Rich Pedroncelli/AP Photo
Christian Jimenez ’22 is a junior majoring in biochemistry and a 2020-21 health care ethics intern at the Markkula Center for Applied Ethics. Views are his own.
Access to healthcare is not the same for everyone and access is specifically difficult for vulnerable populations. Being an undocumented immigrant worker comes with many day-to-day challenges: grueling physical labor, being limited to an entry-level position, a less-than-minimum wage, and a large language barrier. These are but a few of the notable challenges. But there is another issue that is far more complex: what happens if an undocumented immigrant gets sick or injured and is no longer able to work for an extended period of time?
For the average American, the fulfillment of the sick role, the norms and responsibilities associated with someone who is ill, is fluid. If you get sick, you can take time off of work (and the company you work for pays you while you’re away), you schedule an appointment with your doctor, and finally recuperate at home while taking the prescribed medications. But for a truly essential population of our country, these options are not available.
Primarily, the high cost of health insurance is a barrier to health care access for low-income families, especially those which are undocumented. As of 2017, 45% of undocumented immigrants were uninsured and this statistic has not improved over the last decade. It is actually worsening.
The polarizing debates about race and immigration have led to increased tensions within the last decade. This has discouraged certain communities from participating in the U.S. healthcare system and its programs. Specifically, according to a CBS article from 2018, the Hispanic community’s participation in such programs has steadily declined. Daniel Bouton’s nonprofit Community Council specializes in increasing healthcare enrollment for low-income families. Within the organization is a Mexican 52 year-old housekeeper. She previously signed up for federally sponsored healthcare insurance for two years but has since withdrawn and continued to live uninsured in fear of deportation. Through a translated telephone interview, she said, “We’re afraid of maybe getting sick or getting into an accident but the fear of my husband being deported is bigger.” Her thoughts have been echoed throughout the Hispanic community, to the point where individuals decline medical care even when they are sick.
Even if they take the leap to receive care, the possibility of deportation still lurks. According to the CEO of Heath Outreach Partner, “One social worker said she had a client who was forgoing chemotherapy because she had a child that was not here legally.” The lack of insurance is a serious barrier for undocumented families in accessing medical care. While it is true that undocumented families may still go to a clinic or hospital to receive care, the possibility of an extended stay or short-term hospitalization, and added costs associated with aninpatient stay are enough to push immigrants away from receiving care.
In a recent post, my colleague, Ryan Benavente, explored the flaws in the capitalist, market-driven mentality that runs our health care system. It reduces human life to an amount of money available in one’s pocket. Fundamentally, the lack of health care for immigrant workers goes against the idea of a capitalist market driven economy. If the workforce is not healthy, they cannot work and thus become trapped in a vicious cycle of diminishing health with no method to pay or reintegrate themselves into the workforce. From here, they cannot find the time nor the money necessary to restore themselves to optimal health.
So where do we stand? What can we do to help this vulnerable community in need of medical care? An investigation into the Hippocratic Oath may give us an answer. The Oath states that the health of a patient is the primary consideration and later it states that the one taking the oath will not permit any secondary aspect (physical appearance, beliefs, or social standing, etc.) to interfere with the duty to provide the highest standard of care. It is here that the answer to this issue can be found. Physicians' duty to their patients requires basic health care as a fundamental right of all humans. At the least, maintaining one’s health is the avenue by which one can continue to work, an essential component of life. It is a fundamental good because it dictates whether or not we as humans can pursue life, reduce pain, minimize suffering, and provide the necessary basis to live.
In addition, it also requires patient confidentiality. Whether or not disclosing immigration status is covered under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is a source of debate. In a case in January 2019, an undocumented patient’s immigration status, medical information, diagnosis and discharge date was released by a healthcare worker within the hospital to the authorities. Upon the patient’s discharge, the immigration authorities were located outside the hospital waiting for the patient. Is the hospital required to report the immigration status if requested by officials? Does this violate HIPAA?
In 2013, the Arizona House introduced a bill that mandated medical professionals to verify immigration status and then report to the authorities if the patient was undocumented. While the bill was not passed, the idea that such a concept made an appearance in possible legislation is a testament to the tensions around this issue. While the tensions are high, such an action goes against the core tenet of beneficence, doing right by the patient. Thus, it would be immoral for us to mandate health care professionals to report their patients’ legal status to authorities. By doing so, we are punishing undocumented patients who are simply looking to receive medical care.
On the surface, it does not seem medically relevant to ask about immigration status, and thus it should not be considered as protected health information (PHI). However, studies have shown that being an undocumented immigrant increases the risk for several health conditions. These conditions include physical, physchological, verbal, and sexual violence. Therefore, knowing immigrant status as part of the patient’s history may provide physicians and health care professionals with additional information with which to better care for their patient. Clinicians are vigilant to the social disparities that may affect the physiological condition of undocumented immigrant patients. Thus immigration status must be considered protected health information.
In regards to the Deferred Action for Childhood Arrivals (DACA), the American Medical Association (AMA) has set forth ethical obligations which physicians are expected to abide by. The AMA Policy “Opposition to Criminalization of Medical Care Provided to Undocumented Immigrant Patients” strongly opposes policies or other forms of legislation which punish health care workers for providing care to undocumented immigrants. This aligns completely with the oath healthcare professionals take to treat all patients the same Furthermore, health care workers should not be punished for fulfilling their oath. Finally, health care professionals have an obligation to advocate for policy change in order for our system to provide accessible and high quality care to undocumented immigrants.
In summary, the challenges undocumented immigrants face in this country span beyond social considerations and permeate into medical field. Other than added health risks, they face barriers in simple access to adequate care. This adds an exponential burden because the absence of necessary health care to recuperate from their injuries or illness extends the time for them to be out of work. A seemingly unfortunate obstacle becomes a detrimental cycle that over time rapidly increases in overall severity. The physician’s obligation is to abide by the oath they took to treat all patients equally and maintain patient confidentiality. As I have argued, immigration status falls under this umbrella of confidential information. In addition, health care professionals have a duty to advocate for their patients beyond the hospital. While tensions about this issue have risen over the last decade, physicians must do everything possible to ensure the best outcome for their patients, independent of who they are or where they are from.