Forgiveness as morally serious response to errors in healthcare: A narrative review
An interesting and recent discussion paper from Sidney Dekker, exploring forgiveness as a ‘morally serious response’ to incidents, as opposed to retributive approaches.
Tl;dr:
·???????? “while retribution addresses certain ethical concerns, it is incomplete and can be counterproductive, particularly for patient safety and organizational learning”
·???????? “Systems that focus primarily on individual blame risk fostering underreporting, entrenching learning disabilities, and exacerbating harm”
·???????? Instead, forgiveness “offers a morally serious alternative. It facilitates accountability, restoration, and healing without trivializing the ethical weight of the harm done”
·???????? “By encouraging forward-looking accountability, forgiveness allows the wrongdoer to acknowledge their mistakes, make amends, and help improve practice”
·???????? “This not only respects the humanity of everyone involved, and addresses emotional and relational consequences, but also recognizes the systemic factors that contribute to errors”
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Summary
Forgiveness is defined as “the foregoing of vindictive resentment toward a wrongdoer”. While practiced informally, is not often used officially by organisational processes following errors, harm or other undesirable behaviour in healthcare.
Further, “almost nowhere is forgiveness choreographed into organizational ritual or official post-incident action”.
Retribution takes a lot of forms, including verbal criticism, blame, naming and shaming, humiliation, disciplinary action, demotion and more. It’s said that literature and hospital administration practices can see retribution as a morally serious and “ sometimes even necessary response” to errors and undesirable behaviours.
Some reasons why retribution is seen as sometimes necessary:
·???????? It offers a means of deterrence for “wrongdoers”, and compensates the disrespect and contempt that the wrongdoing has for the community and victims
·???????? Redresses any unfair advantage gained by the wrongdoer
·???????? Prevents a wrongdoer from hiding behind system-level explanations
While retribution “exacts dues” for continued membership in a moral, professional community – it does this via resentment and punishment.
While “this may be a morally serious response, it could be considered morally incomplete and possibly counterproductive for patient safety”.
Retribution responses are said to lack a few facets, see the below image from the paper:
Dekker says that lots of healthcare research at the sharp end shoes that behind errors and the undesirable behaviour “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.
Hence, both success and failure are the “joint products of many factors distributed across such a landscape— all necessary and only jointly sufficient”. Errors and undesirable behaviours should be seen as consequences rather than causes of trouble, and improvements come not from targeting individual behaviour but by focusing on the “conditions that generate and shape such behavior— including organizational and technical factors”.
With this perspective, the responsibilities for creating those necessary conditions extend well-beyond the wrongdoer, in the domain of the organisation, teams and more.
Dekker says:
“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”
Further, seeing the frontline workers as causes can allow the “system to escape accountability for setting its people up to fail”. It can also contribute to conditions of risk secrecy, and hamper learning.
In order to have an appropriate alternative to retribution, the alternative must incorporate the systemic trust that has been damaged following the event, and facilitate institutional actors in a quest for transparency, restitution and creating safer systems.
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ACCOUNTABILITY
It’s argued that calls to hold individuals accountable as “moral actors” is a backward-looking view of accountability: looking at who broke what rules, or did what wrong, and which consequences are fitting.
In contrast, forward-looking accountability “refrains from resentment and reprobation”. This view is linked to goal-setting and moral deliberation – what roles the person occupies, the obligations, and how those obligations are best met following the event.
It’s shown that forgiveness, in various guises, involves its own rituals, acting as deterrence and holding people accountable. It also establishes the structures consistent with ethics of professionalism.
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Forgiveness and this ethics of professionalism holds people more keenly accountable for longer, since it “happens on the back of public rituals of confession, criticism, self-blame and exorcism (banning the bad behaviors, errors and incorrect practices)”, and in the context of humility.
Forgiveness also exhibits the virtues of maturity, and “exacts a steep price for re-entry into the moral community”. It “reminds all professionals of the continual dues payable to stay there”. Some work showed that forgiveness and membership into the moral community helped shape those who were unsuitable for membership and subsequently left the profession.
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REPAIR AND RESTORATION
Pursuing forgiveness after harm can also “restore relationships, rebuild trust, or promote healing”. This process allows those harmed to have their pain recognised and acknowledged and provides a pathway for healing.
