is reasonable to the medical fraternity. The only other action available to a dissatisfied patient is to take a complaint through the medical disciplinary system. This places a great deal of weight on the self-policing mechanisms of the profession. New Zealand patients have few legally enforceable rights. This lack of effective patient protection was challenged by the recommendations of the Cartwright Inquiry. The inquiry was chaired by Judge (later Dame) Sylvia Cartwright. It was the first full judicial inquiry to be chaired by a woman, and the majority of the staff of the inquiry were also women. Counsel for the physicians involved was funded by the medical protection societies, which insure physicians. Conducted under judicial rules of evidence, the procedure of such inquiries is similar to a court of law. The Cartwright Inquiry was commissioned in June 1987 and heard evidence from witnesses from August 1987 to February 1988. The report of the inquiry was published in August 1988 (Committee of Inquiry, 1988). The events leading to the inquiry began with the publication in June 1987 of a magazine article by Sandra Coney and me, entitled "An unfortunate experiment at National Women's Hospital" (Coney & Bunkle, 1987; see also Bunkle, 1988). The article was based on the story and medical records of Clare Matheson (Matheson, 1989) and the medical publications of Associate Professor Herbert Green, who had been primarily responsible for the treatment of cervical abnormalities at National Women's Hospital from the late 1950s until his retirement in 1982. Matheson first went to National Women's Hospital in 1964 with a Grade 3 Pap smear ("cells suggestive of but not conclusive for malignancy"). She was admitted to the hospital expecting to have a cone biopsy but was discharged after having had only an examination with the magnifying colposcope. Green told her that he "now believed that a biopsy was not necessary at all" (Matheson, 1989, p. 31). During that same year, Green (1964) published a paper that "proposed . . . to show that the [CIS] lesion is probably benign in the great majority of cases. It is also proposed to question the view that mass cytology programmes are capable of eliminating cervical cancer" (Green, 1964, p. 165). From 1964 to 1979, Matheson made 34 visits to National Women's Hospital, but her abnormal cells were not definitively removed. Her
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first Grade 5 Pap smear ("cells conclusive for malignancy") was done in 1968, but still she was not told that her smear tests suggested cancer. By 1977, multiple biopsies had so scarred Matheson's cervix that menstruation had become difficult. The scarring probably accounts for why, at that time, her smears showed normal cells; nevertheless, pathology on cells scraped from the inside of her uterus showed "fragments of carcinoma . . . probably carcinoma in situ." Despite this, in 1979 after one more visit to the clinic, Matheson was discharged into the care of her general practitioner to whom Green wrote "she has no more chance than the next person of now developing carcinoma of the cervix." In 1985, Matheson asked her general practitioner to do a smear because she had experienced irregular spotting. Invasive cancer was quickly diagnosed, and Matheson had an extensive hysterectomy and radiation treatment. She appears to have fully recovered from the cancer. In the Metro article, we claimed that Green's publications and a research proposal submitted in 1966 to his senior colleagues on the Management Committee of the Hospital, which at that time also acted as an ethics committee, suggested that the physician was conducting research on women with cervical abnormalities that was designed to prove his thesis that carcinoma in situ is not (or is not invariably) a precancerous condition that will progress to cancer if the abnormal cells are not removed (Committee of Inquiry, 1988). Green persistently challenged the idea of a progression from precancerous abnormalities, including carcinoma in situ, to invasive cancer. In her report Judge Cartwright said of the 1966 proposal, "I have come to believe that Dr. Green was in fact trying to prove a personal belief. It cannot be just co-incidence that an interview with Dr. Green, published in the New Zealand Herald on 24th January 1970, quoted him as saying: 'In situ cancer is not a forerunner of invasive cancer' " (Committee of Inquiry, 1988, p. 33). Evidence presented during the inquiry showed that some women who had gone on to develop invasive cancer had also been entered into other studies without their knowledge or consent. In addition, the inquiry found that Green had undertaken a study of cervical smears from more than 2,000 female newboras without the consent of their parents and that students were routinely taught pelvic exams on nonconsenting anesthetized women. Other evidence suggested that some anesthetized women had also been used to teach intrauterine device (IUD) insertion, again without their consent. In an interview in the Sunday Star on September 27, 1987, the chair of the Auckland Hospital Board, himself an obstetrician and gynecologist, justified these practices by claiming that the women gave "implied
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consent" by entering a teaching hospital. It did not seem to occur to him that the quality of this consent was compromised by the fact that National Women's Hospital was the only women's hospital available for approximately one third of New Zealand's female population. For months the inquiry and the report made women's health issues front-page news, stimulating sustained and sophisticated public debate about medical ethics. Throughout 1987 and 1988,1 traveled around the country raising money to sustain our presence at the inquiry. Everywhere I encountered overwhelming support from women of all classes, even in provincial and rural areas where women are said to be more conservative. The women of New Zealand seemed uniquely united in demanding fundamental reform of the medical system. The report recommended sweeping changes that would make effective patient protection a reality. The government of the day promised to implement these recommendations: 1988 looked like the dawn of a new era in patients' rights. What I want to tell you is the truth about how this has not happened (Coney, 1990). I would like to tell you the truth about the women who lost their jobs because they wanted to give information to patients, the women quietly dropped for opposing abuse, the woman whose career is stymied because she dared give evidence at the inquiry, and the truth for me about the personal cost to self and family of being the rubbish bin for the medical system and the personification of "the enemy" to a determined and powerful group. However, I cannot tell you that truth because then the lawyers' letters would start again. For the well resourced, the threat of libel action is an effective weapon. Libel actions cost the individual a huge amount to defend. The professions, on the other hand, can work through their protection societies where they have experienced lawyers to organize their interests without cost to themselves. So what I am going to do is a little clinical cartography of power: describe the medical profession's armamentarium of resistance to change here in New Zealand. It is important that we recognize this armamentarium. So let me say immediately that I am a very nasty person because you will soon be told so. Nice girls do not know what is going on. They do not name names; what makes them nice is their usefulness in maintaining the illusions of the powerful. The moment we question, we jeopardize our feminity. One criticism and you too can become "nasty," "twisted," "unstable," "beady-eyed," and so on down the scale. Crude it may be, but this labeling inhibits change for women, because many women have been made so insecure about self-image that jeopardizing femininity is just too big a risk to take. The Cartwright Inquiry report not only exposed the cervical cancer
