Apology as Accountability

Accountability is part storytelling and record keeping to judge whether standards were maintained and obligations fulfilled (Bovens et al., Reference Bovens, Schillemans, Goodin, Bovens, Goodin and Schillemans2014: 3). It is distinguished from the concept of “responsiveness” despite the fact that the two concepts are related (Thomas, Reference Thomas2001: 12). Responsiveness, as we will see later in our discussion of ethics of care “refers to the inclination and capacity of health institutions and health care providers to recognize and reflect in their actions the needs and wishes of the particular individuals they serve, as well as of society at large” (12).

Accountability emphasizes the structures that secure the accountability of government and the provision of public services through such mechanisms as elections (Bovens et al., Reference Bovens, Schillemans, Goodin, Bovens, Goodin and Schillemans2014: 1–5). In this sense, accountability is concerned with democratic governance and the abuse of power. In Canada, accountability is secured through the doctrine of ministerial responsibility whereby cabinet is held to account for the performance of government (Jarvis, Reference Jarvis, Bovens, Goodin and Schillemans2014: 406; Thomas, Reference Thomas2001: 13–14). Cabinet is accountable for the “overall safety, effectiveness and responsiveness of the health care system” (Thomas, Reference Thomas2001: 13). To illustrate how the doctrine of ministerial accountability works in health care, consider a patient who is discharged from the emergency room and sent home via taxi only to die on their front yard never making it into their house. The minister responsible for health is held to account and expected to provide an explanation for how this incident occurred and institute reforms to prevent similar incidents from occurring (Puxley, Reference Puxley2015). The ability of the minister and cabinet is judged by the electorate for such incidents and may or may not be re-instated.

Of course, such issues of accountability are not limited to elected government officials, but include all those involved in the provision of services to the public. As Allen argues, “accountability is at the heart of the concept of clinical governance. Not only must health professionals strive to improve the quality of care, they must also be able to show that they are doing so” (Reference Allen2000: 608). The introduction of apology legislation is another mechanism to the existing accountability regime already in place for medical professionals dealing with adverse events.

The first line of accountability rests with the fiduciary responsibility of medical professionals, notably doctors, to their patients. This fiduciary responsibility is at the heart of the patient-physician relationship “because the balance of knowledge and information favours the physician, patients are reliant on their physicians and may be vulnerable. The patient must always be confident that the physician has put the needs of the patient first” (College of Physicians and Surgeons of Ontario, nd). It is not surprising, then, that the fiduciary responsibility requires physicians to act in the best interests of patients by respecting their dignity and autonomy (College of Physicians and Surgeons, 2015). More tangibly, the fiduciary responsibility requires physicians to prevent harm by taking reasonable courses of action but to also recognize their limitations and refer patients to specialists when appropriate (Snyder et al., Reference Snyder, Adams, Chen, Birch, Caulfield, Glenn Cohen, Crooks, Illes and Zarzeczny2015). There is also the obligation of informed consent that requires physicians to provide relevant information related to concerns of their patients such as providing information related to the risks and benefits of different treatment options (Snyder et al., Reference Snyder, Adams, Chen, Birch, Caulfield, Glenn Cohen, Crooks, Illes and Zarzeczny2015: 585). Acting in the best interest of patients also includes full disclosure when something has gone wrong (MacDonald and Attaran, Reference MacDonald and Attaran2009). Failure to do so erodes trust and violates the doctor's responsibility to be honest, open and respectful (MacDonald and Attaran, Reference MacDonald and Attaran2009). Moreover, this erodes the ability of the patient to make informed decisions about their health and may actually place them in harm.

Disclosure is not solely an ethical and professional requirement. It is also a legal requirement rooted in common law that has been further strengthened in recent years by the “international shift” away from secrecy to openness with Canada being a leader in working towards greater transparency (McLennan et al., Reference McLennan, Rich and Truog2015). By way of example of this shift, Manitoba introduced legislation in 2006 (The Regional Health Authorities Amendment and Amendments to the Manitoba Evidence Act) that requires no-blame critical incident reporting from the regional health authorities. Beyond disclosure, some jurisdictions may also employ patient-safety indicators, such as the number of patients who acquire an infection during their hospital stay (Stastna, Reference Stastna2013). Moreover, morbidity and mortality conferences are held regularly in health institutions with residency programs that provide opportunities to reflect and learn from adverse events so long as they are not rooted in culpability (Kravet et al., Reference Kravet, Howell and Wright2006).

