Alumni Association, School of Medicine of Loma Linda University … · 2020. 3. 30. · ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY After harm: truth-telling,

88TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING

ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY

After harm:truth-telling, apology,

repair, forgivenessin health care work

Nancy Berlinger

The Hastings Center

2020 Provonsha Lecture

Center for Christian Bioethics

Loma Linda University

March 6, 2020



Moral and ethical dimensions of care work

• How should we respond to one another after a person is harmed by someone whose goal was to heal?

• How should we care for people who are seriously ill or nearing the end of life?

• How should we manage moral problems produced by health care systems and policy?

2

ARE

WORKAROUNDS

ETHICAL?

Managing Moral

Problems in Health

Care Systems

N A NCY BERLINGER



Physicians’ emotions after harm(1)

Physicians “experienced powerful emotions following a

medical error [and] felt upset and guilty about harming

the patient . . . Physicians struggled to find support

following a medical error . . . For many physicians, the

most difficult challenge was forgiving themselves for

the error.”

Gallagher, T. H., A. D. Waterman, A. G. Ebers, V. J. Fraser, and W. Levinson. 2003. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA289, no. 8:1001-1007.



Physicians’ emotions (2)

In the opinion of one physician interviewed:

“Forgiveness is something that I think is tougher for the physicians to give themselves than to get from the patient.”

Gallagher, Waterman, Ebers, Fraser, and Levinson. JAMA 2003.



Physicians’ emotions(3)

“The notion of a ‘blame-free culture’ of errors did not diminish these physicians’ anguish and sense of culpability for errors . . . Better institutional support for caregivers involved in errors would help them focus their attention on the affected patient.”

Gallagher, Waterman, Ebers, Fraser, and Levinson. JAMA 2003.



Ethical and practical challenges

“Deciding how to share the facts of the situation and avoid speculation while simultaneously managing feelings of guilt, the urge to assign blame, and the desire to protect oneself is hardly an easy task.”

Truog RD, DM Browning, JA Johnson, TH Gallagher, Talking with Patients and Families About Medical Error: A Guide for Education and Practice (Johns Hopkins University Press, 2011), 57.



Missing the mark

Jewish traditions and practices concerning

ethical responses to human error:

• chata'ah (“missing the mark”) = error

• kapparah (“atonement”) =

individual obligation following from error



Forgiveness as outcome

Error

↓

Confession (truth-telling, apology)

↓

Repentance/atonement (response to concrete needs of harmed party, e.g., compensation)

↓

Conditions for forgiveness by harmed party



Self-forgiveness

“One cannot forgive oneself for what one has done

if one is not prepared to take responsibility for it,

and the explanation of the failure to take

responsibility for some problematic part of one’s

past might be that one cannot or will not forgive

oneself for it.”

Blustein, Jeffrey, “On Taking Responsibility for One’s Past,” Journal of Applied

Philosophy, 17(2000): 1-19, at 17.



Wrestling with self-forgiveness

Self-reproach (and the need for self-forgiveness) makes

sense “for something over which one had some control.”

(Blustein)

• What happened to that patient was terrible.

• What happened to that patient was terrible, and

I had some control over what happened.

• How much control did I have?





Further readingBerlinger, N. “Resolving Harmful Medical Mistakes—Is There a Role for Forgiveness?” Virtual

Mentor 13, no. 9 (2011): 647-654.

Berlinger N, AW Wu. “Subtracting Insult from Injury: Addressing Cultural Expectations in the Disclosure of Medical Error” Journal of Medical Ethics 31 (2004), 106-108.

Blustein J. “On Taking Responsibility For One’s Past.” Journal of Applied Philosophy 17, no. 1 (2000): 1-19.

Cook RI. “How Complex Systems Fail,” (2000). Cognitive Technologies Laboratory, University of Chicago. Available at: www.ctlab.org/documents/

Gallagher TH., AD Waterman, AG Ebers, VJ Fraser, W Levinson. “Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors.” Journal of the American Medical Association 289, no. 8 (2003): 1001-1007.

Smith AK, MK Buss, DF Giansiracusa, SD Block, “On Being Fired: Experiences of Patient-Initiated Termination of the Patient-Physician Relationship in Palliative Medicine,” Journal of Palliative Medicine 10, no. 4 (2007): 937-47.

Truog RD, DM Browning, JA Johnson, TH Gallagher, Talking with Patients and Families About Medical Error: A Guide for Education and Practice (Johns Hopkins University Press, 2011).



The Hastings Center

Visiting Scholar Program

http://www.thehastingscenter.org/who-we-are/service-to-bioethics/visiting-scholars/

Documents

Alumni Association, School of Medicine of Loma Linda University … · 2020. 3. 30. · ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY After harm: truth-telling,