Guest Column

Rationing of care to undocumented immigrants

By Marc D. Hiller, DrPH
Department of Health Management and Policy
College of Health and Human Services
University of New Hampshire

Is it antithetical to Hippocratic oath?

There is little doubt that the budget problems and added demand on limited resources that undocumented immigrants contribute to health care institutions is real, and that institutions located closest to the border bear the greatest burden. Yet, in wrestling with such issues, hospitals ought not to shun their ethical responsibility to treat, if not seek to heal, the sick without unfairly rationing care as a means to an end.

Fiscal vs. charitable concerns

Health care institutions that turn to rationing health care as a means to improve their fiscal condition need risk shifting from dominant patient care and charitable values, or what Cunningham has described as its healing mission, to a business ethic and a loss of public confidence.1,2 And, doing so with the knowledge and intent that those who will experience the most negative impact of such a move are among the neediest, having little voice and even less power, suggests a failure to respect the long historic humanistic and charitable foundation of nonprofit health care in the United States.3

One needs to ask whether adopting a decision to refuse treatment of one particular group of individuals, i.e., those who are unable to document their status as legal U.S. residents, is consistent with the organization's character as defined by its mission, vision, and core values. While I am unable to speak specifically about the character of University of Texas Medical Branch (UTMB) in Galveston, it is hard to believe that any reputable health care institution would find such a practice within its character.

Violation of Declaration of Geneva

Furthermore, should it be, one could argue that making such a decision seriously risks its violating the internationally respected Declaration of Geneva (adopted in 1948 and amended in 1983) that proclaims that health care providers should not permit considerations of religion, nationality, race, party politics, or social standing to intervene with their duty to serve their patients.4

While it appears that UTMB in Galveston has in the past not shied away from the historic Hippocratic tradition and its long-held commitment toward providing needed cancer treatment to indigent patients, it appears that growing financial pressures are forcing a reconsideration of its values and its practices. Yielding to such pressures, rather than finding or having to make some alternative decision, risks sacrificing its core ethical principles by opting to explicitly ration (or deny) a set of lifesaving services to those who are among the most in need regardless of their unpopular — at least politically — status. While these patients may be unable to document their legal status as U.S. residents, they are human beings in need of the care that UTMB can provide. And, while denying them care may pose the simplest fiscal solution, it does not appear to be a morally justifiable one.

In adhering to the historic Hippocratic tradition, health care organizations must not allow themselves to be blinded to the fundamental ethical duties:

  • Nonmaleficence. This dictim rests at the core of the Hippocratic tradition, "primum non nocere" (or first, do no harm). Knowingly refusing lifesaving care to any population group will result in its being harmed.
  • Beneficence. This duty requires that health care providers benefit, i.e., give meaningful and beneficial treatment, to those in need of those providers' care. Not doing that which is known to benefit a particular population group, such as cancer victims, is wrong.
  • Justice. This duty commands that all people be treated in a fair and just manner as a basic human right, and not unjustly refusing care to any population based on a particular characteristic that deems them less valuable or more expendable than others. This principle is at greatest risk of being violated in imposing any rationing schema that targets or most negatively impacts a single population group, particularly one that is highly disenfranchised, unpopular, and viewed negatively, or otherwise unable to voice an effective opposition.
  • Respect for Persons (Autonomy). This fourth, highly cherished ethical obligation (though in more recent times having been viewed contradictory to the Hippocratic tradition) is extraordinarily embedded in the value structure of this nation (as reflected in the 14th Amendment to the U.S. Constitution) as well as in health care. It serves as a foundation for many of health care's priorities, such as informed consent, confidentiality, veracity, compassion, and possibly above all, respect and trust. Obviously, ignoring the needed treatment of a group of people, deemed less worthy due to their legal status, reflects a lack of respect for them as individuals as well as a population group.

Finally, while rationing is being realized increasingly as a method to control expenditures (or, as some may argue, an alternative to adopting a more just and compassionate health care system that assures universal access), it should never be imposed without serious attention being afforded certain essential ethical criteria.

Dougherty has asserted that "rationing should: be done in the context of universal coverage for basic care, serve the common good, protect those who are most vulnerable, guard such important intangibles as caring and trust, set priorities openly and avoid insidious discrimination, and observe the Golden Rule, meaning those who ration must themselves be subject to rationing."5


  1. Cunningham RA Jr. More than a business: Are hospitals forgetting their basic mission? Hospitals 1983; 57: 88-90.
  2. Cunningham RA Jr. The Healing Mission and the Business Ethic. Chicago, IL: Pluribus Press; 1982.
  3. Summers JW. Doing good and doing well: Ethics, professionalism, and success. Hosp Health Serv Adm 1984; 29: 84-100.
  4. Heeley GF. Leading with integrity. Health Prog 1998; 79: 60-62.
  5. Dougherty CJ. How to avoid flying blind. Health Prog 1997; 78: 20-22.