For “Ask an Ethicist,” members of the SGIM Ethics Committee respond to real ethics cases and questions submitted by SGIM members. Responses are created with input from the Committee but do not necessarily reflect the views of the Committee or SGIM. To submit a case or question, visit: https://www.sgim.org/communities/other-sgim-committees/ethics/ask-an-ethicist, or email the authors of this column.
A 29-year-old woman is admitted to the hospital with sepsis and tuberculous meningitis. She has many complications during her several-month hospital course, including a cardiac arrest, but ultimately her condition stabilizes. Although she is alert and breathing independently, she requires a feeding tube for nutrition and remains delirious, unable to participate in decision-making. When awakened, she cries out for her mother, but can say little more about her background. Her prognosis appears poor.
An investigation by the local police and the Department of Homeland Security indicates that the patient is an undocumented immigrant who may be a victim of trafficking. The house at her address is owned by a local restaurant proprietor. The patient apparently lives there with several unrelated “roommates,” all of whom work at the homeowner’s restaurants. The patient had been found in similar circumstances in two other US cities before, and both times had been deported to Mexico. Homeland Security and the Mexican consulate believe that the patient’s mother lives in Chiapas, a rural part of Mexico, but they have been unable to locate or contact her.
As the patient nears discharge, the hospitalist team considers various options. They could arrange for discharge to a local nursing facility, in which case the hospital would need to assume financial responsibility for her long-term care, and she may not be able to reunite with her family. Alternatively, if an accepting facility can be found in Mexico, the consulate has stated that it can facilitate a transfer. However, due to her condition, she would require a medical flight between facilities at the cost of tens of thousands of dollars, and the team has concerns about the loss of continuity of care and the patient’s safety in returning to Mexico. The team requests an ethics consult to assist with this decision.
The care of undocumented immigrants brings about justified moral distress alongside practical and ethical challenges.1 These patients are often impoverished, with many avoiding care because it is unaffordable.2 Further, such immigrants are often separated from families due to federal policy, the stresses of migration, or family choice about who is to immigrate to the United States.3 Finally, though it is federally mandated and ethically required, language concordant care is often not provided or easily available in our healthcare settings.4 All these considerations are potentially relevant to this case.
The main question in this case, of course, is how to best care for the patient now, and the destination of the patient after discharge. Can we understand what the best place for her might be based on her wishes (i.e., substituted judgment)? How do we supplement considerations for her best interests, that is, where she would be best cared for and safe, where substituted judgment isn’t available? Regarding substituted judgment, perhaps we can contact collateral sources of information, family, or friends, to understand what her wishes would be in this case. Those with knowledge of the facilities available near her family might be able to give a sense of what level and quality of care is available there.
How are these options to be carried out? Medical transport can be very costly; perhaps she could be temporarily discharged to a nursing facility in the United States until she can fly on a commercial flight. There are programs and airlines that provide compassionate use discounted fares to fly terminally ill patients or their loved ones—these may be worth exploring. One of our authors (MG) accompanied a terminally ill patient on a commercial flight home to Mexico, which made the institution more willing to cover the relatively minimal costs. Including a representative of the consulate, where possible, might prove helpful.
When we consider discharging any undocumented patient from the hospital, we need to consider how to keep them safe. While there are limits to how and whether clinicians can intervene in violations of employment law, they should confer with legal experts and perhaps law enforcement about employers suspected of trafficking.
In this case, as in so many ethics cases, the best answer depends on circumstances, but the lack of a better answer depends on policies. People in the United States, regardless of their documentation, should have access to the highest quality care. Identification and reporting of human trafficking depend on a system that believes in the rights of immigrants to freely travel; those fearing deportation will not speak up about trafficking. Only governments that welcome immigrants and care for their health and well-being will be able to have the moral authority to prosecute employers for mistreatment.
- Hacker K, Anies M, Folb BL, et al. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015 Oct 30;8:175-83. doi:10.2147/RMHP.S70173. eCollection 2015.
- Crowley R, Daniel H, Cooney TG, et al. Envisioning a better US healthcare system for all: Coverage and cost of care. Ann Intern Med. 2020 Jan 21;172(2 Suppl):S7-S32. doi:10.7326/M19-2415.
- Khullar D, Chokshi DA. Challenges for immigrant health in the USA—the road to crisis. Lancet. 2019 May 25;393(10186):2168-2174. doi:10.1016/S0140-6736(19)30035-2. Epub 2019 Apr 10.
- Berger Z, Peled Y. Language and health (in) equity in US Latinx communities. AMA J Ethics. 2022 Apr 1;24(4):E313-318. doi:10.1001/amajethics.2022.313.
Clinical Practice, Medical Ethics, SGIM, Social Justice, Vulnerable Populations
Dr. Berger (firstname.lastname@example.org) is an associate professor of medicine in the Division of General Internal Medicine in the Johns Hopkins School of Medicine and Core Faculty in the Johns Hopkins Berman Institute of Bioethics. Dr. Khawaja (email@example.com) is an assistant professor in the Department of Medicine at Baylor College of Medicine and a senior faculty member on ethics committees at the hospital/health system levels. Dr. George (firstname.lastname@example.org) is the medical director of ethics for Grady Memorial Hospital, past chair of the SGIM Ethics Committee, and an associate professor of internal medicine at Emory University.
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