We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).