Bioethics Forum Essay

Supporting Patients and Students Who Are Immigrants: What to Do and Why Most Bioethicists Won’t Do It

A devastating wave of fear now permeates immigrant communities. The rhetoric and spectacle of mass deportations and the efforts to remove previously granted authorization to be in the United States have created a reactive panic in which people sometimes stay home from work and keep their children home from school. And as communities scramble to protect each other, they can become conduits for misinformation-filled rumors and further terrorize themselves. This situation has immediate negative consequences for the health of many people.

Our experiences with anti-immigrant policies in the past suggest that many immigrants today are living in a state of toxic stress. And this state of fear likely has a chilling effect on their willingness to present for care. Many will avoid medical care until illnesses have progressed to an emergency. This is not only bad for the outcomes of particular patients but it can also have significant public health implications.

Fortunately, we have well-developed playbooks on what health care providers and institutions should do immediately. First, they should communicate as clearly as possible that that immigrant patients remain welcome and will be kept safe within their facilities to the fullest extent of the law. Second, they must make their facilities as safe as possible for these patients. This task was made more urgent when the new presidential administration rescinded the sensitive location designation of hospitals (as well as schools and churches) that was designed to prevent routine immigration enforcement actions from occurring at these places.

Facilities need to implement or refresh their front door policies. These articulate the procedure for responding to an ICE request for information about a patient or to apprehend a patient. These policies typically designate an official who responds immediately and demands that ICE produce a judicial warrant to obtain information or gain entry. Of course, ICE, like anyone else, can enter any public area on our campuses, such as waiting rooms, without authorization and subject patients to inquiries and potential intimidation. So, many front door policies include expanding the “private” areas that require authorization to enter and expediting the entry of patients into these areas. Information on these simple steps is readily available in online toolkits.

Some toolkits, such as the Sanctuary Doctoring page that I helped create, also provide templates of resources that health care institutions and professionals can give their patients. For instance, know-your-rights trainings and information, available online, can and help patients to exert some control over their vulnerable situation. There are also a number of excellent online resources to help a family develop an emergency plan should the worst-case scenario occur. And health care providers can adapt the templates to their patients’ needs by adding links to local legal resources.

A similar playbook for undocumented students has been dusted off at many universities. This has involved advising students with DACA (Deferred Action for Childhood Arrivals)  to renew their DACA authorization immediately, suggesting or providing legal screenings, offering know-your-rights-trainings, providing ally trainings, and refreshing/creating front door policies. Of course, the degree to which these steps have been publicized or implemented on campuses vary widely.

I am sure that the great majority of bioethicists who have read this far agree with the logic and ethics of taking these steps in health care facilities, colleges, and universities. Given the health implications at stake, such steps have the status of duties, albeit imperfect ones. And the injustice of the political scapegoating and targeting of these populations heightens the case for empowering them to address their situation. Unfortunately, it is clear to me from past experience and current conversations with bioethicists that very, very few will engage in any activity to advocate for or implement such measures at their university or health system. Why? Several reasons seem paramount.

First, the defined scope of activity of most bioethicists is fairly narrow. We are often involved with clinical ethics case consultations and the accompanying ethics committees, responsible conduct of research programs and related institutional review boards, and teaching and scholarship responsibilities. It is unlikely that the leadership of a health system or university would delegate their bioethicists to address concerns about immigrant patients or students or even expect to hear from bioethicists about these issues. So, engaging in this work will require that bioethicists transgress their normal professional boundaries and seek the attention of leaders of their institutions.

Second, even under the best circumstances, advocating for immigrant patients and students is an uncomfortable role for anyone, including bioethicists. Those doing such advocacy are asking for resources, including time and attention, and offering an uncertain return on investment. For instance, the effective implementation of front door policies requires continual vigilance. I find this akin to tornado preparedness. Here in the Midwest, tornadoes touch down each year and often destroy buildings. Health care facilities and institutions of higher education would do well to maintain a tornado-preparedness program, but someone who advocates for it risks becoming a nuisance to senior leadership. After all, the chances of your campus actually getting hit by a tornado would seem to be small.

Third, these are far from the best of circumstances. Fear is not only prevalent among our immigrant communities but currently permeates our society, especially universities and health care institutions. Our current social and political milieu portrays universities as bastions of wokeism and administrators are trying to avoid attracting attention to their institutions. The health care establishment is not far behind, as the recent experiences of researchers highlight. And with schools, churches, and health care facilities no longer exempt from routine immigration enforcement, it is natural for the leadership of such institutions to prefer a low profile and to hope that the metaphorical tornado does not strike. In such an environment, becoming an advocate for supporting our immigrant patients and students places a bioethicist’s institutional political capital at risk.

I often lose patience with calls for bioethicists to take on issues that are remote from our “day jobs.” However, bioethicists sometimes have a good deal of informal influence in their institutions acquired by having been useful in helping them navigate difficult issues and showing sensitivity and savvy in reconciling a wide variety of interests and considerations. I respectfully ask that bioethicists consider whether they have such social capital and whether this might be the time to spend some of it.

In the current climate of fear, stating the truth about what is ethical and just can be transformative. Academic and health care leaders are generally mission-driven and want to support their vulnerable constituents to the fullest extent of the law. Expressing interest in what your institution is doing in this regard and offering suggestions and help with the work can catalyze a more robust program of interventions. The truth has power, but it sometimes needs a voice. Of course, part of the savvy of bioethicists is engaging in the art of the possible. We must respect the concerns and knowledge of the leadership of our institutions and be sure that as we advocate, we are wisely spending and not torching our political capital. But I suspect that we are in one of those times when the worst thing we can continue to do is nothing.

Mark G. Kuczewski, PhD, HEC-C, is the Michael I. English, S.J. Professor of Medical Ethics and director of the Neiswanger Institute for Bioethics at the Stritch School of Medicine at Loyola University Chicago. He is a Hastings Center Fellow. @bioethxmark.bsky.social LinkedIn: (4) Mark Kuczewski | LinkedIn