However, there are concerns that some incidents are not reported or that the reporting system may not generate learning. In relation to critical incident reporting, Macrae outlines several concerns. First, the definition of what constitutes a critical incident may be quite broad thus missing opportunities to prioritize. Second, while reporting is encouraged, this may not result in learning. Macrae (Reference Macrae2015) suggests that we should not assume that high levels of reporting necessarily mean that learning is occurring because it may only reflect a strong reporting culture. Third, reporting does not necessarily reflect safety and may not be sufficient to capture broad social, cognitive or organizational factors (for example, systemic racism against Indigenous peoples) that undermine patient safety. Last, reports may be biased because they capture the perspectives of the actors involved. Moreover, critical incident reporting may not be applied to the entire health care system. The legislation introduced in Manitoba in 2006 only applies to the regional health authorities so medical professionals outside that system are not held to the same reporting standards.

In the accountability regime, there are also professional regulatory bodies, such as the College of Physicians and Surgeons, that fulfill a self-regulatory function. In this example, the regulatory bodies, like the college, license doctors, investigate complaints of misconduct and maintain reporting systems of adverse events or errors (see Kalra et al., Reference Kalra, Massey and Mulla2005: 308). Investigating complaints of misconduct is an integral component of the accountability regime. Citizens can file a complaint related to a number of concerns including but not limited to the behaviour of the physician, inadequate care provided by the physician, breach of confidentiality and, sexual misconduct. Processes are in place for regulatory bodies to investigate and resolve complaints which can range from providing advice on how to improve their medical practice to outright removal of a physician from practice.

As part of the accountability regime, some hospitals may also employ a “patient representative” to advocate on behalf of families, particularly when errors are not readily apparent such as ongoing delays in treatment (Thomas, Reference Thomas2009). Finally, the accountability regime also affords patients, or their families, to initiate a lawsuit for financial compensation.

We can see that the accountability regime is well developed and has room to deal with adverse events. So, to what extent can apology legislation contribute to accountability? The Canadian literature in this area is sparse, but there are well-grounded concerns. Bailey and colleagues (Reference Bailey, Robertson and Hegedus2007: 34–35), for example, are pessimistic and dismiss the grounds upon which apology legislation has been built. They cite US case law where, in some instances, contradictory decisions have occurred whereby some court decisions determine that an apology is sufficient to determine liability, but in other instances an apology is insufficient. This causes confusion as to whether apology legislation is needed. They also cite Australian case law that supports the position that apologies do not establish liability. They argue what is really needed is better training in the legal, ethical and professional responsibilities when dealing with an adverse event (Reference Bailey, Robertson and Hegedus2007; see also MacDonald and Attaran, Reference MacDonald and Attaran2009). McLellan and colleagues echo this sentiment, stating “without good training and support in this process, apology legislation is unlikely to have much of an impact on the behaviour of health care staff” (Reference McLennan, Rich and Truog2015).

Apology as a Mechanism

The introduction of apology legislation is consistent with an emerging shift in the literature that forces us to start thinking seriously about the accountability of individuals. Warren (Reference Warren, Bovens, Goodin and Schillemans2014) signals that there is a sense of urgency in situating accountability closer to the needs of citizens. He argues that we need to better proximate accountability to those individuals such as medical doctors who are not part of government proper per se but provide valuable public goods. With calls for a shift in how accountability is more proximate to the citizen, how then can this be achieved particularly when accountability is a multi-dimensional concept for which no universal definition can apply? While there are many ways to define this complex concept, this article draws on the work developed by Bovens (Reference Bovens2010) in which he conceptualizes accountability as a mechanism to later understand apology legislation.Footnote ³

Bovens asserts that accountability mechanisms establish a relationship between actors whereby one actor feels compelled to explain his or her actions and justify them to the other actor. In this way, it makes sense to think of it as a “social mechanism” whereby space is created between actors so that an accountability relationship can emerge. This is a crucial point for Bovens: Not all relationships are accountability relationships. In order for a social relationship to be deemed an accountability relationship, actors must feel an obligation to account and take ownership of their performance; otherwise there can be no accountability relationship (Reference Bovens2010). When viewed as a mechanism, the primary focus rests with the institutional design and whether it allows for the emergence of an accountability relationship. The emphasis relates to the configuration of institutions to allow for accountability to be secured, and not whether individuals have acted accountably (948).

