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Mary Jo Bowman
Christian Ethics
April 17, 2007

The Ethics of Forgiveness:
Applying a Jewish/Christian Paradigm to Cases of Harmful Medical Error

 

Introduction

Forgiveness is a core Christian practice which I feel called to study and promote.

As a pastoring person with a bent towards the practical, I am drawn to understanding how Biblical teachings about forgiveness and their practices in the Jewish and Christian traditions might be more fully embraced by the church and offered in ministry to the wider world. A personal experience of trauma has given me impetus to explore the meaning of forgiveness. About ten years ago I found help from the field of interpersonal forgiveness research pioneered by Robert D. Enright of the Forgiveness Institute at the University of Wisconsin-Madison.1 Subsequently, the insights I gained from participating in a course on trauma recovery (STAR)2 offered at seminary have also been helpful. Also at seminary, I did a word study on forgiveness in Biblical languages. This course work was useful for a series of adult Sunday School sessions on forgiveness I designed and led last year, which included stories from the film Journey Toward Forgiveness.3

As a nurse, massage therapist and aspiring health-care chaplain, I am also interested in the field of medical ethics. I was delighted when a hospital chaplain introduced me to Nancy Berlinger’s work with medical error and the ethics of forgiveness.

I see Berlinger’s work as relevant for chaplains in health care, and for any pastor who might be called upon to accompany a church member—be they a health care professional involved in a serious medical mistake or a person/family injured by such an error. I think the guidance she offers and the questions she raises are applicable to a variety of situations facing church leaders and congregations, most especially those involving misconduct of leaders, or in ministering to persons impacted by traumatic situations such as drunk-driving vehicle accidents, violent crimes, and abuse within families. Her method, which draws on her study of Christian Ethics yet incorporates the broader perspective of religious studies, offers opportunity to reflect on the merits and potential problems of applying such interdisciplinary and interfaith paradigms in churches and in public spheres.

 

Nancy Berlinger’s Work with Narrative Religious Ethics and the Process of Forgiveness

This case study is based on Nancy Berlinger’s book, After Harm: Medical Error and the Ethics of Forgiveness.4The book, which expands upon previous articles she has written on this subject, 5 represents a religious studies response to medical error. This work was done following the 1999 publication of the Institute of Medicine’s report on the problem of medical error in the United States entitled To Err is Human: Building a Safer Health Care System. This report, with its startling statistics about the extent and cost of medical error, has gained a great deal of attention. Berlinger seeks to bring the element of forgiveness into the discussion, noting that the IOM’s report leaves out the second half of the proverb from which its title is derived: “To err is human; to forgive, divine.”6 She suggests that

insights from religion and related aspects of culture may help hospitals charged with meeting new standards of patient safety to recognize the restorative role that forgiveness has long played between individuals and within communities and to incorporate forgiveness into their systems for dealing with medical mistakes that lead to injury, death, or other trauma. 7

Berlinger’s approach to religious ethics incorporates the interdisciplinary work of scholars who pay attention to the religious aspects of forgiveness, along with their secular expression. She also draws on the particular area of Christian social ethics, in particular the Christian theological work of Dietrich Bonhoeffer regarding issues of suffering, truth telling, and responsibility.8

The experience of medical error, for “individuals in systems”9 serves as the starting point for Berlinger’s approach. This approach is called “narrative ethics.”10 Within the field of bioethics, this “usually refers to the argument that a patient’s story, voice, and perspective are as important, if not more important, than the clinical account of that patient’s treatment as reflected in the medical records.”11 The personal narrative plays a “clear moral role…as a tool for encouraging medical students and physicians to be ever mindful of the continuing impact of their mistakes on many lives, including, but not limited to their own lives, and for helping them to perceive and acknowledge their concrete obligations to patients and families after harmful mistakes.”12

This narrative approach provides the groundwork for moving through a relational process that has the potential for culminating in forgiveness after medical harm. In the paradigm presented by Berlinger, the steps in this process are disclosure, apology, repentance, and forgiveness. When utilized, this process not only allows for the possibility of recovery from trauma, it has been shown to reduce and prevent medical law suits. We will examine each of these steps before listing the proposals that Berlinger offers for putting this process into practice. But first, let us look at the need for narrative ethics in medicine, followed by Berlinger’s definitions of forgiveness and the religious resources of scripture and tradition.

