GUEST BLOG: Ian Powell – Health leadership, tobacco control and a sacred oath: ‘first do no harm’

On 5 February 2022 I discussed in Otaihanga Second Opinion the Hippocratic medical ethics oath and its continuing relevance to Aotearoa New Zealand’s health system.

Beginning with ‘first, do no harm’, I argued that the oath should be central to the ethical basis of the whole health system, not just medical doctors: An oath that stands the test of time.

Ancient Greek philosopher Hippocrates developed an oath that continues to be relevant to today’s health systems

Around 30 months later the need to be central to our health system is even more necessary. This is well-highlighted in Glenn McConnell’s Stuff article (12 July):  Smokefree outrage within Health New Zealand.

McConnell reports on the response of former Director-General of Health Dr Ashley Bloomfield on the revelation of serious concerns within the leadership of Health New Zealand (Te Whatu Ora).

What sparked the controversy

These serious concerns were over the announced decision last November of the newly elected National-ACT-NZ First coalition government’s decision to repeal world-leading legislation to create a smokefree generation of New Zealanders through increased tobacco controls.

This was the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act 2022. The repeal decision was due to the influence on the new government of the tobacco industry, including through the rightwing Taxpayers Union and NZ First.

Penetrating critical British Medical Journal editorial

The ramifications of this decision were identified in a penetrating editorial in the British Medical Journal (8 December 2023): New Zealand reverses landmark tobacco controls.

I also discussed its ramifications in Otaihanga Second Opinion (12 December 2023):   When smoke gets in your eyes the outcome is perversity.  The 2022 Act was repealed under urgency in February 2024.

The revelation

The revelation was the release of internal Te Whatu Ora emails sent last November. They showed that some of the Government’s top public health advisors were very concerned by its decision to repeal the smokefree law.

The negative health outcomes of the Government’s repeal of new tobacco controls forced its most senior public health adviser, Dr Nick Chamberlain to consider resignation (RNZ photo]

Furthermore, at least one, Dr Nick Chamberlain, considered resignation. He was trained and worked as a general practitioner in Northland before moving into senior management in both the former Capital & Coast and Northland district health boards (DHBs).

Prior to the disestablishment of the district DHBs and the establishment of Health New Zealand on 1 July 2022, Chamberlain had become the well-regarded chief executive of Northland DHB.

Now he is Health New Zealand’s national public health director reporting directly to Chief Executive Margie Apa.

Consequently, in this role, Chamberlain is one of the Government’s most important health officials and advisers. His appointment was a good catch for the new national body.

McConnell refers to the response of Chamberlain and other senior health officials last November to the intended repeal of the legislation as demoralisation and “outright anger”. Further, it conflicted with the Hippocratic Oath taken when becoming a doctor.

Dr Chamberlain put it this way in an internal email last November:

I’m sure we have all been challenged ethically and morally by the notion, firstly that our Government will repeal the smokefree legislation, and even more so that this will help fund tax cuts. I’m sure anyone working in public health will feel pretty demoralised by this, but I’m aware that we signed an oath.

The Government’s announced intention last November to repeal the 2022 Act meant that more New Zealanders (disproportionately Māori and Pacifica) will either die or be permanently harmed as a consequence.

Te Whatu Ora dumps down on Dr Chamberlain

If anything failed the ‘first do no harm’ ethical test, it was this. No wonder Dr Chamberlain and his colleagues were placed in a conflcted position.

Chief Executive Margie Apa unfairly publicly dumped on Dr Chamberlain

If ever there was a time for Te Whatu Ora to stand by its medical staff it was this. Unfortunately its chief executive took a different view.

She publicly and harshly put the boot into Chamberlain asserting that his comments did not meet her expectations for “conducting work with integrity and political neutrality”.

Dr Chamberlain was not lacking integrity; instead he was struggling with the conflict between a cruel harmful political decision and longstanding medical ethics. Nor was he disrespecting political neutrality. Instead he was doing what an ethical doctor should do.

Furthermore, he was doing what a good public servant should do. The relationship between government ministers and senior public servants should be robust. The latter should provide free and frank advice even if the former might not always want to hear it.

This robust relationship is a prerequisite for good governance. The alternative is docile or facile public servants only telling ministers what they want to hear. This is a prerequisite for bad governance.

Enter Ashley Bloomfield

I have been previously critical of the leadership culture of the Ministry of Health that Dr Ashley Bloomfield inherited when he became its Director-General in 2018 and that continued under his watch for another four years.

Dr Ashley Bloomfield makes a principled intervention

However, his comments on this controversy as reported by McConnell are spot on. They are insightful and go to the core of the issue.

He responded that:

… this conflict between personal beliefs and professional obligations was a common issue for those in the public service. However, in this case, he said it wouldn’t have come as any surprise to ministers to hear public health workers were angry about cigarette access liberalised.

Maintaining political neutrality “…didn’t mean those officials needed to see eye-to-eye on everything.”

In Bloomfield’s words:

I don’t think it would come as a surprise to anyone that the officials responsible for the public health of the nation would feel this kind of tension between their professional commitments and their oaths, say the Hippocratic Oath, and what a particular policy might be.

Applying the Hippocratic Oath to the whole health system

In my above-mentioned blog on the Hippocratic Oath I argued that it should apply to the whole of New Zealand’s health system:

It is astonishing that the insights and wisdom of Hippocrates, his oath and subsequent corpus are so relevant to today’s health system and medical profession, both in New Zealand and globally. This is despite the fact that the both modern health systems and the practice of medicine are infinitely more complex than that ancient Greek era. The essence of Hippocrates remains equally instructive.

The sooner health system decision-making (including by its political leadership) is, before considering anything else, based on first do no harm the sooner our health system’s effectiveness, kindness, accessibility, quality and fiscal performance will improve.

One of the lessons of this controversy within the troubled Health New Zealand is that what I advocated in February 2022 is even more necessary now than it was then.

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion