A system without locks

Fittingly, La Feile Muire san Fhomhar has apparently passed without an appeal from Dr Michael Neary against the Medical Council’s long-awaited decision to end his career as a consultant obstetrician. 15 August, the Feast of the Assumption, was the reported deadline.

Media coverage of the case, sluggish at first, gathered momentum during the final stages of the four-and-a-half year Fitness to Practice hearing. Why, oh why, journalists lamented, did he do it, as if it mattered. To focus on motives in this case is to miss the point.

Fintan O’Toole has pointed out that Our Lady of Lourdes Hospital was, in the not too distant past, distinguished not only by a sky-high rate of Caesarean hysterectomy but also by the widespread practice of symphysiotomy, the preferred alternative to Caesarean section in the 18th century.

A 1975 midwifery text records that the operation “is not popular in Britain today but is employed in some African countries where the women are unlikely to return for a repeat Caesarean section”.

Symphysiotomy permanently widens the pelvis, guaranteeing both present and future vaginal delivery by sawing through the junction of the pubic bones. After symphysiotomy, Myles notes that “some women suffer permanent backache; others may have disability in walking”.

Patients have publicly described how the operation left them incontinent, unable to walk, and in perpetual pain.

Now generally found only in developing countries, symphysiotomy was widely practised in Irish hospitals until the 1980s. Dr Peter Boylan, whose hospital, the National Maternity, was the first to be identified with latter-day symphysiotomy, has publicly defended its use by his colleagues.

How symphysiotomy could have persisted in Ireland until the early 1980s, when Caesarean section offered obstetricians an infinitely less debilitating alternative, is a question that must be answered, if accountability in health is to mean anything.

Symphisiotomies were done allegedly for Catholic doctrinal reasons, as they facilitated future vaginal births, avoiding repeat Caesareans, an unwelcome prospect that, it was feared, might induce women to resort to contraception or sterilisation.

347 of these mutilations were performed in Drogheda Hospital, O Toole notes. He comments on the disappearance in medicine, of “real women”, seeing this as a consequence of the politics of abortion, which “distorted” medical ethics. But gender politics only dimly explain how Dr Neary was able to satisfy his predilection for Caesarean hysterectomy, unfettered, for a quarter of a century.

The Neary saga can only be understood in the wider context of medical and obstetric culture, set against the background, as in the industrial and reform school abuses, of State inertia.

The disappearance in Western medicine of “real women”, like that of real men, owes more to medical attitudes than to Catholic teaching. Irish Medical Council “Ethical Guidelines” (1998), for example, assume patient agreement to medical intervention, advocating a morally dubious and legally indefensible notion of “tacit” consent. Asking patients to sign forms “consenting” to unspecified medical procedures is the norm in Irish hospitals.

The gender dimension is best illustrated by “active management”, the norm in Irish obstetrics. Designed to avoid the build-up of bottlenecks in overcrowded labour wards by artificially accelerating labour, active management is based, shockingly, on a bed turnover of three women per bed per 24 hours. Such a turnover leaves no room for the niceties of free will, informed consent or “patient choice”.

A product of the rigid authoritarianism and male chauvinism that characterised Catholic thinking in the 1950s, active management was developed at the National Maternity Hospital. Denying women their right to bodily integrity in childbirth, active management uses intravenous hormones and invasive instruments to keep the assembly lines of modern obstetrics rolling.

Against this background of patriarchal control over women’s bodies in labour, what happened at Our Lady of Lourdes Hospital, Drogheda, becomes a little easier to understand.

Medical culture has always been characterised by a potentially dangerous imbalance of power, between doctor and patient, and medicine and society. Ours is a model of hospital care that allows hospital consultants to run their medical practices, both public and private, as independent fiefdoms, outside the loop of hospital management. Witness consultant resistance to medical audit, a resistance that has so far thwarted its development in Irish hospitals.

