Mitchell Goldstein, MD, MBA, CML; Lily Martorell-Bendezu, MD; Elba Fayard, MD; and T. Allen Merritt, MD, MH

Blame is a toxic emotion that can poison trainees and coworkers in the field of neonatology. It is one of the antitheses of wellness. Blame can arise from various sources, such as parents, colleagues, administrators, learners, or even oneself. It can be directed at individuals, teams, systems, and institutions. Blame may be based on factual evidence, subjective perceptions, or unfounded assumptions. However, regardless of its origin, target, or validity, blame is harmful. It erodes trust, undermines morale, and impedes learning. It creates a culture of fear, defensiveness, and isolation. Blaming others prevents us from addressing the root causes of adverse outcomes or situations and sets back improvements in the quality and safety of neonatal care. 

As neonatologists, we work in a complex, high-risk environment where we face daily challenging care decisions, ethical dilemmas, moral distress, and uncertainty. We care for the most vulnerable patients and their families, who often experience intense emotions, such as grief, anger, guilt, or hopelessness. We also face increasing pressures from external forces, such as regulatory agencies, insurance companies, or legal systems, that may impose unrealistic expectations, conflicting demands, or punitive measures on rational clinicians. In such a context, it is understandable that blame may arise as a way of coping, venting, or seeking justice. Nevertheless, indulging in blame or ignoring its consequences is neither acceptable nor productive. 

What we need, instead of blame, is empathy. Empathy is the ability to understand and share the feelings of another without judgment or bias. Empathy allows us to see the situation from different perspectives, appreciate the challenges and constraints that others face, and recognize our common goals and values. Empathy fosters a culture of compassion, collaboration, and communication. It enables us to support each other, to learn from each other, and to improve together. 

Consider for a moment that blame interacts with the amygdala in the brain’s region involved in emotional processing and plays a crucial role in our response to threats and dangers. Research has shown that blame culture activates the amygdala, leading to feelings of fear, anxiety, and disengagement (1). In other words, blaming another reduces their capacity to have a “learning or teachable moment.”

In contrast, brain structures highly involved in the emotional component of empathy include the inferior frontal gyrus, inferior parietal lobule, anterior cingulate, and anterior insula. These structures create the network responsible for emotion recognition, emotional contagion, motor empathy, and shared pain, or increasing the possibility of learning (2). In their review article, these authors emphasize that empathy and compassion set the stage for new learning and personal growth. These approaches to corrective action offer a neurophysiological explanation regarding the preferred response to errors made by trainees, colleagues, or others in practice. 

Empathy does not mean that we condone errors, overlook failures, or absolve accountability. It means that we approach them with curiosity, humility, and respect. It suggests we seek to understand the factors that contributed to them rather than assign blame. It means we use them as opportunities for feedback, reflection, and growth rather than as sources of shame, guilt, or resentment. Empathy means we offer and accept apologies, forgiveness, and reconciliation rather than inflict or endure punishment, isolation, or ostracism. 

Empathy is not a trait we are born with or acquire once and for all. It is a skill that we can learn, practice, and cultivate. It requires intention, attention, and action. It demands that we listen actively, speak respectfully, and act kindly. It requires that we challenge our assumptions, acknowledge our biases, and correct our mistakes. We must model, teach, and reward empathic behaviors and discourage, correct, and sanction blaming behaviors. It requires that we create and sustain a culture of empathy at all levels, from bedside to boardroom, from classroom to courtroom, and from laboratory to legislature. 

Empathy is neither a luxury nor a weakness nor a distraction. It is a necessity, a strength, and a priority to enhance learning from each other. It is the antidote to blame and the foundation of improving continuing excellence in neonatology. It is what our patients, their families, and ourselves deserve and demand from us. Approaching wellness, empathy, and not blame elevates the conversation and produces the most applicable path toward improved life satisfaction for all involved. 

References: 

1. Hoffman, M.B., Krueger, F. (2017). The Neuroscience of Blame and Punishment. In: Menon, S., Nagaraj, N., Binoy, V. (eds) Self, Culture and Consciousness. Springer, Singapore. https://doi.org/10.1007/978-981-10-5777-9_13 
2. Francis Stevens, Katherine Taber, The neuroscience of empathy and compassion in pro-social behavior, Neuropsychologia, Volume 159, 2021, 107925, ISSN 0028-3932, https://doi.org/10.1016/j.neuropsychologia.2021.107925.