Hastings Center Report

In a time when issues of patient safety, hospital care quality, and tort reform for medical liability are front-page news and hot topics in the halls of Congress, Nancy Berlinger's After Harm presents an opportune and refreshing perspective on medical error. As Berlinger notes, medical error is a significant problem in our health care system—a preventable phenomenon that causes thousands of deaths each year. But preventing medical error is often a more complex process than we acknowledge. We tend to view medical errors like systems failures, such as might be involved in an airplane crash. Doing this means that we make two key mistakes. First, we see medical error as a problem of organizational design, process, and policy, rather than one of individual action. And second (but related to the first), we allow moral responsibility for medical error to remain institutional, rather than individual.

After Harm eschews the systems approach in favor of focusing on the individual agents involved—the health care provider and the patient (or her family). Berlinger effectively uses both physician and patient narratives to convey the drama and trauma of medical error. She tells both sides of the story—the physician's experience of making a mistake that has terrible consequences for her patient, and the patient or family member's experience of having a life shattered. Rather than concentrating on how physicians or health care systems can prevent errors or avoid lawsuits, using narratives focuses the moral lens on the needs of patients and families who have been harmed. This helps the reader to see how medical error is personal, emotional, and similar to other moral situations where one person harms another.

For Berlinger, medical mistakes are more than mere accidents with bad outcomes, not just because of the serious negative health consequences they give rise to, but also because of the nature of the physician-patient relationship. This relationship is one of great trust: one agent commends the care of one's body or mind to another. When medical errors occur, that trust is shaken to its very core.

The nature of the physician-patient relationship—its intimacy, trust, and consequential value—means that medical errors present particular challenges for maintaining or restoring that relationship in the aftermath of medical harm. Medical errors must be acknowledged, accepted, and forgiven if the medical relationship is to survive. For this reason, Berlinger argues that the responsibility for maintaining or restoring the integrity of that relationship is the health care provider's. She must disclose the error clearly and fully, apologize sincerely for the mistake, and repent for the harm done. Each of these steps is essential to redress the harm that has been done and to ensure that physicians fulfill their ethical responsibility for the harm. These three steps are what make the fourth and final step, forgiveness by the patient or the family—arguably the overall goal—achievable.

Berlinger's approach provides a unique alternative to the environment of guilt, shame, and litigiousness that is often the aftermath of medical harm. However, this approach presents no easy road to salvation. Squarely placing moral responsibility on the shoulders of a single individual will be difficult, and even traumatic, for any clinician. And while After Harm effectively argues for the merits of disclosure, apology, and repentance, the method it advocates runs the risk of making the individual practitioner the sole wrongdoer when the situation may be more complicated. Berlinger quite deftly addresses the issues at stake at the level of the individual agent, and she attends effectively to the harmed patient's interests and needs. Yet she fails to confront how to handle moral responsibility for medical errors that result from true system failures, such as a series of poor decisions made by multiple providers.

After Harm: Medical Error and the Ethics of Forgiveness. By Nancy Berlinger. Johns Hopkins, 2005. 156 pages. Hardcover, $35.00.

Because Berlinger rightfully concentrates on the moral response necessary to redress the harms done to a patient or her family, she may actually underem-phasize the fact that these experiences of medical harm are personal and traumatic for health care...