After Harm

September 4, 2006

In a recent article in the New Yorker, physician Atul Gawande detailed how badly the American health-care system deals with physician error; the system, he contended, serves neither the patient nor the physician very well. But what can be done?

Nancy Berlinger has a proposal. She asks not how to reduce the incidence of error, though that is a worthy goal, but how we should treat one another after mistakes have been made.

Berlinger relies on her background in religious studies and on clinical examples to formulate her answer, which is relatively simple. She argues that when a mistake has been made, the parties should admit to one another that it has happened and seek to assist the persons harmed by the mistake so their lives can go forward.

This answer is not new to anyone familiar with the ways various religious communities challenge their faithful to deal with neighbors they have wronged; what is new is that Berlinger proposes such a response as an alternative to the American malpractice system, which revolves around the fear of, and sometimes the reality of, litigation. A strength of the book is that Berlinger displays how medical error has an impact not only on the patients and families who must deal with the consequences of mistakes but also on the physicians who make them, though her primary emphasis is on patients and families.

With intimate familiarity, Berlinger describes the ways in which error is addressed within medicine. Although the system sometimes encourages physicians to be candid with their colleagues and to take responsibility before them for what they have done, patients are not nearly so well served. Physicians are professionally obligated to tell their patients when mistakes have been made, but too often they fail to assume responsibility for what has happened. As a consequence, patients and families turn to litigators to learn what happened as well as to receive compensation for errors. Berlinger shows that even members of the health-care community turn to litigation when errors are made in the care they receive as patients. Virtually everyone seeks to avoid telling the truth, asking for forgiveness and doing repentance. Berlinger offers good reasons why all three should be done.

Berlinger describes three institutions that have successfully supported practitioners in their apologies and have provided patients and their families with what they need after medical errors have occurred. She claims that candor about errors and reparations to patients and families should not be separated; to separate the two is to encourage, albeit unintentionally, sham apologies.

Informed by Christian and Jewish thinking about and practices of forgiveness, Berlinger recognizes both its usefulness and its cultural limits. She does not want to enforce forgiveness, but she does point to ways to make it possible. In the final chapter, which contains a series of admonitions and suggestions for institutions that want to change, we begin to see what a profound difference new ways of addressing medical error would make to the entire practice of medicine in the U.S.

Berlinger is clinically sophisticated and theologically well informed. Her use of Bonhoeffer, for example, is quite astute. After Harm could form the basis of an ongoing discussion in churches about how to make a difference in the health-care system. It should be read in legal services offices and the boardrooms of hospitals as well.

My one regret about the book is its price, which I think excessive for the size. I hope a more affordable paperback edition appears soon because this is an important book that deserves to be read widely. Berlinger has done a signal service by writing it.