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Julian Sheather: Living with your worst nightmare

19 Aug, 11 | by BMJ Group

Once in a while I make a mistake at work – in spite of my best intentions, the human will out. By and large though, people are little inconvenienced by my blunders. And where they are, and where I cannot put them right, I am usually happy to apologise. Taken in the right way there can also be something tutelary about a mistake: if you sit and look at it for long enough it is bound to teach you something, a dark light if you will. Besides, in these clamorous times, humility is a much underexplored virtue, and one almost always closer to the truth than its opposing vice, pride. As Iris Murdoch put it, “humility is not a peculiar habit of self-effacement, rather like having an inaudible voice, it is a selfless respect for reality and one of the most difficult and central of all the virtues.”

Recently though I was having lunch with a friend, a GP. Knowing that my trade is medical ethics she wanted to talk to me about a mistake that she had made, a misdiagnosis that led to the serious harm of one of her patients, a woman with whom she had long enjoyed a good professional relationship. On discovering her error, she did absolutely the right thing. Her response was, if the word can be shorn of its suggestion of rote, textbook. She spoke to the patient. She explained her mistake, she went into detail about how the error came about and its likely consequences. She apologised unconditionally. She spelt out the various forms of redress available to her. There was nothing more that she could have done. What she was left with, and what she really wanted to talk to me about though was how she felt. She wanted to talk about remorse.

I listened. Of course I listened. But the more my friend talked, the less able I felt to respond. More truthfully the less able I felt to respond helpfully. By and large modern medical ethics is concerned, quite understandably, with the making of good or right choices. It is concerned with decision making. Should information about a crime be disclosed in the public interest? Is covert medication of an incapacitated adult permissible? One way or another decisions have to be made. This helps explain the importance of consequentialism, not always the most attractive of moral theories, in contemporary medical ethics. Where decisions have to be made, the consequences of those decisions will always be morally relevant. But my friend had gone beyond decision making.

The word remorse is drawn in part from the Latin remordere, to bite again. My friend had gone beyond decision making and into a tract of experience – of moral experience – in which she was being bitten again and again by the knowledge of what she had done. I know my friend quite well and I have seldom seen her so burdened, so haunted. Her guilt was almost literally consuming her. We spoke at length. I had little to offer. I sensed that she was remote from me, grappling alone with her conscience, struggling with her sense of who she was and what she did.

On and off since that lunch I have been brooding about our conversation, about the nature of the responsibilities my friend accepts as an ordinary part of her job, about how the potential she has to do good is so closely twinned with its opposite. But mostly I have been brooding about her remorse. As usual when trying to get a handle on experience, particularly experience to some degree remote from mine, I turned to literature. “All the perfumes of Arabia will not sweeten this little hand” whispers Lady Macbeth, maddened by guilt. I re-read Conrad’s Lord Jim. In a moment of cowardice, convinced the ship on which he serves is about to sink, Jim jumps overboard with his fellow officers, abandoning the passengers – Muslims on pilgrimage to Mecca – to their fate. The remainder of the novel traces Jim’s flight from his kind as he seeks some form of redemption – and, in the end, a bullet in the chest – in the remotest east. The exercise of conscience, even in its most agonising forms, they both suggest, is deeply linked to what makes us human.

The making of decisions is obviously only one part of the moral life. Understanding what motivates our decisions, trying to understand and respond to the decisions we do make, learning to live with their often complex and unpredictable consequences is another, as is learning to accept and to work with our limitations, our fallibility. My friend had enormously supportive colleagues in her practice. She was able to talk her experiences through with them, to work through to some kind of reconciliation. She was – she is – a fine doctor, but she had made a mistake. When next I saw her she was a little less harried, a little more herself. But there is no doubt that the knowledge will continue to live with her, that she will continue to live with the knowledge.

These days, doctors’ pay is seldom far from the news. What is a medic worth? How many medics make a banker? For that matter, how many thousand nurses to a banker’s bonus? A footling arithmetic at the best of times and these are not the best of times. I trade in the small change of ideas, in the foothills of thought. The very worst that happens is that I don’t think very well. But then I recall my friend and her remorse. Hard to put a cost on that. Hard to put a price.  All the perfumes of Arabia? No, nor all the tea in China.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.

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  • http://twitter.com/Murfomurf Murfomurf

    I think that now is the time for some cognitive psychology to kick in- and maybe there should be short, free courses on this for all young doctors. Basically, after an error when grief & remorse are starting to impair cognitions and work, medical personnel (including researchers attached to their practice/unit) need to try to control their own thoughts. There needs to be separation of the “bad behaviour” from the “bad self”. OK, a mistake was made, there are concrete consequences, but the actions taken in making the mistake are now in the past, they are rare and unlikely to occur again. The person is still the well-intentioned and altruistic person they were before (ie. not a “bad” self at all) and can continue to monitor their behaviour to prevent unintended consequences. Some brief counseling and learning some appropriate positive self-talk should allow adjustment in a reasonable time. If this is not helpful, a course of therapy with an understanding psychologist or psychiatrist could be undertaken.

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