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experiments but examined everyday practices that physicians found normal and nurses justified as inevitable, but which the public found absolutely unacceptable. In the report one patient described her experience at a time when the inquiry was still sitting: And at 4:30 p.m., after about five people who had arrived after roe had been [seen] before me, a nurse came up to myself and another lady waiting with me. They had lost our files and had to call a doctor back to see us. Everybody had packed up and the cleaners were cleaning. Both my husband and myself were nervous, not having had an experience like this before. So anyway, they called us in and told us to get changed into a nightshirt and wait for the doctor. When he came in, he was a horrid old man, obviously disgruntled at having to see us, he didn't look at my file, quickly asked what the problem was, then gave me an examination. The nurse was very nice, after the examination I was in tears as he was rough and the examination was painful. He then told me that my periods can't be like what I had told him and started lecturing me. He said it was all in my mind and that I was obviously emotionally disturbed and he would write to my doctor and tell her that. (Committee of Inquiry, 1988, p. 161) This example says so much: the routine rudeness, the nurse's frustrated sense of powerlessness, the rough examination, the failure to "bother" to read the notes, the a priori attribution of the problem to the woman's mind, and the threat to pass this judgment on to other practitioners. The inquiry allowed these everyday experiences to be examined and legitimated them as important issues of concern to the public. If this patient had tried to complain through the medical system, she would have found that her complaint would have been pared down to the narrowest possible clinical issue. The quality of her treatment as a person would be irrelevant. Yet violation of the patient's humanity is frequently at the core of complaints, but within the profession's disciplinary system this is not usually seen to be relevant to judgments of the doctor's professionalism. The inquiry reversed the usual criteria for judgment. Usually the profession's view establishes reality and the patient's account is judged relative to it. Patients therefore frequently have problems establishing their credibility. In the Cartwright Inquiry, however, the experience of the patient was placed at the center and the profession was judged relative to it. This shift in perspective must happen throughout the health system. The interests of the patient, not the profession, should be central and the system should be judged on how well patients' interests are served. The Cartwright report made a series of suggestions about how this could be
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achieved. The recommendations would break down the self-referencing and self-policing nature of the profession and move toward making it truly accountable for its vast power by establishing a system of external scrutiny. The key to the Cartwright plan for patient protection was to be the establishment of a health commissioner, who would be responsible for the formulation and enforcement of a comprehensive code of patients' rights. Appropriately, the commissioner was to be associated with the Human Rights Commission. The commissioner would monitor complaints throughout the system as well as deal with the concerns of individuals. The commissioner was also to be the employer of advocates, who were intended to be the on-the-spot field workers of patient protection. None of these recommendations has been implemented. The only recommendation implemented has been the establishment of Ethics Committees in each Area Health Board. It is impossible to prove that the medical profession, or at least an influential part of it, has gone from passive resistance to active backlash, but it is clear that medical resistance is effective in preventing change (Coney, 1990). The professions are masters at producing the appearance of change while hanging onto the substance of power. How is this achieved? The first strategy is to keep the real power covert, restricting decisionmaking to silent understandings and telephone conversations. Men get kudos from being included in these informal networks, but by the same token they have to strive to stay inside because they can be excluded so easily. Sometimes they take up, or appear to take up, someone, only to drop him when he is no longer useful. Occasionally even a woman is used in this way. Doris Gordon, founder of the Obstetrical and Gynaecological Society, has been mentioned at this conference. Gordon gave political voice to the obstetricians and gynecologists by organizing them effectively as the dominant force in the control and development of women's health provision. She was also successful in obtaining public support for the foundation of National Women's Hospital. When, however, the real goodies were handed out and control of the institution was at stake, she was dropped. Her tale may be salutary for the many women now busy making it as agents of the system. Another effective strategy of resistance is isolating and discrediting critics. People who raise questions are depicted as "extreme" or "hostile" or as having a "personality problem." The boys tolerate an extraordinary range of quirks among themselves but are quick to discredit others. From a position of power, this is done quite easily. It is especially easy to discredit women because we are expected to fit such a narrow stereotype. In addition, because women live in a highly person-
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alized world, it is often easy to get other women to collude in this process. If this strategy does not work, there is always the threat of job loss. The medical profession has a rigidly enforced professional solidarity and has developed the most extraordinary degree of control over other groups in the industry. Of course, other reasons will always be cited for removing a "troublemaker." Officially, victims will be told their jobs are being restructured or the like, but the real reason will be made abundantly clear, although rarely in a way she or he can challenge. Word travels fast, and it does not have to be done often to successfully bring a whole department or section into line. With the advent of Area Health Boards, this can make someone essentially unemployable within a whole region. If the troublesome person is beyond their immediate reach, they can sometimes use networks of influence to reach into other institutions or try discrediting the person's professional reputation generally. Again it is not hard to do; you just have to have a reason why her or his work isn't quite satisfactory. The fourth strategy involves informed consent. Sometimes it is a concept rather than a person that has to be discredited, and the favorite of the moment is informed consent. The profession argues that informed consent is (a) unworkable, (b) not in the patients' best interests, and (c) not what patients really want. The argument that informed consent is not what patients want or in their best interests amounts to a simple restatement of the profession's absolute right to determine what is in our best interests. The Newsletter of the Medical Association ran the sad story of St. Smitten's, a lampoon intended to show that the complexities of achieving consent would ruin the health system. The story ended with a lengthening queue of suffering patients lining up at the gates, unable to gain admission not because resources are being removed from the public health system but because they could not negotiate the complexities of giving informed consent. Behind the protest that consent procedures cannot work is the veiled threat to make sure they do not work. Those opposed to patients' rights have a vested interest in making consent so complicated that nurses have to get written permission to turn an old lady over in bed. The possibility of overburdening the already tottering public health service is real, but it should not be used to discredit the concept of consent or to distract us from the urgent task of working to develop usable procedures. The task has not been assisted by professional ethicists, who while delighted to have found a public audience have sometimes used the opportunity to discuss rare borderline cases or difficult exceptions rather than striving to put in place workable norms.
