You Think You Can Trust The Veterans Administration, However..
When does unethical behavior become a criminal act? Possibly, when an employee turns rogue in an atmosphere of opportunity stemming from no oversite and twisted rationalization.
It has happened at a Veteran’s Administration once again. This time it is in Clarksburg, West Virginia.
A hospitalized veteran with dementia and many other ailments was injected with insulin on April 9, 2018. It resulted in his death. After a thorough investigation, the death has been ruled to be a homicide. The Veteran’s Administration turned the case over to its “Watchdog Office” after some suspicious concerns were raised. The body had to be exhumed for testing of tissue.
Insulin was found in the body even though the man had no history of diabetes. Then it was further found that the doctors never ordered insulin.
More than an Error
It might have been possible, of course, that the insulin was administered as part of a tragic mistake. However, the investigation revealed something far more troubling. Based on the findings, the lawsuit alleges: “…an unnamed employee who administered the injection was not qualified to be a nursing assistant and that hospital staff failed to take appropriate action to stop the employee from giving the shots.”
If that finding was not bad enough, it was found that 11 veterans died under suspicious circumstances at the same Clarksburg Veterans Administration facility – all with lethal doses of insulin, “despite not being treated for diabetes or high blood sugar.”
When the investigation unfolded, a person of interest (who has not yet been located) was identified. These findings set up a huge range of ethical concerns that have been plaguing the Veterans Administration System for years.
The obvious question is one of pattern. The unnamed, unqualified employee was allegedly allowed to roam the halls and obviously had access to the “drug cabinet.” Who gave that person access and why, in the entire hospital complex, did no one question what he/she was doing on the floors? Who gave that person permission to access drugs and allegedly administer medications?
Unfortunately, 11 people died under the same circumstances. One case of a mistaken dosage might eventually be excused as medical error, but 11 eleven cases? Did no one suspect something was amiss after the first few deaths?
Was there no supervisor in place? Did those in professional capacities not recognize the unauthorized employee was freelancing on patients? Was there no oversite applied or was it a rationalization that because they were busy that this unauthorized person was more than welcomed to play doctor.
Finally (though the ethical questions can go on forever), was there a set of biases in place? The veteran who died had a severe stroke, heart disease and other problems. Was he viewed in a light of being medically unredeemable? That it made no difference whether he lived or died? In fact, because of this attitude, was the unauthorized person almost viewed as a merciful angel of death?
The breakdown at the Clarksburg Veterans Administration facility is not medical. It is ethical. While some might claim it is criminal, that is only partially true. He or she is a murderer but the unethical environment nurtured it. No one cared. No one was invested. Eleven veterans are dead and bad ethics helped end their lives.
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