Uncharted: Medical Care Dilemmas We Face

Editors Note: This article appeared in Salvo 28, Spring 2014 edition and is used by permission.


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When new biotechnology or medical research raises a bioethical dilemma, we naturally seek a decisive answer. But what happens when the right answer is not readily apparent? When the “biohazard” might actually be our own rush to judgment?

While ethics seeks right answers to moral questions, it doesn’t guarantee tidy solutions, particularly when the dilemma involves not just one patient, but an entire system. We might be tempted to resolve the dilemma with a “bumper sticker” quip that shortchanges multiple ethical concerns. A case in point: healthcare for people in the U.S. who do not have legal status.

There are over 11 million undocumented immigrants in the U.S. Without legal status, they cannot access most of the federally funded public assistance programs, such as the Child Health Insurance Program, Medicaid, Medicare, and the Affordable Care Act (ACA).[1] They do have a safety net of access to emergency-room care or primary care at Federally Qualified Health Centers. Most of the “undocumented unwell” are Hispanic (around 80 percent), a population that is particularly vulnerable to chronic conditions that are often beyond the scope of emergency care.

Some chronic conditions could be avoided with appropriate preventive care. Do undocumented immigrants have a moral right (they don’t currently have a legal right) to basic medical care? Is there a corresponding responsibility for hospitals, doctors, the government, or churches to assist? Do biblical injunctions to care for and protect the stranger and foreigner among us apply to a non-theocratic state? To the organized church? Or only to individual Christians?

The ethical issues entangle multiple spheres: enforcement (and evasion) of existing laws, and advocacy for changing laws; the legal and moral status of those in need of medical care; access to a minimum level of care; physicians’ obligation to “do no harm” to patients; medical triage decisions; hospital provision of charity care; tax policies; fair distribution of limited resources; the church as a Good Samaritan.

These systemic issues do affect individual patients. A Guatemalan man named Cifuentes came to the U.S. on a work visa to earn money to send back to Guatemala for his injured daughter’s medical care.[2] Tragedy struck when Cifuentes himself was diagnosed with late-stage cancer. His visa had expired, making him an undocumented immigrant, ineligible either for hospice care or to purchase private insurance through an ACA-established exchange. His physical suffering was real, not a merely academic case study for discussion.

Should a hospital have picked up the tab for his hospice care? Hospitals already provide free care for some undocumented patients, but reimbursements to hospitals that care for the uninsured are being cut.

There is no simple solution, and the problem is not unique to the United States. A Canadian court recently determined that an “illegal migrant” with chronic and severe health problems did not have a right to medical care. The court was worried that Canada would become a “safe-haven” for anyone who needed health services.[3]

Should doctors shoulder the responsibility? Many already do. But sometimes they may be forced to choose to care for some undocumented patients over others, to “work the system,” or else to send such patients back to their home country. And in acting as an advocate for these vulnerable patients—a time-consuming process—doctors may be neglecting other patients.

The questions raised here may frustrate many. That is the point. Issues of this complexity are not neatly resolved in text-message bits. They require time, collegial conversation, and charitable critique.



[1] This discussion is based, in part, on a project of the Hastings Center: http://www.undocumentedpatients.org.

[2] Ricardo Nuila, “Home: Palliation for Dying Undocumented Immigrants,” New England Journal of Medicine, May 31, 2012. http://www.nejm.org/doi/full/10.1056/NEJMp1201768.

[3] Nell Toussaint v. Attorney General of Canada, 2011 FCA 213 (http://www.socialrights.ca/litigation/toussaint/2010_08_06%20judgment%20of%20Zinn,%20J..pdf). The appeal was rejected by the Supreme Court of Canada, leaving the lower court’s decision in place. (http://www.canadianhealthlaw.com/nell-toussaint-v-attorney-general-of-canada-2011-fca-213/).