The pervasive culture of blame

Prevalent in evidence-based medicine is a “quixotic quest for certainty.”^{Reference Hoffman and Kanzaria2} Appeals to medical infallibility and intolerance for error fosters perfectionistic tendencies in medicine.^{Reference Hoffman and Kanzaria2} Perfectionism, fear of punishment, and peer social dynamics can fracture patient safety cultures.^{Reference Hoffman and Kanzaria2} Furthermore, amid the considerable advances of our field is a societal deification of the healthcare professional, which proliferates an unrealistic expectation that there is nothing that the institution of medicine cannot accomplish. The stigmatization of medical errors and negative outcomes contributes to a “culture of blame” within medicine, which we define as an environment that contributes to the proliferation of negative apportionment of blame onto an individual or institution. Symptomatic of this “culture of blame” are the intrinsic and extrinsic expressions of guilt, shame, and isolation that are often felt by healthcare professionals when failures are attributed to them without adequate personal, peer, and administrative support.^{Reference Robertson and Long3}

Although the COVID-19 pandemic has superficially united the population, this crisis has accentuated intergroup differentiation across values, virtues, and beliefs.^{Reference Lam4} Divisiveness and negativity bias promotes unhealthy apportionment of blame, which drives society further from unity and healing.^{Reference Lam4} As healthcare professionals have been subjected to high levels of stress during the pandemic,^{Reference Eftekhar Ardebili, Naserbakht, Bernstein, Alazmani-Noodeh, Hakimi and Ranjbar5} fostering an alternative, restorative culture that remedies toxic blame and promotes the inclusive service of our stakeholders and ourselves is critical.

Religion, spirituality, and science in the era of evidence-based medicine

Although we share Dr Papadakis’ concern for blaming healthcare professionals for negative outcomes, we raise concern with the article’s separation of science and faith. Religion and spirituality are essential healthcare partners owing to the high global prevalence of religiosity,⁶ the contribution of religiosity to human flourishing,^{Reference Koenig7,Reference VanderWeele8} and the increasing calls for the integration of spiritual care into medicine and public health.^{Reference Sulmasy9}

According to the Pew Research Center’s 2017 report, “The Changing Global Religious Landscape,” religiously affiliated people currently make up 84% of the world’s population—a proportion that is projected to increase in the coming decades.⁶ Religious beliefs, directly and indirectly, influence one’s health behaviors and healthcare decision making.^{Reference Koenig7,Reference VanderWeele8} Furthermore, participation in religious and spiritual communities instills meaning and purpose in one’s life, which may provide hope, assist in coping with adversity, and promote the development of healthy behaviors.^{Reference Koenig7,Reference VanderWeele8} Studies have demonstrated that religiosity and spirituality are associated with both positive mental and physical health outcomes.^{Reference Koenig7,Reference VanderWeele8}

In light of the importance of religion and spirituality to human flourishing,^{Reference Koenig7,Reference VanderWeele8} healthcare professionals have been encouraged to holistically assess the biological, psychological, social, and spiritual domains of health.^{Reference Sulmasy9} This comprehensive approach can assist in promoting the provision of excellent, patient-centric healthcare and the implementation of culturally competent interventions.^{Reference Sulmasy9} For instance, the integration of this model during discussions of medical uncertainty and negative outcomes may ameliorate the pain, blame, and fear felt by the patient, provider, or healthcare team. In summary, although Dr Papadakis’ concern for an unbalanced share of praise between the spiritual and the scientific is admirable and worth acknowledging, we encourage a more inclusive appraisal of the role of religion and spirituality in medicine and public health.

Toward a culture of grace

In response to these observations, we propose transitioning from a “culture of blame” to a “culture of grace” in our profession. This culture is marked by an environment in which individuals and institutions are empowered to serve as inclusive agents of goodwill that seek to construct opportunities to promote human flourishing and restoration. Integral to this “culture of grace” is the practice of forgiveness. Given the nearly universal capacity to be wronged, whether individually or collectively, the opportunities for forgiveness in medicine and public health are extensive.^{Reference VanderWeele10} Forgiveness can be defined as the absence of ill will that is often accompanied by expressions of goodwill directed toward an individual, institution, or even toward oneself.^{Reference VanderWeele10,Reference Akhtar and Barlow11}

As we gravitate away from the COVID-19 pandemic, failure to forgive and extend love to our neighbor may further the cycle of negativity, promote more division, and reinforce a “culture of blame” within medicine and the greater public. Individual- and group-level forgiveness interventions have been demonstrated to reduce depression, anxiety, and promote positive affect.^{Reference Akhtar and Barlow11} Interweaving forgiveness into discussions of medical error and negative outcomes amid the traditional expressions of responsibility and harm reduction may assist in ameliorating the stress and stigma associated with these outcomes. Particularly actionable for the healthcare professional, especially amid failure, is the practice of self-forgiveness. Practicing self-forgiveness can plant seeds of grace and mercy within, which, when collectively performed across an institution, can facilitate the blossoming of a redemptive, transformative environment that ameliorates medicine’s “culture of blame.” Therefore, we propose the fostering of a “culture of grace” in our profession, one marked by forgiveness and upbuilding, inclusive healthcare.