This book takes a unique look at medical errors from the perspective of the physician, the victim and their family, and the legal system. Berlinger uses disciplines such as religion to help formulate her ideas. She presents examples from multiple viewpoints to give a non-biased analysis. This book does not look so much at why medical errors occur, but what happens afterwards. Disclosure, apology, repentance, and forgiveness are each discussed in separate chapters. Berlinger provides numerous examples and details that help explain what happens in the aftermath of a medical error. Personal accounts rationalize why some people react the way that they do.
Narrative Ethics
Victims of medical mistakes sometimes choose to write and publish the details of their experiences. These accounts are key in helping ethicists and healthcare professionals understand what happens after a medical mistake occurs (1). Many of these accounts explain how communications between patients and the responsible physician break down, presumable as a response to the physician or facility's fear of legal repercussions (2).
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Physician errors are the cause of thousands of deaths per year.
Image Source: HYMS Surgical Society
Berlinger classifies the use of factual or fictional stories to detail an ethical dilemma as a narrative ethic (2). She describes other disciplines relating to medical error. Medical humanities studies literature and other mediums that use illness or medicine as the subject of their work. Trauma studies focus specifically on narratives of trauma survivors.
Religion is a major discipline that comes up in the discussion of medical errors. Both Catholicism and Judaism both stress confession, apology, repentance, atonement, and forgiveness. Sharing stories and working through the above steps with an actively listening party is important in rebuilding relationships according to both religions. Berlinger relates the religious disciplines to the morbidity and mortality (M&M) conferences in which physician's recount their errors and discuss their actions (9). While the ethical framework of David Hilfiker always portrays the patient as the victim, Dietrich Bonhoeffer introduces the idea that the physician may also suffer from the error (10).
to topPhysicians' Narratives
Physicians will also write narratives detailing their mistakes so that others can learn from the errors they made and hopefully prevent such errors from occurring in the future (11). Berlinger shares some examples of these physician narratives- all of which have the commonality of the physicians wanting to share their mistakes so that others could learn from them (12). The physicians' narratives expand on Bonhoeffer's idea that patients are not the only victims of medical error. Berlinger quotes the emotions of one physician's dialogue published in the a British journal in which the physician dealt with,
the unqualified support of the [physician's] own family; the "mixed" responses of colleagues; the temptations of alcohol; for several months, reliving the mistake through daily thought and nightly dreams; collapsing in tears at the realization that "'getting over it' was not the issue- living with it was"; the disastrous first anniversary (12).
Berlinger includes snippets from other physician narratives that show an array of emotion at different stages in the case.
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Physicians will often document the case.
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Medical educators use different methods when it comes to helping physicians deal with their errors. One method involves the physicians writing anonymous stories detailing their mistakes which are then distributed randomly and read aloud by the group. Another method entails the physician writing about their mistake by writing it in the form of a letter to the patient and/or their family. Third-year medical student Rita Charon developed a third model called the "Parallel Chart" in which the story is written not only from the physician's perspective but also from that of the patient and their family (25).
According to Berlinger, once a patient is affected by medical error, they cease to be a patient in need of compassion and further care and become a legal problem (25). She stresses that it is far more effective to keep the patient and their families abreast of the new treatment plan and tell the truth (26).
to topPatients' and Families' Narratives
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Families can write a narrative as a memorial to a lost loved one.
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Patients and their families also write detailed accounts of the story. Their narratives come in many forms- published essays in health policy journals or patient safety newsletters, memorial websites, advertisements by activists, published as part of a Congressional hearing, captions on photos, and book-style memoirs. Many stories are written by patient's families as they struggle to share the case that took the life of their loved one as a way to preserve their memory (28). After Nancy Lim died as a result of a medical error, her husband created a memorial website detailing her story. He writes that Nancy, "died from misdiagnosed complications from two surgeries to repair a botched Caesarian section" (Barnes). The site focuses on Nancy's medical the treatment, the delivery of the news of her passing to her husband, and how the family is dealing with her death.
While outsiders may view families suing healthcare professionals and institutions as greedy, Berlinger offers an alternative explanation. Michael Rowe and his wife, Gail, stated that, We want to be paid. And if we can't have [our son] back, we want to be paid in understanding, and if we can't have understanding, then we want to be paid in money (qtd in Berlinger 38). The quote emphasizes that money is not the primary concern- what families really want is understanding and compassion from the responsible parties and in lieu of that, they turn to monetary compensation for their loss.
to topDisclosure
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Disclosing error to patients and their families is encouraged.
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All medical ethicists and professionals agree that patients should be told the truth. The discrepancies of the meaning of the word truth lead to problems. To some individuals, telling the truth means not leaving out any details and telling the whole story whereas others consider that they have told the truth so long as they have not lied, meaning that omitting information is acceptable (41). Berlinger analyzes different definitions of what it means to tell the truth and how physicians should approach such situations where they are obliged to tell the truth.
to topApology
Two of the most important words after a medical error are 'I'm sorry'. Berlinger examines how the contexts in which these words are used affect their meaning. For example, there is a difference between saying, "I'm sorry your son died" than saying, "I'm sorry my actions led to your son's death" (51). Berlinger also write about the legal implications of saying, "I'm sorry." Simply saying, "I'm sorry" is not admission of fault unless fault is actually admitted. The laws vary state by state but most states allow for apologies to be issued to victims and their families with some degree of legal protection for the responsible party (53).
to topRepentance and Forgiveness
Berlinger discusses apologies and physical compensation as forms of repentance. Apology, repentance, and forgiveness are essential steps following the commission of a medical error. The ability of forgive is often based in the repentance of the responsible party. It is easier to forgive an individual after they have apologized and repented their actions. The nature of an apology and repentance depend on the case, the responsible party, and the victim and their family. Forgiveness does not apply simply to the victim and their family forgiving the physician, but also to the physician forgiving himself (89).
to topDiscussion Questions
The book concludes with questions organized based on the chapters to stimulate group discussions.
to topWorks Cited
- Berlinger, Nancy. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore: The Johns Hopkin University Press, 2005.
- Barnes, Michael. Blunt Instruments. 31 Oct. 2007 <http://www.nancylim.org/>.