Monday, August 4, 2008

Immigrants, Refugees, and Medical Ethics

After I wrote yesterday's post about refugees and asylum seekers in the British National Health Service, I read a remarkable article in the New York Times about Luis Alberto Jimenez.

Eight years ago, Mr. Jimenez, an illegal immigrant working as a gardener in Florida, was hit by a drunk driver, resulting in severe traumatic brain injury. Martin Memorial Hospital provided care. Given that no insurance coverage was available, Martin was unable to find a rehabilitation placement for Mr. Jimenez. They kept him in the acute hospital, accumulating a bill of $1.5 million. In the midst of litigation about returning him to Guatemala, which his U.S. guardian was resisting, the hospital hired an air ambulance and flew him back.

While accurate figures aren't available, hospital initiated deportations are not uncommon. Advocates for Mr. Jimenez accuse Martin Hospital of "dumping," but it is hard to see how an individual hospital can be expected to provide open-ended financing in circumstances like that of Mr. Jimenez.

An article in this month's Bulletin of the World Health Organization puts Mr. Jimenez's situation into a global context. 200 million or more people are living outside of their country of birth. Access to health care and the question of who will pay is a problem everywhere.

What we're seeing now is the way ethical problems roll downhill when wider societies choose to ignore them. In the U.K., GPs are asked to violate their most fundamental ethical commitments by refusing to treat undocumented immigrants. In Florida, Martin Hospital is asked to finance Mr. Jimenez's care in an open-ended way. Neither request is ethically justifiable.

The U.S., U.K., and every country that receives legal and illegal immigrants need to address the issues openly. International organizations like the WHO are crucial for helping to establish shared expectations and a broad ethical framework. The rehabilitation hospital in Guatemala that Mr. Jimenez was initially transferred to has an annual budget of $400,000, but appeared to provide excellent care. Rather than saddle Martin Hospital with a $1.5 million bill for inappropriate acute care, all parties would have been better served by a U.S.-Guatamala plan for augmenting services in Guatemala.

GP resistance to making them the agents for a National Health Service problem helps to push the complex ethical issues up to where they belong. In the hospital sphere, the American Hospital Association should do the same, so that hospitals like Martin are not forced to choose between financial ruin and spiriting patients out of the country in James Bond fashion.