Forgiveness as morally serious response to errors in healthcare: A narrative review

Forgiveness — the foregoing of vindictive resentment toward a wrongdoer — while practiced informally, is not often inscribed in official organizational processes that are intended to deal with the aftermath of error, harm and undesirable behavior in healthcare. Indeed, almost nowhere is forgiveness choreographed into organizational ritual or official post-incident action.^{[1, 2]} Retribution for errors or undesirable behaviors remains common and can take many forms — from verbal criticism and blame to shaming and humiliation, isolation or exclusion ,^[3] demotion or loss of privileges ,^[4] disciplinary action, increased scrutiny and monitoring, retaliatory assignments or workload, stretched-out investigations, to denial of mentorship and advancement.^{[5,6,7,8,9,10]}

Scholarly literature and hospital administration practices tend to see retribution as a morally serious and sometimes even necessary response to errors and undesirable behaviors in healthcare.^{[4, 11,12,13,14,15,16,17]} The reasons are broadly as follows. Not only does retribution deter a wrongdoer and others from similar behaviors ,^[18] it also compensates the disrespect and contempt that wrongdoing expresses to the (professional) community and victims, and redresses any unfair advantage gained by the wrongdoer.^[19] A wrongdoer or error-prone clinician shouldn’t be allowed to “hide” behind system-level issues that might have conspired against their ability to do well.^{[14, 20]} The balance of social and moral status is best restored by backward-looking resentful blame and just punishment ,^[12] lest it leave the moral field tilted toward wrongdoers and undervalue the dignity and effort of others.^{[20, 21]} What’s more, to respect a wrongdoer as a member of a moral community or profession, is to engage in a backward-looking process of judgment, blame and punishment, restitution and conditional restoration.^[5] Resentment and punishment recognize the wrongdoer’s humanity and affirm their status as a fellow professional, indirectly paying them “something of a compliment.” ^[22]

A morally serious response, then, counterbalances the ethical weight (in broken trust, loss, suffering caused, advantage gained) of undesirable behaviors, and exacts dues for (continued) membership in a moral, professional community. Retribution does this in the form of rightful resentment and just punishment. Whereas this may be a morally serious response, it could be considered morally incomplete and possibly counterproductive for patient safety. For it lacks the following:

• An honest reckoning with individual versus systemic failures, including lessons for and obligations on actors beyond the wrongdoer;^{[23,24,25,26,27]}
• Mitigating the underreporting, risk secrecy and organizational learning disabilities that come from retribution;^{[28, 29]}
• Admitting the workings of power and power gradients in the administration of retributive justice for errors and undesirable behaviors in healthcare;^{[3, 30,31,32]}
• Accountability in the form of eliciting, and acknowledging, the accounts of all involved;^[33,34,35]
• Accountability in a forward-looking way, in which the wrongdoer is encouraged to honor the lessons learned by changing their practice ^[36] and avoid defensive tactics;^[37]
• Restoration of relationships and regaining trust through empathy and action;^[38]
• Repairing the impacts and promoting healing for all involved, including patients, colleagues, family, and institutions.^{[7, 39]}

Below I take these issues into account as I assess how forgiveness can qualify as a morally serious and more complete alternative response to errors and undesirable behaviors in healthcare.^{[40, 41]} I do so by examining, in turn, the three major concerns of learning and quality improvement; accountability; and repair and restoration. I conclude the paper with a concrete proposal for how a process of forgiveness after error in healthcare might look.

In the (patient) safety community, concern about retribution stems in large part from its inability to discover underlying causes because of the focus on personal failings at the sharp end of healthcare delivery.^{[24, 26, 42]} Research in healthcare ^{[25, 43]} has shown for decades that behind errors and undesirable behaviors lies a vast landscape of systems complexity, operational goal conflicts and resource constraints, organizational dynamics, and institutional and engineered sources of both error and expertise.^[44,45,46] This “systems view” holds that both success and failure are the joint products of many factors distributed across such a landscape — all necessary and only jointly sufficient.^{[23, 47, 48]} From this position, errors and undesirable behaviors are foremost seen as consequences rather than causes of trouble.^{[29, 49]} Quality improvement comes not from targeting individual behavior, but the conditions that generate and shape such behavior — including organizational and technical factors.^[50]

This also means that responsibilities for creating the conditions for errors and undesirable behaviors fan out beyond the wrongdoer :^[25] People don’t come on work to make poor choices, they often have poor choices.^[51] In some situations, people working at the point of healthcare delivery and risk are given or left with poor choices.^[52] For a hospital administration, it may be convenient to mistake frontline errors as causes rather than consequences of trouble, but it can allow a system to escape accountability for setting its people up to fail.^{[6, 53,54,55]} It is a dynamic that has been shown to promote risk secrecy ^{[56,57,58,59,60]} and entrench organizational learning disabilities.^[61]