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In the fifth strategy, one of the most powerful weapons in the medical armamentarium is control of who gets into influential positions. Dianne Cameron of Ngati Mutunga said at a session of this congress: Councils and Departments select Maori whom they perceive to be "safe" to be on their committees, Maori people who find it difficult to challenge or people who have not yet formulated a political analysis of their own oppression. These people often do not have secure Iwi connections nor have they internalised Rangatiratanga. The result is Maori representatives who are unable to challenge the Pakeha majority or to access control and resources because their base and networks are not available to support them. People who have positions of authority and individual power identify and select "key Maori" to consult and work with on Maori issues. This has the effect of setting up conflict amongst Maori—the old "divide and rule." Something similar could be said of the representation and employment of women. When there is a real job within the system, they scrape the barrel for good girls, "nice" ones who will signal compliance and who do not understand much except what side their bread is buttered on. Some of these women become the power holders' most effective agents. The mode of representation of consumer interests has become a key issue for the women's health movement. We have pressed for representation at all levels of the system. If a representative is to be truly effective she (a) must have experience in the area, (b) must not be alone and isolated, (c) must be chosen by the people she represents, and (d) must be accountable to the group she represents (Coney, 1989). All these are resisted by the hierarchy who want to retain the power to select and who want inexperienced people on the grounds that they are "neutral" and "unbiased." To have experience in consumer issues or a track record in patient protection makes one absolutely unsuitable for anything official. To have ever stood up for anything makes one irredeemably tainted and biased. This labeling is a major issue. I want to give you a recent example from my own experience. I mentioned that the establishment of Ethics Committees is the only Cartwright recommendation to be implemented so far. As Dame Sylvia said in her report, "Ethical standards must be applied rigourously to research and treatment protocols on behalf of the patients" (my emphasis). She added, "The focus of attention must shift from the doctor to the patient" (Committee of Inquiry, 1988, pp. 176, 213). Patient protection was the key issue, particularly the protection of the participants used in clinical research. At the inquiry and subsequently, Sandra Coney and I pressed for a
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widely defined jurisdiction for these committees so that they could reach those private-enterprise medical doctors doing research away from institutions. We also pressed for wide consumer representation. When the guidelines developed by the Department of Health specified 50% lay membership and a lay chair, we were hopeful that in this instance at least true representation had been achieved. When the composition of the Wellington Area Health Board Ethics Committee was announced over the 1989 Christmas period, I and other consumer groups were publicly critical of it and of the nomination process that appeared to have allowed medical interests considerable influence. In the Dominion newspaper of January 8, 1990, the Wellington Patients Association said that the committee was "a closed shop designed to protect the medical establishment" and continued that it "has not a single person with the slightest public record of interest in protecting the rights of patients." The spokesperson continued, "I believe ethics committees are meant to stop doctors and others again doing what they did at National Women's Hospital. . . . There are cynics who said the doctors would make sure these committees were captured by the profession and the patients left out. The cynics were right." In 1990 I was awarded a social sciences research fellowship. I said I wanted to study the adequacy of pharmaceutical regulation from a consumer perspective. Looking back, my proposing to strike at the heart of the medical/industrial complex was probably foolish. I will spare you the details. Suffice it to say that the Wellington Ethics Committee insisted that the work be submitted to them, whereas the social science funding body felt that their own scrutiny was sufficient. Eventually they reached a compromise in which my work was submitted to the Area Health Board Ethics Committee for comment. I concentrated on the Cu7 IUD device in New Zealand partly because as action research I wanted to do something useful and of direct benefit to women: Action-research is a type of applied social research differing from other varieties in the immediacy of the researchers' involvement in the action process. It aims to contribute both to the practical concerns of people in an immediate problematical situation and to the goals of social science by joint collaboration within a mutually acceptable ethical framework. (Clark, 1972, quoted in Lees, 1988, pp. 4-5)
Part of my project consisted of sending a questionnaire to specialist doctors asking about their sources of information regarding the device. A second questionnaire was to be sent by a lawyer to women who believed they may have been injured to gather the information needed
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for a possible suit against the manufacturer. The questionnaire would provide a great deal of information about the women's experiences, and I wanted to analyze some aspects of the replies, particularly those concerning the consent process and the cost of the injuries. I felt that, given the choice, many women would be pleased to participate in this research, because it would allow a much fuller picture of their collective experience to emerge. The questionnaires, which were ready to be sent, had to be put aside until the Wellington Area Health Board Ethics Committee had commented. Finally, at the end of October, I got a comprehensive condemnation of my work from the committee. Not only had the process run me out of time, but the criticisms were so sweeping it seemed to me that the committee was unlikely to agree to the work I was doing. Consequently, I have had to abandon the questionnaires. The bureaucratic processes of Ethics Committees make action research difficult or impossible because the researcher cannot respond to questions as they arise. Only those issues that have been anticipated can be pursued and even then must be pursued in a rigidly predetermined manner. In my view the guidelines for Ethics Committees were so wide that the establishment of these committees has had the effect of extending the jurisdiction of the medical sector and with it the hegemony of the medical model. The criticisms of my work are couched in terms of "hypothesis," "proof," and so forth. For example, one criticism of my proposal was that "consumer perspective" is a subjective term, which apparently suggests to the committee that it is somehow invalid or inadmissible. Positivist assumptions about what constitutes valid research supports the medical model. Methods or theories that are critical of the limits of that approach are precluded or at least perceived as suspect. The Ethics Committee said that my proposal makes "allegations," presumably about the inadequacy of pharmaceutical regulation, that I do not support by appropriate literature references. It is true that there are very few such references, because the question is rarely addressed (at least within the ambit of medical literature). However, if the paucity of existing studies becomes a reason why a question cannot be addressed, then it will be difficult to introduce new topics for investigation. One of the major criticisms was that my work had multiple aims that were "ethically" incompatible. The nature of the incompatibility was not stated, but in subsequent discussion it was made clear to me that any work with multiple outcomes was inadmissible. I believe that the production of fragmented knowledge is an ethical problem in itself. I proposed to examine many aspects of an issue and provide a critique of the whole process of drug evaluation and regulation. One implication of the
