Joe Craig

19 April 2006

When it comes to discussing the specific role of the Medical Missionaries of Mary the Report into obstetric practices at Lourdes hospital in Drogheda descends into not much more than apologetics.  ‘The religious ethos and the hierarchical system must not be judged too harshly ‘! (p. 250) ‘The MMMs should not be criticised but their ethos understood in the context of the time.’ (p. 251)  ‘The sisters evoked our sympathy. . . They sincerely believed that what they were doing was right.’ (p. 253)  ‘They did not look over his (Dr. Neary’s) shoulder.’ (p. 253)  ‘What is unacceptable now may have been perfectably acceptable in the past.’ (p. 252)

The problem of course is that while the MMMs were capable of preventing tubal ligations they apparently weren’t even aware that large numbers of completely unnecessary hysterectomies were being performed in their hospital. Despite repeated emphasis on the role of the Hospital’s Catholic ethos on how things were done – ‘the role of the strict ethos prior to and post the Papal encyclical Humanae Vitae on obstetric practices in this hospital cannot be overstated’ – the Report ignores its own judgements by exonerating those responsible for this ethos, thus limiting the connections between the ethos and what went wrong. (p. 233)

The report reads as if the Nuns were unaware of any problems, yet it lists examples of criticism of the MMMs throughout this period.  ‘An Bord Altranais carried out periodic assessments of the midwifery school at the Maternity hospital for accreditation purposes.  They advised as far back as 1980 that women should be offered a full choice of contraception… Nothing happened.’ (p. 34)

The women’s movement, to which the Report refers, and a wider constituency were struggling since before Dr. Neary even came to the hospital to allow the legalization of contraception and restrict Catholic control more generally.  The MMMs, like the rest of the Church, fought against them.  To turn round now and speak as if this order was only one party to a unanimous consensus ignores the real history to which the Report refers.

The whole Report in fact is a shocking indictment of just what was compatible with a Catholic ethos while contraception and less invasive forms of sterilisation were not.

The Report details multiple failings in how the hospital was run.  ‘There was no protocol or guideline that required the opinion or assistance of another colleague before hysterectomy was carried out.’ (p. 177).  The Institute of Obstetrics Review group in its report in 1999 noted that there was ‘no audit, no regular meetings, no discussions nor any clinico-pathological conferences and no evidence of organized training programmes.’ (p. 12)

‘Transparency was not a characteristic of the management of this hospital.‘ (p. 182).  In 25 years the Matron ‘never attended a course on management skills, assertiveness, risk management or audit.’ (p. 186)  ‘Nurses did not question nuns or ward sisters and they certainly did not question consultants.’(p. 187). ‘The nuns had created an aura of unquestioning respect around the foundation consultants who were revered.  This attitude to consultants made its way in a watered down version to later consultants but the attitude of not questioning was established.’ (p. 232).  Midwives believed ‘that their training moulded them never to question.’ (p. 297) ‘Several consultants used methods, which they (other doctors) felt were from another era.’ (p. 229)

The lack of communication within the hospital was extraordinary, with one pathologist only learning of a maternal death in 1997 from the Inquiry and another ‘when he saw his colleagues emerging from the coroner’s court on the 9 o’clock national news.’ (p. 212).  Many midwives remained unaware that a maternal death had occurred in 1997 until informed by the Inquiry.

‘This lack of openness, seen in the context of the unchanging ethos of the hospital, provided the backdrop to the tolerance of what can only be described as rebarbative practices throughout the 1990s.’ (p. 265)  ‘It is a story set in a time of unquestioning submission to authority, whether religious or civil, when nurses and doctors were in abundant supply and permanent jobs were few and treasured.  The MMMs ran a very ordered hospital in an austere and dedicated manner.... and was accountable to a religious community rather than to objective medical standards.’ (p. 29)

Job insecurity ‘may have influenced a climate of silence.’ (p. 38) particularly for non-national doctors since their training, employment, future careers and visa for remaining in the country were all dependent on their consultant

Defence

The Medical Missionaries of Mary are afforded space in the Report to defend their position.  Their argument runs as follows: because no specific cases of hysterectomy being carried out in lieu of other procedures were presented to the MMMs ‘it is inappropriate to suggest it was a reality.’  Because they haven’t had any examples put to them it didn’t happen!  Patients ‘accepted the Catholic ethos of the MMMs, but they did not let it interfere with their personal decision about family planning.’ (p. 22)

The purpose of their statements is abundantly clear and has nothing to do with the truth or otherwise of what is printed in the Report, or even with a defence of Catholic teaching.  Its purpose is a purely legal one, to thwart any claims of liability through action by those who suffered in their hospital.

