Plight of undocumented patients: “A difficult position”

Hospital ethics committees can place the care of undocumented patients on their discussion agenda periodically, and can facilitate discussions about this issue during medical or interdisciplinary grand rounds, according to a 2013 report.1 “This could take the form of grand rounds, having the matter put on the agenda of the senior management team or board of directors, or presentations to the Medical Advisory Committee or any other forum which might exist in the organization,” says Thomas Foreman, DHCE, MA, MPIA, director of the Department of Clinical and Organizational Ethics at The Ottawa Hospital in Ontario, Canada. “At that point, they can advocate for the creation of an organizational approach to the issue.”

Both organizations and individual providers have the ability to provide care to undocumented immigrants, argues Foreman. “What they don’t have is the ability to receive reimbursement for the care they provide,” he says. “There is nothing that prohibits the provision of care to undocumented immigrants. It simply isn’t funded — and, ethically, that is significant.”

The inability of undocumented immigrants to access health care raises important ethical questions not just for providers but also for the organization and society, according to Foreman. “There is huge hypocrisy in this issue. There are millions of people living in conditions that most Americans would find to be unacceptable,” he says. “The reality is, people become ill regardless of their legal status. When it suits us, we embrace them. When it becomes more challenging or might cost us something, we deny them. That is a problem ethically, and the health care system finds itself in the middle of that.”

Undocumented immigrants are using costly emergency departments due to an inability to access primary care services, which means providers have no opportunity to care for the patient holistically or build a relationship, adds Foreman.

“This clearly has negative consequences not only for patients but also for providers, who really feel like their hands are tied. Most have gone into the profession with a desire to help, and when they see barriers to being able to help, this presents ethical challenges for them,” says Foreman. “Many physicians really struggle with this. They realize that they can only address crises as they come up and not avert them. That is absolutely not the way health care should be provided.”

Bioethicists might also find themselves in a difficult position in raising this issue as individuals. “The challenge is that because we don’t have a profession, we don’t have the ability to speak as a body. As an individual, I can’t force a conversation, but as a professional body, I might be able to,” he says. “Also, most bioethicists are beholden to those institutions for their jobs. So how big of a thorn do you want to be?”

One possible solution involves hospitals in the region sharing the burden of providing unreimbursed care to undocumented immigrants, suggests Foreman. However, bioethicists might find it difficult to bring up this issue, as there are no clear-cut solutions.

“This is a classic ethical dilemma,” he says. “Either the system has to accept a reduction in revenues or profit, or the undocumented immigrants need to go away. When you think about it in those terms, we have two bad options: Reducing revenues to organizations that need to be sustainable or denying care to people who need it. There is no good solution to this, which is why many people don’t want to talk about it at all.”


1. Berlinger N, Raghavan R. The ethics of advocacy for undocumented patients. Hastings Center Report 2013;43:14–17.