An apology can have tremendous therapeutic potential for both parties. Apologies can reduce anger, promote healing, and repair damaged relationships.^1,–,3 To have positive effects, an apology must be given well. An effective apology generally contains four elements: the acknowledgment of harm, evidence of remorse, an offer to repair any damages, and the promise of behavioral change.^3,–,5 Above all, an apology must be sincere.^3,–,5 Many aspects of an apology signal sincerity, such as appropriate timing, a lack of defensiveness, clear evidence of reparative action, and an absence of any evident ulterior motives for apologizing (e.g., financial reward or avoidance of punishment).^3,4 Of course, effectively incorporating all these elements requires significant interpersonal skills. Even the most effective apology may fall short if the offense is severe enough. Other factors that may affect an apology’s effectiveness include the relationship between the two parties and how motivated they are to reconcile the relationship.

A bad apology is often worse than no apology at all.⁵ Apologies perceived to be inadequate can be met with anger, hurt, and criticism.^4,5 Ineffective apologies are so common that the word nonapology has been created, defined as a statement that takes the form of an apology but does not constitute an acknowledgment or regret for what has caused offense or upset.⁶ A classic example of a nonapology is a statement such as, “I am sorry if I hurt you.” While this statement appears apologetic, a closer look reveals a lack of responsibility or even true acknowledgment of harm.

As the saying goes, “to err is human.”⁷ A well-functioning society requires mechanisms to repair relationships when they are damaged by human error. Apologies, when used correctly, can be a restorative tool. This therapeutic potential has prompted the consideration of apologies and their role in health care systems.

Apologies in Medicine

Bad outcomes, such as illness, injury, and death, are expected in medicine. In the words of author and neurosurgeon Atul Gawande, “Death is the enemy. But the enemy has superior forces. Eventually, it wins” (Ref. 8, p 187). That said, a significant number of harmful patient events are caused by preventable medical errors.⁹ A report published in 2000 by the Institute of Medicine estimated that preventable medical errors cause as many as 98,000 deaths in the United States each year, more than the death toll from car accidents, breast cancer, or AIDS.⁹

When patients are harmed by medical errors, most physicians desire to apologize to patients.^10,–,13 Many medical ethics arguments support error disclosure, including respect for autonomy, non-malfeasance, and beneficence. Consideration for patient autonomy suggests that patients have a right to make their own health care decisions, which requires knowledge of events that have affected their health. Knowledge of a harmful error could help patients avoid related future injury (i.e., non-malfeasance) and improve their health (i.e., beneficence).

Error disclosure in medicine is a relatively new phenomenon. The medical field has a long history of discouraging physician transparency. The American Medical Association’s first Code of Ethics, published in 1847, recommended physicians closely monitor their words and behavior, and “avoid all things which have a tendency to discourage the patient and to depress his spirits” (Ref. 14, p 9). A popular physician training manual written around the turn of the 20th century recommended that physicians be “at liberty to be silent or to say but little regarding the nature or degree of a person’s sickness . . . in every stage of your career aim to convince the world that you, as a physician, are an apostle of hope . . . and that your profession is not in league with the grim forces of death and mourning, but that, on the contrary, all its characteristics are indicative of health-giving and life-restoring power” (Ref. 15, p 140). For many years, physicians were encouraged to instill optimism in patients, at the expense of full disclosure.

With time, this expectation has changed. The landmark cases of Salgo v. Leland Stanford University,¹⁶ Natanson v. Kline,¹⁷ and Canterbury v. Spence¹⁸ established the expectation that physicians discuss information as part of obtaining informed consent from patients. Regulatory bodies and national organizations increasingly have called for improved physician and health care system transparency, prompted in large part by the Institute of Medicine’s report.⁹ The U.S. Department of Health and Human Services finalized rules in 2020 that permit patients full access to their electronic health record, adding a new dimension to physician–patient communication that will need to be navigated.

Patients want to learn about medical errors that affect their health.^12,13 Most physicians support error disclosure and believe they have an ethics obligation to disclose harmful errors to their patients or families, even if this disclosure comes at a personal or professional cost.^10,11,13 For psychiatrists, a common scenario is whether to apologize to a patient’s family after a patient suicide. A related consideration may be whether to attend the patient’s memorial service.

In practice, physicians typically do not disclose harmful errors to patients.^10,11,13 In a survey of U.S. physicians published in 2007, 320 (95%) of the 338 responding physicians indicated that they felt obligated to tell patients about such a mistake; however, only 41 percent of respondents reported that they had in practice disclosed minor harmful errors to their patients, while only five percent reported that they had disclosed major errors.¹¹ Clearly, a discrepancy exists between physicians’ desire to disclose and their practice of disclosing errors.

