Tuesday, April 7, 2020

Kidney Transplant Mix-Up Leads to Potentially Deadly Operation (Nov 2019)

Ethics Case Controversy

       Virtua Health is a healthcare company that provides services throughout New Jersey. Virtua also claims to be South Jersey’s largest health care provider and has been completing organ transplants for over forty years. Virtua Our Lady of Lourdes Hospital, a hospital owned by Virtua Health, accidentally gave a kidney to the wrong patient. The kidney was intended to go to another person who had the same name as the patient who received it and was similar in age. This mistake was discovered one day after the operation had taken place. According to ABC news, “a kidney meant for one patient was mistakenly transplanted into another with the same name who was farther down the priority list”. A member of the hospital realized that the patient had received the kidney out of priority order, as the patient was lower on the transplant matching list (BBC). Luckily, the kidney received by the wrong patient was also a match for the 51-year old woman who received it. Had the organ been transplanted into someone who was not a match, the result could have been deadly (O'Kane). The patient who was supposed to receive the transplant, received one approximately a week later. Both patients are said to be doing well. The identities of these patients have not been released. According to the chief clinical officer of Virtua Health, this was an extremely unprecedented even in their respected 40-plus year transplant program. Following this mix-up, Virtua “immediately instituted additional measures and educational reinforcement to help ensure this does not happen again” (O'Kane).

        Virtua willingly reported the error to the Organ Procurement and Transportation Network and the New Jersey Department of Health (Chang). In addition to willingly reporting this mistake, the medical director and transplant coordinator at Virtua Health visited the patient who was initially supposed to receive the kidney and apologized. Virtua recognized that this could have been easily prevented with the use of additional verification prior to starting procedures. According to the company’s website, Virtua Our Lady of Lourdes Hospital is the sole facility in southern New Jersey that is able to provide kidney, liver, and pancreas transplants. As such, it is clear that the company must be extremely careful and do its due diligence before completing an operation, as many people in the area depend on the success of their transplants. There are currently about 95,000 people on the kidney transplant waiting list (Helsel). With the average wait time of receiving a kidney for those on the list being 5 years, it is critical that hospitals get it correct when a patient is due for a kidney transplant according to their position on the list. About 30 million American adults have chronic kidney disease, and treatment can help prevent further deterioration (Helsel). However, more than 700,000 people have end-stage renal disease, which means they require either a kidney transplant or dialysis to survive.

The Stakeholders

       It is important to consider the parties that were affected or could be affected by this controversy. To maintain a positive public image and ensure the business of their future, it is important for the company to handle this situation correctly. If this controversy was not handled correctly, it is highly possible that the company could suffer from this mistake. Therefore, we will inspect the stakeholders in this case and cover the potential impact from this accident. The stakeholders in the case of Virtua Health, the stakeholders would include the employees, the employee’s families, the patients involved, the patients involved families, and other patients of the healthcare provider. Additional stakeholders include upper management of the company, the CEO of the company, Dennis Pullin, and the Chief Clinical Officer of the company, Reginald Blaber. Had the kidney not been a match for the accidental recipient, the results could have been deadly. For the patient that received the kidney accidentally, they could have suffered death from this accident of failing verification. The intended recipient may have lost out on receiving a life saving kidney transplant. Had the kidney transplant that they did receive come to late, the patient could have passed due to mismanagement at Virtua Health since they were to receive that kidney much sooner.

       The employees of the company could potentially lose their jobs in this situation. The company itself could also take a major hit and force the company to lay off employees or reduce their pay. A mistake of this magnitude could also have major effects on the mental health of the employees. Continuing with employees, the upper management and CEO could see negative consequences from this mistake. This could include fines or other monetary loss from a loss of trust within the company. It could result in major losses for their company as customers may lose trust in the company and fear this mistake occurring again. Upper management could also face losing their positions if the board of trustees finds that they were mismanaging and their negligence resulted in the potentially fatal mistake. 


