In the monthly "Ethical Inquiry" series, we examine ethical questions, highlighting a broad array of opinion from journalism, academia, and advocacy organizations. Our intent is to illuminate and explore the complexity of some of the most vexing ethical questions of our time.

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Ethical Inquiry: March 2012

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Do Undocumented Immigrants Have a Right to Healthcare?

Do all individuals, whatever their citizenship status, have a right to healthcare? Does a society have an ethical responsibility to promote the health of undocumented immigrants within its borders? How should undocumented immigrants get needed medical care, and who should pay? Can nations justify compensating individuals who are illegally within their borders? Does a society have obligations towards people it tried to keep out of its territory?

In this “Ethical Inquiry” we will explore some of the concerns and questions surrounding healthcare for undocumented immigrants, primarily focusing on the debate in the United States. The term “undocumented immigrants” will be used in place of "illegal immigrants" due to the negative connotations some associate with the latter term.

 

Arguments against Providing Healthcare to Undocumented Immigrants

Arguments against providing healthcare focus on issues of legality and on concerns about burdening to the destination country.

Respect for the Rule of Law

This view argues that undocumented immigrants have no claim to health benefits because they have no legal rights in a country. The bottom line is that the law must be respected.

In the article “Seeing Today’s Immigrants Straight” Heather MacDonald writes, "the rule of law ensures that like cases are treated alike and unlike cases distinguished. But if the immigration protesters have their way, someone who ignored all the procedures for legal entry will achieve the same status and benefits as someone who played by the rules…[like] people who have waited for years in their own countries for permission to enter lawfully.” MacDonald contends that “undocumented immigrants are neither having their human rights violated nor being denied respect” because nations do not owe undocumented immigrants any type of services. Any social services that are offered should be graciously received.

Burden on the Healthcare System / Medically Harmful

Many point to over-extended medical practices as another reason to limit healthcare rights for undocumented immigrants. In a controversial 2005 article widely reprinted by anti-immigration activists, “Illegal Aliens and American Medicine,” (in the Journal of American Physicians and Surgeons, a publication not accepted by the mainstream academic community), Madeline Pelner Cosman contends that several California hospitals have gone bankrupt providing free healthcare to undocumented immigrants, that “anchor babies” (babies born on American soil from undocumented immigrants who are automatically granted United States citizenship “anchoring” their families in the United States) are raising the cost of Medicaid and other benefit programs, and that undocumented immigrants are given benefits such as translators and advocates that are often not as readily available to low-income American citizens.

Pelner further argues that undocumented immigrants bring dangerous diseases that are not regularly seen in the United States, increasing hospital costs. She writes “today legal immigrants must demonstrate that they are free of communicable diseases and drug addiction to qualify for lawful permanent residency green cards….by default, we grant health passes to illegal aliens.”

Burden on Taxpayers

Some argue that undocumented immigrants drain tax dollars that would otherwise be spent on legal, law-abiding citizens making these immigrants an added tax burden. According to the Federation for American Immigration Reform, the United States spent $70 billion in 2004 for social services treating undocumented immigrants. Robert Rector writes in “Importing Poverty: Immigration and Poverty in the United States: A Book of Charts,” a report for the conservative think tank The Heritage Foundation, “low-skill immigration siphons off government anti-poverty funding and makes government efforts to shrink poverty less effective.”

The Center for Immigration Studies, which describes itself as a "pro-immigrant, low-immigration think-tank which seeks fewer immigrants but a warmer welcome for those admitted," estimated in 2006 that "state and local governments spend some $4 billion a years to provide health care to illegal aliens [sic] and their U.S.-born children."

 

Arguments for Providing Healthcare to Undocumented Immigrants

Arguments for providing healthcare focus on issues of human rights and long-term societal and health benefits.

