Medical Ethics of Providing Healthcare

Medical Ethics of Providing Healthcare to Illegal Immigrants

Providing healthcare for illegal immigrants has become a major topic of ethical debate and an issue of increasing financial concern in the United States.

Religious institutions are deeply embedded in both health care delivery and health care lobbying, and each activity is consciously driven by understandings of the imperatives of Christian social thought and by institutional missions formulated with the intention of realizing commitments that flow from Christian faith (Cochran pp). Since health care delivery is shaped by public policies at the federal and state levels, religious leaders, theologians, and institutions such as hospitals have been forced to reflect on and to deliver health care within a context powerfully political and public (Cochran pp).

American health care is a disaster from the perspective of Catholic social though, because the system violates principles of justice, stewardship, and care of the poor, and moreover, violates human dignity and the common good by creating a market commodity from what should be a social good (Cochran pp).

The conundrum is that the Catholic Church and Catholic health care are deeply planted in the very system that violates their principles, and is a version of the Constantinian dilemma faced by Christians for the last millennium and a half (Cochran pp). As Bryan Hehir said, "When you try to he both an actor and an advocate, to represent both effective, efficient action and the vision and voice of the prophets, you have introduced significant tension" (Cochran pp).

Health care analysts use three large criteria for assessing a health care system: "the degree of access of citizens to health care; the financial cost of the system; and the quality of care provided" (Cochran pp). Every modern, democratic nation in the world provides universal access to health care for its citizens at a cost lower than the United States and with a high quality of care (Cochran pp). However, Clarke Cochran writes in a 1999 issue of "Journal of Church and State," that the American health care system fails on two out of three criteria (Cochran pp). Access to care for millions of citizens is severely limited, and the cost of health care is by far the highest in the world, "absolutely, per capita, and as a percent of GDP" (Cochran pp). Health care resources are squandered, and the excess social resources flowing into the health care system stymie other social responsibilities (Cochran pp). Only on the standard of quality does the United States look strong, and yet quality of care falls very short in certain respects (Cochran pp). For example, inappropriate care is too often given, particularly close tot he end of life, and millions of persons cannot afford quality care (Cochran pp).

Cochran believes that religious voices have a necessary and creative role to play in public discourse, and summarizes in five guidelines:

religious communities themselves should be communities of moral-conversation;

religious communities need to develop specific politico-theological vocabularies reflecting their own traditions;

such communities should be prophetic rather than priestly with regard to the surrounding political culture;

they must do their policy homework, learning the lore and data of specific policy arenas; and they are charged to live themselves according to the principles they advocate for the larger polity

Church-related hospitals are the most prominent and easily counted sign of religious presence in the most technologically advanced and visible part of the medical system (Cochran pp). In 1995, there were 5,194 community hospitals, of which 3,092, or 60%, were operated by non-government, nonprofit entities, the category that includes church-affiliated hospitals (Cochran pp).

In order for health care to flourish as a community, there needs to be a rough equality among members, meaning "no second-class citizens" (Cochran pp). Health care facilities should be considered as common goods that bind communities together, a belief that is often referred to as the "preferential option for the poor" (Cochran pp). This social thought can be found throughout the Bible in both the Old Testament and New Testament, such as in "Blessed are you who are poor, for the kingdom of God is yours" (Luke 6:20). And again in "He who gives to the poor will lack nothing, but he who closes his eyes to them receives many curses" (Proverbs 28:27). And to ensure that society does not forget, "The poor will always be with you" (John 12: 8). According to Cochran, this principle is especially applicable in health care, "for the sick and the injured are vulnerable to despair, exploitation by the strong, and neglect or contempt by the healthy" (Cochran pp). Thus, the sick and injured become the "least of my brethren" (Matthew 25:31-46. Social programs and policies must be arranged in such a way as to serve the poor and powerless because the poor and uninsured have a special claim on healthcare resources (Cochran pp). Says Cochran, "Health care is not a commodity to be distributed according to merit, worth, income, or desire...health care institutions and health care decisions should be made at the lowest possible level of society, with assistance from levels above" (Cochran pp). This is the principle of subsidiarity, entailing pluralism in health care delivery, and most social service, particularly health care service to the poor, is a partnership between government and private, nonprofit agencies (Cochran pp). Solidarity must be committed to advocacy for and health care delivery to non-citizens, and changes in the health care system itself and in legislation, such as the federal 1996 immigration reform legislation and Proposition 187 in California, jeopardize health care access for legal and illegal immigrants in the Untied States (Cochran pp).