The Report’s author replies to the MMMs by noting that ‘it was acknowledged by …. obstetricians that hysterectomy for sterilisation purposes had been carried out…. .We did not require to put specific cases to any witnesses in the light of the clear and open acknowledgement.’ (p. 23).  This acknowledgement even came from one of the MMMs themselves, a Sister B, who said ‘…that I was aware that hysterectomies were done in Ireland more often than was necessary because sterilisation was ethically non-acceptable.’ (p. 23)

The Report states that ‘there was an abundance of evidence …that compassionate hysterectomies were carried out …’at this hospital and ‘in other Maternity Units in the country and in other Catholic hospitals.’ (p. 24)

The MMMs reject the contention later in the Report that their hospital failed many women, an assertion that simply beggars belief, and once again this can only be understood as an assertion that bearing witness in a civil court is a more important consideration to the MMMs than bearing witness to any God.

For the MMMs their much valued Catholic ethos had no bearing on the occurrence of peripartum hysterectomy and they cite the lower occurrence of this procedure at other hospitals with the same ethos as proof of this.  Again it is simply incredible for the Catholic Church to claim that their ethos has no bearing on obstetric practices since their involvement in this area is justified precisely on these grounds.  As for the lower rate at other hospitals, we have noted that the Inquiry simply does not believe these statistics.

In summation the statements of the MMMs amounts to no defence at all but a legalistic argument designed to disclaim any legal liability.

Problems

While the MMMs must shoulder their full measure of guilt culpability ranges more widely and extends over a broader range of issues.

The hospital had ‘perpetual funding and staffing problems,’ the pathology department for example was ‘overworked, under-resourced and understaffed’ and when ‘the second consultant’s contract was renewed in January 1998, he estimated that he had worked 7 years overtime in a 16 year period.’ (p.50 & 203)  The Report recorded that ‘many witnesses have described the premises as “primitive”, “unbelievable”, “run on a shoestring”, and “Dickensian”. (p. 37)

The shortage of funding and lack of resources was made worse by the role of private medicine which the consultants jealously protected.  The Inquiry reported that management received no cooperation from obstetric consultants in attempts to review their bed use practices.  ‘Some registrars doubted that consultants visited public patients in the postnatal wards unless the patient required special attention.  It was their view that the consultants only visited private patients.’ (p. 133).  At times these amounted to 50% of all obstetric patients. 

The Report laments that ‘there should be no difference in the standard of care applied to a private or public patient.  A consultant should not be engaged in so much private practice that sleep deprivation or exhaustion interferes with public duties.’  Unfortunately the Inquiry recommends no measure that could make this happen.  Of course the only effective measure would be to end private medicine altogether but the Inquiry was never going to propose anything so radical, socialistic and effective.

The maintenance of private practice has major implications even for the quite limited reforms which the Report does recommend.  This is so because it reports that ‘private patient care still takes up a lot of consultant time.’ (p.53).  The Report’s recommendations for clinical audit and criticism that ‘clinical independence should no longer be interpreted as a license for arrogance, disregard for patient choice, dignity and need or freedom from accountability’ are all undermined by the freedom that private practice gives consultants. (p. 54). As the Report itself notes, audit has still not been introduced despite being part of the consultants’ condition of employment.

Other recommendations have not been implemented, for example the 2003 and 2004 annual reports of the hospital had not been published by the time the Inquiry Report was published.  ‘Managements role and actions in addressing the major structural, operational and personal deficits in the Maternity Unit and the hospital since 1998 have been slow and unsatisfactory….Audit is still not seen as an immediate imperative by management.  The tools for audit are not available … There is lukewarm application of risk management amongst some consultants.  Many do not understand what clinical governance means. . . There is still no computerized data collection system in place’ (p. 53).

All this is important because the Report argues that ‘the only process that could have identified the failings and institutional weaknesses of the Unit was robust and meaningful audit where clearly computerization would have been a useful tool.’ (p. 301)

The hospital is ‘still under resourced and under staffed. . . Management structures need serious changes in training, continuity and accountability.  They too need to be subject to audit and review.’ (p. 325)

The State

These failings, while a spotlight has been shone on Drogheda Hospital, should serve as a warning that the State bears its own responsibility for what went on in the hospital and now bears immediate responsibility for failure to fully implement the far from radical recommendations in the Report.

In fact even on the rather narrow issue of which procedures were available the State stood aside and allowed the MMMs strict interpretation of Catholic teaching to be applied with an ‘iron fist.’  ‘For many years, Dr. Neary and Dr. Lynch had sought clarification from the Department of Health, the Medical Defence Union and the Health Board of their legal position with regards to patient choice on offer in other hospitals.  They never received what they considered adequate answers from any source…’ (p. 42).

