Four months ago, headlines in newspapers around the world announced the unfolding saga of apparent medical error occurring within a university hospital with international name recognition.
The newsworthiness of this particular mistake surely had something to do with its origin at Duke, and that it involved the widely heralded “miracle” medicine of organ transplantation. Public intrigue resulted also from photos published of the unfortunate recipient of a botched heart-lung transplantation, a petite and pretty 17-year-old Jesica Santillan. Much was made of the fact that she was Mexican, the child of undocumented aliens who had immigrated illegally.
In sum, Dr. James Jaggers transplanted a mismatched set of organs in Jesica. With incompatible blood types between donor and recipient, the error proved fatal; but not before the Duke team obtained and transplanted a second set, properly matched, of donor lungs and heart. Yet, it was too late. And not only was a vulnerable pediatric patient lost, but two sets of scarce and precious organs were squandered, via medical mistakes.
For many weeks, significant discussion of “the Duke case” occurred in public forums, some engaging relevant matters of law or medicine, and much of it about ethics. In recent months, journalists have shifted to other topics and the general public has focused on issues of war and economics.
But within the organ-procurement-and-transplantation world, heads are still shaking–and tongues wagging–over the Duke debacle. Clinicians and technicians, and “ethicians,” still try to understand what happened there, what went wrong, and how to prevent its recurrence elsewhere. The “transplant community” still is weighing the fallout from negative media attention and the potentially devastating consequences for organ donation of a tarnished reputation and diminished public trust.
A diverse group of panelists at a medical symposium held in Nashville last month discussed this case under the rubric of “Medical Errors’ Effects on Organ Donation.”
A retired transplant nephrologist moderated the session, beginning with a case summary and the maxim, “to err is human.” A Vanderbilt transplant physician involved with cross-matching of donor and recipient blood and tissue samples gave an extensive explanation of the process, the safeguards within it and the points at which mistakes nonetheless might occur. Another physician on the panel spoke about “pursuing perfection.”
A philosopher attempted to make relevant distinctions between medical “error” and medical “mistake.” He raised a question of the Duke transplant program’s credibility relative to its explanation of the “errors” or “mistakes” apparently made. Clearly, his was a trust issue, and one that conference participants readily understood. Some clinicians even speculated among themselves about whether their erring colleague at Duke could have knowingly and intentionally attempted to transplant “ABO incompatible” organs in his dying patient as an experimental act of desperation or hubris.
The perspective I offered then and now is that of a theological bioethicist and a Christian pastor. It occurs to me that both medical mistakes/errors and medical malice fall under the legal concept of medical malpractice, and that all fall under the theological concept of sin. To commit sin, or hamartia, is to “fall short” or “miss the mark.” Indeed, to err–to sin–is human. It is the human condition.
So why are we surprised by this in the context of medical practice? It is not for lack of experience with this sort of sin. By Institute of Medicine estimates, somewhere between 44,000 and 98,000 people die annually in the U.S. from medical errors.
Does the commonplace still shock us because we have deified doctors? Have we considered physicians to be above the sinful human condition? I occasionally encounter a “Dr. God” born of hubris; but often it is patients who place their doctors upon a pedestal too high for any human to reach.
Whether occurring with or without malice, as commission or omission, from medical hubris or mere humanity, the fitting response to sin is repentance. The two choices facing any human following an awareness of having “fallen short” are confession or cover-up.
In medicine, confession has some distinct advantages for the erring sinner. Recent studies have indicated lower incidence of lawsuits when physicians admit their mistakes and apologize to offended patients. Even in this litigious society, we are inclined to forgive those who sin against us–if they confess with full disclosure of what happened.
What we tolerate less well is cover-up or the perception of such. Hence, Watergate seemed newsworthy, as did President Clinton’s primary scandal. What outraged us about the Clinton-Lewinsky affair, even more than adultery and professional sexual misconduct, was the cover-up preceding confession.
Confession has an iconoclastic effect in medicine, both upon a “Dr. God” and the worshipers who set him or her up as an idol. Cover-up, on the other hand, perpetuates such idolatry of self or other.
Whereas confession “is good for the soul,” cover-up exacerbates the sinful state. It demoralizes both patient and physician. There is a loss of one’s morals and morale when sin is covered up rather than confessed. In such an environment, patients whisper to pastors about “what goes on around here,” while clinicians involved in cover-up bear their burden of guilt in silence and secrecy. They are sin-sick souls.
Trust is diminished by cover-up, whereas confession has the opposite effect. This is especially critical in transplant medicine, which depends upon the public trust for organ and tissue donation.
And this is at the heart of what irks transplant clinicians and procurement personnel about “the Duke case.” One symposium panelist asked those who gathered recently in Nashville, “Do you really believe the explanation that has been given by Duke and Dr. Jaggers?”
The explanation referred to is a fairly extensive “chronology of events” compiled by the medical center’s press office. By some accounts, this constitutes full disclosure–a confession of sin.
Others remain skeptical. An online news source for the transplant community refers to the surgeon’s error as still a “mystery,” since his quick acknowledgment of such nonetheless “did not explain how the error occurred.”
The article claims that Duke University Hospital officials “accepted responsibility for ‘a tragic error,’ but failed to fully explain how the system broke down.” Jesica’s family and friends also charged Duke with delayed response, a partial cover-up out of concern for its reputation. And no one is certain that the organ-procurement organization involved is completely without sin in this matter, either.
The jury is still out on this case. What we know for sure is that medical mistakes happen. To err is human, at Duke and by us all. But what appalls us is cover-up when what is called for is confession.
Tarris Rosell is associate professor of pastoral care and practice of ministry at Central Baptist Theological Seminary.
Tarris Rosell is professor of pastoral theology–ethics and ministry praxis at Central Baptist Theological Seminary in Shawnee, Kansas, and holds the Rosemary Flanigan Chair at the Center for Practical Bioethics.