      The core idea behind utilitarianism is to maximize the happiness of oneself and others. We should consider the consequences of all actions to decide whether or not they are ethical. If the consequences of an action increase the overall happiness of yourself and others, then the action is ethical. If the actions only increase your personal happiness, it is not ethical. Likewise, if it does not benefit everyone, it is not ethical. As philosophized by John Stuart Mill, happiness is the only thing of true intrinsic value. Therefore, we should bring happiness to all things able to feel happiness. Additionally, we should maximize our own as well as others happiness since if happiness is the only thing of true intrinsic value, there is no difference between your own happiness and someone else’s. As such, the event that occurred at Virtua Our Lady of Lourdes Hospital is unethical. Accidentally giving a kidney to the wrong patient takes away happiness from others which is unethical. Additionally, the company itself did not gain happiness from this mistake, so it is further seen as unethical. The intended recipient was certainly unhappy to find out that they were supposed to receive a kidney much sooner than they did. This could have potentially been fatal for both parties. Had the accidental recipient not been a match for the kidney, they could have died. The intended recipient could have died from having to wait longer for the life saving operation. The only happiness that was gained in this situation may be from the accidental recipient receiving a transplant sooner than expected. This person may be very happy that they received this transplant and it so happened to be a match. However, the happiness of a single person and unhappiness of many makes this unethical. This all results in a clear take away from happiness for most parties involved and is therefore unethical. 


       An individualist believes that a company should do anything to maximize wealth so long as it is within the law. According to 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” (Individualism slides). Since Virtua is a non-profit organization, it can be difficult to apply the individualistic theories to it. However, we can still evaluate the case from this lens. The mistake that the company made is one that would certainly not maximize the wealth of the company. This mistake could potentially lead to a loss of trust in the company. Future patients and current patients may be afraid to utilize the services of Virtua Health since the mistake had the potential to be deadly. This potentially deadly mistake would leave many people uncertain of how reliable the company is when it comes to organ transplants. This would mean that the company would receive less patients which would mean less money; therefore, an individualist would find this mistake to be very unethical. Less money flowing into the company would mean less money for the owners which an individualist would find unethical. From the employees’ perspectives, it is unethical to make such a large mistake. This could result in a loss of their position at the company which would result in financial loss. As such, this does not maximize their profit, nor would it in the future as they may be warned off as someone who made a potentially fatal mistake.


       The overall idea of Kantianism is 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. Given this, it is easy to see that Virtua Health did not act ethically in making this mistake. It is clearly irrational to give the wrong kidney to a patient for a transplant. There is also a level of disrespect in making this mistake. The incorrect kidney going to the patient could result in death for that patient as well as the patient who had to wait longer for a transplant. A Kantian would argue that the disrespect towards the patient’s well-being and the well-being of their families is unethical. Had this resulted in death, there would have been very serious consequences for Virtua Health and would make the action unethical even further. Since we are to be motivated by good will to be ethical, this would also violate the Kantian belief. Although the condition of the intended recipient prior to their operation was not stated, we can assume it was dire as they were at the top of the list. This also effects the order of all patients in between the two patients that received a transplant and the other patients on the waiting list who were moved down due to someone lower on the list getting a kidney before them. Using the formula of humanity described by Immanuel Kant, the patients were used as a mere means to an end. The hospital did not treat the patients as ends in themselves since the accidental transplant could have been fatal. Virtua kept focus on completing surgeries to stay successful and treated the affected parties as means to their success. Overall, it is clear that a Kantian would not view the actions taken as ethical. 

Virtue Theory

       Virtue Theory stems from the views of Aristotle. Aristotle also believed acting rational was at the core of acting ethically. Additionally, the act must provide happiness in order to fulfill its function and be ethical. Overall, people who live good lives by functioning well will also live happy lives. Virtue Theory considers the function of something and the circumstances surrounding that function. We must consider courage, honesty, temperance, and justice when deciding if something is ethical. Looking at the case of Virtua Health giving the wrong kidney patient, Virtue Theory would find the actions to be unethical. The actions taken by Virtua Health were clearly irrational. It is highly irrational to accidentally give a kidney to the wrong patient that could have resulted in death. As such, this is very unethical. Although this may have been done accidentally, this is still an injustice to violate the ordering of the wait list for a kidney transplant. This does a great injustice to the intended recipient of the kidney as well as everyone on the wait list between the two patients involved in this case. The hospital failed to show temperance in its procedures since they were unable to restrain from making a potentially fatal mistake. As for the honesty of the company, they immediately reported this mistake once it was realized which was the ethical action after making the mistake. They did not try to hide the mistake which means they were in line with being honest. As for courage, Virtua displayed great courage by reporting the incident but failed to show courage in verifying patient information prior to operations. As such, Virtua missed failed to meet all of the considerations in virtue theory to decide if something is ethical. Additionally, this could lead to a substantial mental tole on the parties involved. This would affect their overall happiness and therefore this case is unethical according to Virtue Theory.

