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When the doctor says sorry
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My introduction to the complex and emotional world of adverse events in health care occurred in 2001 when I chaired a committee to review an inquest report into the tragic deaths of 12 infants in a pediatric surgery program in Manitoba. Justice Murray Sinclair, who conducted the inquest, had concluded that at least five of the deaths were preventable.

Back then there was no apology law in Manitoba. Neither the Sinclair report (2000) nor the Thomas report (2001) recommended the adoption of such a law. However, in recognition of the trauma suffered by the families, the government of Manitoba covered their legal bills for the inquest, made a gratuitous monetary payment for their loss and formally apologized, all without accepting liability and without prejudice to their right to sue.

Subsequently, I learned that apology laws had already been spreading around the world. The main reason for creating such legislation was to offer some legal protection against malpractice suits for health-care professionals who wish to apologize for preventable harm that came to patients in their care.

Apology laws have been most popular in the market-based and litigious U.S. health system, with 34 states passing laws between 1998 and 2014.

But Canada has them, too. British Columbia led the way in 2006 with the country’s first apology law. Today, nine provinces and two territories have similar laws.

Why did apology laws become so popular?

Landmark reports documenting the shocking number of preventable health-care-related deaths, high profile tragic health-care-related events, and increasing malpractice suits and settlement amounts (since levelled off) all contributed to the interest in apology laws across the continent. So did the rise of institutions promoting patient safety and the increase in less deferential patients armed with better information.

Lawsuits for negligence or error have always been notoriously complex, time consuming and expensive, with the chance of success very low. Only around two per cent of lawsuits for negligence or error are successful in Canada, according to a 2014 paper.

Apology laws were meant to reduce reliance on litigation when things go wrong, in favour of more constructive processes of mediation and negotiation that are less costly and more expeditious. In situations of anger and bitterness, the trust and confidence that’s meant to exist between patients and providers can be damaged. Less adversarial approaches can help to restore such relationships.

There’s also the related therapeutic argument that open and honest dialogue can help with the physical and mental health of patients and families devastated by adverse events.

Patients need to be heard. They react positively when they receive honest, empathetic and sincere apologies. In the worst case, the death of a loved one, apologies support movement through the grief process.

It’s now well recognized that when errors occur there’s often a second victim: the health-care provider. Professionally committed to putting the patient first, providers can have deep feelings of failure, guilt and shame. Taking refuge in silence had been the preferred coping mechanism. Disclosure and discussion can lead to learning and the restoration of professional confidence and pride.

Apology laws are also meant to provide symbolic assurance to citizens that the health system is responsive to their needs and concerns, and not completely controlled by the self-regulating professionals who deliver the services. Inaction in the aftermath of tragedies and the low success rate in malpractice suits reinforced the public perception that no one was held accountable when serious mistakes or abuses occurred.

So are apology laws working as they should?

The truth is, we don’t really have robust evidence on how they affect doctors – and we know little about the patient experience with such laws.

We do know, however, that apology is a complex, nuanced communication process that goes beyond mere words to include offering explanations, expressions of remorse and sometimes making reparations.

But many health professionals are unfamiliar with the requirements for meaningful apologies. 

Moving the various health professional cultures away from the traditional stance of denial and secrecy towards disclosure and apology is a slow, ongoing process. Ensuring that health professionals receive good training and support in relation to the apology process will be more important than legislation in terms of delivering meaningful apologies.

Apology laws are here to stay. We should make sure they’re working and how they can best be improved – for the good of doctors, patients and their families.

Paul G. Thomas is professor emeritus of Political Studies at the University of Manitoba. From 2004 to 2007, he served as the founding board chair for the Manitoba Institute for Patient Safety. He is an expert adviser with EvidenceNetwork.ca.

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