After Harm: Medical Error and the Ethics of Forgiveness

Preface

Preface In the years since the release of To Err Is Human—the Institute of Medicine’s report on the problem of medical error in the United States—made front-page news across the nation in November 1999, it has become almost de rigueur for scholars, health care professionals, and journalists to begin their books and articles by invoking the report with its startling statistics on the extent and the cost of the problem.∞ This book is no exception, but my reason for doing so is arguably different from the ritual invocation of the report as shorthand for the ‘‘problem of medical error.’’ Rather, I am interested in the implications of the report’s title for how physicians, health care administrators, injured patients, and the families of injured patients think, speak, and act in the aftermath of harmful medical mistakes. Clearly, the phrase ‘‘to err is human’’ is intended as a reminder that attempting to eliminate medical error is futile as long as human beings are involved in delivering health care, because making mistakes is part of being human. But it may also remind us of something important about the aftermath of error; notably, the complete aphorism to which the title alludes is ‘‘to err is human; to forgive, divine.’’ When I first heard the title of the IOM report, I naively assumed that the report was going to say something about the nature of forgiveness after medical error—forgiveness being a time-honored, if imperfect and often misunderstood, way of dealing with the aftermath of intentional and unintentional harm between persons and between societies. Finding nothing in the report about this dimension of medical error, and finding nothing in the burgeoning theoretical and empirical literature on forgiveness that addressed the aftermath of unintended harm in the context of health care, I started thinking, talking, and writing about what ‘‘forgiveness’’ might mean in this context. The result is this book. Forgiveness is a word that signifies ‘‘religion’’ to many people, particularly but not exclusively those who are familiar with Jewish and Christian teachings, practices , and expectations with respect to what ought to happen when one person harms another person. However, these religious teachings, practices, and expec- x Preface tations have permeated secular culture in the West for so long and in so many ways that it is completely natural to talk about error, guilt, shame, confession, apology, repentance, and forgiveness without any reference to religion. Think of any recent confession of wrongdoing by a politician, business leader, or other public figure, which tends to follow this script: Mistakes were made; I am sorry for any pain my actions may have caused, I take full responsibility; I hope those affected by my mistakes will forgive me, find closure, and be healed. Think as well of the post-Watergate lesson reminding public figures that the cover-up is worse than the crime: because a lack of candor breeds suspicion in the minds of others, it is better, ethically and strategically, to tell the truth and accept the consequences than to devote oneself to dissembling, concealment, and lies. Yet there is more to forgiveness than the clichés trotted out in the aftermath of scandal. It is valid and useful to approach the problem of medical error—in particular, the problem of medical harm—from the perspective of how individuals living in this society have long been taught, whether by religion, by other cultural influences, or by their parents, to think about what ought to happen when one person unintentionally harms another person. Most medical harm does not result from the negligence of ‘‘bad’’ doctors. Most physicians feel genuine remorse, even anguish, when they realize that their well-intentioned actions have injured or killed a patient who was under their care, even though they may be in profound conflict about what ought to happen next. They must weigh their obligations toward such patients and their families against their fears about the consequences of fulfilling these obligations. This book looks at medical harm from ‘‘error’’ to ‘‘forgiveness,’’ with stops along the way at ‘‘disclosure,’’ ‘‘apology,’’ and ‘‘repentance,’’ words that describe the sequence of practices and expectations that may culminate in forgiveness—a voluntary response by the person who has been harmed, in recognition of the sincere words and tangible actions of the responsible person or parties. I am not proposing an ethic of forgiveness in which the harmed person is responsible for bringing about resolution simply by forgiving the person...