Potentially Deadly Mistake at Virtua Health
Ethics Case Controversy
Virtua Health is a non-profit healthcare system located in southern New Jersey. Virtua Health operates a network of hospitals, surgery centers, physician practices, and more. Virtua has more than 13000 plus employees which provide care at five hospitals along with 250 other locations. Virtua’s mission is to help people be well, get well, and stay well, which is one that they may have failed in November of 2019. Virtua Our Lady of Lourdes hospital located in New Jersey admitted to an incident that occurred at the transplant center in Camden. On the 18th of November a 51 year old patient underwent a successful kidney transplant, but “the organ was intended for another priority patient in need of a kidney. The two individuals share the same name, according to CBS3, which first reported the incident.” (Tanenbaum) The patient who should have received the kidney was higher on the matching list which is managed by United Network for Organ Sharing. The hospital stated that the patient who should have received the first kidney underwent successful transplant surgery six days later. The nonprofit handles about 600 organ recoveries each year, and this is the first time a mistake to this extent has occurred. The demand for kidneys is very high in the United States, “About 30 million adults in the U.S. have chronic kidney disease and approximately 94,000 people were on the national organ waiting list in 2018.” which is very clear from these statistics. (Tanenbaum) Of those people who are affected by chronic kidney disease, “Only about 21,000 people received kidney transplants last year. Typical wait times can fall between four and five years if the patient is unable to find a donor before that time.” (Tanenbaum) It is important to bring attention to the people affected that were on the transplant list waiting for a transplant that could very well extend or improve the quality of their lives. The average wait time for a kidney from the national deceased donor waiting list in the US is 5 years (American Kidney Foundation). The information that Virtua Health has chosen to release does not include whether or not the patient who received the kidney was on the list, and if so, what their rank was. This affects many parties, especially those who have finally reached their time for a kidney donation. Someone along the line that was on the UNO donor list was negatively affected by this mistake as well.
Many people and various aspects were affected by the mistake made by Virtua Health, most prominently, the company itself. Virtua Health just recently acquired the New Jersey Our Lady of Lourdes Hospital earlier in the year of 2019. The company was greatly affected and had effects on the patients and families who were involved in the kidney mix up. Dr. Reginald Blaber, executive vice president and chief clinical officer of Virtua Health played a large role in making sure the company did what felt most proper in order to settle the dispute with the case. It has become clear through research that the patients involved in the mix up signed patient confidentiality as their names and details of the case have not been revealed. Those involved also include those who were on the waiting list for a kidney transplant. Somewhere along the line one who was on the organ list was not given their fair chance to receive a kidney which may have been detrimental to their quality of life.
Ethical Theories
Individualism
According to the ethical theory of Individualism, Virtua Health did act ethically. According to Friedman, “When it comes to social responsibility, he says it goes beyond the interest of their stockholders. The only obligation is to maximize profits as long as it's legal. (Page 54) Friedman says that we should aim to not deceive anyone or use resources on deceit. Virtua Health does not go out of their way in order to deceive anyone, and the way the situation was defused kept the name for the company in a good light. Keeping in mind that Virtua Health is a non- profit organization, there is a level of difficulty when applying this theory. The mistake that was made by Virtua Health was one that definitely did not earn profits for the company. The way the company responded to the incorrect transplant can be seen as that. The company did not necessarily go out of their way to publicize the issue or make it any more of a deal than it had to be. According to Friedman, the only social responsibility is to maximize profits for the stakeholders. Virtua Health did do this by not hiring or firing any employees. Introducing new management with more skill or better work ethics would have been costly for Virtua Health, and unnecessary according to an Individualist. When analyzing the information given about the surgical mix up, it is clear that Virtua Health maximizes their profits by the route they took to fix the issue. They could have gone through much costlier solutions to the problem to ensure it didn't happen again, but that would be necessary. The name was restored (if ever hindered) by the minute amount of press the issue got, and the company did not suffer any large financial losses. This includes from both the mistake the company made and the way they chose to deal with the mistake. When looking at Virtua Health according to Individualism, it is clear that the company is looking out for what is best for the company in the long term. From the individualist perspective, Virtua Health has acted ethically.
