Five months ago, the Journal of the American Medical Association (JAMA) published an editorial entitled “Can Physicians Work in US Immigration Detention Facilities While Upholding Their Hippocratic Oath?” (Spiegel, Kass and Rubenstein, JAMA online August 30, 2019). This article generated a lot of interest and comment in the lay press. As just one example, NBC News wrote “Medical care for detained migrants violates doctors’ oath, says physician in JAMA commentary.”
As you will remember, there was a lot of media coverage at the time about reported inhumane treatment of migrants, especially children, in US detention facilities. Many of these migrants were seeking asylum and were detained pending court hearings. Many children were detained apart from their parents or guardians. This article stated that the Immigration and Customs Enforcement (ICE) facilities were “overcrowded” and “existing standards for conditions of confinement are often not met.” The article stated that “Children should not be detained for immigration reasons, at all, according to numerous professional associations . . .” I have no argument with any of this.
But then, the authors turned next to disparage the physicians (and other health care professionals) who work in these facilities. These physicians have “a responsibility to provide the highest standard of care to detained children.” And should “advocate for improved conditions.” This is absolutely right! And I am sure that they do!
However, the authors note, “Currently, all DHS employees, consultants and subcontractors are required to sign nondisclosure agreements” that create a problem of “dual loyalty,” meaning (I guess) that loyalty to the “system” of incarceration would take priority over providing medical care to patients in these facilities. The authors ask how can physicians can uphold their Hippocratic Oath while working where there are “reports of inhumane, overcrowded, and unsanitary conditions?” The clear implication is that they can’t; the physicians working in these facilities are violating their Hippocratic Oath simply by being there.
The authors propose utilizing “clinicians who are neither employed by the government nor by a government-contracted company whose employees lack complete clinical independence . . .” They don’t say how this would work. I assume it means bringing an international organization like Doctors Without Borders into US Detention Facilities.
Now I understand that the entire immigration issue is a political “hot button” issue and I don’t want to over-politicize my response. However, as I read this article, I was struck by these thoughts:
“Dual Loyalty” is an important insight and, indeed, can result in inferior medical care. However, Dual Loyalty does not just exist in correctional facilities. As one example, for-profit hospitals often demand loyalty from their physicians to the hospital and brand and will punish physicians who fail to demonstrate “appropriate” loyalty. I have seen it! This is a subject for a much larger discussion than was done in this article.
However, Dual Loyalty is not the main issue here—not by a long shot. The single most important consideration at these facilities is the juvenile patients who desperately need medical care. Who is going to provide this for them?
Consider two physicians who want to help these needy kids. When presented with a nondisclosure agreement, the first physician says “No! I won’t sign!” and subsequently is not allowed access to the children housed inside the detention center. The second says, “You know, these kids with medical needs are more important than my speaking to the press.” She signs the non-disclosure agreement, and begins to work full time (and more!) among these displaced and indigent children, many with serious medical needs. Now you tell me who may have violated their Hippocratic Oath!
Also, the idea that the United States under this administration (or any administration, for that matter) would relinquish medical authority in its Federal detention facilities to an independent entity strikes me as being jaw-droppingly naïve. It will never happen! Let’s look for solutions to problems within our correctional facilities in ways that potentially could happen.
Finally, I am disappointed that the authors (who have never worked themselves in a correctional facility) would throw the health care professionals who do provide care for the immigrants at these facilities under the bus. Remember please that these physicians, nurses and other health care professionals could make far more money and receive far more prestige working elsewhere than they could helping the children in US immigration detention facilities. They are fighting the good fight and I am grateful for them. They are making these kids’ lives a little better by being there.
As always, what I have written here is my opinion, based on my training, research and experience. I could be wrong! If you think I am wrong, please say why in comments.
This article was first published in MedPage Today.