Addressing institutional trauma in health care: the case for a structured ethical framework

In recent years, many health care professionals have been confronting the challenging chapters of their institutions’ history, as societies more broadly grapple with how to deal with past institutional trauma. Whether it is problematic medical experiments; abuses of authority; systematic patterns of neglect, discrimination, or racism; or funders with questionable sources of wealth, many institutions now have to reckon with their past.

Some of these transgressions will be addressed in courts. In other cases, institutions may be asked to offer substantial gestures of redress.

Little in medical education or practice offers clinicians a good preparation for addressing such challenges. At the same time, leaders can expect to be challenged if they fail to address these issues. When mistakes get made in the process, reputations suffer with an impact on staff morale and patient confidence. How, then, can health care professionals deal with complicated legacies?

A structured ethical framework may offer one sensible solution to address the multidimensional character of public sensibilities. The Ethics of Political Commemoration offers a framework that is increasingly used in other contexts to deal with national or local challenges of remembrance. Ethics here means, at the very least, that one seeks arrangements that can be sustained. The approach distinguishes the question of whether to commemorate loss and trauma from considerations on how to commemorate.

The criteria were developed in part based on the just war tradition. This ethical framework, developed over centuries, seeks to restrain the use of force. It emphasizes that action should be oriented on reestablishing a better future, and urges mutual respect and restraint, which is also a sensible approach for commemoration. One indication of the reach and impact of this tradition is that, as the International Committee of the Red Cross highlights, key aspects of the just war tradition have been integrated into international humanitarian law. This framework is also referenced in the medical literature.

In a first step of dealing with institutional trauma, under the Ethics of Political Commemoration’s Ius ad Memoriam (best translated as “can commemoration be justified”), one main focus is the intention of commemoration. For most medical institutions, this will be to reassure patients, staff, and the broader community that the institution is truly dedicated to do its best for them. This will typically entail acknowledging that suffering occurred as part of committing to do things differently.

The process of addressing historic challenges should be based on legitimate authority that involves a range of voices, from groups that have been affected in the past to current stakeholders and those committed to the institution’s future. Top-down decision-making is not enough to address past trauma. Time is needed, too, for people to feel comfortable sharing their stories and contributions and for due reflection.

At the same time, any proposals must have a reasonable chance of success at a proportionate level of effort. Little is gained if proposals for addressing the past are sweeping at the expense of presently providing care for the community.

In a second step, Ius in Memoria (best rendered as “how commemoration should be conducted”), institutions can consider how to address institutional trauma.

In medical and other institutions, commemoration should create a larger sense of “we” that is inclusive and does not set up — or repeat — patterns of “us versus them.” To state the obvious, everyone currently working in an institution should be able to identify with its commemoration of trauma, rather than feeling that remembrance is a way of implicating them in deeds committed by others, usually many years or decades earlier. Commemoration should help institutions do better, not set up new distinctions or dysfunctionalities.

Contained unfathomability is another sensible criterion of the Ethics of Political Commemoration, clunky as the phrase may seem at first. When it comes to past transgressions, it is advisable to be specific with dates and locations as a way to contain what happened. At the same time, it is important to acknowledge the difficulty of comprehending the “unending absence that follows,” as writer Joan Didion described traumatic loss in her book “The Year of Magical Thinking.” For that reason, too, it can make sense to keep the number of victims in broad categories, such as “dozens” or “hundreds.” In many cases, establishing the precise numbers of victims may be difficult. A meticulous accounting of cause and effect is rightly the task of historians, and not for commemoration.

Many institutions have found that art is central to acknowledging the unfathomability of past trauma. The Helios Clinic in Berlin-Buch in Germany, for example, has an art installation by the Argentinian-born artist Patricia Pisani in the middle of its medical campus to commemorate patients killed by the Nazis at this and other locations. Art allows for multiple interpretations and can speak where words may fail. As in the case of the Berlin-Buch clinic, the process of integrating such a memorial in institutions and public spaces, often as part of an open competition, can be a chance for joint reflection.

In the end, commemoration should help individuals assert their own moral autonomy, and emphasize the part every individual can and should play in keeping institutions on track. For that reason, too, one sensible focus can be on those who helped to right wrongs.

By applying this comprehensive ethical framework to institutional trauma, institutions can address the most challenging chapters of their past. Leaders at large institutions may have resources to retain professional support and commissions, yet with this guiding framework smaller institutions can also take steps towards healing. There will not always be agreement, but there can be a structured process of acknowledging and accounting for different views.

If approached carefully and honestly, institutions can emerge from such a reckoning with strengthened trust. Institutions that are perceived to be taking the right steps in response to past transgressions are likely to consolidate staff morale and strengthen patient confidence and community support, which ultimately contributes to financial performance as well.

Because addressing past trauma is an emergent concern across society, health care professionals can help their institutions track these issues. And the wider health care community may want to highlight examples of how the past has been addressed well. Sharing such examples can help institutions to stabilize their pasts, so that they can move, hopefully, to a better future.

Hans Gutbrod is an associate professor at Ilia State University in Tbilisi, Georgia, and a senior fellow at the Center for Peace and Conflict Studies at Seton Hall University in South Orange, N.J.