Later in the Report the Inquiry complains that it ‘was unimpressed by the unwieldy bureaucracy of the Health Board. . Over and over, we were told of political interests and political motives for taking or not taking certain steps.’ (p. 341).  The Inquiry ‘was equally disturbed that provincial hospitals are not expected to provide the same level of care as the Dublin training hospitals.’ (p. 341)

The Inquiry also complained about the surprising fact that ‘there is currently no legislation regulating the setting up of a hospital.  We could find no evidence of any controls over private hospitals including maternity hospitals apart from the inadequate and unused Maternity Homes Act.  There must be a monitoring body for standards in all health care facilities.’ (p. 345)
 

Proposals

The scandal at Lourdes should have hammered home some obvious lessons but unsurprisingly the Inquiry has refused to draw them.  These are that the health service needs to be adequately resourced,  that the Church should play no role in health care provision,  that private practice should be prohibited and that the much vaunted independence and self-regulation of doctors must end.  While the maintenance of training and ‘professional’ standards should naturally be the concern of a ‘professional’ medical body the power of clinicians must be placed firmly within a framework of democratic control over all health service provision.

It is this lack of democratic organisation and control, with mechanisms of responsibility and accountability, which the Inquiry seeks to solve through its repeated emphasis on audit, as if review of practices after the event and their reporting through the structures being investigated are enough.  Audit undoubtedly has a role in a democratically run health service but in itself it is a woefully inadequate substitute for democracy.  The Report notes that what is required is ‘objective critical analysis’ and that ‘a good health system must surely be one of the best assets of a sophisticated democracy.’ (p. 324)

What isn’t appreciated is that sophisticated democracy is needed for the health service itself and only in a system democratically controlled by all staff will the latter have the power and interest in employing ‘objective critical analysis.’  In modern management jargon this is called the staff having ‘ownership’, a term which both expresses the only way in capitalist ideology it is thought commitment can be obtained and unconsciously hypocritical since the last thing ever considered is that the staff actually hold the power currently conferred by private ownership.

The Report genuflects to this concept when it recommends the election of a ‘lead clinician modeled on the Mastership system of the Dublin maternity hospitals’ who would, among other things, ‘establish guidelines of what constitutes an acceptable amount of private obstetric practice.’ (p. 326 & 327).  But why should the elective principle be restricted to doctors?  Could the health service last a week without all the other staff, and thus do not their opinions on how their work is best organized not also matter a great deal?

The impotence of the Inquiry’s own proposals is revealed in its recommending a ‘confidential help line for medical practitioners who have serious concerns about a colleague.’ (p. 340).  This is raised because it is recognised that there are real social pressures on such people in a tightly self-regulated profession.  The answer is to open up the profession to outside scrutiny, not give a back door entry.

Predictably the Inquiry remains wedded to a rose-tinted view of unnecessary social hierarchy which it mistakenly confounds with inevitable division of labour.  ‘Hospitals appear to run in a hierarchical system based on division of tasks.  There is a hierarchy among the nurses, and a co-relating medical hierarchy, from the medical students to the interns, the SHOs, the registrars and the consultants.  Hierarchy works well in normal life.  A move up the ladder ought to be commensurate with experience and increased knowledge, with the higher echelons reserved for candidates who show leadership qualities.’ (p. 40)

It is as if the Report’s author had failed to digest everything she had discovered through the Inquiry!  Hierarchy did not work well at Drogheda hospital and normally only works well ‘in normal life’ for those at the top of it.  Increased experience and knowledge may give additional responsibility and authority but the latter are not the same as higher skills and knowledge.  They must be controlled by continuous accountability that can only arise in a real democratically controlled system.  Was it forgotten that Dr. Neary was not a ‘surgeon with poor surgical skills or a doctor deficient in academic excellence.’ (p.34)

The proposals on patient involvement are perhaps the weakest, ironic given that it is they who suffered.  It is recommended that they ‘be encouraged to identify deficits in service at every stage of their visit to the hospital.’  Unless however they are fully informed, and the medical environment is one in which this can happen, calls for patient involvement will fail.  At most user groups will generate public representatives who become less representative as soon as they take up their position and become even less so with each passing day.  This does not mean that patient involvement must not be organised but wider involvement of ordinary people in how their society is run, including health care, can only realistically take place after a truly revolutionary change in how they relate to the power structures of society.

In the end therefore the Report fails to take the axe to the root of the environment within which the appalling events at the Lourdes Hospital were able to happen.  Its merit lies in the fact that it has provided enough evidence to condemn the Church, State and medical profession as unfit to run the health service.  The 26 county state is still a confessional state.  The Catholic church still hold a ‘special position’ and have domination of their ethos and strategic organisational control in many areas of the health service. They can rely on the support of the state and of the capitalist class and these forces will cover up and defend them when they come under attack. These are the real lessons of the ‘Neary’ Report.