Overall, the incident that occurred at Virtua Health in November of 2019 was unethical and could have been handled much differently. Although the actual occurrence was an accident, Virtua Health should have responded by making changes within the hospital to ensure patients safety. They should have taken time to detect why the issue occurred and take the time to train staff and change protocol to ensure a deadly mistake like this doesn't happen again. Virtua Health did not release much information about the details of the incident, and because of the (completely avoidable) mistake that was made, patients on the UNOS waiting list who may have needed a kidney to survive were negatively affected.The small amount of information that Virtua Health provided makes it difficult to determine if they acted ethically in handling their problem. Along with that, Virtua Health did not seem to make any substantial changes after the incident or take any precautions for the future. Other than news releases, Virtua Health did not make any extra efforts to make both patients and future patients aware of what happened and the changes the company set forward to make.It is clear after a careless mistake like this has occurred, that a degree of measures needed to be taken to improve the quality doctors and nurses provide to patients whose lives are at stake.
Stakeholders
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| Dr. Reginald Blaber |
Ethical Theories
Individualism
According to the ethical theory of Individualism, Virtua Health did act ethically. According to Friedman, “When it comes to social responsibility, he says it goes beyond the interest of their stockholders. The only obligation is to maximize profits as long as it's legal. (Page 54) Friedman says that we should aim to not deceive anyone or use resources on deceit. Virtua Health does not go out of their way in order to deceive anyone, and the way the situation was defused kept the name for the company in a good light. Keeping in mind that Virtua Health is a non- profit organization, there is a level of difficulty when applying this theory. The mistake that was made by Virtua Health was one that definitely did not earn profits for the company. The way the company responded to the incorrect transplant can be seen as that. The company did not necessarily go out of their way to publicize the issue or make it any more of a deal than it had to be. According to Friedman, the only social responsibility is to maximize profits for the stakeholders. Virtua Health did do this by not hiring or firing any employees. Introducing new management with more skill or better work ethics would have been costly for Virtua Health, and unnecessary according to an Individualist. When analyzing the information given about the surgical mix up, it is clear that Virtua Health maximizes their profits by the route they took to fix the issue. They could have gone through much costlier solutions to the problem to ensure it didn't happen again, but that would be necessary. The name was restored (if ever hindered) by the minute amount of press the issue got, and the company did not suffer any large financial losses. This includes from both the mistake the company made and the way they chose to deal with the mistake. When looking at Virtua Health according to Individualism, it is clear that the company is looking out for what is best for the company in the long term. From the individualist perspective, Virtua Health has acted ethically.
Utilitarianism
The ethical rule for Utilitarianism is that business actions should aim to maximize the happiness in the
long run for all conscious beings that are affected by the business action. A Utilitarian thinker would
analyze the costs and benefits, not just for the individuals or the company, but for all beings affected
by the actions taken. From this ethical perspective, Virtua Health handled the situation ethically.
There is a greater benefit that is achieved by some losses. By this I mean Virtua Health could have done
more in order to prevent this kind of incident from occurring again, but the company did what they
needed to in order to fix this situation for the people involved. In the long run, the amount of information
the company revealed about the case saved its reputation for the future. The patients (were said to) have
recovered safely with no complications. Virtua Health did have to take a kidney from another priority
patient in order to fix their mistake and give the second patient a kidney, but if they had not taken those
measures it is likely that patient would have died. The actions they took to fix the mistake that was made
had some losses, but overall, the long- term costs benefit from the actions Virtua Health made. Virtua
Health did what had to be done in order to solve the incident that occurred due to miscommunication.
The way the company went about solving the issue was acceptable according to utilitarian ethics. This
theory determines right from wrong by focusing on one outcome. The way Virtua Health addressed the
mistake can be looked at as the greater good for the greatest number of people. In this case, the company
did not face much backlash, their name and credibility were not sufficiently affected because the situation
never blew up. Both patients received a kidney, and, as far as reports go, they are both healthy. long run for all conscious beings that are affected by the business action. A Utilitarian thinker would
analyze the costs and benefits, not just for the individuals or the company, but for all beings affected
by the actions taken. From this ethical perspective, Virtua Health handled the situation ethically.
There is a greater benefit that is achieved by some losses. By this I mean Virtua Health could have done
more in order to prevent this kind of incident from occurring again, but the company did what they
needed to in order to fix this situation for the people involved. In the long run, the amount of information
the company revealed about the case saved its reputation for the future. The patients (were said to) have
recovered safely with no complications. Virtua Health did have to take a kidney from another priority
patient in order to fix their mistake and give the second patient a kidney, but if they had not taken those
measures it is likely that patient would have died. The actions they took to fix the mistake that was made
had some losses, but overall, the long- term costs benefit from the actions Virtua Health made. Virtua
Health did what had to be done in order to solve the incident that occurred due to miscommunication.
