After Harm: Medical Error and the Ethics of Forgiveness

7. Forgiveness

c h a p t e r s e v e n Forgiveness The title of the landmark Institute of Medicine report on medical error, To Err Is Human, is derived from Alexander Pope’s ‘‘Essay on Criticism’’ (1711): ‘‘To err is human; to forgive, divine’’ (l. 525).∞ Given how familiar this proverb is in its entirety, it is striking that the IOM report itself contains no reference to forgiveness , divine or otherwise, in its treatment of medical error, even as its title hints at a fundamental relationship between error and forgiveness. A systems approach to medical error, the approach advocated by the IOM and the national patientsafety movement alike, may similarly ‘‘forget’’ to engage forgiveness as a tool for addressing the needs of all parties affected by medical error: patients, families, clinicians, administrators, and institutions. Insights from religion and related aspects of culture may help clinicians, ethicists, and other professionals involved in nurturing ‘‘cultures of safety’’ within health care institutions, or medical educators responsible for introducing students to the sensitive issue of their own fallibility and its potential impact on patients, to recognize the restorative role that forgiveness has long played between individuals and within communities and to incorporate forgiveness into ways of thinking about and addressing medical harm. What follows is a broad ‘‘religious studies’’ rather than a strictly ‘‘theo- 82 After Harm logical’’ or ‘‘doctrinal’’ perspective on forgiveness, one that incorporates insights from Jewish and Christian social ethics, ritual studies, the sociology of medicine, and medical anthropology, as well as from clinicians themselves. Dena Davis defines the task of the religious ethicist working on clinical issues as describing what real people really believe and how they really act, a definition worth keeping in mind whenever the word ‘‘religion’’ comes up in relation to clinical medicine.≤ That said, several concepts borrowed from Christian theologian Dietrich Bonhoeffer—‘‘cheap grace’’ among them—are integral to the argument against what might be termed forgiveness as a self-interpreting principle. What is meant by this phrase is a way of formulating ‘‘forgiveness’’ so that its relational character—the actions that various persons undertake in relation to one another so forgiveness can take place—is forgotten. This relational understanding of forgiveness may be replaced by a cheap grace that, in formulating forgiveness as automatic, either acknowledges no role for the injured person as agent of forgiveness , or assumes that this person should offer forgiveness in the absence of truth telling, apology, fair compensation, or other goods that we might place under the ethical principle of justice. In cases of medical harm, a cheap-grace approach on the part of professional caregivers, including clinicians, chaplains, social workers, or pastors, may also place pressure on injured patients and their families to forgive automatically—by reminding them, in subtle and not-so-subtle ways, that ‘‘good’’ people are ‘‘forgiving,’’ or by assuring them that offering forgiveness will bring them ‘‘closure,’’ or by telling them that, after all, nobody meant to harm them—even as these patients and their families remain profoundly distressed by not knowing what really happened, or by the absence of any acknowledgment of their suffering by those directly responsible for it. In avoiding nonrelational approaches to forgiveness, we must keep in mind that forgiveness is a ‘‘Janus’’ word, in that it holds contradictory meanings—to engage and to detach—that are often conflated or insufficiently distinguished in everyday conversation and in scholarly discourse: One of the most important questions you can ask about forgiveness is what you mean when you use this word. In the Jewish and Christian traditions, the deepest meaning of forgiveness is detachment . Forgiveness as cheap grace, as entitlement rather than outcome, ignores this deep meaning by refusing to ask what those harmed through medical mistakes may need to achieve detachment, or by pressuring them into engagement or acquiescence, even into a divine, salvific role, instead of allowing detachment to take place over time—in what the Christian Bible refers to as kairos, the Forgiveness 83 appropriate time, as opposed to chronos, chronological time—once justice has been secured.≥ Arguing for a definition of forgiveness after medical harm that holds detachment as the ultimate goal of the process does not mean that injured patients—or clinicians who have made errors—should simply be encouraged to ‘‘detach’’ from incidents of medical harm, and from their feelings concerning these incidents. Even in mundane interpersonal...