Tuesday, August 24, 2010

More on Forgiveness

Posted by Jon Stanger, MD

[Five years ago, in the wake of a troubling case involving delayed diagnosis, a subgroup of our Ethics Committee was convened to consider and make recommendations for appropriate management of adverse patient outcomes and medical error within our system. The Subcommittee’s findings and recommendations led directly to the formation of our current Medical Error and Adverse Outcome (MEAO) Committee. I invite you read the final “Report of the Subcommittee on Disclosure of Medical Error.” It can be found in the “Ethics” folder on the desktop of any computer in our system, within the subfolder “3.0 – Policies and Reports,” and under the heading “Medical Error Disclosure Subcommittee Report.”]

Kudos to our CEO for having the courage, once again, to engage a very complex and critically important topic – without presuming to have all the answers. This time Anna has invited us to consider the painful reality of error within our professional practice and the prospect for forgiveness. Anna’s comments and references urge us to look beyond formal responses and institutional structures, to consider the personal, spiritual meaning of harmful error brought about by good people while trying to help others - and the potential for healing afforded by forgiveness.

Forgiveness is a tricky business and, I believe, it is important to resist facile formulations. Two possible conceptual traps in considering forgiveness I would call “cheap forgiveness” and “forgiveness denied.”

“Cheap forgiveness” comes into play when we see forgiveness as something we are entitled to. The reasoning goes something like this:

Medicine is a risky business from the outset. The patient comes to us for help and we do our best, but there can be no guarantees. Even in the best of circumstances, complications and mistakes are liable to occur. It is unreasonable for the patient and family to hold us morally or legally accountable for these unintended consequences... They owe us forgiveness.

It’s not that there isn’t some validity to this line of reasoning. Indeed, I think this is a powerful rebuttal to the current system of medical malpractice liability in our country. The error here is that this depiction, just like the legalistic remedy it seeks to counter, reduces a complex human reality – the specter of a vulnerable patient coming to harm at the hands of those trusted with his/her care – to a simplistic calculus of rights and obligations. This is a demand for “cheap forgiveness.“

Forgiveness – at least the kind of forgiveness that has a potential to heal – cannot be demanded or won as matter of rights or entitlement. Forgiveness is never an obligation of the aggrieved. It must be freely given, if it is to be authentic. And it must take account of the human dimensions and relational realities of the situation – realities like suffering, guilt, and perceived betrayal of trust. It must be earned.

What are the elements of “earning” this kind of forgiveness? Anna refers us to the wise counsel of the Reverend Victor Carpenter on the occasion of honoring Nelson Mandela at Harvard University. In this speech, Rev. Carpenter alludes to the work of Archbishop Desmond Tutu and the Truth and Reconciliation Commission in South Africa. During my years in seminary at the Graduate Theological Union, I had the opportunity to study Tutu’s Ubuntu theology and the history of the T & R Commission in some depth. Principles pertaining to forgiveness and reconciliation that have emerged from international experiences like that of South Africa include:

· Never ignore or trivialize the victim’s suffering.

· Causes must be uncovered and confronted.

· Repentance comes from the perpetrator, but reconciliation and forgiveness must come from the victim.

· Reconciliation involves construction of a new narrative of meaning that acknowledges the trauma while recognizing the humanity of the offending party and daring to trust and commit to relationship again.

· Forgiveness and reconciliation are processes that often take time.

I don’t think that it’s a stretch to see the relevance of these principles to our consideration of forgiveness and reconciliation in the setting of medical error. Here as well, forgiveness of the patient or family cannot be presumed, and reconciliation has certain prerequisites to re-establish the trust required for a therapeutic relationship. “Earning” reconciliation in the medical setting requires:

· Prompt discovery and honest disclosure of causes, to the extent possible.

· Sincere expression of regret or apology.

· Time taken to answer questions and to listen to the patient’s story.

· Demonstrable commitment to learn from the error and to prevent future recurrences.

Any expectation of forgiveness or reconciliation that side steps these elements of the process would be evidence of “cheap forgiveness.”

The second trap of forgiveness I call “forgiveness denied.” “Forgiveness denied” applies when the clinician, having taken the steps to facilitate reconciliation, remains unable to learn from the mishap and move ahead without the patient’s explicit forgiveness – which may not be forthcoming.

This concept raises the question, “Whose forgiveness am I seeking?” I would argue that there is not a single answer to this query. Certainly, our first reaction must be to say that we are seeking (or hoping to earn) the forgiveness of the patient and/or family. I have seen the transformative, healing power of this experience – when the care-giver’s honesty, sincere expression of regret, and demonstrated commitment to prevent future recurrences are met by acceptance, understanding, and forgiveness on the part of the patient and family. No one who has been involved in such a case will ever question the healing power of the experience.

However, I have also seen any number of instances in which the most earnest efforts of the professional are not followed by any expression of forgiveness by the patient. Here again, I think we are wise to avoid falling back into the trap of “cheap forgiveness” that assumes we are entitled to such a response. So, is the dedicated professional in such a circumstance left to merely hope for some future softening of the patient’s disposition? To a certain extent, yes – while maintaining compassionate contact and openness to being with the patient through the process.

But there is more to the dynamic of forgiveness than seeking absolution from the patient or family. Indeed, I believe that the primary moral valence of any expression of forgiveness by the patient is as an indication of healing of the patient himself. This is not to say that the effect on the caregiver is not profound – it certainly is. When the family says, “We forgive you,” the physician is granted permission … to what? To forgive herself.

This gets us back to the question I raised earlier, “Whose forgiveness am I seeking?” and my suggestion that “the patient’s or family’s” may not be the only answer. It is critically important to recognize that clinicians also suffer in these cases. The emotional toll upon clinicians involved in cases of medical error can be devastating. And the all-too-common “shame and blame” response has the potential for personal and professional destruction, even as it obstructs constructive efforts to help this, and future, patients.