A morally serious response, as laid out above, acknowledges and counterbalances the advantage yielded by the wrongdoing. A wrongdoer, after all, “enjoys the system’s benefits without having to shoulder [their] fair share of the burdens that make those benefits possible.”^[12] But the major advantage (which may for example have allowed things in the hospital to go faster or cheaper through workarounds, interruptions and shortcuts, thus multiplying error opportunities) ^[62,63,64] was gained not by the wrongdoer, but by the organization which got things done despite risks, obstacles and difficulties. The ethical weight of the wrong may then rest more with organizational complicity, because of its implicit disrespect for both the patient and the frontline healthcare worker. A morally serious response must take into account the systemic trust that has been damaged. Institutional actors should be committed to transparency, restitution, and creating safer systems, acknowledging that harm is often multifactorial. Forgiveness and restoration of frontline workers involved in adversity, then, redresses the equilibrium of social and moral status which was disturbed when workers were set up to fail. Forgiveness may need to go both ways, with the worker(s) empowered to relinquish blame and resentment toward the hospital and its management.

Notwithstanding the systems view, calls to hold individual healthcare workers accountable as moral actors remain strong.^[16] This is necessarily a backward-looking accountability, asking questions about who broke what rules or did what wrong, and who are now deserving of which kinds of consequences.^[65] Forward-looking accountability, on the other hand, refrains from resentment and reprobation, and putatively “treats practitioners as mere pieces to be managed, cogs in a (safe) machine.”^[12] It was conceived, however as a morally serious engagement with the obligations entailed in creating a safer health care environment.

“The forward-looking or prospective sense of responsibility is linked to goal-setting and moral deliberation… about the particular roles that a person may occupy, the obligations they entail, and how those obligations are best fulfilled. Prospective responsibility is oriented to the deliberative and practical processes involved in setting and meeting goals. Given a systems approach to error, these obligations entail a high degree of transparency about errors, analysis of errors to determine their causes, and the implementation of systemic improvements. To the extent that current structures prevent health care providers from meeting these responsibilities, the structures are inconsistent with the ethics of professionalism” (Sharpe, p S10).^[66]

Bosk^[5] was among the first to describe the dynamic of forward-looking accountability (without calling it that) in relation to surgical residency training. Taking a fairly transactional view of forgiveness but calling it “forgiveness” explicitly, he observed how the rituals surrounding forgiveness (which frequently included public humiliation and reprobation among peers and other professionals) themselves operated as a deterrence to further errors and work by holding the worker accountable in a forward-looking way, but also establishing those “structures” that are consistent with the ethics of professionalism as detailed by Sharpe above:

“…the subordinate becomes more vigilant in the immediate future… it is quite common for a subordinate to spend extra time with each patient on work rounds double-checking to make sure results are satisfactory. When a subordinate sees his … errors are forgiven, he recognizes that he has no incentive to hide them. … Forgiveness encourages ‘help-seeking’ behavior and removes the stigma” (p. 178).

Bosk noted how forgiveness is not only a morally serious response because it holds the wrongdoer keenly accountable (for a long time after the original error or behavior!), but also because it typically happens on the back of public rituals of confession, criticism, self-blame and exorcism (banning the bad behaviors, errors and incorrect practices). In Bosk’s study, he saw this in its most formalized format at mortality and morbidity conferences where erring practitioners got to wear the “hairshirt” in a public confession, evaluation (and reprobation) of their behaviors or errors. Hairshirt rituals are anthropologically consistent across a wide variety of professions, cultures and expressions (as well as the wrongs they seek to address). They serve to enforce professional standards and group cohesion, as well as reintegrate the wrongdoer into the group through confession, repentance, promises of atonement (to be patrolled through forward-looking accountability mechanisms), and eventual forgiveness. Braithwaite ^[67] called these rituals “reintegrative shaming.” Forgiveness, like compassion, can be seen as a virtue that reflects moral character through courage, empathy, and humility.^[68]

Forgiveness is morally serious in this sense because it exhibits the virtues that reflect maturity and integrity in dealing with error and harm, and exacts a steep price for re-entry into the moral community. It reminds all professionals of the continual dues payable to stay there. Bosk ^[5] documented how practitioners who were incapable of integrating lessons from forgiveness into their subsequent practice were deemed morally unsuited and eventually (or sometimes quickly) exited from the profession. It affirms how explanations of errors and undesirable behavior are not excuses; how, even with a systems view of healthcare safety, practitioners retain a discretionary space for moral decision making that is theirs alone — and into which no systems incentive or inhibition can reach.^[69] It is one of the hallmarks (and deep attractions) of professional work and its fiduciary relationship and moral obligations to fellow human beings.^{[70, 71]} Being an ethical co-professional, however, entails securing a space for professional redemption, learning, and support to other colleagues.