The idea that Mr Neary is simply one bad apple in an otherwise healthy barrel is one that the Medical Council would have us believe. But there are unmistakable signs that the barrel itself has rotted.

Medical culture is characterised by intense loyalty to colleagues. Following the intervention of the Irish Hospital Consultants’ Association, Mr Neary was initially exonerated by three eminent Dublin obstetricians, John Murphy, Walter Prendiville and Bermard Stuart. Six months’ re-education, not suspension, was what the Institute of Obstetricians and Gynaecologists advised, having reviewed Neary’s practice in 1999.

Today, five years after the whistle was first blown, neither the medical profession, nor the State, have devised systems to protect the patient. While some monitoring has been instituted in Drogheda, according to NEHB, these controls, inadequate in themselves, lack transparency and accountability.

National or local systems of surveillance in hospital medicine do not generally exist. Few statistics, except the most meagre, are in the public domain, National enquiries into maternal deaths, stillbirths and deaths in infancy, routine in Britain, are unknown here. Sweden, with its national register logging all Caesarean, vacuum and forceps deliveries, could teach us a thing or two. Hospital inspectorates are common in European countries such as The Netherlands. Here, we inspect restaurants, but not acute hospitals.

But then, catering has its standards. Irish Hospitals are not even required to publish annual clinical reports; had Lourdes not ceased to publish its annual clinical report in the late 1980s, Aileen Gough, and others, might have been left with their bodies intact.

Last month, the Royal College of Surgeons (Charters) Amendment Act, making the College immune to public scrutiny, was passed without comment from our legislators, all of whom with the honourable exception of Monaghan’s Paudge Connolly and Caoimhghin O Caolain, failed to see any significance in the Bill. The Neary Case proves just how wrong the legislature got it.

Ours is a system without locks. Wildly varying rates of medical intervention in maternity care, for example, testify to idiosyncratic medical practice.

Such huge variations in, for example, vacuum extraction can be explained, not by evidence, but by what Americans call “ the physician factor”.
How can a system based, apparently, on the personal belief systems of individual doctors ensure public safety?

Compelling hospitals, and doctors, to publish detailed statistics on all procedures they undertake, and their outcomes, would change the face of medicine, enabling comparisons to be made between hospitals, and, more importantly, between doctors.

Service user representation in health would be another effective link in the long chain of ensuring safe, high-quality, evidence-based care. But here, unlike Britain, the voice of the service user is mute. Hospitals, health boards, regulatory and other health bodies are all closed systems, impervious to the public gaze. Regulatory and other bodies, such as the Medical Council, continue to be immune from the Freedom of Information Act, itself worded to exclude private hospitals. Publicly funded voluntary hospitals are still outside the remit of the Ombudsman’s Office. All is secrecy, and secrecy is all.

The culture described by the 1998 Commission of Nursing as “a rigid, hierarchical culture derived from a semi-militaristic and religious service background”, was one that, perhaps inevitably, led to abuse. We have seen how this happened in industrial and reform schools, thanks to Mary Raftery’s seminal documentary. Perhaps RTE would now fund a similar investigation into Irish maternity units, where, if we define abuse as the enforced administration of medical procedures, abuse is widespread.

Since Mr Neary was struck off, six more women have come forward to say that they, too, have suffered gynaecological damage following surgery.
It would be a mistake to cast Lourdes as the villain.

Within a model of care that gives total power to consultants, how can lesser mortals retain a sense of responsibility to the patient? Present in the theatre when Alison Gough was operated on were two anaesthetists, two paediatricians, two midwives and a student. The team failed to protect the patient. Omerta – silence - reigned for another seven years. Just how many doctors, nurses and midwives stood and watched - or heard - and said nothing, as women were being stripped of their reproductive organs?

Only a hermetically sealed, profoundly patriarchal and violently authoritarian system could have allowed these horrors to happen. The era of laissez faire medicine must now be ended. A public inquiry into Drogheda Hospital would be a beginning, and only that.

Marie O’Connor
Northern Standard on 21 August 2003