The way the company went about solving the issue was acceptable according to utilitarian ethics. This
theory determines right from wrong by focusing on one outcome. The way Virtua Health addressed the
mistake can be looked at as the greater good for the greatest number of people. In this case, the company
did not face much backlash, their name and credibility were not sufficiently affected because the situation
Kantianism
The ethical rule when it comes to Kantianism is to always act in ways that both respect and honor
individuals and their choices. (Salazar 2) The idea of Kantianism is to act rationally, which Virtua
Health failed to do. There is a level of disrespect towards the individuals involved in the transplant.
Those employed at Virtua Health likely did not make this mistake intentionally, but making a mistake
like this isnt from good will. The mistake that occurred also prevented those on the UNOS waiting list
from getting their kidney when they were supposed to according to their ranking. On another note,
Virtua Health’s response to their mistake was best for the company's reputation, but did not overall
benefit existing or potential new customers. Their response does not meet certain standards that
demonstrate the respect for all people affected by the action” (Salazar 2) The people affected by this
and those possibly affected in the future would benefit more from true transparency. That is, having the
full knowledge and ability to assess whether this company is one they would trust their health with.
Although it seemed as though Virtua Health was being honest with what happened with the kidney,
many pieces were left out which makes it difficult to truly evaluate the case. It can be argued that
those involved at Virtua Health treated those involved in the wrong transplant as a mere means in order
to save their own reputation. The company's motivation and actions taken regarding the wrong kidney
transplant can be seen as neutral which means “they cant get credit for acting morally, even if they
didn't do anything wrong” (Salazar 2) It would not be accurate to say that Virtua Health acted with
bad intention in the actual action of performing the wrong kidney transplant. The issue occurs when
the motivation to fix this problem seems to be not to actually stop this issue from happening in the
future or making sure patients are safe after this mistake was made. While Virtua Health did make the
efforts towards addressing the miscommunication by apologizing and making sure the other patient
received a kidney, they did not publicize the dangers of what occurred. Virtua Health could have been
more clear to the public about the events that occurred and the true deadly outcomes as well. It can be
interpreted as self-seeking to not shut down their practices and make more of an effort to stop this issue
from occurring again. This puts patients in danger because they may not be aware of unsafe practices that
had previously occurred and may occur again.
individuals and their choices. (Salazar 2) The idea of Kantianism is to act rationally, which Virtua
Health failed to do. There is a level of disrespect towards the individuals involved in the transplant.
Those employed at Virtua Health likely did not make this mistake intentionally, but making a mistake
like this isnt from good will. The mistake that occurred also prevented those on the UNOS waiting list
from getting their kidney when they were supposed to according to their ranking. On another note,
Virtua Health’s response to their mistake was best for the company's reputation, but did not overall
benefit existing or potential new customers. Their response does not meet certain standards that
demonstrate the respect for all people affected by the action” (Salazar 2) The people affected by this
and those possibly affected in the future would benefit more from true transparency. That is, having the
full knowledge and ability to assess whether this company is one they would trust their health with.
Although it seemed as though Virtua Health was being honest with what happened with the kidney,
many pieces were left out which makes it difficult to truly evaluate the case. It can be argued that
those involved at Virtua Health treated those involved in the wrong transplant as a mere means in order
to save their own reputation. The company's motivation and actions taken regarding the wrong kidney
transplant can be seen as neutral which means “they cant get credit for acting morally, even if they
didn't do anything wrong” (Salazar 2) It would not be accurate to say that Virtua Health acted with
bad intention in the actual action of performing the wrong kidney transplant. The issue occurs when
the motivation to fix this problem seems to be not to actually stop this issue from happening in the
future or making sure patients are safe after this mistake was made. While Virtua Health did make the
efforts towards addressing the miscommunication by apologizing and making sure the other patient
received a kidney, they did not publicize the dangers of what occurred. Virtua Health could have been
more clear to the public about the events that occurred and the true deadly outcomes as well. It can be
interpreted as self-seeking to not shut down their practices and make more of an effort to stop this issue
from occurring again. This puts patients in danger because they may not be aware of unsafe practices that
had previously occurred and may occur again.
