With regards to the death of Jessica Santillan

The death of Jessica resulted from preventable mistakes in the organ donor system, and from negligence on the part of the medical professionals involved. Reading the timeline dictating the actions of each individual involved with obtaining Jessica’s first donated lungs and heart, one finds it incredulous that her entire medical chart was not available, or obtained by, to the individuals “buying”, “selling”, and transporting her organs. In the series of events surrounding the transfer there were three opportunities to catch the mistake prior to entering surgery. First by the person at the New England Donor Bank, and second by the person at Carolina Donor Services; both operated on the assumption that neither would be asking for the organ if it wasn’t the right blood type but given the information that organs are sometimes placed to individuals off the “match-up” list, blood type should definitely be involved in the conversation. However these two persons are not medical professionals, and in the course of events the person who should have caught the mistake first was Shu Lin, a relatively experienced medical resident, who fetched the organs from Boston. The fact that this person in the chain was neither familiar with the patient’s medical history nor in possession of Jessica’s entire chart is where the system really breaks down. One would think there would be a form with boxes to check when one is picking up an organ. For example that individual should be able to look and say “Okay, Heart and Lungs? Check; Right Size? Check; Good Condition? Check; Cooler with Ice? Check; Blood Type? Check.” It seems asinine that this was not done by Mr. Lin, but checking the blood type was not a standard procedure. The last link in the chain however, is Dr. Jaggers the surgeon. The three prior failings, though avoidable through a little extra effort, were those of the system and Dr. Jaggers unfortunately placed 100% reliability on the system, which he should have known better than to do. He is the captain of his Surgery, and to not check on the statistics of the donated organ himself before beginning the procedure was his own personal failure. The attributions of this situation were of low consensus and consistency, and high distinctiveness. However, if one takes into account all the deaths resulting from hospital mistakes one would find a much higher consensus and consistency, and a much lower distinctiveness, somewhat assuaging Dr. Jaggers’ sole culpability in the matter of Jessica’s transplant.
These events reveal breakdowns and imperfections in the systems by which individuals receive treatment in the US, However it is my opinion that hospitals generally do a relatively good job (when compared with say the US auto industry, or the US government) of correcting the system when unfortunate things occur. The changes enacted because of Jessica’s death will save lives in the future, and though hindsight is always 20-20, there will always be personal failings because we are human and we make mistakes, and though it is unfortunate that this happened, the girl was undergoing a procedure to lengthen a life that nature deemed unlivable a long time prior (and according to Comorow’s article only 50% of heart-lung transplant patients live 5 years after surgery).
The events, statements, and feelings following her death are too difficult to unravel as it is unclear who said what but Dr. Jaggers is ultimately responsible and should bear all the accountability even if unfairly. Taking Jaggers' license or suing him and the hospital (especially when all the medical treatment the Santillans were receiving was free of cost) is frivolous because the hospital acted within an insufficient system, and the world needs doctors even those who may make one mistake. Dr. Jaggers' motivations are difficult to read but I think he was internally motivated to “cure” Jessica and especially after his initial mistake, he was too focused on his own internal sense of his professional success (and a really cynical person might say his own ego) to take close enough account of his patient’s condition and the high risk in a second transplant attempt in her weakened state. It was impossible to determine whether the hospital or the surgeon advocated for the second surgery but either way there should have been a closer assessment of Jessica’s condition prior to initiating the procedure. And it was this procedure that ultimately led to Jessica’s death.
Jessica’s family was motivated to cross borders and reside illegally in the US in order to obtain the best medical care for her in an attempt to prolong her life. One cannot blame them for the extraordinary actions they took on behalf of their child, a lot of parents take similar actions, however they should be grateful that their daughter lived to the age she did, and that a surgeon, the hospital he worked for, the community they lived in, and the taxpayers of this nation, donated their time and money to help them at all because this is help they wouldn’t have received in their home country. It is cruel to say “beggars can’t be choosers” in this situation, but it applies, and the Santillans taking out their wrath on the monies of Dr. Jaggers and Duke won’t assuage their anguish but knowing that the misfortune suffered by them will help to save numerous lives in the future will. Even if everything had gone perfectly with Jessica’s surgery there is only a 50% chance that she would be alive today. And revoking Jaggers’ license doesn’t help anyone; perhaps the world is better served if he was held accountable by donating his service to Doctors Without Borders or a similar organization in need of skilled professionals.
In conclusion what happened to Jessica was avoidable and tragic, but the fact remains that people die from mistakes made by hospital organization systems and the people that work within those systems everyday. The rare nature and mortality rates of individuals with congenital heart defects like Jessica make the individuals that suffer with these diseases miracles in themselves, and even had everything gone perfectly with her transplant her survival rate would still have been extremely low, and the lifestyle she would have been forced to live would have been as restrictive as it would have been expensive. Mistakes are made constantly, and consistently, by individuals populating imperfect systems, and until one can foresee the future we can only better our systems by doing as Duke has done and learning from our mistakes, making changes in systems to decrease the frequency to which mistakes occur because as long as human beings are involved there will be imperfections.