Healthcare as a Human Right

According to Article 25 of the 1948 Universal Declaration of Human Rights

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Many use this declaration as the basis for the "Humanist" view that all human beings have a basic right to healthcare. Humanists say societies must provide both citizens and undocumented immigrants with reasonable, comprehensive health benefits.

In 1990, the "United Nations International Convention on the Protection of the Rights of All Migrant Workers and Members of their Families," was convened, which recognized that even migrants who enter a country illegally are entitled to a basic level of assistance, including medical care. This declaration continued the conversation of healthcare rights for all individuals on an international stage. The Committee on Migrant Workers held its first session in 2004.

Norman Daniels discusses a related argument in his 1981 article “Health-Care Needs and Distributive Justice,” healthcare is a right because health needs are “those things we need in order to maintain, restore, or provide functional equivalents (where possible) to normal species functioning.” According to Daniels, to prevent normal species functioning is to hinder individuals from fully constructing their life-plans and striving for a pursuit of happiness, which is oppositional to both themselves and their role in society.

He writes “[by] keeping people close to normal functioning, healthcare preserves for people the ability to participate in the political, social and economic life of their society. It sustains them as fully participating citizens – normal collaborators and competitors – in spheres of social life.” To Daniels, denying healthcare to anyone is a grievous act that prevents individuals from being whole. Beyond increasing emergency department visits and the spread of communicable diseases is the dehumanizing effect denying healthcare has on the individual identity and self-worth of undocumented immigrants.

Another belief is that, regardless of one’s political views, the issue of undocumented immigration is separate from healthcare policy and it should be conceptualized as two separate issues: one of immigration policy and one of national health policy, void of immigration status. In the article “Denying Care to Illegal Immigrants Raises Ethical Concerns”

Ruth Faden writes, “The problem of illegal immigration should be solved by immigration policy, not health policy. People who are in this country illegally have broken our laws, but the magnitude of their crime does not justify depriving them of the basic right to health care coverage while they are in our midst.

Discriminatory and Dehumanizing to Deny Healthcare

In the article "Illegal Immigrants, Health Care, and Social Responsibility," James Dwyer writes, “simply being in the United States illegally is not a sufficient reason to be denied needed health care,” but “rising health care costs, budget reduction programs, and feelings of resentment sometimes transform the ethical question into a political debate.” Dywer adds that many people break laws and are not denied access to public services for these violations. Whether a violation of a law should disqualify someone from public services depends on “the nature and purpose of the services, the nature and the gravity of the violation, and many other matters.”

This is a point on which Ceri Oeppen expands in “Hopes, Needs, Rights and Laws: How do Governments and Citizens Manage Migration and Settlement?”, noting that not providing healthcare to undocumented migrants is a “discriminatory practice based on their group identity as undocumented immigrants as opposed to the rest of the population.” In other words, the benefits received from these immigrants are being completely overlooked based solely on how they got into a country.

Undocumented Immigrants are Contributing Members of Society

Many argue that the impact of undocumented immigrants is a net gain for society.

James Dwyer writes in his article "Illegal Immigrants, Health Care, and Social Responsibility," that he believes “in many respects illegal immigrants are social members. Although they are not citizens or legal residents, they may be diligent workers, good neighbors, concerned parents, and active participants in community life. They are workers, involved in complex schemes of social cooperation.”

According to John Price in "Illegal Immigration Strengthens the American Economy," (in Illegal Immigration, edited by David Haugen and Susan Musser) “excluding the positive economic impact of lower undocumented migrant wages from the equation is like declaring the 8.1 billion hours of free service by America’s 61 million volunteers as economically irrelevant.”

Price believes undocumented immigrants are a net economic gain for society, positively contributing to the American economy: the lower wages that undocumented immigrants are willing to work for raise profitability and lead to considerable savings for American businesses and consumers. He contends that as contributing members of society, undocumented immigrants deserve healthcare.

