adriano pessina, justice and pardon in the art of medicine

The concepts of “damage” and of compensation for “damage” are unfortunately well known to those who practice the art of medicine. Italian physicians often complain about being subject against their will to undue interferences by magistrates, who are blamed for interfering in legal terms rather in the name of patients’ (or their relatives’) expectations, with regards to medical conduct, than in the name of actual negligence.
The question of so-called “legal pressure” on medical conduct, at least in Italy, is amongst the most controversial and is, obviously, interpreted in a different way whether seen from the patient’s or from the physician’s point of view. The recourse to law in order to settle questions of a medical nature is also a sign of a situation of unease, which seems to go beyond legitimate intervention with respect to behaviours that violate the law and the code of ethics. In fact, one of the factors that cause this “legal pressure” is that people do not understand the empirical nature of the art of medicine, which as such is exposed to error, and this is why they have developed too much faith in the possibilities (sometime more abstract than real) of medicine.
But, while this subject is often discussed, anything concerning the theme of “pardon” is hardly ever mentioned. The absence of this theme is significant. In fact, the subject of pardon has a specific importance in interpersonal relations, particularly in those that have a high moral depth. The concept of pardon is not only a religious issue, but has a remarkable social importance. Pardon is a different aspect from that of compensation, because it refers to damage that objectively cannot be “repaid”, since what has been violated is a human being’s personal dignity, or something directly related to that dignity.
Pardon has the function of social pacification, because it interrupts the cycle of revenge, severing the relations between action and reaction and permitting a form of reconciliation between the offended and the offender.
The requests for pardon, in our society, are often associated with strictly pragmatic functions, that is they seem to be used to attenuate the form of compensation. But, if we only consider this utilitarian perspective of pardon, we loose sight of that which constitutes its moral specificity. Indeed, there are certain conditions depending on which it is possible to ask for pardon and under which one feels the necessity for this request.
The first condition is that the person who asks for pardon feels truly responsible for this action: which means that the fault cannot be ascribed to circumstances or factors beyond his/her choice. It is possible to be objectively wrong without being subjectively guilty from a moral point of view: for example, it is possible to make mistakes without negligence being involved, when one has acted with insufficient information.
The damage remains, the chargeability for the damage remains, but there is no subjective moral responsibility. Therefore, a request for pardon requires the full awareness of a wrong choice made while exercising one’s free will.
The request for pardon hence involves a special moral awareness. This means that the request becomes necessary not as a shortcut to reduce the weight of compensation, but as a desire to reintegrate one’s own morality by pushing away the chain of faults which weigh down on one’s own personal history. In this case pardon is a form of reconciliation with oneself, which arises from a willingness not to reconcile oneself with one’s past faults and at the same time a desire to sever another chain, which is not that of revenge and compensation, but that of a guilty past which weighs on one’s conduct.
Therefore, to ask someone for pardon does not mean wiping out a fault, but rather making it inactive in the dynamics of one’s life: it means laying down the conditions for a personal renewal. Therefore, pardon re-establishes another level of justice that had been lost, the level that is concerned with the moral (and not only legal) significance of damage to human dignity.
How is it that the concept of pardon is not mentioned in reflections devoted to medical practice?
On one side this absence seems to be related to a specific aspect of the relationship between the doctor and his patient, which is usually exercised in relation to the subjects of health and physical functions: these dimensions seem to have an “objective” aspect, in which it is easy to appreciate the damage, but difficult to determine the offence in moral terms.
This aspect is real and should not be undervalued, and yet there are conditions under which we should wonder whether moral guilt may not also be involved in the way in which patients are treated. How many times have we heard complaints about the way fatal prognoses have been communicated without any regard for the other person? And how many times has a patient’s body been treated in ways which did not take into account that it was a person’s body and not just a sick body?
And is not due respect for a sick person, for his/her need for modesty, understanding and comfort often violated in the name of effectiveness, of efficiency, even of “professionalism”?
We should consider the fact that there are situations in which, even if we have not caused any physical harm, or we have even obtained good or satisfactory clinical results, we have acted without real respect for the other person. When exercising everyday medical practice (but this can also be referred to other professions involving strong interpersonal relations, such as in teaching, for instance) it is possible to commit many “invisible” or non-punishable acts of injustice.
Familiarity with attitudes which are not sufficiently respectful towards other people’s dignity facilitates some kind of indifference for the personality of patients (whom today are also referred to as “users”), which is a sign of the progressive withering of physicians’ own dignity, as they are starting to merely view themselves as workers. In this age of work, responsibility and action segmentation, in this age of technological mediation, it is the human depth of physicians that is in danger of cracking.
Therefore, the subject of “pardon” in medical practice is worthy of space for reflection. Indeed, whilst paying full respect to the importance of competence, specialisation and professionalism in the art of medicine, the moral aspect of “pardon” involves the clear need for medicine to be practiced by those who know that, when acting within borderline situations arising from other people’s pain and illness, their moral identities depend on their ability to express human respect.
Can anyone say they have nothing to be pardoned?
Translated by Interpres sas

Adriano Pessina
Cattedra di Bioetica
Università Cattolica di Milano