Beyond disclosure: seeking forgiveness.

In a Boston hospital delivery unit, a series of small mistakes--compounded by everyday stressors, personality conflicts, and the harried schedules familiar to every health care professional--culminated in the loss of a newborn and the serious compromise of the mother's health. Sachs, who tells this extraordinary story in JAMA, (1) should be commended for his discussion of mistakes in health care, the costs to everyone involved, and this particular medical team's generative approach to improving their practices. But what makes the article extraordinary is its focus on offering an apology. In doing so, the involved health care professionals moved into a position of seeking forgiveness.

Forgiveness themes have surfaced, albeit infrequently, in the health care literature. One notable example is a widely read study--written by medical sociologist Charles Bosk and published in the book titled Forgive and Remember: Managing Medical Failures (2)--documenting surgical error in the 1970s. The term "forgiveness" might be stumbled upon, rarely if at all, in professional ethics texts, especially those few that are virtue-based in approach or written within the context of particular religious ethics approaches. The concept of forgiveness is glaringly absent, however, in the medical and nursing literature and in the curricular materials of those professional education programs. But the medical and nursing professions are not unique. Apology and forgiveness themes are seldom, if ever, the focus of ethics cases in professional physical therapist education or plenary sessions at APTA meetings. Apology just isn't in the clinical vocabulary or, for that matter, in the clinician's line of vision.

Why is the idea of apologizing absent from the health care professions at a time when taking precautions to prevent mistakes, being reflective, and being accountable are increasing in the literature and guidelines about professionalism?

I believe that apology is largely absent from the discussion because the professions and society have yet to face head-on that competence and good intent may not be adequate safeguards to forestall the causing of harm. Society wants to be able to count on professionals and wants to assume that their practices are fail-safe--and the professionals want to reinforce those expectations. The prospect of apologizing would transform acknowledgment of a mistake into a direct message of failure, something neither the professions nor society want to hear.

To become a health care professional, physical therapist students submit to years of fact-intensive training in order to avoid doing harm to patients and to achieve professional accountability. This is laudable. Left unsaid is an unintended but untoward side effect, namely that this type of training cannot make clinicians immune to situations where harm occurs. Harmful situations exist regardless of level of competence and goodness of intentions. Lack of preparation for handling such exigencies leaves clinicians vulnerable; they might respond with remorse or denial, but they won't know how to mend the problem.

What does apology require from us? First, it requires us to acknowledge that a problem for someone else was created by something we did, whether by intent or by accident. We have to acknowledge this to ourselves and then to the one who was harmed. Acknowledging the problem to ourselves sometimes is much more difficult than might be expected. Denial is an important psychological coping mechanism when something goes amiss, and I have found many, many physical therapy colleagues who share this propensity, however ineffective it is in the end. In fact, denial is so pervasive in our profession that I have long thought that every curriculum should require a course in dealing with avoidance and denial, so that breaking through them in difficult circumstances can become part of the professional physical therapist's competencies.

Once we are successful in breaking the denial barrier, however, we may find that acknowledging the situation to the other person is no piece of cake either. Some physical therapists are more willing and skillful than others when it comes to disclosing this kind of problem to the patient and other involved parties, and I believe their success is due in part to physical therapists' growing professionalism in an era that is autonomy driven. The cognitive reasoning on autonomy correctly supports the idea that full disclosure is necessary for true advocacy to take place and professional autonomy to be exercised. This approach places acknowledgment in the same bailiwick of professional activity as obtaining informed consent and disclosing treatment or research risks and benefits. In other words, the admission (and explanation) of mistakes or other harms falls on the continuum of information disclosures. This appears to be the tone of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regulations requiring physicians to acknowledge mistakes and make appropriate amends (a mandate that does not extend to other health care professionals, as I read it). An increasing body of medical malpractice literature indicates that frank disclosure usually is a deterrent to malpractice lawsuits and may embolden some health care professionals to take the step of acknowledging the problem that they have created for other individuals.