Justified Ethics Evaluation

      The accidental transplant of a kidney to the wrong patient by Virtua Health was extremely unethical by many standards.  It’s clear that the company needs to have additional verification steps prior to starting a procedure. Especially one as complicated as an organ transplant. I would argue that without the guidance of the theories applied in this post, many would likely find this mistake highly unethical. I do think that they did do some things right after this occurred but more could have been to correct this. I think it was ethical of them to visit the intended recipient and apologized to them and their family for the mistake that could have cost the woman her life. Additionally, the fact that the accidental recipient happened to be a match and the surgery went successfully certainly prevented this mistake from being much worse. I think a larger apology is due to all of the stakeholders, especially those who were on the organ recipient list and may have been moved down on that list as a result. All of those on the waiting list who are affected may not receive the life-saving transplant that they need in time. It seems as though the company came out of this unscathed aside from damage to their reputation and potentially a lost of trust in them by current and future patients. Due to this highly unethical mistake, I believe there should have been more consequences.

Action Plan
       Virtua Health is clearly facing many potential negative effects from this potentially deadly mistake they have made. No major plan of action has been outlined by Virtua Health publicly aside from increasing verification steps to avoid this issue in the future. As such, I will be formulating a plan for the company to improve efforts to fix this mistake. I believe more steps should be taken by Virtua Health to fix their reputation as well as make things right for the patients affected. After the mix-up, Virtua “immediately instituted additional measures and educational reinforcement to help ensure this does not happen again” (O'Kane). However, the company did not go any detail on this. Going forward, it would be best for Virtua to include additional verification steps prior to the commencement of a procedure, especially one of this level of importance. As this was an issue of miscommunication and mis verification, the company clearly must work on these two concerns. More communication should take place between all of the staff members to ensure proper verification.
       A way the company could do this is to immediately implement a way for more than one staff member to confirm the identity of the patient. There is much less of a chance for multiple people to mis-identify a patient about to undergo a procedure. As a non-profit organization, Virtua Health must ensure that their future patients trust them and are willing to continue to receive medical care from the company. Their sole purpose to fix this issue should be for the patients to know they will be provided with quality healthcare. According to their website, Virtua Health’s mission is to get patients to “Be Well, Get Well, and Stay Well”. This potentially deadly mistake clearly would not fit into their mission. I believe Virtua Health should do it’s best to get back on track with its mission which may include altering their mission and living by that mission.
       Staff training as well as public support would be the best way for Virtua Health to recover from this mistake. The company must show that they take the matter extremely seriously and show that they are making a valiant effort to ensure this issue never happens again. As Virtua is a non-profit company, they will benefit most by ensuring their patients continue to trust them for the best healthcare since they will not benefit in a monetary manner. Building community trust and ensuring the safety of all of their patients will help Virtua recover after this potentially deadly mistake.

Works Cited:
ABC News, ABC News Network, abcnews.go.com/Weird/wireStory/hospital-kidney-wrong
Chang, David. “NJ Hospital Gives Kidney Transplant to the Wrong Patient.” NBC10
Philadelphia, NBC 10 Philadelphia, 27 Nov. 2019,
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
“Kidney Transplant given to Wrong Patient in New Jersey Hospital.” BBC News, BBC, 27 Nov.
2019, www.bbc.com/news/world-us-canada-50571698.
O'Kane, Caitlin. “New Jersey Hospital Admits to Giving Kidney Transplant to Wrong
Patient.” CBS News, CBS Interactive, 27 Nov. 2019, www.cbsnews.com/news/wrong

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