For patients, a morally serious response considers the breach of trust, the emotional impact, and the vulnerability they experience. The pursuit of forgiveness after harm can help restore relationships, rebuild trust, or promote healing.^[72] Their suffering calls for a response that acknowledges their pain and provides a pathway to healing. But it is well-known that the impacts don’t stop there. Involvement in medical error or undesirable behaviors can create multiple victims.^{[73,74,75,76,77]} Second victims are the healthcare providers whose self-blame can seldom be matched by anything the hospital imposes on them, and whose enduring torment can end up corroding the fabric of compassionate care ^{[6, 73, 77,78,79,80,81]} or worse.^[82] A morally serious and complete response evaluates the consequences for all involved — patients, healthcare professionals and hospital workers, even the wider (hospital) community. Whereas resentment, backward-looking accountability and just punishment take the relational aspects of harm quite seriously, repair is not as strong a part of their idiom.

Yet it could be argued that the very principles of non-maleficence and beneficence carry over into a moral duty to repair relationships damaged by harm; and a care ethic adds to this by emphasizing the importance of relationality, empathy, and compassion. Repair and reconciliation require time and effort from all involved, including exposure of truth (or “confession,”^[72]), empathetic engagement of all concerned — even before repentance — and joint exploration of what is needed for reconciliation. Individual and community wellbeing are advanced through the preservation or transformation of interpersonal connections — rather than their severing through retribution.^[83] A morally serious process of forgiveness, then, considers the emotional and relational aspects of harm in this way, adding to the forward-looking accountability expected of a wrongdoer and the community surrounding them.

The application of forgiveness after errors or undesirable behaviors in a healthcare setting can feel like a bit of a stress test — for all those involved.^[84] There are at least three parts to the stress test:

• The first is to understand if things could have got worse. If they could, but didn’t, then that points to aspects of the team, of the individual, of the organization, that supply a modicum of resilience: the ability to absorb and recover from harm or challenges that may have been outside what the team was prepared or trained for. This can be celebrated as the presence of capacities that help make things go well ^[85] and used as a basis both to inspire forgiveness and to explore further opportunities for forward-looking accountability: what must be done to set each other up for success?
• The second part of the stress test is to avoid attributions of individual error where there is clear systems involvement in the production of trouble. Morally serious forgiveness involves recognizing the broader systemic issues at play — organizational culture, resource constraints, goal conflicts, technological obstacles, and more. It requires collective responsibility and action from hospital boards and professional bodies to recognize and rectify systemic weaknesses that helped produce the conditions for harm to occur.
• The third part of the stress test considers how the people involved are treated. Of course, forgiveness, to be morally serious, must not serve as a shield for avoiding accountability. It involves an honest reckoning with what went wrong and a commitment to transparency to prevent future harm. When harm occurs, trust is fractured, and forgiveness can become morally serious if it actively engages people in rebuilding that trust through action. That may likely include confession (truth-telling, acknowledgment of error), repentance (expressions of remorse and commitment to improvement) and atonement (actions to improve, make right, assure restitution) and eventually readmitting people to the moral community. Re-entry into the moral community of professionals through repair of harm and broken relationships is possible when the damage that was done is first broadly acknowledged; and it becomes sustainable only when accompanied by a longer-term, active commitment to restoration, avoidance and improvement.^[86]

Forgiveness comes down to our willingness to abandon our “right to resentment, negative judgment … toward one who unjustly injures us, while fostering the undeserved qualities of compassion, generosity.”^[83] Forgiveness cannot emerge without pre-existing resentment and negative judgment.^[87] Forgiveness can first begin to happen when everybody understands that a wrong has been committed and that there are victims and wrongdoers; that victims’ experiences are real and that they may be expected and justified to express retributive passions.^[88] Acknowledging this is the necessary first stage of forgiveness ,^{[7, 38, 89, 90]} and it turns forgiveness into a morally serious response that starts dealing with the ethical weight of broken trust, loss, suffering and any possible advantages gained by the wrongdoer. Grace doesn’t come cheap — or at least it shouldn’t.^{[39, 91]} In a sense ,^[22] what it takes to receive forgiveness can be experienced as “just punishment” in its own right.

No funding was received or used to produce this article.

The authors declare they have no conflicts of interest.

Obtained.

The Publication Ethics Committee of the Sciedu Press. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are not publicly available due to privacy or ethical restrictions.

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