CMDA's The Point

Medical Errors and the Gift of Grace

June 2, 2022
06262022POINTBLOG

by Kathryn Butler, MD

In a conclusion to a case that has gripped the nation, on May 13, 2022 a judge in Tennessee sentenced former nurse RaDonda Vaught to three years’ probation with a judicial diversion, rather than a maximum sentence of 8 years in prison, for clinically negligent homicide. Ms. Vaught was convicted of criminal charges earlier this year in the 2017 death of Ms. Charlene Murphey, a patient at Vanderbilt University Medical Center who died after Ms. Vaught accidentally administered vecuronium instead of midazolam. The verdict ignited a firestorm of debate in the medical community, with nursing organizations warning that the conviction could shift medical errors into the domain of criminal litigation, discourage prompt reporting of mistakes and, ultimately, threaten patient safety. In the face of such concerns, Ms. Vaught’s lenient sentence garnered applause.

Many of us in the healthcare professions watched the court proceedings with our jaws clenched and our muscles tightened because we, too, could envision ourselves in Ms. Vaught’s position. While her errors and negligence were undeniable, the case confronted us with the ugly truth that haunts all in healthcare: we strive to love neighbor through medicine, but times will come when we fail. Even as we strive to do no harm, we are fallen, we are finite and we are in desperate need of forgiveness.

The Price of Fallenness

I will never forget the first patient I failed. Over the years and thousands of patient interactions, certain faces, names and catastrophic moments burn into our minds, haunting us in the early hours of the morning while our families still sleep peacefully. No matter how many people we return home to their families, we can never sponge away the stain of our failures. Our suture lines that did not hold. The bleeding we could not stop. The diagnostic clues we missed.

The American dream purports that our justification hinges upon working hard enough. In the land of opportunity, it asserts, effort and success are bound in a one-to-one correspondence. Work hard enough, and you can forge your own destiny. Perform enough good deeds, and you can repair a broken past.

In this fallen world, however, such assertions are deceptive. The truth is that no matter how dutifully we strive to do good, crookedness still lurks within our hearts and works its terrible poison. “The Lord looks down from heaven on the children of man, to see if there are any who understand, who seek after God,” the psalmist writes. “They have all turned aside; together they have become corrupt; there is none who does good, not even one” (Psalm 14:2-3, ESV).

While we desperately strive to heal, sin hums through every corridor and surges within our own veins. Patients die despite technology, expediency and finely-tuned protocols. Cancer recurs despite our declarations of cure. When we lose a patient, we consider our flimsy books, our hands that could not deliver, and we despair. We offer our report in monotone, while the full weight of our sin bears down upon us, stealing all breath and sight and hope.

And yet, “But God shows his love for us in that while we were still sinners, Christ died for us” (Romans 5:8, ESV). While our failings drive us to our knees, in Him we have hope.

God’s Gospel of Grace

We can neither ignore our wretchedness, nor correct it with desperate strivings. The errors we make in healthcare stalk us like phantoms, and they plague us with every medication we draw up and every turn of the needle driver. Yet the churning pangs of guilt that torment us also direct us to the cross. Beneath its imposing shadow, we encounter the stunning breadth and depth of God’s grace. We deserve no pardon. Our hearts are corrupted. And yet, God sacrificed His own, blameless Son to cleanse away our sins, “For our sake he made him to be sin who knew no sin, so that in him we might become the righteousness of God” (2 Corinthians 5:21, ESV).

Where we have only defilement and sin and guilt, Christ renews us. He washes our stained hands in righteousness. He molds our contorted hearts with righteousness. He wipes away our jealousy, greed, deceit and pride, and He scatters our filthy rags like waves breaking from behind a ship, leaving only righteousness shimmering in their wake. And not righteousness of the world, but of God! Holy, unblemished. Made new.

Guilt steeps us in misery, but the cross washes us in living hope (1 Peter 1:3). Jesus laid down His life for us out of love (John 15:13).  That love has the power to redeem us, to mend our fractured souls, to undo all the evils our feeble hands cannot repair.

About Kathryn Butler, MD

Dr. Katie Butler (MD, Columbia University) trained in general surgery and surgical critical care at Massachusetts General Hospital and Harvard Medical School, where she then joined the faculty. She left clinical practice in 2016 to homeschool her children, and now she writes regularly for desiringGod.org and the Gospel Coalition on topics at the intersection of faith and medicine. She is the author of Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care and Glimmers of Grace: A Doctor's Reflections on Faith, Suffering, and the Goodness of God.

3 Comments

  1. Don Davies on June 12, 2022 at 3:38 am

    I’ve only heard good things about this clinic, and I feel it’s one of the best in the region! My kids also go to a superb pediatric dentist in Rome, GA, and I feel that parents should do their research when it comes to obtaining the best dental care for their children!

  2. Joseph Soler MD on June 19, 2022 at 8:10 am

    Very well thought out and written by Dr Butler. Thank you – good work.

  3. David W. Fricke, MD, FACS on July 5, 2022 at 12:05 am

    I have a few examples of having patients under your care, you are unable to do the right thing, and the patient dies– that is a heart-rending event for the doctor or surgeon and his staff. We all make mistakes. The Lord knows if they are thoughtless or negligent. We must confess these errors– to Him and to colleagues. He is compassionate and forgiving– He knows we are but dust.
    1. I had a young patient in Tansen, Nepal, who endured a fulminent course to death. At term pregnancy in labor, she had been carried for miles and congestive heart failure. What a trip over those mountain trails! Hemoglobin was 4 Gm/100ml. She needed stat: a ventilator, expert intensive care, and blood. We would have to recruit donors. We gave oxygen by mask and diuretics, but she did not respond and died before we could marshall the blood..
    2. I recall another sad case– a young adult with diphtheritic laryngitis who we thought needed a tracheostomy. Not many of us have seen severe diptheria — she was toxic, temp 104, hypotensive, heart failure. She had a fulminant downard course from this beastly disease, and died in about two hours. No diphtheritic antitoxin in that little hospital.

    Such catastrophes and one’s experience in having some kind of role in them are a fact of life for one who would like to care for patients in places where facilities are woefully inadequate. Of course, It is a great blessing to to see healing, but there is still a great emotional and spiritual cost from those that we are unable to help. Thank you for allowing me to share this here.

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