Four elements comprise this approach. First, responsibilities are assigned to the various agents, generally an accountee and an accountor; second, the accountee provides an account of their performance of responsibilities to the accountor; third, the accountor questions and monitors the accountee; and last, the accountor issues consequences or rewards—formal and informal—to the accountee. The actors involved can be individuals (for example, journalists, public servants or cabinet ministers) or organizations, even institutions (for example, legislatures or the courts) according to Bovens. As a research agenda, accountability as a mechanism is more focused on “who is accountable and for what” and “to whom is accountability owed and when” and “how sanctions or rewards” are applied (Bovens, Reference Bovens2010: 953).

Apology legislation reflects mechanistic forms of accountability that proximates accountability at the service provider level. As a mechanism, it creates space for an accountability relationship to solidify between a patient and health care professional, notably physicians, when an adverse event occurs such as mistakenly administering a drug other than the one prescribed.

As an expression of public policy, apology legislation is thought to contribute to the transformation of health care to become less about anger and the pursuit of lawsuits, and more about empathy, forgiveness and the pursuit of understanding to overcome the culture in medicine of “sealed lips” and promote learning (Zylberman, Reference Zylberman2009: 187). As Aucoin and Heintzman observe, accountability can be conceptualized as “continuous improvement” through learning rather than blaming (Reference Aucoin and Heintzman2000: 52). While apology legislation does not allow for the issuance of rewards or consequences there may be healing effects resulting from apologizing for both the health care professional and patients which should not be overlooked when considering the impact and value of an apology, although this potential impact is far from being proven in the existing literature. As Regehr and Gutheil observe, while we often assume an apology will contribute to the healing process, the therapeutic value has yet to be determined” (Reference Regehr and Gutheil2002: 427). What is needed, we argue, is more empirical research that involves patients and medical professionals to determine the impact of apology legislation in these areas.

Apology legislation may not fit neatly into current conceptualizations of accountability mechanisms, but it is a mechanism nonetheless. It is an additional accountability tool that is layered onto the current accountability regime to further develop the relationship between the patient and the medical professional. While apology legislation works with the existing medical accountability regime to further create space for an apology to occur by offering the mechanism to do so, how, if at all, does it work to change our public institutions and practices? It is to this question we now turn.

Can Institutions “Care”?

What does it mean to care? Is it a private matter or a public responsibility? Can public policy create care? These questions are central for any society and yet the notion of care remains marginal within our political theories and practices. There was, however, a “minor revolution” in the study of ethics that began in the 1980s. “The constellation of the moral universe in Western culture was enlarged by the introduction of ‘care ethics’” (Hamington and Miller, Reference Hamington and Miller2006: xi). First introduced by Carol Gilligan (Reference Gilligan1982: 12), “care ethics” was originally premised on the notion that two distinct moral perspectives become manifest in human development due to markedly different contexts of socialization. More specifically, Gilligan argued, the experiences of the female child are markedly distinct from the experience of the male child, “from very early […] because they are parented by a person of the same gender […] girls come to experience themselves as less differentiated than boys, as more continuous with and related to the external object-world, and as differently oriented to their inner-object world as well” (12). These differences in sense of self culminate in differences of perspective that shape the priorities and values of the subject through the life cycle. Thus, when the subject is female, she is likely to be working from a perspective based not on the primacy of the unencumbered individual self but rather on a self that is constituted through connections and relationships to others. Defining themselves in a “context of human relationships” leads women to judge themselves not in terms of individual self-maximization but in terms of their “ability to care.” From this standpoint, moral dilemmas are not about how to “exercise one's rights without interfering with the rights of others” but rather about how to “lead a moral life which includes obligations to others” (8).Footnote ⁴

In its earliest or “first wave” conceptualization, an ethics of care was juxtaposed to the dominant “ethic of justice” and these two ethics—justice and care—were posited as separate and distinct from one another. The ethics of justice emphasizes abstract reasoning, human separateness and some form of equality while ethics of care emphasizes context, connectedness and the maintenance of relationships (Clement, Reference Clement1996: 11). The ethics of justice is premised on the primacy of personal autonomy through individual rights whereas the ethics of care is premised on individuals’ ability to recognize themselves as part of a larger whole.