When we compassionately consider the position of the care-provider, as well as the individualized reality of the patient’s response, it becomes unreasonable to require the patient’s forgiveness before the clinician can find some peace in the wake of a mistake. Provided careful attention has been paid to the elements of earning reconciliation as discussed above, we must guard against dependence upon “forgiveness denied” just as we have rejected the facile expectations of “cheap forgiveness.” In a very important sense, then, another legitimate answer to the question, “Whose forgiveness am I seeking?” may be “my own”, or for those with a religious faith orientation, “God’s.”

Let me close this overly long commentary by strongly recommending two films. The first is “Long Night’s Journey Into Day,” a moving documentary of the Truth and Reconciliation process in South Africa.

My second recommendation is Ingmar Bergman’s masterpiece “Wild Strawberries.” This film is a harsh, but ultimately warm and very human story of an elderly physician who has been chosen to receive an honorary degree in recognition of his 50 years of service. During his lengthy road trip to the site where he will receive his award, Dr. Borg reflects on his life course, both personal and professional, and strives to come to terms with the realization of his own shortcomings. His sleep is disrupted by a dramatic nightmare in which he is called into a medical lecture hall to take a clinical examination in front of a large audience. Filled with self-doubt, he is grilled by the examining professor in the same “callous, selfish, and ruthless” manner that he has adopted toward his own students over the years. Now in the role of student himself, he is unable even to focus the microscope for identification of a bacterium on a slide. His diagnosis of a patient’s clinical condition is egregiously wrong. And, in the final question of the exam, he is asked to complete the sentence, “The first duty of the physician is … …” His mind is a blank. He can think of nothing.

Final grade – “Incompetent.”

We think we know the answer, don’t we? I thought I did. You… we… are wrong. The answer in the film? “The first duty of the physician is … … to ask forgiveness.”


  1. Dr Stanger,
    I think this is the same for nurses. I don't know you but work in your hospital. It hasn’t happened on my ward but when something does happen rumor travel fast and believe it or not we all are thankful it wasn’t us because it could’ve been. I have been a nurse for over twelve years and worked in another hospital and a error occurred there. The patient wasn't hurt badly but it was something that could’ve been very bad. This was not me but everyone was punished. The nurse and doctor involved weren’t protected in public and rumors that blamed them and ruined their reputation were allowed to run wild. I don’t know what happened to the doctor but the nurse eventually left. I felt bad and felt afraid if I ever made a mistake I would be in the same situation. Back to here. There was an error, like the other hospital I heard no one was badly hurt but there were rumors. The rumors were that the head of ethics came to help. A team of administration came in and the CEO came in and told the patient she was responsible and she was sorry. All the administrators took care of the staff. I never heard rumor or personal attacks on people involved and don’t know who the actual people were. This was very different from my past experience. I do feel supported but I do still worry one day it could be me.

  2. Partners in Forgiveness

    As I read the posts on forgiveness by Anna and Dr. Stanger, I was once again struck by the healing opportunities before our healthcare community in Contra Costa County. We are fortunate to have their leadership and grace to light our way. I had a recent conversation with Anna about forgiveness and we shared personal struggles. She mentioned Reverend Carpenter’s speech, “Forgiveness, the Mandela Principle.” I am grateful for this lesson. The majestic humanity of Mandela, in spite of the harm to him and his countrymen, caused me to ponder my own journey with harm.

    I traveled back through the past thirteen years and relived the harm that has come to my first born son and our family, by the system of care charged with protecting his mental health. I recalled Danny’s first appointment with a psychiatrist at the age of 15 when he was slipping fast into a serious mental illness. I had shared my family history with the doctor. It included my brother’s mental illness and diagnosis of schizo affective disorder. I had been taught that a family history would be helpful in treating my son. What I didn’t know was that the prescription for an anti depressant, that was intended to help my son move off the couch that held his clinically depressed young body, would alter his brain chemistry and trigger his first manic episode. That prescription caused my son harm, but that event will not show up in any Medical Error and Adverse Outcome Committee. In fact, the Doctor may not even know how much harm that prescription caused my son and my family. I am glad for this because additional suffering of another human being will not change the outcome.

    For many years, I blamed the psychiatrist who I believed should have known that an anti depressant was ill advised for my son due to the family history. I also blamed myself for filling the prescription and giving the medication to my son. My son blamed me, too. So much blame, so much shame. The harm that I caused my own child almost killed me. The only way for me to live with this was to seek help, seek change and seek forgiveness. I couldn’t do it alone. I needed partners in forgiveness.

    I have described myself recently as a recovering angry mom. Like anyone in recovery, it is one day at a time and there are slips along the way. I forgive myself those lapses and push forward. In recovery you need to share your pain without judgment or defensiveness. You must have your feelings honored and protected. You need to hear about the pain of others and learn from their mistakes and triumphs. I am in the process of peeling away the layers of anger and replacing them with hope. That hope was born out of the forgiveness that I see taking place at CCRMC. It is not simple or cheap. It is “participatory.” It is “ubuntu.”

    There is no healing in a place of shame and blame. There is no social justice in a system that will not offer authentic forgiveness. There is no radical respect in a system that can not admit mistakes. There is no continuous learning in a system that can not reveal its errors. CCRMC is demonstrating that it is a place of healing where social justice, radical respect, and continuous learning will prevail. As healthcare partners we will heal together and show others the way.

    I want to be free. I no longer want “…to be bound by past wrongs.” I forgive the psychiatrist who first treated my son. I forgive myself too. If I have caused you harm, please forgive me.