Bioethics Forum Essay
From Outcry to Solidarity with Migrants: What Is the Good We Can Do?
Another June. Another public outcry about cruelty as policy harming migrants in United States custody. Another Niemöller moment in which American citizens feel, viscerally, that silence equals complicity. Last summer, the unbearable moment came when we heard the voice of a 6-year-old girl speaking truth to power under terrifying conditions.
This summer, the photo of a drowned family, Óscar Alberto Martínez Ramírez and his daughter, Valeria, of El Salvador, shocks the conscience.
This summer, reporters from AP, The New Yorker, and other media outlets are documenting the inhumane conditions in a Border Patrol facility where hundreds of children have been held. Lawyers monitoring the facility’s compliance with the Flores Settlement Agreement of 1997, an ongoing court case that limits the time the Border Patrol can hold children and sets standards concerning their treatment, are speaking on the record to reporters about seeing toddlers in the care of children and babies with their teenaged mothers, about lice and flu, about lack of diapers, soap, clean clothes. (In response to outcry, authorities relocated children to shelters and a tent facility, then moved more than 100 children back to the Border Patrol facility.)
Eight hundred and thirty-seven bioethicists and other colleagues have signed a letter to legal counsel representing migrant children covered by Flores, underscoring that conditions harmful to the health of children are unethical and inhumane. The growing body of evidence on the health harms of toxic stress and of family separation suggests that the effects of these conditions will have lasting effects on immigrant families and developmental effects on children.
There is no ethical dilemma about policies of cruelty and neglect targeting children. The cruelty is the point. Once we recognize that a profound moral and ethical wrong is being perpetrated in our name, and will continue as long as it is politically expedient to dehumanize and scapegoat immigrants and as long as conditions in Central America – poverty, violence, unsustainable agriculture, weak or corrupt public systems – continue to push families through Mexico to the U.S., risking life in search of safety and the hope of a better future, how should our field respond between these moments of public outcry?
To answer this question, The Hastings Center held a national convening last fall, funded by a rapid-response grant from the Public Health Program of the Open Society Foundations, to explore feasible ways for health systems, as a sector of American society, to counter the harmful effects of federal policies and messages concerning immigrants. Participants included practitioners in health care, health law, immigrant health advocacy, and municipal government, reflecting the range of sectors (which also includes investigative journalism) involved in ongoing response to the current political environment in the U.S.
Through discussions during and following the convening, we identified a set of challenges that clinicians often grapple with in isolation as they try to serve a low-income patient population fearful of separation and detention and wary of encounters with authorities and government programs. Physicians for Human Rights, whose program staff participated in the convening, has recently reported on the broader health consequences of immigration enforcement for immigrants living in the militarized U.S.-Mexico border region. Even in immigrant-friendly cities far from the border, the “crisis” framing of immigration in politics and media impedes communication about the costs of health care for immigrants (relatively low) and about how heavily American society relies on immigrant labor and wages. The Hastings Center is developing new projects informed by these insights, aimed at supporting collaboration between frontline practitioners and administrative “champions” in health systems serving the largely urbanized immigrant population.
Bioethicists are often based in health professions and involved in health systems. Our field can support ethical practice by clinicians and administrators wrestling with social determinants of health that include longstanding problems such as lack of insurance due to immigration status plus new policy-induced problems, such as barriers to using health-related services, housing insecurity, and toxic stress affecting immigrant households. Ethics education activities, ethics committee discussions, journal clubs, and other venues convened by bioethics faculty should all serve as ongoing, structured, and safe opportunities for practitioner discussion and policy review and development. While health systems must also serve other vulnerable populations, in these times there is a special obligation to structurally support the duty of care to a population that is being systematically separated from care and from health.
A recent report by the community ethics committee of the Harvard-affiliated hospitals, on “Access to Medical Care for Undocumented and Uninsured Immigrants,” has potential to support candid discussion about clinical problem-solving in immigrant health care. The report (which I contributed to via committee discussions) responded to a request for input by hospital clinicians on the ethics of workarounds – in this case, diverting medical supplies to immigrants who need but cannot afford them. These dilemmas are common but can be hard to talk about. Our field can extend itself, to help clinicians feel less isolated with justice problems, to support nascent networks of practitioners in the same system or city, and potentially to engage system leaders in finding more sustainable ways to meet needs.
What else can we do, individually and as a field, mindful that some of us live in sanctuary cities and work in “sanctuary hospitals” while others have far less local support for immigrant-focused work? Bioethicists who are health professionals can join the Physicians for Human Rights Asylum Seekers Network for training and support in conducting medical and psychological evaluations of asylum seekers. Clinical ethicists can connect with hospital-based medical-legal partnerships that may help immigrant patients resolve health-related needs; medical-legal partnerships with immigration expertise are also resources for clinician education. Public health ethicists can contribute to empirical research and policy analysis on improving care and limiting variation in services for immigrant populations in the current environment. (The Hastings Center maintains a public database of published research, grey literature, and media reports on health care access for undocumented immigrants and on the chilling effects of Trump Administration policy priorities and changes on health care-seeking behavior.) Bioethicists who are attorneys can work with law school immigration clinics and community-based organizations to meet the immense need for legal services. Bioethics educators can integrate immigration issues into curricula and create opportunities for immigrant students to enter health professions. We can learn about the community-based organizations that are the crucial links between immigrants and systems, find out what this sector needs from us, and collaborate to inform health policy and services at municipal or state levels.
These are a few of the possibilities for moving from outcry to solidarity in bioethics work, and for integrating the care of migrants into our individual and collective professional practice in these times.
Nancy Berlinger is a research scholar at The Hastings Center, where she codirects the Undocumented Patients project. On Saturday, October 26, she will be part of a panel, “‘But what can I actually do?’ How bioethicists can and do work for immigrant justice,” at the annual meeting of the American Society for Bioethics and Humanities (ASBH) in Pittsburgh.