Dwyer also believes there is a social responsibility to help undocumented immigrants, as contributing members of society. By providing healthcare to them, society will be rendering these vulnerable workers the social respect they deserve. He writes "what is false is the idea that we have to choose between basic health care for illegal aliens and basic health care for citizens. Many other tradeoffs are possible, including an increase in public funding” to ensure these valuable residents are provided adequate healthcare.

To Dwyer, access to healthcare should not be contingent upon the fact that undocumented immigrants have violated a law. Instead, healthcare is a necessary reward for the low-paying, difficult work these immigrants contribute and the sales, gas, income and property taxes these immigrants do pay.

Provides a Public Health Benefit to Everyone

Despite economic contributions and issues of social justice, these immigrants are a high-risk population for communicable diseases and among the least likely to seek care. As Ceri Oeppen remarks, "irregular immigrants are often employed in what are sometimes referred to as '3D' jobs – dirty, difficult, and dangerous (or demeaning).” She continues "irregular migrants are likely to be exploited by unscrupulous employers who see them as a cheap and expendable source of labor. They are usually paid below a minimum wage and then have to work above maximum hours to earn enough money to survive and send money to their families. They cannot complain about exploitation or poor treatment to the police or local government because they are afraid of being caught. Often, irregular immigrants are also too afraid of deportation to risk accessing healthcare. This may contribute to the spread of infectious diseases as well as threaten the migrant's own health,” negatively impacting society.

Dwyer sees a denial of healthcare to undocumented immigrants as negatively impacting society, leading to increases in infectious diseases like tuberculosis – and as in conflict with the creed of the medical profession to help those in need.

The Massachusetts New Americans Agenda from the Massachusetts Office for Refugees and Immigrants cites research showing that non-citizens are more likely than citizens to postpone care for illness. The report states that “…delays in treatment are often precipitated by language and insurance barriers and can lead to longer illness, permanent ailments, and premature death.” It goes on to suggest that “[t]hese devastating effects impact not only individual families and the broader immigrant community but also impose serious burdens on the health system by creating an overreliance on emergency services. Access to regular medical treatment and preventative care provides significant health benefits while also decreasing the overall cost of care.”

Dr. Fred Ralston, president of the American College of Physicians, further emphasized that “access to care for immigrants is a public health issue and should be a concern to all of us” citing the ability of several diseases to cause exponential havoc if left untreated in this immigrant population. While some see providing healthcare as a duty to an exploited population, others see the argument of providing healthcare to prevent infectious diseases from a nationalistic perspective, contending that treating undocumented immigrants will physically and psychologically protect legal residents in a country from others who reside there; as a nation’s responsibility to protect its’ citizens, all residents must receive medical treatment.

 

Final Thoughts

Undocumented migration is a phenomenon that is not likely to go away soon. Healthcare access for undocumented immigrants is an issue that needs serious consideration and deliverable national standards and/or restrictions.

In general, individuals attach either a sense of personal loss and assault or a sense of injustice and discrimination to the presence and treatment of immigrants who are not legal residents, creating a polarized debate. It is an issue that is politically and emotionally charged, involving aspects of multiple social sectors. It is impossible to discuss healthcare for these immigrants without also considering issues of economic stability, legal relevance, social justice and education.

While the Universal Declaration of Human Rights boldly asserts that all human beings deserve proper healthcare, there is no global policy or “police” to ensure that all people receive such care. To further complicate matters, national instability raises concerns of government allocations and often raises an “us versus them” mentality. 

Have suggestions for additional content that looks at the ethical issues surrounding undocumented immigrants and healthcare? Let us know: This installment of "Ethical Inquiry" was researched and written by Kathleen Rees ’10. Kathleen was a 2009 Sorensen Fellow and is currently pursuing an MD/MPH with a focus in global medicine and community health. Read her reflections on her Sorensen Fellowship working on issues of healthcare in rural Peru [PDF]. Read her earlier Ethical Inquiry, “Is ‘Ethnic Modification’ Surgery Ethical?”