Can Physicians Work in US Immigration Detention Facilities While Upholding Their Hippocratic Oath?

Spiegel P, Kass N, Rubenstein L.
JAMA. Published online August 30, 2019.
doi:10.1001/jama.2019.12567

The modern successor to the Hippocratic oath, called the Declaration of Geneva, was updated and approved by the World Medical Association in 2017. The pledge states that “The health and well-being of my patient will be my first consideration” and “I will not use my medical knowledge to violate human rights and civil liberties, even under threat.” Can a physician work in US immigration detention facilities while upholding this pledge?

There is a humanitarian emergency at the US-Mexico border where migrants, including families, adults, or unaccompanied children, are detained and processed by the Department of Homeland Security’s (DHS) Customs and Border Patrol and are held in overcrowded and unsanitary conditions with insufficient medical care.2 Children (persons <18 years), without their parents or guardians, are often being detained in these detention facilities beyond the 72 hours allowed under federal law. Adults and children with a parent or legal guardian are then transferred from Customs and Border Patrol facilities to DHS’ Immigration and Customs Enforcement facilities, which are also overcrowded and where existing standards for conditions of confinement are often not met. Unaccompanied minors are transferred from Customs and Border Patrol detention facilities to Health and Human Services (HHS) facilities run by the Office of Refugee Resettlement (ORR). The majority of these unaccompanied children are then released to the care of community sponsors, while others stay, sometimes for months.

Children should not be detained for immigration reasons at all, according to numerous professional associations, including the American Academy of Pediatrics.3 Detention of children has been associated with increased physical and psychological illness, including posttraumatic stress disorder, as well as developmental delay and subsequent problems in school.

Given the psychological and physical harm to children who are detained, the United Nations Committee on the Rights of the Child stated that the detention of a child “cannot be justified solely on the basis of the child being unaccompanied or separated, or on their migratory or residence status, or lack thereof,” and should in any event only be used “…as a measure of last resort and for the shortest appropriate period of time.”6 The United States is the only country not to have ratified the convention on the Rights of the Child, but the international standard is so widely recognized that it should still apply. Children held in immigration detention should be released into settings where they are safe, protected, and can thrive.

The info is here.

How Should Clinicians Treat Patients Who Might Be Undocumented?

Commentary by Jeff Sconyers and Tyler Tate
AMA Journal of Ethics. March 2016, Volume 18, Number 3: 229-236.
 doi: 10.1001/journalofethics.2016.18.03.ecas4-1603.

Here is an excerpt:

Ethical Considerations

In terms of the ethical analysis of this case, there is no better place to start than the Hippocratic Oath. While the oath never explicitly states primum non nocere (first do no harm), a phrase it is often assumed to contain, it does give us the informative statement “Into whatever homes I go, I will enter them for the benefit of the sick…whether they are free men or slaves” [10]. The normative claim implicit here is that it is the duty of the physician to take care of anyone who comes to him or her for care, regardless of that person’s societal status. This claim is intimately related to the principle of beneficence, which is a broad concept encompassing acts of mercy, kindness, charity, altruism, love, humanity, and a deep concern for the promotion of the good of others [11]. At times, the demands of beneficence can conflict with an agent’s desire for a comfortable life; this conflict will influence Dr. Connelly’s analysis of a relationship with Ms. Nunez.

We believe that if a patient has an acute life-threatening condition (for example, a stroke, respiratory distress, or ongoing blood loss), it is the physician’s moral obligation to treat him or her, except under rare and extenuating circumstances—such as certain risk of dangerous exposure, injury, or death from attempting treatment. (This moral obligation is different from the legal rules outlined above.) If a patient is in extremis, a physician must attempt to treat. However, these clear obligations need not apply in less acute scenarios like that of Dr. Connelly and Ms. Nunez.

The article is here.

So much for Hippocrates: Why docs won’t reveal each other’s mistakes

Research suggests physicians are concerned about becoming known as a tattler and losing referrals

By Marshall Allen
Propublica
Originally published November 12, 2013

Patients don’t always know when their doctor has made a medical error. But other doctors do.

A few years ago I called a Las Vegas surgeon because I had hospital data showing which of his peers had high rates of surgical injuries – things like removing a healthy kidney, accidentally puncturing a young girl’s aorta during an appendectomy and mistakenly removing part of a woman’s pancreas.

I wanted to see if he could help me investigate what happened. But the surgeon surprised me.

Before I could get a question out, he started rattling off the names of surgeons he considered the worst in town. He and his partners often had to correct their mistakes — “cleanup” surgeries, he said. He didn’t need a database to tell him which surgeons made the most mistakes.

The entire story is here.

Thanks to Gary Schoener for this article.