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Ethics Committee's restrictions is to make it difficult to develop a critique of the structure of "medical" processes. The committee's most interesting criticism of my work concerned my intention to share the results of the questionnaire to doctors, including the doctors' names, with women. This was deemed unethical because it would infringe the "confidentiality" of the doctors' replies. Without a guarantee of "confidentiality," they "cannot validly give their informed consent" to take part in the survey. The committee appears to have lost sight of the fact that Ethics Committees were set up primarily to protect patients, such as Matheson, who are used as subjects in clinical research. In law, the right to confidentiality belongs only to the patient. Patients are allowed to disclose anything about their treatment, including what they know of the doctors' information or knowledge base. In applying the right of confidentiality to doctors, the Ethics Committee is extending the profession's rights beyond even those comprehensive protections already guaranteed them by the law. Coney and I found it difficult to obtain information about the research conducted at National Women's Hospital. If the principle of confidentiality is used to protect doctors, then access to this information will become even more difficult. It is, I think, a classic example of how a measure introduced to protect patients can be turned around and used to protect the profession and the institution. It seems to place them once again beyond public scrutiny. I will go so far as to say that consumers have a right to the disclosure of the type of information I was seeking and that, far from being protected, the doctors have an obligation to disclose it. When even "informed consent" can be used to protect the profession from disclosing their sources of information and their treatments, then consumers are denied information vital to their well-being and to their right to make an informed choice. Informed consent becomes another barrier to public scrutiny and accountability. When informed consent works against the public's right to know, it gives the profession's interest priority over that of the consumer, the very thing the Cartwright reforms were designed to prevent. It is a fascinating example of how institutional power protects itself and of how the reforms we worked so hard for can be used against us. Many women's health groups seek information from medical doctors about their attitudes, their information, and the nature of the treatment they offer. If it is accepted that the compilation and distribution of this information breaches the doctors' right to "confidentiality," then it seems that women's health and other consumer-based groups are involved in unethical research. It seems that a process instituted to open up institutions to critical
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gaze and to free access to medical information has been successfully turned around to seal it off once again behind a protective barrier of "confidentiality." Part of the medical armamentarium is co-optation. Accommodation thus can be an effective tactic in the preservation of power. Where does the women's health movement go from here? The first step, it seems to me, is to identify where you are in the system. This entails stepping out of the personalized female world that absolves women from responsibility for institutions and that allows us to be drawn into conscious and unconscious collusion with it. It is a step away from the pervasive depoliticization of women. As we analyze our own roles, we also begin to recognize the roles, rules, and silences that allow the system to be oppressive and exploitative. Having clarified our own roles, it is possible to see where we can fit into collective action. There is a need for action everywhere. Pat Hickson presented a paper at this congress that dealt with the implications for nurses of the Cartwright Inquiry findings. Afterward a woman in the audience said "change comes from the collective action of people treating each other with respect." We begin the process of change when we step out of our isolation and begin collective action. If we treat each other with respect, we will not be afraid to be seen. Without collective action, we will be picked off one at a time. Having respect for each other means offering visible support, and it means refusing to allow the labeling of brave women as deviants. We need to develop some of the solidarity the boys have; after all, they do not isolate one of their number because he is a "bit funny," has an "unfortunate" personality, or "can't work with others." The women's health movement is very real, but it is fragmented, and from the perspective of the mainstream it is often almost invisible. To be truly effective, we must also come together to organize. I believe that coming together is what this congress has been about. May its legacy be long success.
REFERENCES Bunkle, P. (1988). Second opinion: The politics of-women's health in New Zealand (pp. 130-189). Auckland: Oxford University Press. Clark, P. (1972). Action research and organizational change. New York: Harper & Row. Committee of Inquiry. (1988). Report of the Committee of Inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters. Wellington: Government Print. Coney, S. (1989, July). Taking the power off the doc: Wrestling for consumer input into medicine. Broadsheet: New Zealand's Feminist Magazine, No. 170, pp. 24-27.
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Coney, S. (1990). The Cartwright Inquiry: The aftermath. In Out of the frying pan: Inflammatory writings, 1972-1989 (pp. 199-245). Auckland: Penguin Books. Coney, S., & Bunkle, P. (1987, June). An unfortunate experiment at National Women's Hospital. Metro: New Zealand's First City Magazine, pp. 46-65. Green, H. (1964). Cervical carcinoma in situ: True cancer or non-invasive lesion? Australian and New Zealand Journal of Obstetrics and Gynaecology, 4, 165-173. Lees, R. (1988). Research strategies for social welfare. (Library of social work series, pp. 4-5). London: Routledge and Kegan Paul. Matheson, C. (1989). Fate cries enough. Auckland: Hodder and Stoughton.
BIBLIOGRAPHY Armstrong, N. (1990, November). An unfortunate experience. Paper presented at the Fourth International Congress on Women's Health Issues, Palmerston North, New Zealand. Coney, S. (1988). The unfortunate experiment. Auckland: Penguin Books.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
Women and power: How can we change the system? Phillida Bunkle BA(hons), AM
a
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Women's Studies Department , Victoria University , Wellington, New Zealand Published online: 14 Aug 2009.
To cite this article: Phillida Bunkle BA(hons), AM (1991) Women and power: How can we change the system?, Health Care for Women International, 12:4, 379-391, DOI: 10.1080/07399339109515962 To link to this article: http://dx.doi.org/10.1080/07399339109515962
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WOMEN AND POWER: HOW CAN WE CHANGE THE SYSTEM? Phillida Bunkle, BA(hons), AM
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Women's Studies Department, Victoria University, Wellington, New Zealand
In 1988 a judicial Committee of Inquiry was commissioned to investigate allegations concerning research undertaken at National Women's Hospital in Auckland, New Zealand, on women with cervical abnormalities. The inquiry found mat this and other research had been undertaken and that senior academic and clinical staff had known but that the women had rarely been informed. Their report found that many women had been undertreated and some had died. The findings stimulated widespread public debate on issues of medical ethics. The report made recommendations for reform, but few have been implemented. These events and an analysis of the resistance to reform, especially on issues concerning patient rights and medical ethics, are the focus of this article.