While the distinction between these two ethical perspectives is helpful for analytical clarity, not all ethics of care scholars insist that the two ethics can or should be understood as opposed to one another (see, for example, Hankivsky, Reference Hankivsky2004; MacDonald, Reference MacDonald2010; Nedelsky, Reference Nedelsky1989). As care ethics have developed, many of its advocates have taken the position that care and justice are not mutually opposed ethical approaches, but rather distinct yet related understandings of morality that can work harmoniously under certain conditions. “Such harmony has been harmed by the suppression of the voice of care, but the reclaiming of this voice could produce a healthy balance” (Hamington and Miller, Reference Hamington and Miller2006: xii). It is also important to emphasize here that while “first-generation” care scholars (see Gilligan, Reference Gilligan1982; Noddings, Reference Noddings1984; Ruddick, Reference Ruddick1989) emphasized that care ethics are inherently gendered, “second-wave” care scholars (see Hankivsky, Reference Hankivsky2004; Sevenhuijsen, Reference Sevenhuijsen1998; Tronto, Reference Tronto1993, Reference Tronto2010) propose that care is “central to all human life” (Hankivsky, Reference Hankivsky2004: 11). It is this second wave of scholars who first articulated the potential of care in our theories of citizenship practice and policy paradigms.

According to “second wave” care scholar, Selma Sevenhuijsen, care ethics can and should inform our responsibilities as democratic citizens. For Sevenhuijsen, integrating values of care such as “attentiveness, responsiveness, and responsibility” into models of citizenship will produce “a dual transformational effect” whereby the concept of citizenship is more deeply developed to integrate diversity and plurality and care is “de-romantisized” and reconceptualized as a source of political virtues (Reference Sevenhuijsen1998: 15–16). Such an approach is further defended by Hamington and Miller in their notion of “socializing care” which entails the application of care ethics to reconstruct institutions, politics and social dynamics as part of a larger shift to deconstruct the boundaries between home and community (Reference Hamington and Miller2006: xiv).

Central to any effort to “socialize care” is the concept of relational autonomy. While there is no single agreed-upon definition of relational autonomy a number of ethics of care scholars (Fox Keller, Reference Keller1985; Mackennzie and Stoljar, Reference Mackenzie, Stoljar, Mackenzie and Stoljar2000; MacDonald, Reference MacDonald2010; Nedelsky, Reference Nedelsky1989) invoke this idea as a concept that offers the ability to successfully combine the prima facie oppositional claims of “the constitutiveness of social relations” and “the value of self-determination” (Nedelsky, Reference Nedelsky1989: 9) and in so doing to reconcile the insights of care ethics with the importance of individual freedom in democratic societies. As Iris Marion Young argues, relational autonomy entails both a “presumption of non-interference” but also the recognition that “agents are related in many ways they have not chosen, by virtue of economic interaction, history, proximity or unintended consequences of action” (Reference Young2000: 258).

From this perspective, autonomy is still central in practising care but the notion of autonomy itself is expanded and/or enhanced to recognize that autonomy is always socially constituted. Social relations will unavoidably include relationships of dependence. This reality is not in and of itself a problem as dependence is not only a part of the human condition but it can also be a fulfilling and nurturing part of our relationships with others.

Some scholars of medical ethics have also taken up the principles of care theory and the concept of relational autonomy in particular. Baylis and colleagues, for instance, propose “a relational concept of personhood” in their model for both clinical and research ethics. Such a concept, they argue, “allows us to see how questions of social justice are central to many aspects of personhood” by highlighting that all persons are socially constructed, “also reminds us that we are not all constructed as equals” (Reference Baylis, Kenny and Sherwin2008: 6).

This relational emphasis is particularly essential for health care, given recent stories that may leave some citizens with the growing perception that health care staff do not care, a perception that is correlated with a decline in public support for public health care (Armstrong, Reference Armstrong and Dobrowolsky2009: 96). One recent example of this growing discontent comes from Manitoba where, according to one patient, suicidal patients are discharged at 1:00 am with few supports beyond a bus ticket:

As Armstrong details in her account of social cohesion and the neoliberal welfare state, neoliberal restructuring of public health services translates into deficit reduction, staff reductions, amalgamation of hospitals and the imitation of corporate practices centred on market principles (Reference Armstrong and Dobrowolsky2009: 96). Health professionals are also starting to speak out on how increased funding cuts to health care institutions displace caring and leaves them, and their patients vulnerable. A nurse in the British National Health Service tells The Guardian how her employment as a mental health nurse in the UK health care system drained her of her compassion:

The narratives above speak to the need for, but also the complex challenges in creating caring institutions reminding us that care must be front and centre for the individual health care professional, caregiver and patient, and must also be part of the material environment. Does the introduction of apology legislation aid in the development of caring institutions and/or socializing care? As the next section will outline, apology legislation has the potential to aid in transforming our current policy paradigm but without additional changes in institutional culture, material resources, funding and support this act may remain a mechanism of accountability, but will not on its own lead to more caring institutions.

