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What do you say to someone who you
have harmed, especially someone who you were trying to help? What if they died?
What should you do? How should you act? What are the consequences and
responsibilities? What are the ethical challenges? Is this a matter of
conscience or the law? Does forgiveness have any part in this? Should it? Can
it? The question of the aftermath of medical errors is at the heart of Nancy
Berlinger's thoughtful, compassionate and even-handed book.
Accidents happen, mistakes are made, to err is human
as Alexander Pope reminds us. Medical error is cited as a leading problem of
health care (in the USA, but one presumes elsewhere as well). More people are
said to have dies as a result of medical error than motor vehicle accidents or
breast cancer or HIV/AIDS, but still, Berlinger argues, we are challenged,
perhaps even afraid to consider what actions should follow the death of or
injury to a patient.
Berlinger begins with some
startling discussions of the incidence of medical mistakes and the processes of
narrative ethics. Is this the error that dare not speak its name? How does the
telling of a story, witnessing if you will, begin the process of healing? The
personal narratives of both physicians and patients are vividly recounted and
have a cathartic and validating affect. The need on the part of some physicians
to tell, to explain, to try to work through what happened seems so strong that
at times the event appears to be more important to the physician than the
patient or the relative. This can be carried to an absurd length with complete
loss of insight. One example is quoted in which a surgeon tells the widow of a
man who has died on the operating table that while her husband's death may have
been "unpleasant" for her, for the surgeon it was
"shattering". But there are also doctor's tales of confession and
humility, of abject apology and seeking forgiveness or absolution, of intense
self-doubt and hubris, of a challenged self-image and a determination to learn.
If errors are inevitable we cannot blindly pretend they will never happen, but
we can take something from the experience, be it a resolve to learn from a
mistake or a revealed sense of purpose. Occasionally though, all that happens
is that the wounds of the error defeat everyone.
In her search for a productive
approach to the aftermath of medical error, Berlinger looks at some legislative
initiatives such as the "I'm sorry" Laws in Colorado and Oregon. The
Oregon House Bill 3361 was developed with the support of the state's medical
association and protects any licensed physician's "expression of regret or
apology". It prevents any such apology being used in any civil action, and
so may open the way to a more open, and less fearful, communication. Colorado's
House Bill 1232 is a little different in that the protection is extended to
health care facilities and other care givers, and admission of fault, not just
regret. Nevertheless, neither of these laws exclude the possibility of being
sued, just what can used in evidence. Clearly, tort law reform appears to go
some way to easing the fears of medical practitioners, but it is still situated
in the legal rather than moral and ethical arena.
Berlinger looks for other processes
and she then begins to consider the notion of forgiveness, not with any
particular religious overtones for she believes that it is a concept that
appears in most, if not all, traditions, but with the view that it releases all
parties from the burden of the harm the error may have caused. She does not
suggest that saying sorry is all that is required, or advocate the "cheap
grace" about which Dietrich Bonhoeffer spoke, and concludes with a
consideration of ethical action which focuses on interpersonal and relational
ethics rather than litigation and fault-finding. She notes with interest
examples in which an admission and apology have obviated a lawsuit, and the
lack of them has led to one.
She is able to bring together her
background in religious studies and the intense personal and professional
issues involved in medical error. Sometimes there is error, sometimes accident,
sometimes it might be negligence, but at every point, Berlinger suggests, there
is a human dimension and a litigious approach alienates and depersonalizes both
It is a thought-provoking and
deeply considered argument that may not yet be fully worked through, and has
considerable importance to all health care professionals, not just physicians.
Interestingly, the book contains an appendix with a "Readers' Guide"
"to provoke inquiry into the themes of this book". It is suggested
that they may be helpful to groups when they study the book, but they may also
help any reader who endeavors to be self-reflective and conscientious, but not
self-punishing. Certainly recommended reading.
© 2005 Mark Welch
Mark Welch, Ph.D. Assistant Professor in the Faculty of
Nursing at the University of Alberta, Edmonton, Alberta and Co-Director of the
PAHO/WHO Collaborating Centre for Nursing & Mental Health.