Heart at work: professionals who care

ON JANUARY 10, 2002, a healthy 57-year-old man underwent a liver donation procedure that successfully resected approximately 60 percent of the right lobe of his liver in preparation for transplanting that liver into his brother, a 54-year-old man who suffered from a degenerative liver disease. After what was described as a technically uneventful transplant, the donor patient seemed to do well on the first postoperative day. He began to manifest some tachycardia, abnormally rapid heartbeat, late on the second postoperative day. Early on the third day, he began to hiccup and complained of being nauseated. He was given symptomatic treatment. Later that day he began to vomit brownish material. He became oxygen-desaturated (lacking adequate oxygen in the bloodstream) and was placed on 100 percent oxygen by mask. He was pronounced dead on that third day.

Three months later, the state health commissioner issued an incident report that said, "The hospital allowed this patient to undergo a major, high-risk procedure and then left his postoperative care in the hands of an overburdened, mostly junior staff, without appropriate supervision. Supervision of medical residents was far too lax, resulting in woefully inadequate post surgical care."

I do not doubt that the hospital, inadequate staffing, inexperience and lax supervision are all to blame. I do not doubt the importance of identifying and fixing these system problems. But I am struck by the abstract, impersonal quality of this language, as if no one involved had a name. This analysis assigns culpability not to people but to nouns: hospital, staffing, inexperience, supervision. When systems analysis is our only approach to a catastrophe of this sort, it becomes one more way that we allow the logic of institutions, which is about self-preservation, to overwhelm the logic of the human heart, which is about love and duty. In the process, systems analysis can contribute to the long-term decline of compassion, responsibility and courage in our culture.

As I read the case study, trying to bring it down to human scale, two details caught my eye. First, at the time of the donor's death, a surgical resident with only 12 days of experience in the transplant institute had been left alone to attend to this man--along with 34 other intensive-care patients--during a critical three-hour period when the donor developed serious symptoms. Clearly, the resident could not give her charges the attention they required. She later described herself (in what must be an understatement) as "feeling 'overwhelmed' by the responsibility of caring for so many patients."

Second, the donor's wife was at the hospital during the entire postoperative period attempting to advocate for her husband. Her description of his final hours is heart-wrenching: "I was present ... while my husband coughed up blood for two hours before he finally choked on it and died. [I] begged for attention to his condition and got none."

I think often about this woman and the nightmare she endured, a nightmare she lives with to this day. I think also about the young resident who was abandoned by her colleagues during that critical time, and I have empathy for her as well. Surely she was left with a nightmare of her own. But a moral response to this catastrophe ends neither in personal empathy nor in the penalties the New York State Health Department imposed on the hospital. We must ask how medical residents might be educated to con front institutional inhumanity of this sort instead of collaborating with it through action or inaction. If that question were answered, it might go a small way toward redeeming the suffering of all involved the man who died, those who loved him, and the health-care professionals who have accepted the burden of responsibility for his death.

Surely this resident knew that the system was collapsing around her. As she rushed frantically from bed to bed, she must have been aware of the human cost that might be extracted from her patients, their kin and herself. What kept her playing her role as an obedient underling in this tragedy instead of speaking truth to power? What kind of action might she have taken to bring reinforcements running? Is there a moral equivalent in the workplace to sending up flares, sounding the alarm, blowing whistles, raising holy hell? And what does it take to act this way in the moment, while there is still something to be salvaged, instead of waiting for a review board to ask what went wrong?

Of course, we might view the resident as another victim of the system, the pawn of superiors whom she could not confront because they had power over her career. That is how many of us excuse ourselves from workplace lapses of morality. But if we give her a moral pass on these grounds, we fail to honor the heart of the healer in her, to say nothing of failing to honor the man who died and the family and friends who must go on without him. Not just the system failed in this ease. The heart of the healer failed as well, a heart that surely knew what was occurring but refused to recognize the fact.