Ethical to report illegals?

[gtb]

Is it ethical to report patients that are in the US illegally?

I'm interested in an ethical discussion. I'll state up front that I'm not a bleeding heart kind of doc willing to watch American medicine destroyed so we can be health care to the world.

Let the flames begin.

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[southerndoc]

I think our oath of "first do no harm" doesn't allow us to report illegal immigrants. If we reported them, then those that are truly sick might not seek medical attention. As a physician, it's my responsibility to take care of the good, the bad, and the illegal.

 

[gtb]

If harm is the issue, then the balance of resources becomes an issue. For example, itraconazole is a great antifungal, especially good for chronic necrotizing Aspergillus pneumonia, allowing much lower daily doses of steroids. Without itraconazole, patients end up chronically taking higher dose steroids. However, itraconazole is is too expensive to be formulary for some hospitals treating excessive numbers of uninsured. Since many uninsured are illegal aliens, one logical conclusion might be that illegal aliens are inducing harm by preventing the use of the best medications for some patients. So, by allowing treatment of illegal aliens, we are indirectly harming patients?

"I will apply, for the benefit of the sick, all measures which are required, but above all I will strive to do no harm."

The way I read it is that one should not perform a medical treatment this might create harm. By law some states require you to report patients that have conditions that make driving dangerous. Seizures for example. But these individuals might not be able to work, or even make it to the grocery store if they can't drive. Is it also unethical to report them to the state?

 

[GopherBrain]

Not only that, I call the law every time a patient admits using illegal drugs. I call wives if a husband comes in with an STD. Hell, I'm the doc, I set the moral standards. If they don't like it, they don't need my care.

 

[AJM]

For example, itraconazole is a great antifungal, especially good for chronic necrotizing Aspergillus pneumonia, allowing much lower daily doses of steroids. Without itraconazole, patients end up chronically taking higher dose steroids. However, itraconazole is is too expensive to be formulary for some hospitals treating excessive numbers of uninsured. Since many uninsured are illegal aliens, one logical conclusion might be that illegal aliens are inducing harm by preventing the use of the best medications for some patients. So, by allowing treatment of illegal aliens, we are indirectly harming patients?

I don't mean to be a ninny, but I believe you are talking about ABPA, not necrotizing (aka invasive) Aspergillosis. One does not treat invasive Aspergillosis with steroids, but you can treat ABPA with them. It's also pretty uncommon, and primarily an outpatient disease, so probably not the best example of distribution of resources.

It does raise the issue of the difficulty in treating any uninsured patient on an outpatient basis, though -- if I wanted to give an uninsured patient itraconazole for ABPA, for example, they would have to go to an outpatient pharmacy and pay $1000 of their own money for a month's supply. No one who's uninsured can afford that, so therefore I would not be able to treat them with itraconazole.

Carry on.

 

[Anasazi23]

Not only that, I call the law every time a patient admits using illegal drugs. I call wives if a husband comes in with an STD. Hell, I'm the doc, I set the moral standards. If they don't like it, they don't need my care.

I've always been tempted to do this. I know there are more subtle complexities, but the majority of the patients I see in the ER (I'm psychiatry resident) have (+) utox's.

In an example where a patient admits they've murdered someone, or if a child with a suspicious injury comes in, we're obligated to report it. However, the use of heroin, last time I checked, is illegal, even here in NY city. Now I just ask the questions I feel like asking..."how do you pay for your $2000 a day heroin habit?" The answer most often is either "don't worry about it," or "stealing, mugging, selling other drugs, auto theft, etc," Why can we not report this? From a behavioral standpoint, we're simply reinforcing unbelievably wrong and unethical behavior (treating and retreating and retreating the patient who has self-inflicted leg cellulitis from shooting.)

Alas, I don't see change any time soon.

 

[gtb]

Not picky at all, I should have used an example I'm more familiar with than one I know little about. Thank's for the correction. Instead consider another example: propofol vs. thiopental as an anesthesia induction agent. The local county hospital uses almost exclusively thiopental because it's so remarkably inexpensive compared to propofol, but leaves patients with a not so insignificant hangover after surgery.

 

[gtb]

Not picky at all, I should have used an example I'm more familiar with than one I know little about. Thank's for the correction. Instead consider another example: propofol vs. thiopental as an anesthesia induction agent. The local county hospital uses almost exclusively thiopental because it's so remarkably inexpensive compared to propofol, but leaves patients with a not so insignificant hangover after surgery.

 

[doc05]

Is it ethical to report patients that are in the US illegally?

