The
Case
Virtua Health is a not-for-profit
health organization and it is Southern New Jersey’s largest health system. They
are committed to the mission of helping people be well, get well, and stay well
and they average more than one million patient encounters each year. Virtue
Health houses 5 hospitals, 8 urgent care facilities, and 28 primary care
offices in Southern New Jersey. All of which provide comprehensive care as well
as bringing health services directly into communities through home health,
rehabilitation, mobile screenings, and its paramedic program. Virtua has 2,850
affiliated doctors and other clinicians, and its specialties include
cardiology, orthopedics, advanced surgery, and maternity. Virtua is affiliated
with Penn Medicine for cancer and neuroscience, and the Children's Hospital of
Philadelphia for pediatrics (Virtua Health).
On November 18, 2019 Virtua Our Lady
of Lourdes Hospital accidentally gave a kidney to the wrong patient. Virtua Our
Lady of Lourdes Hospital is the only facility in southern New Jersey to provide
kidney, liver and pancreas transplants, according to their website. The mix-up
was discovered the day after the procedure by a member of the hospital's
clinical team and voluntarily reported the incident to the Organ Procurement and
Transplantation Network and the New Jersey Department of Health. Virtua also
notified the affected patients. Both patients on the transplant waiting list
had the same name and a similar age, and both were waiting for a matching
kidney, according to Virtua Our Lady of Lourdes Hospital in Camden. The patient
who should have received the kidney was higher on the matching list managed by
the United Network for Organ Sharing (Mulford). Although the designated patient
who originally was supposed to receive the new kidney received the transplant a
week later, both patients underwent successful surgeries and are doing well. The
medical director and transplant coordinator visited the patient who was supposed
to get the kidney to apologize.
Stakeholders
The main stakeholders in this case
are the two patients who were directly impacted by Virtua Health, as well as the patients families. Other stakeholders involved
in this case would be the doctors and nurses working directly with the two
patients. From the doctors working with the patients before and after the
transplants, to the surgeons performing the transplants.
Individualism
Theory
According to Milton Friedman the
only goal of business is to profit, so the only obligation that the business
person has is to maximize profit for the owner or the stockholders, but it must
be within the law. According to Tibor Machan the only direct goal of business
is to profit, and the primary obligation of the business person is to maximize
profit. But Machan’s theory goes on to say the direct goal of profiting may
need to be met by indirect goals not aimed at profiting and business people may
have other goals and those goals may at times be prioritized over the goals of
profit-maximizing.
This is a unique case because Virtua
Health is a not-for-profit organization. Under Friedman’s Individualism theory,
Virtua did not maximize profit nor did they maximize their distribution of
services in this case within the constraints of the law. As for Machan’s
individualism theory, even though Virtua’s primary goal is something other than
to profit, they still did not maximize their distribution of services. Virtua
was not acting ethically. Had they just made sure the kidney was going to the
correct patient, none of this would have happened and they would have maximized
profit AND their distribution of services.
Utilitarianism
Theory
According to John Stuart Mill, utilitarianism
says that happiness or pleasure are the only things of intrinsic value. Also,
we ought to bring about happiness and pleasure in all beings capable of feeling
it, and do so impartially. Basically, the goal of utilitarianism is to maximize
happiness in yourself as well as others, while taking a stakeholder’s approach.
Nothing in this case appeared to bring happiness to any of the parties involved.
In fact, it maximized unhappiness in each of the stakeholders involved,
especially the two patients.
A utilitarian would argue that Virtua
Health did not maximize happiness within the stakeholder’s involved. The staff
at the hospital working directly with the two patients messed up their
information, which ultimately could’ve led to a deadly mistake. If they had
just taken the extra time to verify the correct patients, this mistake would
not have happened, and a successful kidney transplant would have resulted.
Kantianism
Theory
Immanuel Kant came up with the four
basic principles of Kantianism. These are to act rationally; allow and help people
to make rational decisions; respect people, their autonomy, and individual
needs and differences; and be motivated by good will, seeking to do what is
right because it is right. The mistake that Virtua Health made in giving a
kidney to the wrong patient goes against what a Kantian would think. Virtua
Health was not acting rationally nor did they do the right thing in this
scenario. By giving a person the wrong kidney, they did not respect the
autonomy of this person or the other patient involved whatsoever.
Virtue
Theory
Virtues are the characteristics that
allow things to function properly. Aristotle came up with the virtue theory and
said that rationality is the distinguishing characteristic amongst people. The
four main virtues of character are courage, honesty, temperance/self-control,
and justice/fairness. Aristotle also added that a thing is happy if it fulfills
its function. So, a person or company cannot fulfill their happiness if they do
not display these main characteristics. Virtua Health displayed little to none
of these characteristics, and in turn found themselves unhappy as well as their
patients. The one thing I would say is that Virtua was honest throughout their
mistake. Although they didn’t exactly treat the two patients right by giving
them the wrong kidneys, they told the truth to the two patients involved and to
the public. But they lacked the other characteristics and ultimately led to
unhappiness throughout their healthcare system. A virtue theorist would say
that Virtua Health did not possess courage, honesty, temperance, or justice and
led to an irrational mistake.
