Avoiding cheap grace. Medical harm, patient safety, and the culture(s) of forgiveness.

Dena Davis defines the job of the religious ethicist working on clinical issues as describing what real people really believe and how they really act. (2) If so, then insights from religion and related aspects of culture may help hospital administrators charged with meeting new standards for patient safety to recognize the restorative role that forgiveness has long played between individuals and within communities and to incorporate forgiveness into their systems for dealing with medical mistakes that lead to injury, death, or other trauma) What follows is a broad "religious studies" rather than a strictly "theological" or "doctrinal" perspective on forgiveness, one that incorporates insights from Jewish and Christian social ethics, ritual studies, sociology of medicine, and medical anthropology, as well as from clinicians themselves. That said, several concepts borrowed from Christian theologian Dietrich Bonhoeffer--"cheap grace" among them--are integral to my argument against what might be termed "forgiveness as self-interpreting principle." What I mean here is a way of formulating forgiveness so that its relational character--the actions that various actors undertake in relation to one another so forgiveness can take place--is forgotten. This relational understanding of forgiveness may be replaced by a cheap grace that, in formulating forgiveness as automatic, either acknowledges no role for the injured person as agent of forgiveness, or assumes that this person should offer forgiveness in the absence of disclosure, apology, accountability, compensation, or other goods that we might place under the principle of justice. In cases of medical harm, a cheap grace approach on the part of professional caregivers, including clinicians, chaplains, social workers, or pastors, may also place pressure on a patient and family to forgive automatically--by reminding them that "good people are forgiving," or by assuring them that offering forgiveness will bring them "closure," or by telling them that, after all, nobody meant to harm them--even as the patient's and family's distress is prolonged because they do not know what really happened, or because there is no acknowledgment of their suffering by those directly responsible for it. In avoiding non-relational approaches to forgiveness, we must keep in mind that "forgiveness" is a Janus-faced word. It holds contradictory meanings--to engage and to detach--that are often conflated or insufficiently distinguished in everyday conversation as well as scholarly discourse. In the Jewish and Christian traditions, the deepest meaning of forgiveness is detachment. Forgiveness as cheap grace, as entitlement rather than outcome, ignores this deep meaning by refusing to ask what those harmed through medical mistakes may need in order to achieve detachment, or by pressuring them into engagement or acquiescence, even into a divine, salvific role, instead of allowing detachment to take place over time--in what the Christian Bible refers to as kairos, the appropriate time, as opposed to chronos, chronological time--once justice has been secured. (4) Arguing for a definition of forgiveness after medical harm that holds detachment as the ultimate goal of the process does not mean that injured patients--or clinicians who have made errors--should simply be encouraged to "detach" from incidents of medical harm, and from their feelings concerning these incidents. Forgiveness entails more than detachment. Even in mundane interpersonal situations, forgiveness-as-detachment can be unsatisfying: after we have succeeded in emotionally detaching ourselves from a painful situation, we may still hesitate to say "I forgive you" if we believe that, by doing so, we are excusing bad behavior rather than affirming changed behavior. One caution about the Jewish and Christian traditions is in order: while they are powerful if not always acknowledged influences upon Western culture and Western medicine, they are not universal. …