There is also the recognition that those directly harmed aren’t the only victims – e.g. harm spreads to second and third victims, like the healthcare providers who blame themselves, or to families and friends.
Dekker argues that:
“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”.
Further, repair and reconciliation require substantial time and effort from all involved – requiring empathetic engagement, and joint exploration to find what’s needed for reconciliation.
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APPLYING FORGIVENESS TO HEALTHCARE WORKERS
Dekker suggests a forgiveness approach can feel like a stress test, involving three parts:
1)????? Understanding if things could have got worse. If they could but didn’t, then this points to the capacities of the individual, team and organisation to absorb and recover from harm or challenges
a.?????? “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”
2)????? Avoid attributions of individual error where “there is clear systems involvement in the production of trouble”
a.?????? Hence, there should be an earnest search for broader systemic issues at play – cultures, resource constraints, goal conflicts and more
b.?????? These are the factors that “helped produce the conditions for harm to occur”
3)????? Consider how the involved people are treated
a.?????? Forgiveness “must not serve as a shield for avoiding accountability”, but rather “involves an honest reckoning with what went wrong and a commitment to transparency to prevent future harm”
In concluding, Dekker says:
·???????? Forgiveness requires a willingness to abandon our “right to resentment” or negative judgement towards those that injures us, while fostering compassion and generosity
·???????? “Forgiveness cannot emerge without pre-existing resentment and negative judgment”
·???????? Forgiveness can start once everybody accepts that a wrong has been committed and that “there
·???????? are victims and wrongdoers”
·???????? That the victims’ experiences are real and that “they may be expected and justified to express retributive passions”
·???????? “what it takes to receive forgiveness can be experienced as “just punishment” in its own right.”
Ref: Dekker, S. W. (2024). Forgiveness as morally serious response to errors in healthcare: A narrative review.?Journal of Hospital Administration,?13(2), 52-58.
CEO - International Federation of Airworthiness (IFA)
2 周Thoughtful as ever. But. Coincidentally a conversation this week with a sub contractor that does work for hospitals brought to my attention just what a tick box culture now exists in health care.
Hmmmm, Having recently experience such a situation I am 'concerned' A diagnosis requiring a minor procedure, then two years (reassuring) monitoring, and given the all clear; a year later a surprising letter from the hospital. The carefully crafted text suggested 'false positive', but not stated as such. The background theme was of human error, not stated, which had instigated a wide ranging review. My initial diagnosis was incorrect. My immediate, subconscious, reaction was litigation ! Why, did I think that? The procedure and follow up were not overly stressful, no life impact, etc, yet my reaction surprised me. I relate to a non-litigious national culture, and personally not inclined to do so; even arguing against litigation in HF / safety. The issue is closed without action; but … Where did my reaction come from; a life-heuristic, influencing worldly views, a basic human trait ? Whilst rational consideration by academics argue morality, is the basic human condition amoral ? Are we human because we react this way, irrational, only reflecting on morals over time ? Human science aspect; a reasonable argument in theory, but not in practice. I remain sceptically concerned.
Leadership and Organisation Development consultant
2 周For me, Dekker has resurfaced something subtle but important regards culture that I hadn't considered before i.e., 'forgive and remember' (that Bosk wrote about in his book originally published in 1979!). So many concepts, models, strategies, policies, rules etc. have emerged since e.g. Error, mistake and violation categories, Just Culture, Reporting Culture, Learning Culture, Psychological Safety, Crew resource management and so on that I can't help feeling the guiding moral principle and language of 'forgive and remember' has been lost in the corporate machinery. As an OD consultant first and foremost, I will certainly work hard to keep this uppermost in my mind. As ever, thanks for the post Ben Hutchinson
Sociological Safety? | The Sociological Workplace | Trivalent Safety Ecosystem
2 周Interprofessional Primary Care Institute
It’s hard to disagree with any of that really, I’m going to use “People don’t come on work to make poor choices, they often have poor choices” wherever I can! That being said, there’s an enormous gulf between where most healthcare providers are and where they need to be for a culture of forgiveness. There would also need to be change for regulators and professional bodies, not just providers. Otherwise you might not be fired but you could be struck off.