New Zealand has a unique no-fault system for dealing with medical misadventure that stands at the opposite extreme to the litigious excesses of the United States. The Accident Compensation Act came into effect in 1974. It established the Accident Compensation Corporation, which was responsible for compensating the victims of accidents on a no-fault basis. If a medical misadventure is accepted by the corporation as an accident, then it is compensated from this scheme, but with the exception of earnings-related compensation this is set at an extremely low level. Some jurists maintain that if medical misadventure is not accepted as accidental, then the patient could bring an action under common law for negligence, but no one has successfully brought such an action since the introduction of the act. In effect, the concept of malpractice has ceased to have legal meaning, giving the medical profession a practical immunity from suit.*
*This, however, is currently being challenged by Clare Matheson and other survivors of the "unfortunate experiment." Health Care for Women International, 12:379-391, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Some jurists maintain that the right to consent to medical treatment is protected under English common law, although once again no one in New Zealand has successfully brought an action for a violation of informed consent. English law uses the criterion of what a reasonable doctor would tell a reasonable patient, in effect leaving judgments about what is reasonable to the medical fraternity. The only other action available to a dissatisfied patient is to take a complaint through the medical disciplinary system. This places a great deal of weight on the self-policing mechanisms of the profession. New Zealand patients have few legally enforceable rights. This lack of effective patient protection was challenged by the recommendations of the Cartwright Inquiry. The inquiry was chaired by Judge (later Dame) Sylvia Cartwright. It was the first full judicial inquiry to be chaired by a woman, and the majority of the staff of the inquiry were also women. Counsel for the physicians involved was funded by the medical protection societies, which insure physicians. Conducted under judicial rules of evidence, the procedure of such inquiries is similar to a court of law. The Cartwright Inquiry was commissioned in June 1987 and heard evidence from witnesses from August 1987 to February 1988. The report of the inquiry was published in August 1988 (Committee of Inquiry, 1988). The events leading to the inquiry began with the publication in June 1987 of a magazine article by Sandra Coney and me, entitled "An unfortunate experiment at National Women's Hospital" (Coney & Bunkle, 1987; see also Bunkle, 1988). The article was based on the story and medical records of Clare Matheson (Matheson, 1989) and the medical publications of Associate Professor Herbert Green, who had been primarily responsible for the treatment of cervical abnormalities at National Women's Hospital from the late 1950s until his retirement in 1982. Matheson first went to National Women's Hospital in 1964 with a Grade 3 Pap smear ("cells suggestive of but not conclusive for malignancy"). She was admitted to the hospital expecting to have a cone biopsy but was discharged after having had only an examination with the magnifying colposcope. Green told her that he "now believed that a biopsy was not necessary at all" (Matheson, 1989, p. 31). During that same year, Green (1964) published a paper that "proposed . . . to show that the [CIS] lesion is probably benign in the great majority of cases. It is also proposed to question the view that mass cytology programmes are capable of eliminating cervical cancer" (Green, 1964, p. 165). From 1964 to 1979, Matheson made 34 visits to National Women's Hospital, but her abnormal cells were not definitively removed. Her
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first Grade 5 Pap smear ("cells conclusive for malignancy") was done in 1968, but still she was not told that her smear tests suggested cancer. By 1977, multiple biopsies had so scarred Matheson's cervix that menstruation had become difficult. The scarring probably accounts for why, at that time, her smears showed normal cells; nevertheless, pathology on cells scraped from the inside of her uterus showed "fragments of carcinoma . . . probably carcinoma in situ." Despite this, in 1979 after one more visit to the clinic, Matheson was discharged into the care of her general practitioner to whom Green wrote "she has no more chance than the next person of now developing carcinoma of the cervix." In 1985, Matheson asked her general practitioner to do a smear because she had experienced irregular spotting. Invasive cancer was quickly diagnosed, and Matheson had an extensive hysterectomy and radiation treatment. She appears to have fully recovered from the cancer. In the Metro article, we claimed that Green's publications and a research proposal submitted in 1966 to his senior colleagues on the Management Committee of the Hospital, which at that time also acted as an ethics committee, suggested that the physician was conducting research on women with cervical abnormalities that was designed to prove his thesis that carcinoma in situ is not (or is not invariably) a precancerous condition that will progress to cancer if the abnormal cells are not removed (Committee of Inquiry, 1988). Green persistently challenged the idea of a progression from precancerous abnormalities, including carcinoma in situ, to invasive cancer. In her report Judge Cartwright said of the 1966 proposal, "I have come to believe that Dr. Green was in fact trying to prove a personal belief. It cannot be just co-incidence that an interview with Dr. Green, published in the New Zealand Herald on 24th January 1970, quoted him as saying: 'In situ cancer is not a forerunner of invasive cancer' " (Committee of Inquiry, 1988, p. 33). Evidence presented during the inquiry showed that some women who had gone on to develop invasive cancer had also been entered into other studies without their knowledge or consent. In addition, the inquiry found that Green had undertaken a study of cervical smears from more than 2,000 female newboras without the consent of their parents and that students were routinely taught pelvic exams on nonconsenting anesthetized women. Other evidence suggested that some anesthetized women had also been used to teach intrauterine device (IUD) insertion, again without their consent. In an interview in the Sunday Star on September 27, 1987, the chair of the Auckland Hospital Board, himself an obstetrician and gynecologist, justified these practices by claiming that the women gave "implied
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consent" by entering a teaching hospital. It did not seem to occur to him that the quality of this consent was compromised by the fact that National Women's Hospital was the only women's hospital available for approximately one third of New Zealand's female population. For months the inquiry and the report made women's health issues front-page news, stimulating sustained and sophisticated public debate about medical ethics. Throughout 1987 and 1988,1 traveled around the country raising money to sustain our presence at the inquiry. Everywhere I encountered overwhelming support from women of all classes, even in provincial and rural areas where women are said to be more conservative. The women of New Zealand seemed uniquely united in demanding fundamental reform of the medical system. The report recommended sweeping changes that would make effective patient protection a reality. The government of the day promised to implement these recommendations: 1988 looked like the dawn of a new era in patients' rights. What I want to tell you is the truth about how this has not happened (Coney, 1990). I would like to tell you the truth about the women who lost their jobs because they wanted to give information to patients, the women quietly dropped for opposing abuse, the woman whose career is stymied because she dared give evidence at the inquiry, and the truth for me about the personal cost to self and family of being the rubbish bin for the medical system and the personification of "the enemy" to a determined and powerful group. However, I cannot tell you that truth because then the lawyers' letters would start again. For the well resourced, the threat of libel action is an effective weapon. Libel actions cost the individual a huge amount to defend. The professions, on the other hand, can work through their protection societies where they have experienced lawyers to organize their interests without cost to themselves. So what I am going to do is a little clinical cartography of power: describe the medical profession's armamentarium of resistance to change here in New Zealand. It is important that we recognize this armamentarium. So let me say immediately that I am a very nasty person because you will soon be told so. Nice girls do not know what is going on. They do not name names; what makes them nice is their usefulness in maintaining the illusions of the powerful. The moment we question, we jeopardize our feminity. One criticism and you too can become "nasty," "twisted," "unstable," "beady-eyed," and so on down the scale. Crude it may be, but this labeling inhibits change for women, because many women have been made so insecure about self-image that jeopardizing femininity is just too big a risk to take. The Cartwright Inquiry report not only exposed the cervical cancer