The Need for Narrative Ethics in Medicine

Berlinger insists that physicians must learn to tell the stories of their errors to their peers, superiors and employers in ways that redemptively deal with their own trauma and assist them in taking responsibility for what they have done or failed to do. Traditionally, physicians have told their stories to each other, as in the forum of the Mortality and Morbidity (M&M) Conference, a “hair-shirt ritual (of ) self-criticism, confession and forgiveness…which serves to reintegrate offenders into the group and to reaffirm group norms…and exact the allegiance of its members to its standards.”13 A significant shortcoming of this practice is that “the patient has no role, no voice, no representation within this private ritual, and cannot rely upon it for justice, nor for the possibility of being able to forgive and heal.”14 In addition, M&M tends to focus on self-forgiveness, thereby neglecting the essential concern for the physician-patient relationship.

What Do We Mean When We Say “Forgiveness”?

Berlinger takes a religious studies approach to forgiveness, not a strictly theological or doctrinal one. First, forgiveness is relational; it involves “actions that various persons undertake in relation to one another so forgiveness can take place.”15 Second, because it is relational, forgiveness is not automatic; it is not a “self-interpreting principle.”16 Drawing on Dietrich Bonhoeffer’s objection to “cheap grace,” the kind of forgiveness Berlinger promotes gives attention to the role of the injured person as an agent with choice. Instead of insisting on the formula that “good people are forgiving,” injured persons should not be pressured to forgive, nor should they be falsely reassured about the promise of closure or the motives of the offender. In other words, forgiveness is not a right to be claimed as an entitlement.17 Third, “forgiveness” holds contradictory meanings--both “to engage” and “to detach.”18 According to Berlinger, “in the Jewish and Christian traditions, the deepest meaning of forgiveness is detachment.19 This detachment takes time,20 and is most authentic when the truth has been told and justice has been done. While detachment might be the ultimate goal in dealing with medical error, Berlinger argues that this cannot be achieved authentically without engaging the steps toward forgiveness. Fourth, we must name another caution: while widely influential in Western culture and medicine, the Jewish and Christian notion of forgiveness is not “universally understood as a principle, norm, or religious or secular practice…It would not be appropriate to talk the ‘Buddhist’ or ‘Hindu’ understanding of forgiveness, not because these traditions are ‘unforgiving,’ but because ‘forgiveness’ as a metaphor for a relationship between autonomous persons simply may not work in traditions in which a concept of the self as independent form others persons or one’s past lives is not the norm. ”21 Berlinger advises that doing religious ethics calls for “describing what real people really believe and how they really act”22—taking care not to over-simplify or sentimentalize complex relationships. Fifth, in considering what we mean by forgiveness, Berlinger does not agree with Enright and his colleagues who suggest that “the ability to forgive is a marker of psychological health and may be indispensable to the healing of relationships.” 23 She insists that making forgiveness a norm or virtue puts too much onus on the injured party, requiring that she “both be good and be God.”24

Scripture and Tradition

While Berlinger’s approach focuses on experience and paradigm, she does touch on Scripture and tradition. Instead of studying Biblical words for “forgiveness,” she focuses on “sin.” Starting with the Hebrew Bible, she looks at the word heť, which is typically translated into English as “sin.” However, she notes that “its oldest meaning...is ‘to miss the mark’…Heť is also used to describe breaches of social ethics, as when someone ‘misses’ an opportunity to assist another. It has a theological dimension when one misses with respect to one’s relationship with God, or in the performance of religious rites.”25 In the context of the Hebrew Bible, heť more accurately means “error” rather than “sin” in the “post-Augustinian sense of original sin or moral taint. (This requires) close attention to context to determine whether a given error was intentional, unconscious, or avoidable, a matter of judgement, skill, experience or character. ”26 This nuanced meaning is especially significant in the field of medicine.

