Reviews Book

After Harm: Medical Error and the Ethics of Forgiveness

BMJ 2005; 331 doi: (Published 01 December 2005) Cite this as: BMJ 2005;331:1343
  1. Farr A Curlin, assistant professor (fcurlin{at}
  1. section of general internal medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago

    The title of the US Institute of Medicine's 1999 report, “To Err is Human,” truncates a well known aphorism, “To err is human; to forgive, divine.” In After Harm, Medical Error and the Ethics of Forgiveness Nancy Berlinger notes that the omission of the second clause symbolises the way modern health care has, in its preoccupation with preventing medical error, neglected the moral obligations that follow from the errors that human agents inevitably commit. In a laudable effort to address the imbalance, Berlinger applies a “religious studies perspective” to describe the words and actions that make forgiveness possible after medical harm.

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    Nancy Berlinger

    Johns Hopkins University Press, £23.50/£35, pp 176 ISBN 0 8018 8167 6

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    Before harms can be addressed they must first be disclosed. In a turn that initially seems paradoxical, Berlinger commends the norm of disclosure by appropriating the German pastor Dietrich Bonhoeffer's theological justification for lying to his Nazi interrogators in the period before his eventual execution. Bonhoeffer was repulsed by Immanuel Kant's notion that lying, on principle, is not justifiable even to defend the innocent from evil. Against Kant, Bonhoeffer argued that our moral obligations can never be reduced to anything less than a “total and realistic response of man to the claims of God and of our neighbour.”

    To discern what a “total response” requires, clinicians must gain what Bonhoeffer called “the view from below,” which subsists in the”perspectives of those who suffer.” In the contemporary medical context, Bonhoeffer's insight is echoed by “narrative ethicists,” who emphasise the centrality of the patient's voice in clinical ethical deliberations. In the stories of patients who have been harmed, several of which are related in the book, Berlinger finds indispensable resources for forming and refining the moral sensibilities of clinicians.

    Patients tell doctors, for example, that a “total response” to medical harm necessarily begins with a candid disclosure of doctors'errors and their consequences. Yet, disclosure is not sufficient: patients also need to hear an apology. Statements of sympathy are not enough. Genuine apologies must acknowledge responsibility for the error and its consequences. For example, saying “I am sorry your father died” is not the same as saying “I am sorry for my error that contributed to your father's death.”

    Berlinger is careful to note that acts of disclosure and apology in no way obligate patients and families to forgive those who have harmed them. Demands for forgiveness are demands for what Bonhoeffer called “cheap grace”—absolution without repentance. The Jewish and Christian concept of repentance requires a genuine effort to right the wrong that has been done. Because medical harm usually causes the loss of something that cannot be restored, reparations must be made. Berlinger urges clinicians and the organisations they work in to proactively and fairly compensate victims of medical harm rather than retrenching in ill advised efforts to fend off possible lawsuits. Fair compensation sets the stage for forgiveness by showing that the clinician or institution acknowledges error, takes responsibility for it, and seeks to restore the relationship with the one who has been harmed.

    Doing what is right, particularly in the face of fear, is difficult. Doing right after medical harm is no exception

    Berlinger draws her normative concepts from religious resources, but she eschews theological arguments in favour of appeals to the usefulness of these concepts in practice. Judaism and Christianity, she argues, have so shaped the Western mindset that even secular persons “know” that harm cries out to be forgiven and that forgiveness is made possible when the one who has caused the harm confesses, apologises for, and repents of the error. Shrewd policies will therefore take these norms into account. Indeed, the most persuasive component of Berlinger's analysis is her judgment—based on careful analysis of experiences in different regions with different healthcare systems—that the ethics of forgiveness works. Those policies that foster greater degrees of disclosure, apology, and fair compensation actually reduce overall liability costs while improving patients' satisfaction and doctors'morale.

    Yet, by eschewing the limitations of religious particularity and invoking the pragmatic utility of the religious concepts apart from their theological moorings, Berlinger exposes important limitations of her analysis. We may, as she puts it, “engage forgiveness as a tool for addressing the needs of all parties affected by medical error,” but to use forgiveness as a tool, even for therapeutic purposes, is to do some violence to the moral significance of forgiveness. As Bonhoeffer might have said, genuine confession and repentance are incompatible with instrumental aims—or any aim that falls short of a total response to the just claims of both neighbour and God. Moreover, if Westerners indeed know intuitively that wrongs must be followed by some form of confession, apology, and repentance, then clinicians' failures in this domain are due less to lack of knowledge than to lack of sufficient will to act on what we already know. Doing what is right, particularly in the face of fear, is difficult. Doing right after medical harm is no exception.

    After Harm, then, provides a valuable counterbalance to innumerable calls for systemic reforms to reduce medical error. To err is human, and human error requires the response that Berlinger thoughtfully summarises in her ethic of forgiveness. By clarifying the nature of our moral obligations after medical harm, Berlinger's book also highlights a complex challenge for the medical profession: how to form medical professionals who will, in the face of real threats to their own reputations, pride, and financial security, willingly disclose medical harm, apologise for their errors, and take concrete steps to fairly compensate patients for what has been lost. Such actions require more than knowledge of cultural norms. They require virtue because, in some real and necessary way, faithfulness to Berlinger's ethic of forgiveness places the doctor at the mercy of those who have suffered harm. Nothing less will count as a total response to God and neighbour, and nothing less will make possible the forgiveness for which clinicians hope.

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