I'm interested in an ethical discussion. I'll state up front that I'm not a bleeding heart kind of doc willing to watch American medicine destroyed so we can be health care to the world.

Let the flames begin.

reporting their status is unethical. Physician-patient confidentiality protects this.

 

[doc05]

I've always been tempted to do this. I know there are more subtle complexities, but the majority of the patients I see in the ER (I'm psychiatry resident) have (+) utox's.

In an example where a patient admits they've murdered someone, or if a child with a suspicious injury comes in, we're obligated to report it.

Obviously you're a mandated reporter for suspected child abuse. But I don't think you can ethically report a patient's having told you he's murdered someone. As far as I recall, Tarasoff requires you to report a patient if they are about to committ a dangerous/criminal act. Since it's in the past tense, it's priviledged communication.

 

[gtb]

reporting their status is unethical. Physician-patient confidentiality protects this.

This is a good point, but in my mind physician-patient confidentiality is more of a legal concept than an ethical concept. Certainly I would never report 99% of the goofy things you hear from patients, but if a patient told me he molested his daughter, I'm calling social services. If a patient told me he was wanted for murder, and I knew it to be true, I'm calling the police. Yes the oath I took says, "I will respect the sanctity of the patient-physician relationship, keeping those confidences entrusted to me." The same oath also says, "I will speak out when silence is wrong." Maybe the ethical conclusion is a result of whether an individual feels that illegal Mexican patients are creating harm for patients legally in the US.

Given that Mexican physicians are every bit as talented as American physicians, I do not believe that deportation will harm the patient in any way, provided of course all emergent conditions are adequately treated and stabilized.

The original Oath of Hippocrates says, "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." So another question is, what knowledge should be secret and what is fairly revealed?

 

[bts4202]

If you start reporting people for illegal immigration, then people will stop coming to the hospital when they are sick. They will stop being honest with doctors for fear or retribution. How effective is patient care then?

What happens when Jose decides that instead of seeing a doctor about this cough he has had for 3 months and risk deportation, he takes robotussin and wonders around the city with a nasty case of TB for another few months, "sharing the wealth" with everyone in the community?

What happens when Carlos notices a sore on his penis and is too scared to see a doctor about it and ignores it?... it goes away after a little while and he forgets all about it. he then sleeps with a few more women and spreads his syphillis around the community. Its not till he ends up dead or psychotic that it comes to everyones attention that he could have been saved with a measly single dose of pennicilin and now the public health department has to spend loads of money tracking his sexual history and map out where this syphillis could have been passed along to.

How about someone running around hepatitis untreated? How about AIDS? How about the kids? What if an illegal won't bring their kids in for checkups and immunizations cause they are scared of being deported? Those kids, if born here, are american citizens. Now what happens if you deport dad or mom or both? Do the kids stay and are orphaned? Do we also essentially kick out an american citizen just because they came to you to get health care?

What about pregnan women? Should they have to risk having a baby alone and risk death of themselves or their baby cause they are too terrified of going to a hospital and being deported? Should they be forced to risk creating fistulas and all the other non-fatal risks of delivery just cause the doctor may call the police on them? Should women try to have abortions at home with coat hangers again cause they are scared of the doctors?

yeah, i think we should preserve doctor patient confidentiality.

 

[Apollyon]

This is a good point, but in my mind physician-patient confidentiality is more of a legal concept than an ethical concept. Certainly I would never report 99% of the goofy things you hear from patients, but if a patient told me he molested his daughter, I'm calling social services. If a patient told me he was wanted for murder, and I knew it to be true, I'm calling the police.

It doesn't matter what it is in your mind. Go ahead and do these things. Sure, there's crime there. However, do NOT be surprised - one bit, at all - when your license gets pulled (and not just suspended - revoked). It WILL happen.

 

[Anasazi23]

Obviously you're a mandated reporter for suspected child abuse. But I don't think you can ethically report a patient's having told you he's murdered someone. As far as I recall, Tarasoff requires you to report a patient if they are about to committ a dangerous/criminal act. Since it's in the past tense, it's priviledged communication.

Indeed you're correct in a sense. The simple knowledge that a physician possess of a felony committed by a patient is not reason enough to report said knowledge That said, Tarasoff deals with specific credible threats to known and specific parties. Like a poster mentions above, certain crimes, though past tense, are reportable (abuse). Even if it werent, I have to think that I'm going to think for myself, and call appropriate authorities when I feel I must - I really don't give a damn about HIPAA or any other beaurocratic organization created by lawyers to constrain my own natural code of ethics.

