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Apologizing for medical errors: the ethical approach
Also now seen as risk management strategy
From a grassroots organization's efforts to make medical error disclosure and apology part of the U.S. health culture to more hospitals and other health care players are beginning to be aware of apology, and it would appear that more organizations agree that offering an institutional "I'm sorry" is the right thing to do.
Ethicists have long endorsed this approach to medical errors, i.e., disclose and apologize. But data now seem to be showing that it has benefits from a risk management perspective, and in one case, a hospital is using the data to analyze why the errors are occurring to begin with and introducing those findings to improve its patient safety initiatives.
"[Hospitals] have to be concerned about this kind of stuff, because it's really on the front burner of the national consciousness," says John D. Banja, PhD, professor of rehabilitative medicine and clinical ethicist with the Center for Ethics at Emory University in Atlanta. "I mean, we frankly admit the 20th century approach to [this issue], which was don't apologize and don't disclose, that that's ethically wrong — that's just not the right thing to do. And I think we all agree about that. I think where we may have some disagreement today is maybe at the margin. How much should you tell this [injured patient], and should you say the words, 'I'm sorry'?" Banja tells Medical Ethics Advisor.
Expression of sympathy vs. apology
An important distinction to make is between an expression of sympathy and an actual apology, Banja suggests.
"In other words, those two words — I'm sorry — they can be an expression of sympathy, which just simply means, 'I wish that you didn't experience what you did, and it must have been very unpleasant, and I'm sorry that you went through that," Banja explains. "That's an expression of sympathy, such as when a friend of yours has a loved one who passes away [i.e.] 'This is sad, and I empathize with you.''
"On the other hand, an apology — a really true apology — it's not that I wish you didn't have to experience that. A true apology — if I'm truly apologizing to you for something — what it means is, you shouldn't have had to experience that, and it was my fault."
The latter option is the one physicians and other health care providers should choose when there is a clear case of medical error involved in a patient's harm or injury by the physician or health care institution, Banja says.
Expressions of sympathy are more appropriate when there was an unexpected complication, but not necessarily a medical error, he adds. "You're only going to use an expression of sympathy when it wasn't your fault," Banja says.
Informed consent as risk management tool
A solid informed consent process and discussion can be an effective risk management tool.
"A good informed consent is really a risk transfer mechanism, because if you're my patient, and I say to you, "Well, this is what we can expect after this operation. These are some of the unpleasant things that can happen, and they can happen even if I do everything right," Banja says. "If these risks materialize — even though [the doctor has] done everything right," if the patient has decided to proceed with the surgery, for example, the patient then bears the responsibility for them, because he or she consented to the procedure.
However, at the very least, Banja says, "patients should be able to demand from their health care professionals that their health care professionals treat them according to the standard of care."
If the standard of care is the guideline for treatment or intervention, and an error occurs, it means the clinician did not follow the standard of care, he explains.
"That's what I am implying is: a pretty good definition of error is, it is an unwarranted violation of the standard of care. Or, I have not accommodated the standard of care, or I don't have a good reason why I did not follow the standard of care," Banja says.
Apologies can be difficult and unpleasant
Banja suggests that error disclosures and apologies for medical errors appear to be "very, very difficult for lots of health care professionals to do."
"Because if I'm right, and I think I am . . . when you apologize, that's really an admission of fault," Banja explains. "For lots of health care providers, that's a very, very difficult admission to make.
Banja has written a book on this topic titled "Medical Errors and Medical Narcissism'
"When you apologize to someone, that's an act of humility on your part. You're humble when you're apologizing to someone. You're not narcissistic, and that's why people with narcissistic tendencies or dispositions — or people who have a very, very deep desire to maintain their self-esteem, have a real hard time with apologizing."
The flip side is: when you apologize to someone, they feel respected, which is what makes the apology so therapeutically effective, he says.
"If patients honestly think that their doctor has harmed them through error, and that physician is trying to conceal that fact and is not apologizing, they feel disrespected," he notes. 'And it's very, very hard to trust somebody who you think does not respect you. And that's where things break down. I think that's where the therapeutic kernel of the apology consists. It just speaks to a very, very deep need for self-respect that we human beings have, and that's why it works so well when you apologize to someone in the correct circumstances," Banja suggests.
He emphasizes that the apology is just as therapeutic for the health care provider as for the patient.
"What it does is, it tempers physicians' narcissism," he says. "It injects that humility reminder in that health care professional that medicine has its limits, that I have my limits, and [the] whole point of ethical behavior is patient-centeredness."