In looking at the New Testament, Berlinger focuses on the Lord’s Prayer. Matthew’s version is best known with the phrase: “forgive us our debts as we also have forgiven our debtors” (Matt.6:12, NRSV). She observes:

the ‘debt’ language, which has many antecedents in the Hebrew Bible, means God forgives sin by releasing the believer from the error that is holding him captive, and that one human being forgives another by detaching from that person, and the harm than persons has caused, as a source of pain, anger, and injustice. The underlying metaphor is the cancellation of a financial debt that can never be repaid; the metaphor itself is grounded in a culture in which debt-servitude was common.27

The version of the Lord’s Prayer in Luke 11:4 makes clear the Jewish roots of the Christian understanding of how forgiveness works: “forgive us our sins, for we ourselves forgive everyone indebted to us” (NRSV). Berlinger sums it up this way: “God forgives the error, but people must forgive each other.”28

In comparing Jewish and Christian approaches to forgiveness, Berlinger observes that “Jewish traditions…emphasize human agency to a somewhat greater extent than do Christian traditions, in which divine agency, often represented by clergy, may be more prominent.”29 (emphasis mine). She gives the example the understanding of “atonement.” The Hebrew word for “atonement” (kapparah) refers to “the reconciliation of the person who has committed an error with the person he or she has injured.” 30 This process involves restitution, or compensation, with the injured party playing an active role in the repentance of the offender.31 In contrast, despite the emphasis in Jesus’ teachings about the interrelatedness of divine and human forgiveness, Berlinger notes:

Christian paradigms of error and forgiveness may stress personal salvation (the repair of one’s relationship with God) over the concrete making of amends to the injured party...These tendencies can lead to a truncation, even a perversion, of the process…that Bonhoeffer...calls ‘cheap grace…cut-rate forgiveness…grace as a doctrine, as principle, as system.’ In this ‘system,’ disclosure, apology and repentance—all the traditional, specific responsibilities of the person who has harmed another—are eliminated, as forgiveness is elevated to a ‘general truth.32

The Process of Moving Toward Forgiveness

As stated earlier, Berlinger outlines the process as steps of disclosure, apology, repentance and forgiveness. This section will discuss definitions, practices, and challenges related to these steps when considered as responses to medical error.

Disclosure, the first step, has to do with truth-telling. In medicine, honesty and openness with patients is fundamental to professional ethics. Berlinger observes, however, that while most physicians would agree that telling patients the truth about medical mistakes is a professional obligation, the practice of disclosure is “among the most highly contested and emotionally fraught issues”33 regarding patient safety. Definitions of “truth-telling” may be reduced to “not-lying” and errors can be explained as “complications” or blamed on patient “noncompliance.” Fear of litigation is a significant factor, as well as the “hidden curriculum” in which medical students and residents learn “that their mentors and supervisors believe in, practice, and reward the concealment of errors.”34

Bonhoeffer’s prison essay on “What is ‘speaking the truth’?”35 serves as a key resource for Berlinger’s discussion of the meaning of disclosure. Bonhoeffer insists on framing the practice as one which is “embedded in human relationships and social contexts.”36 The tension between individual and authority in Bonhoeffer’s essay is a significant factor in the uneasy relationship between physicians and hospitals. Themes in Bonhoeffer’s essay on truth-telling are related to other themes in his writings which are relevant to our topic: i.e. “the ‘view from below’ as an ethical standpoint and ‘responsibility’ as an ethical norm.”37 The standpoint of “view from below” embraces personal suffering rather than seeking personal good fortune.38 In the case of health care systems, this perspective calls for seeking justice rather than focusing on protecting the medical profession or institution.39 “Responsibility” has to do not only with offering comfort but trying to stop harm from happening. 40

The second step toward the goal of forgiveness is apology—saying “I’m sorry, ” taking responsibility, and acknowledging regret. After medical harm, apology is complicated by the existence of “I’m sorry” laws, which have been adopted in many states to “offer varying degrees of legal protection for expressions of sympathy and even admissions of fault.”41 Another complicating factor is that unintentional harm which may legally considered “negligence” is still harm, and needs to somehow be reckoned with. Jonathan Cohen observes that “it is the failure to apologize, not the accident itself, that leads to ‘relational breakdown’ and thence lawsuits.”42 In the physician-patient relationship, the power dynamic—the physician’s position of trust and the patient’s vulnerability are significant factors in the apology process.