Apology as Care

Given our current neoliberal context of funding cuts, restructuring, and privatization, the potential impact (both direct and indirect) of an apology in a context of medical error or mistreatment is complex and yet little research exists on the topic.Footnote ⁵ Lazare's work (Reference Lazare2006) helps to fill this gap and suggests ten ways in which apology can potentially contribute benefits for those involved. These contributions include the restoration of respect and dignity to the patient and/or family to address any feeling of disrespect and humiliation, a feeling of being “cared for” by the physician or practitioner communicated through various actions including follow-up telephone calls and attending a patient's funeral when the outcome is death, a restoration of power to the patient and/or the family of the patient, some level of “suffering” by the offender, a validation that an offense has occurred, designation of fault and/or responsibility to the medical practitioner as opposed to the patient and/or family of the patient, assurance of shared values, an opportunity for dialogue in which patients and family can ask questions and express their feelings, experiences and concerns, a “promise for the future”—that is, a commitment to correction and/or prevention in future cases and finally reparations may be an important part of addressing damages in some cases (Reference Lazare2006: 1402).Footnote ⁶

These potential outcomes of apology are very consistent with ethics of care. Actions like attending the funeral of a patient challenge traditional notions of public-private division and professionalism centred on separation between physician and patient and highlight how context is of fundamental importance when determining the correct ethical action or inaction. Most significantly, the practices highlighted by Lazare are centred on the relationships between medical professional and patient as citizens well beyond any consumer of service–supplier of service models recognize.

Apology legislation may therefore aid in challenging previous traditions in health care policy and administration by challenging the dominance of an ethics of commodification consistent with liberal notions of justice in contemporary neoliberal policy practice and evaluation. For ethics of care advocates, “there is a great danger in thinking of care as commodity, as purchased services rather than as a process” (Tronto, Reference Tronto2010: 164). Apology legislation addresses long-standing gaps in how we as a society think about health care and respond to patients and families in ways that challenge the dominant “consumer of services” role. It is in this sense that apology legislation has the potential to destabilize traditional notions of social citizenship.

While apology legislation has this potential to create new understandings it also appears to directly decrease actions associated with prior “tight lipped” practice. There is significant research that links apology legislation with decreases in the likelihood of litigation. Lazare explains, “Although the goals of policies regarding disclosure and apology were to enhance patient safety and fulfill an ethical commitment of honesty to patients, an outcome unexpected by many was a reduction in the number and cost of malpractice claims” (Reference Lazare2006: 1401). This decrease in litigation lends support to the notion that “the medical malpractice litigation problem” is often “a human relations problem.” Fiesta argues:

The significance of concern in medical relationships is also comprehensive in nature. As Lazare argues, the apology process should not be limited to the realm of medical errors but should include all aspects of the medical setting in which a person could be offended or humiliated (Reference Lazare2006: 1403). Lazare also includes the relationships among health professionals—relationships that are also constituted by significant power and gender dynamics—as important targets for concern and, at times, apology, as we shift from the “ritual practice” of humiliation of medical students by their superiors. Moving away from these hierarchical humiliating practices is an essential part of creating caring institutions. Developing a culture of respect, transparency and accountability among health professionals is foundational to developing such a culture between patients and health care providers. Apology legislation creates space and opportunity for increased expressions of care more broadly. As Hankivsky argues, “Policy texts and legal texts are, after all, ‘stories in themselves’: they include patterns of dealing with things which are often the result of political compromises and discursive traditions. They often contain fixed patterns of speaking and judging, but they can also open up unexpected discursive spaces, where new forms of thinking and judging can start” (Reference Hankivsky2004: 31).