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experiments but examined everyday practices that physicians found normal and nurses justified as inevitable, but which the public found absolutely unacceptable. In the report one patient described her experience at a time when the inquiry was still sitting: And at 4:30 p.m., after about five people who had arrived after roe had been [seen] before me, a nurse came up to myself and another lady waiting with me. They had lost our files and had to call a doctor back to see us. Everybody had packed up and the cleaners were cleaning. Both my husband and myself were nervous, not having had an experience like this before. So anyway, they called us in and told us to get changed into a nightshirt and wait for the doctor. When he came in, he was a horrid old man, obviously disgruntled at having to see us, he didn't look at my file, quickly asked what the problem was, then gave me an examination. The nurse was very nice, after the examination I was in tears as he was rough and the examination was painful. He then told me that my periods can't be like what I had told him and started lecturing me. He said it was all in my mind and that I was obviously emotionally disturbed and he would write to my doctor and tell her that. (Committee of Inquiry, 1988, p. 161) This example says so much: the routine rudeness, the nurse's frustrated sense of powerlessness, the rough examination, the failure to "bother" to read the notes, the a priori attribution of the problem to the woman's mind, and the threat to pass this judgment on to other practitioners. The inquiry allowed these everyday experiences to be examined and legitimated them as important issues of concern to the public. If this patient had tried to complain through the medical system, she would have found that her complaint would have been pared down to the narrowest possible clinical issue. The quality of her treatment as a person would be irrelevant. Yet violation of the patient's humanity is frequently at the core of complaints, but within the profession's disciplinary system this is not usually seen to be relevant to judgments of the doctor's professionalism. The inquiry reversed the usual criteria for judgment. Usually the profession's view establishes reality and the patient's account is judged relative to it. Patients therefore frequently have problems establishing their credibility. In the Cartwright Inquiry, however, the experience of the patient was placed at the center and the profession was judged relative to it. This shift in perspective must happen throughout the health system. The interests of the patient, not the profession, should be central and the system should be judged on how well patients' interests are served. The Cartwright report made a series of suggestions about how this could be
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achieved. The recommendations would break down the self-referencing and self-policing nature of the profession and move toward making it truly accountable for its vast power by establishing a system of external scrutiny. The key to the Cartwright plan for patient protection was to be the establishment of a health commissioner, who would be responsible for the formulation and enforcement of a comprehensive code of patients' rights. Appropriately, the commissioner was to be associated with the Human Rights Commission. The commissioner would monitor complaints throughout the system as well as deal with the concerns of individuals. The commissioner was also to be the employer of advocates, who were intended to be the on-the-spot field workers of patient protection. None of these recommendations has been implemented. The only recommendation implemented has been the establishment of Ethics Committees in each Area Health Board. It is impossible to prove that the medical profession, or at least an influential part of it, has gone from passive resistance to active backlash, but it is clear that medical resistance is effective in preventing change (Coney, 1990). The professions are masters at producing the appearance of change while hanging onto the substance of power. How is this achieved? The first strategy is to keep the real power covert, restricting decisionmaking to silent understandings and telephone conversations. Men get kudos from being included in these informal networks, but by the same token they have to strive to stay inside because they can be excluded so easily. Sometimes they take up, or appear to take up, someone, only to drop him when he is no longer useful. Occasionally even a woman is used in this way. Doris Gordon, founder of the Obstetrical and Gynaecological Society, has been mentioned at this conference. Gordon gave political voice to the obstetricians and gynecologists by organizing them effectively as the dominant force in the control and development of women's health provision. She was also successful in obtaining public support for the foundation of National Women's Hospital. When, however, the real goodies were handed out and control of the institution was at stake, she was dropped. Her tale may be salutary for the many women now busy making it as agents of the system. Another effective strategy of resistance is isolating and discrediting critics. People who raise questions are depicted as "extreme" or "hostile" or as having a "personality problem." The boys tolerate an extraordinary range of quirks among themselves but are quick to discredit others. From a position of power, this is done quite easily. It is especially easy to discredit women because we are expected to fit such a narrow stereotype. In addition, because women live in a highly person-
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alized world, it is often easy to get other women to collude in this process. If this strategy does not work, there is always the threat of job loss. The medical profession has a rigidly enforced professional solidarity and has developed the most extraordinary degree of control over other groups in the industry. Of course, other reasons will always be cited for removing a "troublemaker." Officially, victims will be told their jobs are being restructured or the like, but the real reason will be made abundantly clear, although rarely in a way she or he can challenge. Word travels fast, and it does not have to be done often to successfully bring a whole department or section into line. With the advent of Area Health Boards, this can make someone essentially unemployable within a whole region. If the troublesome person is beyond their immediate reach, they can sometimes use networks of influence to reach into other institutions or try discrediting the person's professional reputation generally. Again it is not hard to do; you just have to have a reason why her or his work isn't quite satisfactory. The fourth strategy involves informed consent. Sometimes it is a concept rather than a person that has to be discredited, and the favorite of the moment is informed consent. The profession argues that informed consent is (a) unworkable, (b) not in the patients' best interests, and (c) not what patients really want. The argument that informed consent is not what patients want or in their best interests amounts to a simple restatement of the profession's absolute right to determine what is in our best interests. The Newsletter of the Medical Association ran the sad story of St. Smitten's, a lampoon intended to show that the complexities of achieving consent would ruin the health system. The story ended with a lengthening queue of suffering patients lining up at the gates, unable to gain admission not because resources are being removed from the public health system but because they could not negotiate the complexities of giving informed consent. Behind the protest that consent procedures cannot work is the veiled threat to make sure they do not work. Those opposed to patients' rights have a vested interest in making consent so complicated that nurses have to get written permission to turn an old lady over in bed. The possibility of overburdening the already tottering public health service is real, but it should not be used to discredit the concept of consent or to distract us from the urgent task of working to develop usable procedures. The task has not been assisted by professional ethicists, who while delighted to have found a public audience have sometimes used the opportunity to discuss rare borderline cases or difficult exceptions rather than striving to put in place workable norms.
