After Harm


After Harm: Medical Error and the Ethics of Forgiveness

Author: Nancy Berlinger


This book is the outcome of the author’s disappointment with the iconic Institute of Medicine (IOM) report, To Err is Human, which did not mention the subject of forgiveness. The author points out that the report’s title is adapted from a line in Alexander Pope‘s ‘An Essay on Criticism‘ which ends with ‘to forgive, divine’. This oversight is at odds with the recognition that forgiveness, is the ‘…time-honored, if imperfect and misunderstood’ approach of dealing with harm in all other circumstances (page ix). With this background, she explores the range of concerns that arise after patients are harmed, drawing on both religious and secular sources such as the theologian Dietrich Bonhoeffer, and the physician Albert Wu.


The book first deals with the lack of candour that is prevalent in healthcare after adverse events, a shortcoming the author says breeds suspicion and suggests a lack of compassion. She dismisses the rationalisations that physicians use to justify their lack of openness but acknowledges the obstacles to open disclosure. One such concern is the fear of litigation even though, citing the Harvard Medical Practice Study, less than 2% of patients who suffer harm take legal redress (page 38). She admits that ‘telling the truth is hard, and changing the norms of professional and institutional culture from nondisclosure to disclosure is even harder’ (page 49). The book however makes the case that it is the ethical responsibility of physicians to disclose harm and urges doctors ‘…to make a conscious effort to see the situation… from the patient’s perspective’ (page 48). The author recognises the contribution of systemic problems to clinical errors, but she maintains that the physician bears equal responsibility; she asserts that ‘… personal accountability to individuals affected by medical mistakes can and should coexist with the system’s ability to investigate, identify, and correct systems errors…’ (page 97).

A key impediment to open disclosure is physicians’ ignorance of the appropriate words to use when talking to patients about harm, and the book discusses this matter exhaustively. The first step the book suggests is to understand the patients’ perspective because the patient’s story is more important than the clinical account documented in the medical records (page 3). The author therefore advises physicians to listen to the ‘voice of the patient‘ (page 9) and she refers to the works of Arthur Kleinman and Arthur Frank on ways to elicit patients’ stories. These stories, in the process called ‘narrative ethics’, help to guide the choice of appropriate words and actions, and the book gives several illustrative examples of patients’ narratives.



Narratives are also useful in mitigating the impact of mistakes on the affected physicians. These physician narratives help doctors come to terms with their errors and aid the important process of forgiving themselves. The book illustrates this point with the published stories of Atul Gawande and David Hilfiker (page 16). Physicians also face the ‘difficult and humbling task’ of making apologies, and the author discusses how institutions may support them through this (page 62).

Forgiveness is the expected outcome of the sequence of acknowledgment, disclosure and apology. The author emphasises the need for this process and discourages automatic forgiveness or forgiveness given under pressure. Part of the process of achieving forgiveness is compensation and the book argues the case for a fair compensation scheme. Such a scheme should bypass the tort system which makes financial amends only if harm is proved to be the outcome of negligence (page 64). She refers to the “I’m sorry laws” which protect physicians from liability when they express sympathy or regret after harm. She also advocates, amongst other things, ethics education for healthcare institutions and involvement of injured patients in hospitals’ quality improvement processes.




This book comprehensively covers the issues that arise after harm. It highlights the effect of mistakes on the patient-doctor relationship, and gives guidance on how best to make amends. The ‘language of forgiveness’ is not often heard in healthcare perhaps because of its theological connotations. I thought the author made an excellent job of raising its profile and making it acceptable to a secular world. She achieved this by her dispassionate and non-prescriptive approach to the topic. The book chapters are well arranged and the sequence of topics made it easy to appreciate each theme. There was a disproportionate reference to Dietrich Bonhoeffer but the wide reference-base the book cites does enough to prevent a biased view of the subject.


The ethics of harm is an important issue for doctors and healthcare and this book addresses it comprehensively. The subject deserves greater attention from doctors and I recommend it.


  • Publisher, place, date: Johns Hopkins University Press, Baltimore, 2005
  • Edition: 1st
  • Number of chapters: 8
  • Pages: 156
  • ISBN: 978-0-8018-8769-7
  • Price: £18
  • Star rating: 5 stars


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