Justified
Ethics Evaluation
From all the information I’ve
gathered about this case, Virtua Health was acting unethical. This mistake
could have been prevented had they used proper procedures and acted in the
interest of the patients. Now, this was purely an accident. The healthcare professionals
involved did not just decide that they were going to give a patient the wrong
kidney on purpose. A lack of many different factors is what ultimately led to
this mistake. Virtua Health was acting unethical when they did not dig deeper
to make absolute certain that the correct patient was getting the right kidney.
Virtua Health was acting unethical when they should have had the proper
procedures and guidelines put in place from day one. Virtua Health was acting
unethical when they made this, almost deadly, mistake of giving a patient the
wrong kidney.
Action
Plan
Our
bodies health is, without a doubt, one of the most important things that we
look out for. That being said, Virtua Our Lady of Lourdes Hospital did just the
opposite of that on November 18, 2019 when they accidentally gave a kidney to
the wrong patient. Both patients on the transplant waiting list had the same
name and a similar age, and both were waiting for a matching kidney. The
patient who should have received the kidney was higher on the matching list,
which is managed by the United Network for Organ Sharing. Although the
designated patient who originally was supposed to receive the new kidney
received the transplant a week later, both patients underwent successful
surgeries and are doing well. The medical director and transplant coordinator
visited the patient who was supposed to get the kidney to apologize. Virtua
Health is committed to the mission of helping people “be well, get well, and
stay well”. Obviously, this potentially deadly mistake showed that Virtua was
not acting in the interest of their mission. Even though the hospital was
honest and completely transparent to the patients and the public about what
happened, it does not remove the fact that they need to be held accountable and
enforce new policies within their healthcare system to protect their patients
from accidents like this. The most important thing Virtua Health needs to do
now is regain the lost trust from their patients and the general public by
implementing these new policies and rules into their health system.
Although accidents happen and
mistakes are made, this specific scenario could have and should been prevented.
It is clear that a mistake of this magnitude was made due to a lack of many
different factors on Virtua’s part. It is also clear that the healthcare professionals
involved, as well as the entire Virtua Our Lady of Lourdes Hospital, need to
fix these problems so a mistake like this does not happen again.
Virtua
Health should come up with a more in-depth system to easily identify patients,
especially patients with identical information, such as names and birthdays, so
it wouldn’t be possible to mix them up. They should widen the criteria to check
for on a patient to make sure they are getting the right surgery or the right
care and that they are the correct patient. Added verification can make a
tremendous difference in ensuring a mix up such as this would not happen again.
Added communication efforts between
everyone working directly with a single patient could also ensure that not just
one worker is checking the patient’s information but numerous healthcare
workers. If one worker sees something wrong or sees a flaw, they need to let
another worker know immediately and take charge of a possible disastrous
situation.
Lastly, Virtua Health needs to
continue being honest and transparent with themselves, their patients, and the
public. It would be a great idea for Virtua Health to come up with a new
mission statement to show their patients and the public that they can rely on
Virtua Health. A new mission statement would also ensure that they took this
matter very seriously and want to better themselves as a healthcare network. They
made this mistake which easily could have been prevented, but in the end, they
did not try to cover it up and everyone involved was okay. They were held
accountable and they told the truth about what had happened and that is
something that should be recognized. Nurses, doctors, and health care workers
are the backbone around the globe, especially with everything going on right
now. Mistakes will happen, and if they do, it is best to implement new policies
and rules in which hopefully those mistakes will not happen again.
Works Cited
Mulford, Kim.
“Hospital Says Donated Kidney Was Transplanted into Wrong Patient in NJ.” USA
Today, Gannett Satellite Information Network, 27 Nov. 2019, www.usatoday.com/story/news/nation/2019/11/26/kidney-transplanted-into-wrong-patient-new-jersey-hospital-says/4314849002/.
“Kidney Transplant
given to Wrong Patient in New Jersey Hospital.” BBC News, BBC, 27
Nov. 2019, www.bbc.com/news/world-us-canada-50571698.
Helsel, Phil. “New
Jersey Hospital Gives Kidney to Wrong Transplant Patient.” NBCNews.com,
NBCUniversal News Group, 27 Nov. 2019, www.nbcnews.com/news/us-news/new-jersey-hospital-gives-kidney-wrong-transplant-patient-n1092361.
Bryan, Cleve.
“EXCLUSIVE: Lourdes Hospital Transplant Center Admits Giving Wrong Person
Kidney Transplant.” CBS Philly, CBS Philly, 26 Nov. 2019, philadelphia.cbslocal.com/2019/11/26/exclusive-lourdes-hospital-transplant-center-admits-giving-wrong-person-kidney-transplant/.
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