There are likely many reasons for the discrepancy noted above. Lack of comfort with this type of difficult conversation may pose a barrier to disclosure. Less experienced physicians are generally less likely to disclose errors, suggesting that a lack of practice and confidence are factors.¹¹ Physicians also wonder what information to disclose, such as details about the error and prevention of similar errors in the future.^11,13 Physicians can be affected deeply by harmful errors, with reactions including insomnia, guilt, poor concentration, anxiety, and self-doubt.^11,13 Strong emotional reactions may make the prospect of having these already difficult conversations more daunting. Physicians may struggle with determining how much of their own emotions they should share with patients and families, concerned that these responses may be a burden.¹⁷ Physicians may also worry that disclosure could erode patients’ trust and damage the physician–patient relationships. ^11,13 Professional ramifications of disclosure are another concern. Physicians fear negative reactions from colleagues and damage to their professional reputations.^11,13 Finally, a major reason physicians worry about disclosing medical errors with patients is the concern that this disclosure will lead to a malpractice suit.

Apologies and Malpractice

Most physicians in the United States face at least one malpractice lawsuit over the course of their careers.¹⁹ Malpractice is a common and costly occurrence in the United States.^19,–,21 Malpractice also takes a significant emotional toll on physicians, regardless of the outcome.²² Most physicians worry about facing a malpractice suit and its many implications, including professional, financial, and psychological challenges.^22,23 Physicians may therefore avoid disclosing errors to patients in an effort to avoid incurring a malpractice claim.

In theory, telling a patient about an error may make patients more likely to pursue litigation. In practice, however, bad outcomes alone are typically not reason enough for patients or their families to file malpractice claims.^24,25 A major reason malpractice claims are pursued is related to bad feelings evoked.^24,25 These bad feelings can be prompted by real or perceived problems with physicians’ communication skills.^12,24,25 Physicians who appear to be insensitive, unavailable, or critical are much more likely to be sued.^24,25 Patients and families are also more likely to sue if they feel a physician is hiding or withholding important information.^12,24,25 In this instance, litigation may be viewed as a means of obtaining the desired information.^12,24,25

Malpractice lawsuits may also be viewed as a way to prevent similar errors from occurring to other patients in the future.²⁴ A physician who does not demonstrate remorse for a harmful error may make patients more likely to consider legal recourse. ²⁴ An apology, through its acknowledgment of fault, expression of remorse, offer to repair damages, and promise of behavioral change, could assuage many of these patient concerns, thereby reducing the likelihood that patients will file malpractice claims. Many patients explicitly identify a lack of apology as a reason they chose to pursue a malpractice suit.^12,24

Hospital-based error disclosure programs demonstrate a role for apologies in reducing malpractice claims.^26,–,30 Several hospital systems around the United States have implemented disclosure programs with the goal of increased transparency and reduced medical errors.^26,–,30 The programs generally involve the proactive identification of harmful medical errors and disclosure of these errors to patients and families.^26,–,30 These programs often provide extensive communication training to providers, including advance preparation for challenging discussions and instruction on active and reflective listening skills.^26,28 In addition, these programs offer financial compensation to those affected by medical errors.^26,–,30

Hospitals with such disclosure programs have not seen a higher malpractice burden, and many have observed fewer malpractice claims and reduced costs overall.^28,–,30 As an example, the University of Michigan Health System’s disclosure program has resulted in a decreased number of malpractice claims, from an estimated monthly rate of 7.03 per 100,000 patients in 2001 (i.e., at the start of program implementation) to 4.52 per 100,000 patients in 2007 (i.e., at the end date of data collection).²⁸ They also observed a decreased average cost per lawsuit from $405,921 to $228,308, as well as an expedited claim resolution process in this time period.²⁸ Another such program at an academic health system in Tennessee also demonstrated fewer malpractice claims, lower legal costs, and shorter time from claim to resolution.³⁰ Disclosure programs and their demonstrated reductions in malpractice events and costs substantiate the hypothesis that physician apologies decrease, not increase, the risk of malpractice litigation.^28,–,30 Patients themselves may prefer this process to a malpractice suit, particularly given that many of the outcomes may be comparable with the outcome of a successful malpractice suit, including physicians’ apologizing for the error and financial compensation being provided.

There are some potential criticisms of these programs. While financial compensation alone is typically not reason enough for a patient to pursue a malpractice suit,²⁸ it is worth noting that offering an easier route for financial compensation could motivate patients to accept this offer in lieu of pursuing a malpractice claim. Some might also argue that these programs may hide information about medical errors about which the public should be aware. It is worth noting, however, that information about malpractice claims may not be routinely and publicly available. These programs therefore do not function inherently to restrict access to information that would otherwise be available to the public.

With these overall promising results of hospital disclosure programs with regard to rates of malpractice, other entities have also explored apologies as a tool for reducing malpractice claims. This consideration has led to the development of state-legislated apology laws that protect a physician’s apologetic statements in the event of a malpractice suit.