After Harm: Medical Error and the Ethics of Forgiveness (review)

In November 2005, Washington-state voters faced two ballot initiatives dealing with medical malpractice and patient safety. The measures pitted medical societies and hospital associations against plaintiffs' attorneys and victims' advocates. The campaign eventually shattered spending records for ballot initiatives in the state. Unfortunately, the situation confronting Washington voters was representative of the current U.S. medicolegal environment and, more generally, of how our society deals with medical harm and errors. In such an adversarial climate, Nancy Berlinger's After Harm: Medical Errors and the Ethics of Forgiveness seems especially timely. Berlinger is interested in medicolegal issues, but her greater interest is the broader context of how we respond in the aftermath of harm incurred during medical care, particularly harm resulting from medical error.

Organized into three sections, After Harm integrates themes of patient safety, the doctor-patient relationship, narrative ethics, religious studies, and public policy. The first section considers how narrative ethics provides a better understanding of the experience of medical harm. The second section "explore[s] each of the sequential steps in the relational process that may culminate in forgiveness after medical harm" (xiv), with individual chapters dedicated to themes of disclosure, apology, repentance, and forgiveness. In the final section, Berlinger attempts to synthesize a unified conception of how patients, families, and clinicians involved in an episode of medical harm might achieve forgiveness.

After Harm is relatively short at only 113 pages, with an accompanying study guide. The target audience appears to be humanities scholars, ethicists, and medical educators, rather than practicing clinicians. In the preface, Berlinger references the Institute of Medicine's 1999 report on medical error in the United States, To Err is Human. She distinguishes her interest in the report by noting, "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" (ix). She notes that the report's title acknowledges the ubiquity of error but fails to address the second half of the famous aphorism: "to forgive is divine." Building on a foundation of religious studies, Berlinger frames her thesis within the traditional practices of confession, repentance, and forgiveness.

The opening section outlines the field of narrative ethics and then specifically considers both physician narratives and patient and family narratives. Berlinger acknowledges the need for clinicians who have caused medical harm, particularly when due to error, to process the experience, and she addresses how rituals such as the Morbidity and Mortality Conference facilitate this processing. However, she rightly critiques physician narratives as being predominantly focused on the clinician's experience, with injured parties and their families relegated to subordinate roles. Although these narratives provide insight into the trauma clinicians experience after causing harm, they shift the focus away from those who bear the greatest burden from medical harm. To achieve a more fully realized response to medical harm, Berlinger proposes the inclusion of patient and family narratives in medical and ethics education:

A clear moral role exists for the personal narrative of medical harm as a tool for encouraging medical students and physicians to be ever mindful of the continuing impact of their mistakes on many lives, including, but not limited to, their own lives, and for helping them to perceive and acknowledge their concrete obligations to patients and families after harmful mistakes. But stories written by physicians, about physicians, in most cases for physicians, can tell only one side of the story of a mistake. The personal narratives of injured patients and their families are also crucial tools for dealing the patient back in.

(26–7)

Berlinger reviews representative family narratives, including a poignant "web documentary" still active more than a decade after the patient's death due to medical error (35). She cites Anne Hunsaker Hawkins: "Only when we hear both the doctor's and the patient's voice will we have a medicine that is truly...