Repentance is the third step toward forgiveness. As Desmond Tutu said so eloquently:

“If you take my pen and say you’re sorry, but don’t give me my pen back, nothing has happened.”43 Repentance implies accountability and involves fair compensation. Since restitution (the restoration of the actual thing) is rarely possible in the case of medical harm, compensation after medical harm calls for reparation, i.e. concrete action which

symbolizes a willingness to repair the damaged relationship between injured patients and providers. It also represents a willingness to acknowledge and repair the actual damage done to the body and life of an injured patient as a result of a medical mistake.44

 

To illustrate the viability of practicing repentance in cases of medical error, Berlinger highlights three “fair-compensation programs”: in a Veterans Administration hospital, a large network of Catholic hospitals, and a malpractice insurance provider.45

These three steps in the process--disclosure, apology, and repentance—are necessary conditions for reaching the goal of forgiveness. They make take many forms, depending on the situation, yet each step requires “direct engagement with the injured party and attentiveness in their stated needs”46 as revealed in the narrative of the harm experienced. The final step of forgiveness is the taken at the prerogative of the injured party.

 Proposals for Ethical Action

Berlinger concludes her book with proposals for “ways to improve how individuals working within systems care for injured persons and their families and for clinicians whose mistakes harm patients.” 47 These proposals summarize the principles (not rules) that are meant to guide pragmatic ethical action in cases of medical harm. She organizes them into the traditional Western religious categories of confession, repentance, and forgiveness, as follows:48

Confession(encompassing truth-telling and apology):

Repentance:

Creating conditions appropriate for Forgiveness:

Conclusion

How might Nancy Berlinger’s work be a resource for the church? I stated my observations on possible applications in the introduction to this paper. The reader’s guide at the end of After Harm was developed by two physicians to help health care professionals study the book; this would be useful for a special interest group within a congregation or network of churches who might want to explore this topic further. For the purposes of this class and the seminary community, I suggest the following questions for consideration and discussion:

1. What is your personal experience with medical harm, as a patient, family member, friend, pastor, chaplain, or health care professional?

2. In what ways does Berlinger’s approach seem relevant to your experience?

3. How might you use Berlinger’s insights in your ministry?

4. How is her inter-religious and interdisciplinary approach relevant (or not) to situations which arise in the church?

5. How does Berlinger’s treatment of scripture and the Jewish and Christian traditions line up with your understanding?

6. What do you think of her definitions of forgiveness, and the process of moving toward that goal?

7. What are your reflections on her use of Bonhoeffer?

8. What do you think of her proposals for ethical action in health care?

9. What did you learn from her? What would you critique?

Bibliography

Berlinger, Nancy. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, Maryland: Johns Hopkins University Press, 2005.

———. "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(s) of Forgiveness." The Hastings Center Report 33, no. 6 (N/D 2003): 28-36.

Enright, Robert D., and Joanna North, eds. Exploring Forgiveness. Madison: University of Wisconsin Press, 1998.

Jerry Holsopple, Producer, Executive Producers: Burton Buller, and Dave Pomeroy. "Journey toward Forgiveness: From Rage to Reconciliation." 58 minutes. Harrisonburg, Virginia: Mennonite Media Productions, a division of Mennonite Mission Network, 2001.

Additional Resources

Berlinger, Nancy. "Broken Stories: Patients, Families, and Clinicians after Medical Error." Literature and Medicine 22, no. 2 (2003): 230-40.

———. "Fair Compensation without Litigation: Addressing Patients' Financial Needs in Disclosure." Journal of Healthcare Risk Management 24, no. I (2004): 7-11.

———. "Promoting Patient Safety: Implications for Pastoral Care." Journal of Pastoral Care and Counseling 58, no. 1-2 (2004): 55-61.