We might breathe a sigh of relief, thinking that an admission of "I did it" made to ourselves and to the other person is sufficient! But the never-silent philosophers would spout off that those admissions are necessary but not sufficient for accomplishing the task. Acknowledgments really place us only at the halfway house to the destination of a mended human bond. That's what the article by Sachs is about, too. The most challenging part--apologizing--is still to come.

Why is it so difficult to say, "I apologize, I'm sorry, forgive me" and (your mother speaking here) mean it? It requires us to give up that last stubborn core of willfulness. It also requires us to give up our selfassured standing in our relationship to the person who is associated with our distress--a person we cannot blame for causing the distress. The person may not be someone we especially like, may not accept the offering of our apology, and may even retaliate or be crushed by our admission.

"Therein lies the rub," as Shakespeare was wont to have his hapless characters point out at a dramatic turning point. When we take the step of apologizing, we indeed have lost control of the situation. And there is no shortcut home, back to that familiar territory that existed before the breach of trust and mutual contracting that had given legitimacy to the relationship. Passing "go" requires accepting the consequences, whether they are positive or negative. It's not a role that we professionals relish taking: to become the searcher, the beseecher, hoping for exactly what the other person had hoped for in us for repair in spite of brokenness.

To put it in everyday terms: When a patient seeks you out, the two of you get on immediately by focusing on his or her condition. The patient's symptoms give the cue for the direction that your journey together must take to evaluate what is broken and needs to be fixed, what needs to be kept working as optimally as possible, or what needs to be enhanced. But in the moment that you, the therapist, offer an apology and seek forgiveness, the lens turns on your broken relationship, one that can be mended only through your act of apology and seeking of forgiveness and through the patient's act of understanding, forbearance, or even full acceptance. Only then is there hope that both therapist and patient can confidently get back on the path of the original patient-oriented goals.

What can professional physical therapist education programs and APTA's educational offerings do to help prepare members of the profession become better equipped for apology and forgiveness conduct when it is warranted? First, include this topic in the curriculum, including the recognition that apologizing will require courage even when the therapist knows it's the right thing to do. Second, encourage all educators and physical therapist students to view this conduct as an inherent part of development toward full professional standing, recognizing that disclosure of error or other problems created for the patient, taken alone, is not sufficient to mend the professional-patient relationship. Finally, prepare physical therapists to understand that many grievous harms are not solely the result of individual conduct but also are due to shortcomings in institutional practices and procedures. From the get-go, physical therapists need to work with team members and others, not only in shaping policies to prevent error but in advocating for policies that will provide support and guidance when apology is warranted.

Many who heard APTA President Ben Massey's address in Boston last June at PT 2005 were inspired by his well-conceived rationale for autonomous practice and responded with well-deserved thunderous applause. But a part of his call was for constant vigilance as to what we are asking for and how we will position ourselves for such a future. If our mission, core values, ethics code, practice guides, and educational priorities fail to leave room for acts of apology, forgiveness, and, when appropriate, retribution, we stand to fall behind in realizing our vision. Considerations of the basic human bond must remain part and parcel of the prized goods we carry with us as we prepare to go the road alone.

The good news is that articles such as the one in JAMA will continue to appear, signaling that the health care professions are on the same road toward addressing this and related issues that affect the health of the relationship between the professional and the patient. Together we can shape a common professionalism. I believe that we can count on society to meet us more than halfway when we embrace acknowledgement, apology, and forgiveness as ingredients of respect for those we have the privilege to treat.

References

(1) Sachs BP. A 38-year old woman with fetal loss and hysterectomy. JAMA. 2005;294:833-839.

(2) Bosk C. Forgive and Remember: Managing Medical Failure. Chicago, Ill: University of Chicago Press; 1979.

Ruth B Purtilo, PT, PhD, FAPTA 

Editorial Board Member

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Dr Purtilo is Professor and Director of the Ethics Initiative, MGH Institute of Health Professions, Boston, Mass.