An Elite University’s Epic Error

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February 8, 2024

An Elite University’s Epic Error

Duke University is renowned for its elite education, attracting students from all over the world due to its prestige. However, the university’s reputation was deeply, potentially indelibly, marred in the early 2000s following a devastating medical malpractice case that occurred at its medical facility. The horrific situation was made all the more devastating when considering not only considering how easily preventable the entire situation was, but also how poorly the university handled the situation in its immediate aftermath, as detailed in the following analysis.

In 2003, Jessica Santilian, who was only 17 years old, went to Duke University Hospital to receive a heart and lung transplant, which should have been a fully standard procedure with fully standard protocols in place. Unfortuantely, Duke University Hospital violated the most basic protocol of all, which was to obtain the blood type of the organ donors to ensure that they matched with Jessica’s blood type, which is vitally important when receiving a transplant. As a result of failing to follow a fully standard procedure, Jessica tragically experienced severe, irreversible brain damage; her body went into complete shock and began to shut down (Glannon, 2007).

While Duke University Hospital’s failure to follow perhaps one of the most standard medical procedures associated with organ transplants was bad enough, the medical facility’s response to the travesty was even worse, especially as it violated another protocol. In cases wherein such a grave mistake was made, immediate efforts should have been undertaken to find a new donor that might be able to reverse the internal damage that Jessica suffered from. Unfortunately, Duke University Hospital opted to violate this protocol as well, and in the worst way possible: by attempting to cover up what had happened (Glannon, 2007). 

For a period of eleven days, Duke University Hospital refused to admit its error, which wasted precious time in which Jessica theoretically could have found a donor to reverse the course of her body’s shutdown. By the time the medical facility was finally forced to admit the error, the 17-year-old had passed away due to combination of dually violated protocols and blatant dishonesty as Duke University Hospital attempted to cover up what it had done.

The coverup was not only inappropriate, it was unconscionable, as the university cared more about its public reputation than saving the life of a teenager (Wailoo et al., 2009). 

Ironically, the medical facility’s reputation was further ruined at that point in time from not only making such an egregious error in the first place, but then poorly attempting to cover up a situation that would clearly not be buried for long. Indeed, Duke University Hospital’s reputation remains, to a degree, marred to this day, and it is routinely cited as one of the worst medical malpractice cases in modern history (Wailoo et al., 2009). The coverup also immediately brings to mind immediate biblical connections, particularly the Book of Proverbs: “The Lord detests lying lips, but he delights in people who are trustworthy” (Proverbs 12:22). Unfortuantely, Duke University Hospital opted to lie through its shameless coverup, which ended up causing the most lasting damage. While a mistake may be forgiven, willful deception that leads to death is an entirely different scenario that speaks to deep rot within the medical facility’s culture.

Following the travesty of Jessica’s case, Duke University Hospital did implement changes to ensure such an egregious issue would never occur again. The most important policy implemented was implementing a new system that required for organ donors’ blood type to be confirmed at least twice to ensure such a tragedy never happens again (Resnick, 2003). Thus, the medical facility did implement policies that serve to avoid such a tragedy, though such policies are highly recommended to be accompanied by an accountability system to ensure they are followed. In general, the national furor has long since died down, but the deliberate deception following the tragedy continues to be a dark stain on Duke University Hospital’s record.

References

Glannon, W. (2007). A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of 

Medical Citizenship. Perspectives in Biology and Medicine, 50(4), 637-639.

Resnick, D. (2003). The Jesica Santillan tragedy: lessons learned. The Hastings Center 

Report, 33(4), 15-20.

Wailoo, K., Livingston, J., & Guarnaccia, P. (Eds.). (2009). A death retold: Jesica Santillan, the 

bungled transplant, and paradoxes of medical citizenship. Univ of North Carolina Press.