The writer Ambrose Bierce said that guilt is felt by one who has committed an indiscretion but failed to cover his tracks, while forgiveness aims to throw an offender off his guard and catch him red-handed in his next offence (Bierce, 1967). Leaving aside Bierce's cynicism, to err is human, and sometimes the outcome is trivial; other times, disastrous. So perhaps it is worth considering philosophical perspectives on guilt and forgiveness.
Schrøder et al (2017) found that, in the aftermath of a difficult childbirth, obstetricians and midwives struggled with blame and guilt, and noted how these feelings contrasted with a blame-free patient safety culture that approaches errors as systemic failings, not individual ones. Furthermore, Skinner and Maude (2016: 35) detected a shift in midwifery in recent decades, with skilful practice and conscious alertness apparently ‘replaced by the concept of risk with its connotations of control, surveillance and blame.’
Against this background, midwives are not only individual moral agents, but also part of a team in an organisation that applies policies and protocols to promote safe environments for patients and staff. But in a working culture that encourages blame-free attitudes, but where the concept of risk still carries connotations of blame, what of the moral dimension to medical error? Does moral responsibility rest with the institution or the individual?
My personal experience in a hospital laboratory demonstrates this ambiguity. In the days of glass blood sample containers, these would occasionally be dropped and broken. But rather than reporting that the sample had been destroyed in an accident, laboratory protocol dictated that a further sample be requested, with no explanation offered. How many patients might have inferred that our request for a further sample indicated a grave diagnosis? The laboratory felt no guilt, but as the person who had dropped the tube, I did.
Tigard (2019: 101) argues that despite modern healthcare's shift away from apportioning blame, ‘it would serve the medical community well to retain notions of individual responsibility and blame in healthcare settings.’ Expressions of moral emotions—such as guilt, regret and remorse—contends Tigard (2019), have an important role to play in disclosing harmful errors to patients and their families.
This attitude of being seen to take the blame for an error may have prompted approaches such as that of open disclosure (Sorenson et al, 2009), which acknowledges that patients' interests play a greater part in framing healthcare policy. Sorenson et al noted that early disclosure of adverse events helped to allay suspicion that information might be withheld, while accepting that such disclosure might entail providing information without full knowledge of all the facts.
When a mother and/or her child have been the subject of a serious medical error, what, if any, is the role of forgiveness? Perhaps forgiveness (if a patient chooses to forgive) can only happen after an apology from the guilty party. This raises the nature of apologies. For example, in 2012, the company Gruenenthal—responsible for the morning sickness drug thalidomide that caused birth defects—apologised after 50 years (Dove, 2012). But it was a qualified apology, claiming that thalidomide's side-effects could not have been detected before it was marketed. In response, the UK's Thalidomide Trust said any apology should admit wrongdoing, with one member of its advisory council saying it ‘should be an unreserved apology, not a conditional apology’, and others calling Gruenthal's apology ‘insulting’ (Dove, 2012).
If, however, a suitable apology has been given, is a harmed patient under any obligation to forgive? By identifying systemic failings as against individual ones, Schrøder et al (2017) raise the awkward question of whether it is easier for an aggrieved patient to forgive a healthcare organisation or an individual. I would guess the latter. Who does forgiveness benefit the most: the patient or the health professional? Perhaps receiving the forgiveness of a harmed patient makes it easier for the clinician to forgive themselves.
Moral questions, unlike hospital policies and protocols, cannot always be easily framed, let alone understood, resolved and acted upon. But our understanding can sometimes be enriched by knowing some of the questions than all the answers.