A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship (review)

In A Death Retold, authors from a wide range of disciplines exhaustively analyze the factors that influenced medical decision-making in a high-profile transplant case, as well as the public response to it. A 17-year-old undocumented immigrant with restrictive cardiomyopathy, Jesica Santillan had traveled with her family from Mexico to North Carolina with the hope of receiving a heart-lung transplant that would extend her life. Through the help of a paternalistic benefactor, Mack Mahoney, enough money was raised to pay for the operation. The transplant was performed at Duke University Hospital on February 7, 2003. Tragically, Jesica's newly transplanted organs failed immediately because her blood type was incompatible with that of the donor, a fact that was overlooked in what turned out to be an irreparable error. A second transplant was performed on February 20. But the acute rejection of the first set of organs resulted in severe brain damage that also doomed the second transplant. Jesica was declared dead by neurological criteria on February 23, 2003.

The essays in this richly textured volume are informative, thoughtful, and at times poignant. They insightfully show how this case and its immediate context serve as a microcosm of larger vexed issues in American culture and advanced medical technology. Specifically, the two failed transplants of Jesica Santillan raise questions about the human cost of attempting to extend life, medical oversight, medical futility, the promises and pitfalls of high-tech medicine, and the role of immigration in determining what constitutes a just system for allocating scarce medical resources. The book is divided into four parts. Each part consists of essays offering different perspectives on various aspects of the case.

Part I, "Medical Error and the American Transplant Theatre," includes discussion of the intense media coverage of the case, public perception of the transplant, and portraits of Jesica, her mother, Mack Mahoney, and transplant surgeon Dr. James Jaggers. But the main focus here is on medical error. Richard Cook's "Hobson's Choices" is particularly helpful in explaining histocompatibility and the critical issue of matching the blood type of organ donors with the blood type of organ recipients. He also highlights the challenges of communication between organ procurement organizations and transplant centers in different regions of the country (in this case, Boston and Durham, NC) to ensure matching of compatible blood and HLA types. A single glitch in this system can have fatal consequences, as occurred in the case of Jesica Santillan. The other authors in this section point out that the organ mismatch resulted from both a systems error and an individual error by Dr. Jaggers, who failed to realize the incompatibility until Jesica's own organs had been removed on the operating table. The mistake of mismatched organs has moved Duke and other transplant centers to implement policies and procedures to minimize the possibility of a similar event occurring in the future. In "All Things Twice, First Tragedy Then Farce," however, Charles Bosk expresses skepticism that these measures will prevent or eliminate errors and suspects that they will do more to protect institutions and administrators rather than patients.

In Part II, "Justice and Second Chances Across the Border," the authors address the apparent futility of the second transplant. They support the general belief that it was a desperate attempt to "fix" the mistake of the first botched transplant and was motivated by guilt and embarrassment. Rosamond Rhodes, in "Justice in Organ Allocation," appeals to principles of what she calls "clinical justice" (urgency, need, equity, and efficiency) to argue persuasively that while the decision to give Jesica a new set of organs in the first transplant was justified, the second decision for an additional set of organs and retransplantation was not. This essay is significant because its principled reasons and arguments cut through the distorting lenses of the media and...