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In the fifth strategy, one of the most powerful weapons in the medical armamentarium is control of who gets into influential positions. Dianne Cameron of Ngati Mutunga said at a session of this congress: Councils and Departments select Maori whom they perceive to be "safe" to be on their committees, Maori people who find it difficult to challenge or people who have not yet formulated a political analysis of their own oppression. These people often do not have secure Iwi connections nor have they internalised Rangatiratanga. The result is Maori representatives who are unable to challenge the Pakeha majority or to access control and resources because their base and networks are not available to support them. People who have positions of authority and individual power identify and select "key Maori" to consult and work with on Maori issues. This has the effect of setting up conflict amongst Maori—the old "divide and rule." Something similar could be said of the representation and employment of women. When there is a real job within the system, they scrape the barrel for good girls, "nice" ones who will signal compliance and who do not understand much except what side their bread is buttered on. Some of these women become the power holders' most effective agents. The mode of representation of consumer interests has become a key issue for the women's health movement. We have pressed for representation at all levels of the system. If a representative is to be truly effective she (a) must have experience in the area, (b) must not be alone and isolated, (c) must be chosen by the people she represents, and (d) must be accountable to the group she represents (Coney, 1989). All these are resisted by the hierarchy who want to retain the power to select and who want inexperienced people on the grounds that they are "neutral" and "unbiased." To have experience in consumer issues or a track record in patient protection makes one absolutely unsuitable for anything official. To have ever stood up for anything makes one irredeemably tainted and biased. This labeling is a major issue. I want to give you a recent example from my own experience. I mentioned that the establishment of Ethics Committees is the only Cartwright recommendation to be implemented so far. As Dame Sylvia said in her report, "Ethical standards must be applied rigourously to research and treatment protocols on behalf of the patients" (my emphasis). She added, "The focus of attention must shift from the doctor to the patient" (Committee of Inquiry, 1988, pp. 176, 213). Patient protection was the key issue, particularly the protection of the participants used in clinical research. At the inquiry and subsequently, Sandra Coney and I pressed for a
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widely defined jurisdiction for these committees so that they could reach those private-enterprise medical doctors doing research away from institutions. We also pressed for wide consumer representation. When the guidelines developed by the Department of Health specified 50% lay membership and a lay chair, we were hopeful that in this instance at least true representation had been achieved. When the composition of the Wellington Area Health Board Ethics Committee was announced over the 1989 Christmas period, I and other consumer groups were publicly critical of it and of the nomination process that appeared to have allowed medical interests considerable influence. In the Dominion newspaper of January 8, 1990, the Wellington Patients Association said that the committee was "a closed shop designed to protect the medical establishment" and continued that it "has not a single person with the slightest public record of interest in protecting the rights of patients." The spokesperson continued, "I believe ethics committees are meant to stop doctors and others again doing what they did at National Women's Hospital. . . . There are cynics who said the doctors would make sure these committees were captured by the profession and the patients left out. The cynics were right." In 1990 I was awarded a social sciences research fellowship. I said I wanted to study the adequacy of pharmaceutical regulation from a consumer perspective. Looking back, my proposing to strike at the heart of the medical/industrial complex was probably foolish. I will spare you the details. Suffice it to say that the Wellington Ethics Committee insisted that the work be submitted to them, whereas the social science funding body felt that their own scrutiny was sufficient. Eventually they reached a compromise in which my work was submitted to the Area Health Board Ethics Committee for comment. I concentrated on the Cu7 IUD device in New Zealand partly because as action research I wanted to do something useful and of direct benefit to women: Action-research is a type of applied social research differing from other varieties in the immediacy of the researchers' involvement in the action process. It aims to contribute both to the practical concerns of people in an immediate problematical situation and to the goals of social science by joint collaboration within a mutually acceptable ethical framework. (Clark, 1972, quoted in Lees, 1988, pp. 4-5)
Part of my project consisted of sending a questionnaire to specialist doctors asking about their sources of information regarding the device. A second questionnaire was to be sent by a lawyer to women who believed they may have been injured to gather the information needed
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for a possible suit against the manufacturer. The questionnaire would provide a great deal of information about the women's experiences, and I wanted to analyze some aspects of the replies, particularly those concerning the consent process and the cost of the injuries. I felt that, given the choice, many women would be pleased to participate in this research, because it would allow a much fuller picture of their collective experience to emerge. The questionnaires, which were ready to be sent, had to be put aside until the Wellington Area Health Board Ethics Committee had commented. Finally, at the end of October, I got a comprehensive condemnation of my work from the committee. Not only had the process run me out of time, but the criticisms were so sweeping it seemed to me that the committee was unlikely to agree to the work I was doing. Consequently, I have had to abandon the questionnaires. The bureaucratic processes of Ethics Committees make action research difficult or impossible because the researcher cannot respond to questions as they arise. Only those issues that have been anticipated can be pursued and even then must be pursued in a rigidly predetermined manner. In my view the guidelines for Ethics Committees were so wide that the establishment of these committees has had the effect of extending the jurisdiction of the medical sector and with it the hegemony of the medical model. The criticisms of my work are couched in terms of "hypothesis," "proof," and so forth. For example, one criticism of my proposal was that "consumer perspective" is a subjective term, which apparently suggests to the committee that it is somehow invalid or inadmissible. Positivist assumptions about what constitutes valid research supports the medical model. Methods or theories that are critical of the limits of that approach are precluded or at least perceived as suspect. The Ethics Committee said that my proposal makes "allegations," presumably about the inadequacy of pharmaceutical regulation, that I do not support by appropriate literature references. It is true that there are very few such references, because the question is rarely addressed (at least within the ambit of medical literature). However, if the paucity of existing studies becomes a reason why a question cannot be addressed, then it will be difficult to introduce new topics for investigation. One of the major criticisms was that my work had multiple aims that were "ethically" incompatible. The nature of the incompatibility was not stated, but in subsequent discussion it was made clear to me that any work with multiple outcomes was inadmissible. I believe that the production of fragmented knowledge is an ethical problem in itself. I proposed to examine many aspects of an issue and provide a critique of the whole process of drug evaluation and regulation. One implication of the
