Apology works

Dr KK Aggarwal

Padma Shri Awardee

AIIMS New Delhi, a premier institute of the country, has tendered an apology to a patient who underwent a wrong procedure.

The written apology was sent to the 30-year-old patient, a resident of Bihar, and her husband was contacted with an offer for additional treatment. Allegedly, an arteriovenous fistula was made in the patient who did not have any kidney-related illness and instead was seeking treatment for pain in abdomen. AV fistula is created surgically in chronic kidney disease patients undergoing dialysis. Documents were allegedly tampered with to cover up the medical negligence.

Primum non nocere i.e. “first (above all) do no harm” is the cardinal principle that guides the ethics of practice of medicine. From it is derived the principle of non maleficence (do no harm) and its natural corollary, the principle of beneficence (do good).

Doctors never harm a patient intentionally. But sometimes, errors do happen even with all precautions.

In the event of any unanticipated adverse incident or outcome that may cause harm to the patient, patients now want answers. They can no longer be pacified with medical jargon; instead, they want to know the facts of the matter and the circumstances leading to it. They also want to know if a medical error could have caused the adverse outcome and want doctors and establishments to apologize to them, if the error was ‘avoidable’.

Non disclosure or ‘hushing up’ of errors increases feelings of anger and blame in the patients and creates distrust between the doctor and patient. And the aftermath is well-familiar to us all – negligence lawsuits against doctors and hospitals or angry relatives and friends ransacking the hospital or assaulting the doctor and other staff.

Apologize to the patient in such situations…an apology works.

While an apology does not undo the damage caused, it can alleviate the resulting feelings of anger and distrust. An apology can be either with admission of guilt or without admission of guilt.

But doctors find it difficult to admit to a mistake. Doctors are apprehensive – quite rightly so, given the absence of apology laws in the country – that apologizing for a mistake can be considered an ‘admission of guilt’ and used as evidence in courts of law.

Some states in the US have apology laws that protect an apology from being admissible as evidence in courts of law in medical negligence cases

While saying sorry for any wrong done is an immediate instinct of human nature, on the other hand, the fear of ensuing litigation prevents doctors from admitting to their mistakes. It is a classic ‘Catch-22’ situation because the outcome may anyway be a medical malpractice claim now or at a later date, when the mistake may be discovered.

Saying “I/We have made a mistake” and acknowledging that mistake with an apology takes lot of courage. But it goes a long way in restoring trust between the doctor and the patient and may defuse a situation that is just ready to explode.

Opinion 8.121 of the American Medical Association (AMA) Code of Medical Ethics says “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.”

The Joint Commission standard also says, “Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes” (RI. 1.2.2).

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