———. "What Is Meant by Telling the Truth: Bonhoeffer on the Ethics of Disclosure." Studies in Christian Ethics 16, no. 2 (2003): 80-92.

Berlinger, Nancy, and Albert W. Wu. "Subtracting Insult from Injury: Addressing Cultural Expectations in the Disclosure of Medical Error." Journal of Medical Ethics 31 (2005): 106-08.

Burrell, D, and S. Hauerwas. "From System to Story: An Alternative Pattern for Rationality in Ethics." In Knowledge, Value, and Belief, edited by H.T. Engelhardt and D. Callahan. Hastings-on-Hudson, NY: Hastings Center, 1997.

Cooper-White, Pamela. The Cry of Tamar: Violence against Women and the Church's Response. Minneapolis, Minn.: Fortress Press, 1995.

A feminist ethicist who, along with Marie Fortune (cited below) argues against an ethic of instant forgiveness.

Fortune, Marie M. "Forgiveness: The Last Step." In Abuse and Religion: When Praying Isn't Enough, edited by A.L. Horton and J.A. Williamson. Lexington, KY: DC Health and Company, 1988.

Gilbert, Sandra M. Wrongful Death: A Memoir. New York: W.W. Norton, 1997.

Literature scholar and poet tells of her husband’s death after surgery for prostate cancer. Her story is an example of cases (like that of Carol Levine cited below) in which there is clear evidence of error, yet the hospital failed to fully explain what happened. Litigation thus followed, especially because of how the family was treated after the error.

Gwande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. New York: Henry Holt and Company/Metropolitan Books, 2002.

Reflecting on his experience with a nearly deadly mistake as a surgical resident. He describes his experience with the Morbidity and Mortality (M&M) Conference, and addresses issues of the “hidden curriculum” of how error is handled among physicians and the influence of risk management departments on the practice of medical ethics.

Hilfiker, David. "Facing Our Mistakes." New England Journal of Medicine 310, no. 2 (1984): 118-22.

A personal narrative of medical error told from a physician’s perspective in which the author reveals his year-long emotional process in the aftermath of his mistake. As a general practitioner in a rural practice, he diagnosed a miscarriage and performed a dilation and curettage only to discover that the patient was indeed pregnant with a viable fetus. In effect, he had performed an abortion.

———. "From the Victim's Point of View." Journal of Medical Humanities 22, no. 4 (2001): 255-63.

———. Healing the Wounds: A Physician Looks at His Work. New York: Pantheon Books, 1985.

Levine, Carol. "Life but No Limb: The Aftermath of Medical Error." Health Affairs 21, no. 4 (2002): 237-41.

Written by a prominent bioethicist about her experience of a medical error that necessitated the amputation of her husband’s arm after other grave injuries from a car accident. (See note under Gilbert above.

Ofri, Danielle. Becoming a Doctor at Bellevue. Boston: Beacon Press, 2003.

A story…of a medical resident (working as an internist) whose patient’s unusual medical history and the several errors in the hospital system, including her own, culminated in the patient’s death. She reflects on how the M&M ritual sometimes functions as a place to blame residents for mistakes.

Rasmussen, Larry. "The Ethics of Responsible Action." In The Cambridge Companion to Dietrich Bonhoeffer, edited by J.W. deGruchy. Cambridge: Cambridge University Press, 1999.

Weiss, R. "Medical Errors Blamed for Many Deaths: As Many as 98,000 a Year in U.S. Linked to Mistakes." Washington Post November 30, 1999.

Endnotes

The following book of essays is a sample of this field of social scientific study: Robert D. Enright and Joanna North, eds., Exploring Forgiveness (Madison: University of Wisconsin Press, 1998), 3.

See also www.forgiveness-institute.orgwww.forgiveness-institute.org

Strategies for Trauma Awareness and Resilience (STAR), a program for empowering church and community leaders related to the Center for Justice and Peacebuilding at Eastern Mennonite University.