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Ethics Committee's restrictions is to make it difficult to develop a critique of the structure of "medical" processes. The committee's most interesting criticism of my work concerned my intention to share the results of the questionnaire to doctors, including the doctors' names, with women. This was deemed unethical because it would infringe the "confidentiality" of the doctors' replies. Without a guarantee of "confidentiality," they "cannot validly give their informed consent" to take part in the survey. The committee appears to have lost sight of the fact that Ethics Committees were set up primarily to protect patients, such as Matheson, who are used as subjects in clinical research. In law, the right to confidentiality belongs only to the patient. Patients are allowed to disclose anything about their treatment, including what they know of the doctors' information or knowledge base. In applying the right of confidentiality to doctors, the Ethics Committee is extending the profession's rights beyond even those comprehensive protections already guaranteed them by the law. Coney and I found it difficult to obtain information about the research conducted at National Women's Hospital. If the principle of confidentiality is used to protect doctors, then access to this information will become even more difficult. It is, I think, a classic example of how a measure introduced to protect patients can be turned around and used to protect the profession and the institution. It seems to place them once again beyond public scrutiny. I will go so far as to say that consumers have a right to the disclosure of the type of information I was seeking and that, far from being protected, the doctors have an obligation to disclose it. When even "informed consent" can be used to protect the profession from disclosing their sources of information and their treatments, then consumers are denied information vital to their well-being and to their right to make an informed choice. Informed consent becomes another barrier to public scrutiny and accountability. When informed consent works against the public's right to know, it gives the profession's interest priority over that of the consumer, the very thing the Cartwright reforms were designed to prevent. It is a fascinating example of how institutional power protects itself and of how the reforms we worked so hard for can be used against us. Many women's health groups seek information from medical doctors about their attitudes, their information, and the nature of the treatment they offer. If it is accepted that the compilation and distribution of this information breaches the doctors' right to "confidentiality," then it seems that women's health and other consumer-based groups are involved in unethical research. It seems that a process instituted to open up institutions to critical
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gaze and to free access to medical information has been successfully turned around to seal it off once again behind a protective barrier of "confidentiality." Part of the medical armamentarium is co-optation. Accommodation thus can be an effective tactic in the preservation of power. Where does the women's health movement go from here? The first step, it seems to me, is to identify where you are in the system. This entails stepping out of the personalized female world that absolves women from responsibility for institutions and that allows us to be drawn into conscious and unconscious collusion with it. It is a step away from the pervasive depoliticization of women. As we analyze our own roles, we also begin to recognize the roles, rules, and silences that allow the system to be oppressive and exploitative. Having clarified our own roles, it is possible to see where we can fit into collective action. There is a need for action everywhere. Pat Hickson presented a paper at this congress that dealt with the implications for nurses of the Cartwright Inquiry findings. Afterward a woman in the audience said "change comes from the collective action of people treating each other with respect." We begin the process of change when we step out of our isolation and begin collective action. If we treat each other with respect, we will not be afraid to be seen. Without collective action, we will be picked off one at a time. Having respect for each other means offering visible support, and it means refusing to allow the labeling of brave women as deviants. We need to develop some of the solidarity the boys have; after all, they do not isolate one of their number because he is a "bit funny," has an "unfortunate" personality, or "can't work with others." The women's health movement is very real, but it is fragmented, and from the perspective of the mainstream it is often almost invisible. To be truly effective, we must also come together to organize. I believe that coming together is what this congress has been about. May its legacy be long success.
REFERENCES Bunkle, P. (1988). Second opinion: The politics of-women's health in New Zealand (pp. 130-189). Auckland: Oxford University Press. Clark, P. (1972). Action research and organizational change. New York: Harper & Row. Committee of Inquiry. (1988). Report of the Committee of Inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and into other related matters. Wellington: Government Print. Coney, S. (1989, July). Taking the power off the doc: Wrestling for consumer input into medicine. Broadsheet: New Zealand's Feminist Magazine, No. 170, pp. 24-27.
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Coney, S. (1990). The Cartwright Inquiry: The aftermath. In Out of the frying pan: Inflammatory writings, 1972-1989 (pp. 199-245). Auckland: Penguin Books. Coney, S., & Bunkle, P. (1987, June). An unfortunate experiment at National Women's Hospital. Metro: New Zealand's First City Magazine, pp. 46-65. Green, H. (1964). Cervical carcinoma in situ: True cancer or non-invasive lesion? Australian and New Zealand Journal of Obstetrics and Gynaecology, 4, 165-173. Lees, R. (1988). Research strategies for social welfare. (Library of social work series, pp. 4-5). London: Routledge and Kegan Paul. Matheson, C. (1989). Fate cries enough. Auckland: Hodder and Stoughton.
BIBLIOGRAPHY Armstrong, N. (1990, November). An unfortunate experience. Paper presented at the Fourth International Congress on Women's Health Issues, Palmerston North, New Zealand. Coney, S. (1988). The unfortunate experiment. Auckland: Penguin Books.
