How to find forgiveness for the costliest of mistakes

Part of being human is making mistakes. But what we say and do after the mistake makes a tremendous difference.

When a mistake involves serious injury or even death, the stakes are high. A highly publicized 1999 report from the Institute of Medicine, "To Err Is Human," estimates that nearly 100,000 hospital deaths each year may be caused by preventable errors.

The report has energized efforts to reduce mistakes in a medical system that is complex and in many ways archaic. Hospitals are adopting new practices such as computerizing records and prescriptions to curtail medication errors, requiring surgeons to complete airline-style checklists before operating, and having the patients themselves mark the correct locations for their surgeries.

But what role should be played by the latter half of Alexander Pope's famous maxim: "To err is human; to forgive, divine"? What actions promote forgiveness, and how might a greater attention to seeking forgiveness improve our medical system? What part does forgiveness play in healing?

Forgiveness on the part of an injured patient, or the family if the patient has died, comes as a result of both words and actions on the part of doctors and hospitals, says Nancy Berlinger in her thoughtful and well-researched book "After Harm: Medical Error and the Ethics of Forgiveness."

Judeo-Christian principles can inform proper action, regardless of the religious backgrounds - or lack thereof - of those involved, she says.

The victims of true mistakes, unintentional harm, include the doctors or other medical workers themselves.

"Most medical harm does not result from the negligence of 'bad' doctors," she writes. "Most physicians feel genuine remorse, even anguish, when they realize that their well-intentioned actions have injured or killed a patient who was under their care."

Telling the truth about mistakes is hard and humbling for anyone, she says. But fear of lawsuits makes many doctors even more reluctant to speak candidly with patients and families.

Yet less than 2 percent of patients who are harmed in hospitals actually sue their doctors, according to The Harvard Medical Practice Study, Ms. Berlinger says.

Ironically, lawsuits are often filed because families feel their grief is being ignored. The silence suggests that - to the doctor and hospital - nothing important has happened. Mistakes can be forgiven, she says, but indifference is much harder to forgive.

Often lawsuits are undertaken, at least in part, not to win compensation, but to discover the truth. Said the mother of one victim: "[I]f we can't have Jesse back, we want to be paid in understanding, and if we can't have understanding, then we want to be paid in money."

The keys to evoking forgiveness include promptly acknowledging the error, apologizing and expressing sincere remorse, and offering compensation, Berlinger says. A number of states have passed "I'm Sorry" laws that encourage doctors to apologize by exempting the apology itself from being used in court against them.

But alone, apologies are not enough, she says. Fair compensation must be considered. Apologies that lack accompanying actions, Christian theologian Dietrich Bonhoeffer suggests, result only in "cheap grace" or "cut-rate forgiveness."

In the King James Bible's version of the Lord's Prayer, she notes, the words "Forgive us our debts" employ a financial metaphor for forgiveness.

One result - or, in a religious sense, a blessing - from apologies and compensation can be a reduction in lawsuits and costs to hospitals and insurers.

One veteran's hospital in Kentucky with an active policy of seeking forgiveness reduced the average settlement to victims of medical errors to $15,000, compared with an average of $98,000 at all veterans' hospitals.

COPIC, a medical insurer based in Denver, instituted what it called a 3R program - Recognize, Respond, and Resolve - toward patient injuries. The cost of its claims dropped from an average of $78,741 to $1,820. COPIC's guidance to doctors restates Jesus's imperative to "do unto others as you would have them do unto you."

"[W]e must treat our patients as we would want ourselves or our families to be treated," COPIC says.

Recent studies suggest that an inability to forgive, and its accompanying feelings of hostility and anger, may be harmful to one's physical health. With this in mind, hospitals and physicians who free injured patients and their families to forgive medical mistakes can be seen as advancing their own fundamental goal: healing.

• Staff writer Gregory M. Lamb covers healthcare issues for the Monitor.