Producer Jerry Holsopple, Executive Producers:Burton Buller, and Dave Pomeroy, "Journey toward Forgiveness: From Rage to Reconciliation,” ( Harrisonburg, Virginia: Mennonite Media Productions, a division of Mennonite Mission Network, 2001). This documentary was originally produced for ABC-TV in cooperation with the National Council of Churches and the Interfaith Broadcasting Commission, and aired on numerous ABC stations.

Nancy Berlinger, After Harm: Medical Error and the Ethics of Forgiveness (Baltimore, Maryland: Johns Hopkins University Press, 2005).

Berlinger is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary. She is Deputy Director and Research Associate for Religious Studies with the Hastings Center, an independent, nonpartisan, and nonprofit bioethics research institute founded in 1969 to explore fundamental and emerging questions in medicine, health care, biotechnology. She is a volunteer chaplain at Memorial Sloan-Kettering Cancer Center in New York.

In particular, Nancy Berlinger’s "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(s) of Forgiveness," The Hastings Center Report 33, no. 6 (N/D 2003), was expanded to produce the book After Harm. Available through EMU’s online database (Wilson Web), accessed through the Humanities Index.

Nancy Berlinger, "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(S) of Forgiveness," The Hastings Center Report 33, no. 6 (N/D 2003): 28.

Ibid.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 128n33. Bonhoeffer may be identified as a medical ethicist, because n Ethics he reflected on euthanasia and eugenics.

Ibid., xii. She distinguishes her approach from an approach that pits individuals against systems. Instead, she “focuses on the experience of individual clinicians, patients and family members the aftermath of medical harm” in a way that assumes a systems context.

Ibid., 3-5. Narrative ethics is an interdisciplinary approach which includes bioethics, medical humanities, literary studies, trauma studies, and rituals.

Ibid., 3.

Ibid., 26-27.

Berlinger, "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(S) of Forgiveness," 31-32. M&M is a form of medical peer review described and critiqued by Charles L. Bosk’s classic study Forgive and Remember: Managing Medical Failure (Chicago and London: University of Chicago Press, 1979).

Ibid.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 82.

Ibid.

Ibid.

Ibid.

Ibid.

Ibid. 82-83. This is the kind of time that the Christian Bible refers to a kairos (the appropriate time) rather than chronos (chronological time).

Ibid., 83. Berlinger observes that the Buddhist concept of “compassion” might be a more appropriate metaphor for a significant minority of the U.S. population. She notes that 20% of physicians practicing in the United States were born and raised in Asia, as were 25% of the foreign-born residents.

Ibid.

Ibid., 87.

Ibid.

Ibid., 84.

Ibid.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 85.

Ibid.

Ibid., 84-85.

Ibid.

Ibid. Observant Jews ritually enact this process each year prior to Yom Kippur.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 85-86. The Bonhoeffer quote is from “Costly Grace” in Discipleship, ed. Kelly and Godsey and trans. B. Green and R. Krauss. ( Minneapolis: Fortress Press, 2001), 43.

Ibid., 41.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 41.

Ibid., 42. From Letters and Papers from Prison, Ed. E. Bethge (New York: Simon and Schuster, 1997)

Ibid., 43.

Ibid., 44.

Ibid., 48-49.

Berlinger, "Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(S) of Forgiveness," 34.

Berlinger, After Harm: Medical Error and the Ethics of Forgiveness, 48.

Ibid., 51.

Ibid., 55. Quoted from “Legislating apology: The pros and cons”. University of Cincinnati Law Review, (2002) 70:819-72, p. 843. Cohen is a law professor and economist, and also a scholar of Jewish ethics.

Ibid., 61. Quoted in C.D. Schneider “What it means to be sorry; The power of apology in mediation” Mediation Quarterly 17 (3). Available online at www.mediation-matters.com/Resources/apology.htm.

Ibid., 67.

Ibid., 69-78.

Ibid., 80.

Ibid., 92.

Ibid., 92-113. This list is annotated by Berlinger, with extensive comments. Berlinger notes that professional chaplains can play key roles in the actions which I have marked with an (*); See p. 90, 99, 170-108. Considering that chaplains can play a key role in shaping the ethics of the institution where they work, I have marked areas which I consider to be potential additional areas of chaplain involvement with an (&).