In 1994, the death from acute leukaemia of a twelve-year-old boy, Julio Cano, was cited by immigrant rights advocates as the first casualty of California's controversial Proposition 187 (Virtue pp). The boy's death fuelled the confusion and fear being sown by Proposition 187, that along with denying public services, would require teachers, police and healthcare workers to report anyone they suspect of being illegal immigrants (Virtue pp). Cano's illegal immigrant parents said they delayed seeking medical treatment for their son because they feared deportation following passage of the 'Save Our State' ballot (Virtue pp). Although it remained unclear whether the boy could have been saved by earlier medical intervention, Hispanic activists blamed his death on Proposition 187, which calls for cutting off education, welfare and non-emergency healthcare to the state's estimated 1.7 million illegal immigrants (Virtue pp). However, proponents of the measure charged that the boy's case was being exploited for political purposes (Virtue pp). And although California voters strongly approved Proposition 187 during elections, U.S. court orders temporarily blocked the state from enforcing it (Virtue pp). In California in May 2004, H.R. 3722 was defeated which would have required hospitals to document the immigration status of patients seeking emergency health care services (California pp). Under the provisions of the federal Emergency Medical Treatment and Active Labor Act, EMTALA, hospitals must provide emergency health care services to anyone that seeks treatment in an emergency department, and are not allowed to turn patients away because of their immigration status or ability to pay (California pp).

In December 2001, Harris County District Attorney, Chuck Rosenthal stated that a probe of the Harris County Hospital District, one of the nation's largest providers of uncompensated care, was on hold (Jaklevic pp). The investigation had alarmed public healthcare advocates and immigrant groups around the country, who had blasted a written opinion by Texas Attorney General John Cornyn that said it was illegal in Texas to use public money to fund care for undocumented workers with public money (Jaklevic pp).

According to the Immigration and Naturalization Service, INS, approximately 7 million undocumented immigrants resided in the United States in 2000 (Tieman pp). Compared with other countries, Mexico is far and away the largest source of illegal immigrants, supplying over one-third of all illegal immigrants in the United States (Hudson pp). However, Haitians comprise an immigrant group that has increased dramatically in the United States over the past three decades (Folden pp). Faced with burgeoning populations of undocumented people, many big Southern states in particular are changing strictures governing access to healthcare (Axtman1 pp). Hospitals do not routinely screen patients to determine their residency status, and industry lobbyists recently quashed a bill that would have required such screenings in order for hospitals to obtain money earmarked in the Medicare law for treatment of illegal immigrants (Tieman pp). Hospital administrators said the task of demonstrating how many illegal immigrants they treat is not easy (Tieman pp). David Sakai, chief financial officer of two-hospital University of California San Diego Medical Center, which generates 25% of its business from charity-care patients, including those in the United States illegally, says, "We really are in a dilemma" (Tieman pp). Sakai said the system does not collect immigration information and therefore has no specific figure on how many illegal immigrants it treats, however physicians and other staff members anecdotally report that many of the charity-care patients are in fact illegal immigrants (Tieman pp).

In 2004, Arizona's Proposition 200 wanted state and local governments to verify the identity and immigration status of all applicants for certain public benefits, and to require government employees to report violations (Wood pp). Attitudes about the problem have hardened in recent years in some states, both out of concern about the economic impact, particularly in a time of slow job growth, and out of concern about the security threat posed since 9/11 (Wood pp). The concern over illegal immigration has intensified as the federal government has shifted more of the cost and control of welfare benefits to the states, further burdening state budgets (Wood pp). Some anti-immigrant groups say illegal immigrants siphon more than $1 billion a year in social services from the Arizona treasury, roughly $700 per family in the state (Wood pp). Ira Mehlman of the Federation for Immigration Reform, says, "Arizona has a serious problem on its hands in paying $1.3 billion a year in services to illegals..."All the state is trying to do is provide a check to see if people are eligible to receive the benefits they are applying for" (Wood pp).

A study by University of California at Los Angeles and Rand Corporation found that most Latino children in Los Angeles, California, qualified for the Medicaid program, however few receive full coverage (Shinkman pp). The survey of 812 Latino households found that 84% of the households' children qualified for Medicaid, yet 19% did not use the program and 21% received only sporadic care (Shinkman pp). The lack of citizenship of the children's parents was listed as a major obstacle to care, for although 96% of the children surveyed were born in the United States, 80% of their parents were not (Shinkman pp).

Pediatricians and hospitals with special pediatric expertise are facing the dilemma of rationing care to uninsured, undocumented children, especially for expensive life-saving care such as transplants, chemotherapy, and dialysis (Berman pp). In fact, almost every community in the United States faces the challenge of providing care to this population, because the federal government has left much of the funding of health care for uninsured undocumented persons to individual states, local governments, hospitals, and clinics (Berman pp). Says Stephen Berman in the November 2004 issue of "Pediatrics," "There is an urgent priority for discussion and research initiatives to take place at the city, county, state, and federal levels to address the delivery and financing of medial care to foreign national undocumented children residing in the United States' (Berman pp). If not, major adverse consequences for our health care delivery system will persist and perhaps worsen if we continue failing to address this issue rationally and equitably (Berman pp). In 1997, the American Academy of Pediatrics recommended that all pediatricians take an active role in assuring the provision of health care to the children of immigrants living in the United States, and that they should oppose any law banning the provision of services to illegal immigrants (Health pp). Moreover, they cautioned for physicians to be aware of the health problems of immigrants, which include "hepatitis B, tuberculosis, syphilis and parasitic infections...poor nutrition, delayed development, and poor dental and mental health" (Health pp).