Apology legislation has the potential to create discursive spaces about care and yet the legislation itself is only one small contribution to the development of caring institutions. While apologies are important to transforming how we think about, talk about, and practice care they are also reactive rather than proactive in nature. Institutional and professional cultural factors are crucial in working to prevent medical errors or mistreatment in the first place. Liability experts suggest a link between poor communication between health professionals and patients—such as medical staff interrupting or failing to allow patients to finish speaking during initial appointments—and misdiagnoses and/or medical mistreatment (Fiesta, Reference Fiesta1994: 14). It is also worth noting that the likelihood of both medical mistakes and subsequent litigation are correlated with the nature and scope of patient-institution relations even at what may appear to be the most trivial levels such as a call to a hospital switchboard. Fiesta explains:

To truly create caring institutions then we need to develop comprehensive and proactive approaches to care as citizenship. Such an approach requires challenging traditional notions of professionalism as impartial, abstract, and objective. As Sevenhuijsen aptly observes, care and citizenship are often constructed as separate, if not oppositional, practice. Judgments in the public sphere are typically associated with distance, impartiality and a “general viewpoint” while care ethics such as compassion, attentiveness, empathy and specificity are depicted as belonging to a “different sphere,” that is, the sphere of “interpersonal and private relationships” (Reference Sevenhuijsen1998: 5).

Deconstructing the divide between public judgment and private care is at the centre of the necessary cultural shift at the institutional and societal level. At the same time we must not assume that increased care means decreased conflict. As Tronto reminds us, “the reality is that care is rarely without serious problems and conflict” (Reference Tronto2010: 167). Creating caring institutions requires that we make democratic space(s) for the politics of care that offer “explicit locus for the needs-interpretation struggle.” According to Tronto (Reference Tronto2010: 168) that comes with providing, receiving, and debating care and our contesting and changing notions of what care means. It is also worth noting that Tronto's work points to at least two significant dangers that accompany efforts to “emphasize care as purposive practice.” These are the dangers of “power and particularity.” More specifically, the dangers of paternalism—“in which care givers assume that they know better than care receivers what those care receivers need”—and the dangers of parochialism—“in which care givers develop preferences for care receivers who are closer to them”—are tendencies to guard against (161). Challenging traditional understandings of professionalism will require significant learning and reflection within institutions working to socialize care. Virtues such as compassion, attentiveness and reciprocity must be considered and expressed with the dangers of paternalism and parochialism in mind. The concept of relational autonomy is, we argue, a key concept in pursuing such as balance. From this perspective, public institutions, such as hospitals and other medical care facilities, should identify how best to ensure practices and processes that recognize, as Mackenzie and Stoljar argue, a context of social relationships that are always shaped by “a complex of intersecting social determinants such as race, class, gender, and ethnicity” (2004: 4).

Ensuring practices of non-domination is fundamental to practising care ethics in the administration of health care. Citizens receiving care are often in highly dependent relationships with health practitioners and policy makers leaving them particularly vulnerable to the dangers of paternalism and parochialism highlighted by Tronto. A recent case prominent in Canadian media helps to illustrate this reality. In May 2016, the CBC reported that a Quebec City man with multiple sclerosis and significantly limited mobility launched an online crowdfunding campaign in order to raise sufficient money to pay for showers in the long-term care home where he lives. While the institution does provide showers to residents, government funding will not provide more than one shower weekly.

This case shows a clear deficit in both care ethics generally, such as compassion, attentiveness and responsiveness, and the principles of relational autonomy and non-domination more specifically. It also demonstrates how care cannot be fostered without the necessary material resources. Finally, this example also showcases a clear and illustrative resistance to these deficits.

By initiating a crowdfunding initiative and speaking to media Marcotte is resisting the passive subjectivity and domination current policies and practices enforce. A system that truly embraced an ethics of care would not only avoid such humiliating and dominating policies but would also work to develop a context in which the autonomy of citizens like Marcotte is supported and enhanced through the provision of necessary resources in an institutional context of dignity and respect. As Nedelsky argues, autonomy is both a capacity and a feeling:

Clearly the circumstances Marcotte has revealed show that this institution fails to pass the threshold of autonomy as capacity or feeling. It also reveals many of the complex factors at play when thinking through how to transform care. While apology legislation has the potential to enhance the capacity and feeling of autonomy for patients and professionals in various scenarios, this case reminds us that there are many aspects to ethical care that fall beyond the scope of apology, most notably, material resources. It also reminds us that health care is an area already laden with complex dynamics of power and dependency that must be taken into account if a meaningful shift to care as citizenship practice is to be implemented. Apology legislation has the potential to help lead us to such a change if we conceptualize the legislation as a starting point rather than an end in and of itself.