Virtue Theory
Virtue ethics is a philosophy developed by Aristotle and other ancient greeks. Virtue theory stands by the fact that rationality is the distinguishing characteristics of people. People must practice and exercise rationality in order to function well and live good lives. The theory abides by the fact that a thing is happy if it fulfills its function, so people who live good lives by functioning well will also live happy lives. Virtues, which is the entire basis of the virtue theory, depends on both the thing’s function and the thing’s circumstance. A virtue theorist looks at the character traits of individuals. This theory goes off the basis of each specific situation and how it was handled in relation to the main virtues. When evaluating each aspect of the case, there is more that could have been done and should be done in order to prevent this type of mistake from happening again in the future. Virtua Health lacked compassion, prudence, and concern for their customers' health. Did the company serve justice to everyone involved? To a certain extent, yes, although it has been proven through other cases that there was a better, more thorough way to prevent this from occurring again. The company did not take any actions to fix or change the situation in any way. The incident that occured at Virtua Health in November 2019 is an incident which is rare in the medical world, but not unheard of. In February of 2011, “USC University Hospital voluntarily shut down its kidney transplant program after a man was reportedly given the wrong kidney.” (ABC News) Leslie Ridgeway, US director of media relations states that “No patient was harmed. However, as patient safety is the hospital's number one concern, the hospital inactivated the program while clinical protocols are assessed and additional safeguards to the kidney transplant program are developed". USC Hospital has willingly taken the necessary steps in order to ensure the safety of their patients, and develop the program to the best of its abilities before returning back to practice. The transparency of this article is much more clear than that of Virtua Health, the hospital addressed the issue, took full responsibility, then closed the practice to further improve on the healthcare. Virtua Health did not have the courage to come out and fully admit what they had done, and do the appropriate thing for the greater good, which may have included closing the practice for time to find new and better ways to deal with this issue. Although the Virtua made a mistake and mistakes do happen in the medical field and in every other aspect of life, this had high stakes and could have been dealt with in a more virtuous way rather than what is best for the company.
Justified Evaluation
Overall, the incident that occurred at Virtua Health in November of 2019 was unethical and could have been handled much differently. Although the actual occurrence was an accident, Virtua Health should have responded by making changes within the hospital to ensure patients safety. They should have taken time to detect why the issue occurred and take the time to train staff and change protocol to ensure a deadly mistake like this doesn't happen again. Virtua Health did not release much information about the details of the incident, and because of the (completely avoidable) mistake that was made, patients on the UNOS waiting list who may have needed a kidney to survive were negatively affected.The small amount of information that Virtua Health provided makes it difficult to determine if they acted ethically in handling their problem. Along with that, Virtua Health did not seem to make any substantial changes after the incident or take any precautions for the future. Other than news releases, Virtua Health did not make any extra efforts to make both patients and future patients aware of what happened and the changes the company set forward to make.It is clear after a careless mistake like this has occurred, that a degree of measures needed to be taken to improve the quality doctors and nurses provide to patients whose lives are at stake.
Action Plan
Based on these arguments, I would suggest to the company to change the standards they work by and hire more employees to validate that procedures are done correctly without fault. Supplementing this with perhaps an outside consulting/audit company would also establish the precedent of the new procedures. Virtua Health should promote themselves as a company working together to ensure safe practices, and show the amount of investment in establishing safe practices and a patient first philosophy. The company executives should introduce changes in the senior management team. This new management team should explain to the workers the importance of communication and working diligently at all times. This should be reinforced with regular, scheduled training sessions to serve as a refresher and reinforcement of Virtua Health practices and procedures. Employees need an understanding of the detrimental results a mistake or miscommunication can have on a person's life, or, in this case, many lives. Management should train employees in a way where practice variation is limited. All workers should be on the same page by standardizing practices across multiple entities within a single health system. Lastly, there should be less reliance on memory, which, when strained, has been shown to be a major source of human errors or oversights. It would also have to be made clear to employees that mistakes and errors like these will have repercussions, in order to create some type of incentive to work harder and earnestly. If need be, Virtua Health should hire more employees to validate that procedures are done correctly without fault. This solution will definitely help with each person knowing their specific role in the procedure in making sure the standards are fulfilled. Rather than one person holding too much responsibility, resulting in human error. Although not explicitly admitting wrongdoings of the past, the unveiling of the new senior team and mission statement provides the public with confidence that they can trust the company with their health. This advertising approach will inherently address any negative attention that may reemerge. This plan will allow for patients to build trust in the workers at Virtua Health and in turn, create a better reputation for the company.
-Jennah Lough
Works Cited
ABC News, ABC News Network, abcnews.go.com/Health/Wellness/usc-shuts-transplant-program-man-wrong-kidney/story?id=12951883.
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/.
“Camden Hospital Admits Performing Kidney Transplant on Wrong Patient.” PhillyVoice, 26 Nov. 2019, www.phillyvoice.com/camden-virtua-our-lady-lourdes-hospital-kidney-transplant-wrong-patient-2019/.
“How We Match Organs.” UNOS, unos.org/transplant/how-we-match-organs/?gclid=CjwKCAiA-vLyBRBWEiwAzOkGVAhSRCL5ORpw1Wu4nfEepB-8K4fZRpWih2luxIYEFdl4UpRffu9cvRoC4fwQAvD_BwE.
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/..
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