¶ … cabinet-level agency in the U.S. government termed "Agency X" herein is the largest healthcare provider in the nation. With a multi-billion dollar budget, virtually universal support from the American public and a national network of healthcare facilities, Agency X should be well situated to achieve its mission to "care for him who shall have borne the battle, and for his widow, and his orphan." Unfortunately, on far too many occasions, Agency X has failed to deliver the high quality health care services the nation's veterans deserve and hundreds if not thousands have died as a result. In order to gain a better understanding of these failures, this paper reviews the relevant literature to provide an analysis of the ethical and social issues faced by Agency X and its administrators, followed by a summary of the research and important findings concerning ethics and social justice at this organization in the conclusion. Ethics and Social Justice at the U.S. Department of Veterans Affairs

Introduction

With a $168.8 billion annual budget (Facts about the VA, 2015), nearly 9 million enrolled patients and 300,000 employees, together with a nationwide network of 1,221 outpatient clinics, 144 hospitals, and 300 Vet Centers, one U.S. government cabinet-level agency is responsible for operating the nation's largest healthcare system (VA facilities, 2016). In addition, the organization in question also provides training opportunities for more than 90,000 physicians, representing more than half of the doctors trained in the United States each year (Fast facts about VA, 2016). The mission of this federal organization, hereinafter alternatively referred to as "Agency X," is taken from President Lincoln's Second Inaugural Address in which he promised that the nation would "care for him who shall have borne the battle, and for his widow, and his orphan." Given the importance of this mission and the enormity of its healthcare operations, there is an overarching need for ethical practices and social justice at Agency X which has unfortunately been sorely lacking in many areas that have adversely affected the quality of its healthcare services to the point where thousands of veterans' lives have been jeopardized. To determine the facts, this paper provides an analysis of the ethical and social issues faced by the government organization and public administrators in question, followed by a summary of the research and important findings concerning ethics and social justice at this organization in the conclusion.

Ethical issues related to two philosophical theories

Although it has failed to achieve it on numerous occasion, the above-stated mission of Agency X is highly congruent with a consequentialist perspective that holds that "among all the possible courses of action, an agent should pursue the one that, overall, brings about the greatest amount of good -- or, in jargon, the one that maximizes good" (Borghini, 2016, para. 2). An application of consequentionalist philosophy to Agency X's operations would therefore indicate that its public administrators must ensure that there are bureaucratic mechanisms in place that provide access to the healthcare services needed by the organization's millions of patients for optimal clinical outcomes.

Given the organization's mixed track record of success in achieving its mission, however, it remains questionable whether Agency X can be regarded as applying a consequentalist philosophy to its operations. As Narita (2009) points out, "Consequentialism is an ethical doctrine according to which a fact is good only if it has good consequences" (p. 37); however, as discussed further below, many of the consequences that have been directly caused by Agency X in recent years have not satisfied this fundamental ethical requirement.

Similarly, another form of consequentialism, utilitarianism, holds that "the rightness or wrongness of an action is determined by its usefulness in bringing about the most happiness of all those affected by it" (Smart & Williams, 1973, p. 37). As the research that follows will show, though, the actions by Agency X in recent years cannot be viewed as useful in achieving this desirable outcome and the health of thousands of patients has been threatened by its failures, an eventuality that cannot be regarded as contributing to their overall happiness which is a hallmark of utilitarianism. In this regard, Schwelk (1999) reports that, "One of [utilitarianism's] major objectives was to imbue a sense of the inevitability of human progress toward a consummation in which the utilitarian ethic will emerge triumphant and the conquest of the sources of human suffering will be all but complete" (p. 20). Unfortunately, rather than conquering the sources of human suffering for thousands of its patients, Agency X has actually become the source of suffering as discussed below.

A summary of the major ethical challenges and conflicts of responsibility presented to individuals in the organization to the organization as a whole

Although Agency X has experienced...

A representative sampling of these high-profile incidents is provided in Table 1 below.
Table 1

Representative samples of recent high-profile incidents involving Agency X

Description of incident

Agency X notifies more than 6,000 patients who went to a sponsored medical center in Murfreesboro, Tennessee, that they may have been exposed to infectious diseases at the clinic due to contaminated endoscopic equipment.

An agency-sponsored medical center in Augusta, Georgia, notifies more than 1,200 people that they may have been treated with contaminated equipment.

Agency X sends letters to more than 3,000 people who may have had colonoscopies at facilities in Miami, warning that they may have been exposed to hepatitis and HIV. According to hospital officials, a review of safety procedures found that tubing used in endoscope procedures was rinsed but not disinfected.

2011

Nine patients in Ohio test positive for hepatitis after routine dental work at an Agency X clinic in Dayton, Ohio. A dentist at the medical center there acknowledged not washing his hands or even changing gloves between patients for 18 years.

A CNN investigation shows that patients are dying because of long waits and delayed care at Agency X hospitals. The organization confirmed six deaths tied to delays at its medical center in Columbia, South Carolina.

January 30, 2014

At least 19 patients diagnosed with cancer in 2010 and 2011 died because of delays in simple medical screenings like colonoscopies or endoscopies, at various Agency X hospitals or clinics.

A retired Agency X physician reveals that it maintained a secret list of patient appointments, designed to hide the fact that patients were waiting months to be seen. At least 40 patients died while waiting for appointments.

Employees at numerous other healthcare facilities admit to manipulating patient waiting list data and an investigation is launched at 26 Agency X facilities.

June 9, 2014

An internal audit of hundreds of Agency X facilities reveals that 63,869 patients enrolled over the past 10 years have yet to be seen for an appointment.

June 24, 2014

A report issued by Oklahoma Senator Tom Coburn's office finds that more than 1,000 patients may have died in the last decade because of malpractice or lack of care from Agency X medical centers.

November 10, 2014

Agency X terminates or disciplines 5,600 employees as a result of these scandals.

March 10, 2015

Agency X releases a report that shows that more than 1,600 patients waited between 60 and 90 days for appointments at facilities in Los Angeles. Approximately 400 patients waited 6 months for an appointment and the average wait time for appointments as of January 15, 2015 was 48 days.

September 2, 2015

Agency X releases a review of alleged mismanagement at its eligibility center that showed more than 307,000 deceased veterans were listed as enrollees with pending applications. Estimates indicated that more than one-third (35%) of all pending records were for deceased patients, many of whom many have died while awaiting treatment.

Source: Adapted from Facts about the VA, 2015, para. 3

A summary of the strategies that the organization uses to maintain responsible conduct

Because the operations of Agency X are far-flung and span the entire nation including one of its unincorporated territories overseas (Fast facts about VA, 2016), the organization uses several different strategies to maintain responsible conduct among its nearly 300,000 employees including peer-review of questionable practices by healthcare providers at the local and regional level (Tarlov & Stroupe, 2010) as well as a national inspector general who is tasked with these responsibilities at the national level. The inspector general also maintains a toll-free "hot-line" that allows anyone, including Agency X employees, to report instances of misconduct (Office of Inspector General, 2016).

An explanation of recommendations for addressing the issues, including a rationale and an explanation of why they might be effective in addressing the issues, with consideration given to the possible involvement of guerrilla government employees

Despite enjoying a multi-billion dollar annual budget that has received consistent increases over the years, Agency X has been unable or unwilling to take the aggressive steps that are required to reform this organization so that it lives up to its executive mandate, suggesting that simply throwing more money into this bureaucratic black hole makes little business sense. Moreover, from both a consequentialist and utilitarian perspective, continuing to fund a federal…