April 28, 2003
Apology, forgiveness, and disclosing medical error
Consider the following hypotheses: (1) When health professionals realize they have committed a serious, harm-causing error, their feelings of humiliation, betrayal of the patient, and fear of lawsuit can be so unbearable that many will resort to all sorts of conscious and unconscious strategies to diminish or eliminate the emotional pain they are experiencing; and (2) When individuals who have gone for health care strongly suspect that they have been seriously harmed by a medical mistake, they will often experience intense feelings of bewilderment, sadness, and anger. If these feelings are not addressed, they can easily escalate into sadistic rage.
In fact, both of these hypotheses have been pretty well confirmed by psychologists studying forgiveness. They have found that wrongdoers tend to dismiss or de-emphasize the gravity of what they have done, either because they have little sense of guilt or conscience or, as is more likely in the case of health professionals, because they feel so awful from having caused harmful error and instinctively try to ease their pain by disowning or distancing themselves for what occurred. Alternatively, the persons who have been harmed tend to replay their having-been-harmed experience over and over in their minds. That “repetition phenomenon” causes them to feel increasingly outraged over what happened, and unless the flames of their anger are extinguished, many will entertain revenge fantasies or at least seek restitution for what they have suffered.1
The research I have done leads me to think that just as much as health providers fear a lawsuit resulting from acknowledging and apologizing for a harm causing error, so they also resort to rationalizing, shifting blame, or just numbing themselves when errors occur. Dr. Jones’s convincing himself that a lethal error ought to be dismissed (much less should it be disclosed) because the patient was probably going to die anyway, or that if the patient had taken better care of himself the harm from the error wouldn’t have been so bad are (maladaptive) ways Jones employs to reduce his anguish and guilt. His inclinations may then be strongly reinforced by lawyers and insurance carriers who instruct Dr. Jones not to admit his error and not to apologize.
But these narcissistically based, ego-soothing, distancing-myself-from-the-error strategies run exactly contrary to the way errors are experienced by their victims. The longer that error victims’ questions, feelings, and suspicions about what happened remain ignored or dismissed, the greater the likelihood that they will consider the compensatory possibility of a malpractice suit. Consequently, because the psychological trajectories of offenders and victims run in opposite directions, they tend to compromise the prospects for healing and reconciliation. The offender is instinctively drawn to dismissing, forgetting about, or diluting the impact of the error, while the victim cannot help but perseverate on what happened and become increasingly bitter.
Health providers must realize that their acknowledging and apologizing for a harm causing error can be immensely healing and reconciliatory because it is experienced by the harmed party as empathic. The apology and request for forgiveness essentially says to the harmed party: “You are absolutely right to feel as you do. This error ought not have happened to you. All of your feelings that say you have been unfairly and unjustly wronged are totally appropriate and correct. While we certainly didn’t mean to hurt you, in no way does that excuse what we did to you. You did nothing to deserve this. We are indescribably sorry that this happened, and we ask your forgiveness.” Health providers must come to understand how healing these words are; how they enable, as much as possible, a reconciliation to occur between the health professional and the harmed party; and how they keep instances of harm causing error from proceeding to litigation.
The challenge for health providers is to overcome the fear and embarrassment they associate with the language of apology and forgiveness. That language, which is alien for many if not most health professionals, is the surest and certainly the most ethical way for them to mitigate the damage that can occur and then escalate from error. Neil Galatz, a well-know plaintiff attorney from Las Vegas, recently observed to a group of physicians, “Your first loss is your cheapest loss.” Health providers need to learn that doing the right thing at the earliest opportunity will diminish what can be enormous emotional, professional, and financial suffering downstream.
1 Julie Juola Exline and Roy F. Baumeister, “Expressing Forgiveness and Repentance: Benefits and Barriers,” in M. McCullough, K. Pargament, C. Thoresen (eds), Forgiveness: Theory, Research and Practice (New York: The Guilford Press, 2000): 133-157.
John Banja, PhD does research on medical errors and lectures to health professionals throughout the United States on how to manage and disclose medical error. He is a medical ethicist at Emory University in Atlanta and can be reached by phone at (404) 712-4804 or emailed at jbanja@emory.edu.
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