By Paolo Spriano, MD

Apologies are commonly defined as “a regretful acknowledgment of an offense or failure; a formal, public statement of regret.” In healthcare, apologies offered with honesty and transparency are an essential part of addressing medical errors. An effective apology acknowledges what happened, accepts responsibility, and expresses sincere regret for the patient’s suffering. When done properly, an apology can have profound healing effects for everyone involved. For clinicians, it can help ease feelings of guilt and shame; for patients, it can foster forgiveness and form the basis for reconciliation.

Patients harmed by adverse medical events often pursue legal action not primarily for financial compensation, but because they perceive a lack of apology or sincerity. Despite legal and policy reforms in several countries to modernize how medical negligence is handled, patients continue to report unsatisfactory responses, while clinicians frequently cite fear of legal liability as the main reason for not apologizing.

In England and Wales, one proposed solution has been apology legislation, which would make apologies inadmissible as evidence of liability in court — thereby encouraging open communication while reducing legal risk. Critics, however, warn that such laws could lead to formulaic or strategic apologies rather than authentic, compassionate responses that genuinely support patients and families.

Importance of Apologizing

International evidence suggests that receiving an apology can have a significant positive impact on patients and families. Many consider an apology to be the most meaningful part of communication after a medical error. Yet, even when clinicians recognize their ethical obligation to disclose mistakes, fear of blame or litigation often holds them back.

The human cost of this hesitation is powerfully illustrated in the Canadian Medical Association Journal account by a mother whose child sustained severe neurological and physical disabilities at birth. She describes a 13-year struggle for acknowledgment and redress and the emotional and financial toll it took on her family. The trauma of her child’s injury, she writes, was worsened by the medical profession’s silence and defensiveness.

She concluded with words that deserve reflection. “My son, my family, and I were deeply hurt by a profession that failed us and then employed the least constructive, most conflict-laden means possible to address the error. What we craved — what we deserved — was timely support, clarity, and genuine remorse about our son’s injuries and our ongoing challenges. What we got, instead, was silence, judgment, and a lengthy and painful legal ordeal.”

“Twenty-five years later, much of the damage is beyond repair, but not all. The medical profession could still apologize,” she added.

Her experience underscores a universal truth: When harm occurs, the absence of acknowledgment and apology deepens resentment and anguish — emotions that can harden over time.

The sooner an apology is offered, the greater the opportunity for healing. Patients and families are often less concerned with legal arguments or institutional defensiveness than with having their suffering seen, acknowledged, and understood.

Apologies and Medical Liability

Traditionally, individuals and institutions in healthcare have been reluctant to offer apologies after an adverse event; and, in many cases, legal advisers actively discourage them. In several health systems, including Canada and the US, apologies are viewed as risky for two main reasons: first, the fear that an apology could be interpreted as an admission of guilt or liability, and second, the concern that it might invalidate professional liability insurance coverage.

Nevertheless, there is broad agreement that disclosing adverse events and apologizing to harmed patients is ethically the right course of action, regardless of whether it increases or decreases the likelihood of litigation. To bridge the gap between the ethical imperative to disclose and the legal instinct to remain silent, some jurisdictions have introduced apology legislation aimed at reducing the perceived legal risks.

Since 2006, Canada has had an apology law that applies in clinical contexts. Under this law, apologies made by clinicians to patients and families after an adverse event cannot be used as evidence of fault or liability and do not affect professional liability insurance coverage. The law defines an apology broadly to include “words or actions [that may] admit or imply an admission of fault,” protecting both expressions of sympathy (“I’m sorry this happened to you”) and explicit acknowledgments of error (“We made a mistake, and we’re sorry for the suffering it caused”).

However, there remains significant skepticism that such laws alone can substantially improve patients’ experiences after medical harm.

Apologies Can Heal Recipients and Providers

The existence of apology legislation does not automatically make clinicians feel comfortable apologizing when something goes wrong, especially in a culture that employs “the least constructive, most conflict-laden means possible to address the error,” as MacGregor described in her tragic account.

A paradigm shift is needed: one that recognizes apologies can be therapeutic not only for patients and families, but also for the clinicians involved. Advising clinicians to protect themselves by remaining silent may, in fact, deepen their psychological distress.

Healthcare professionals, regulators, and system leaders must acknowledge the dual healing role of an apology. It can ease the compounded harm experienced by patients and families while also supporting the mental well-being of clinicians — often referred to as the “second victims.”

The concept of the “second victim” emerged more than 20 years ago to describe the emotional and psychological toll experienced by healthcare professionals involved in patient harm caused by human or systemic failures. For clinicians, apologizing after an error is among the most difficult conversations in medicine. Without proper training, institutional support, and a culture of psychological safety, apology laws alone are unlikely to transform professional behavior.