I mean let's use our brain people. If you're mandated to report child abuse, why are you not mandated to report murder?

If a family member of yours was murdered, would you want some physician to sit on that knowledge while scores of people searched and hundreds of thousands of dollars were spent on the recovery effort, not to mention taking dozens of police off the streets?

I'd find a way to do it without losing my license.

 

[doc05]

I mean let's use our brain people. If you're mandated to report child abuse, why are you not mandated to report murder?

because (1) the criminal acts are ongoing, and you've every reason to believe it will happen again; and (2)the victims are minors, you must act in their best interest, which means reporting to the authorities. Remember domestic abuse is not reportable, since the victims are adults and hence can decide whether to report on their own.

Though it doesn't sit well with me either, you cannot simply report a criminal act that a patient tells you about, except in certain exceptional circumstances and generally under subpoena. Otherwise doctor-patient confidentiality goes out the window. Remember how history is 90% of the diagnosis? -- there goes the 90%.

 

[docB]

Given that Mexican physicians are every bit as talented as American physicians, I do not believe that deportation will harm the patient in any way, provided of course all emergent conditions are adequately treated and stabilized.

Mexican physicians are better than American physicians because they are products of a morally superior third world country that is not tainted by the self important paternalism and decadence of capitalism. The only reason that the Mexican system can not deliver better care than the American system is that they are under the thumb of the imperialist jingoism of the United States. Ultimately the only way to bring true justice to the people of the third world is to completely socialize the entire economy of the US and redistribute all of that ill gotten wealth. The current administration and Halliburton are minions of Satan and must be tried in The Hague for war crimes and crimes against The World.

 

[docB]

How about the kids? What if an illegal won't bring their kids in for checkups and immunizations cause they are scared of being deported? Those kids, if born here, are american citizens. Now what happens if you deport dad or mom or both? Do the kids stay and are orphaned? Do we also essentially kick out an american citizen just because they came to you to get health care?

This is a good point. What we really need is to eliminate the gift of citizenship that is bestowed upon the child of any illegal that can manage to be north of the border when the water breaks. I suggest changing the rules so that citizenship requires at least one parent in the US legally.

Ultimately we must remove this issue from the arena of medicine and keep it in the justice and immigration systems. For the time being our only role will be to dispense free care without protection from liability.

 

[medlaw06]

Mexican physicians are better than American physicians because they are products of a morally superior third world country that is not tainted by the self important paternalism and decadence of capitalism. The only reason that the Mexican system can not deliver better care than the American system is that they are under the thumb of the imperialist jingoism of the United States. Ultimately the only way to bring true justice to the people of the third world is to completely socialize the entire economy of the US and redistribute all of that ill gotten wealth. The current administration and Halliburton are minions of Satan and must be tried in The Hague for war crimes and crimes against The World.

here we go....let the flood gates open....

 

[southerndoc]

Mexican physicians are better than American physicians because they are products of a morally superior third world country that is not tainted by the self important paternalism and decadence of capitalism.

Right. Isn't it the greed of the Mexicans desiring to "live the American dream" that is driving the illegal immigration to the US?

 

[Anasazi23]

because (1) the criminal acts are ongoing, and you've every reason to believe it will happen again; and (2)the victims are minors, you must act in their best interest, which means reporting to the authorities. Remember domestic abuse is not reportable, since the victims are adults and hence can decide whether to report on their own.

Given the severity of the crime, and the recidivism rates for murder and rape (since you correctly point out that in child abuse, the abuse is ongoing), I'll take my chances on the anonymous letter to the cops.

If if was your husband/wife/whatever, you'd want the same.

 

[Retinamark]

yes - report them

 

[bts4202]

hello? Off topic...

Murder is not quite the same thing as illegal immigration... wouldn't you agree?

 

[hans19]

The same oath also says, "I will speak out when silence is wrong." Maybe the ethical conclusion is a result of whether an individual feels that illegal Mexican patients are creating harm for patients legally in the US.

Given that Mexican physicians are every bit as talented as American physicians, I do not believe that deportation will harm the patient in any way, provided of course all emergent conditions are adequately treated and stabilized.

Since when did illegal come to mean illegal Mexican? Why not an illegal Canadian? Or Ukranian?

BTW, how can you tell a Mexican or anyone else is illegal in the first place? By the way he/she looks? Your post wreaks of xenophobia.

Let the flames begin.

 

[toughlife]

Since when did illegal come to mean illegal Mexican? Why not an illegal Canadian? Or Ukranian?

BTW, how can you tell a Mexican or anyone else is illegal in the first place? By the way he/she looks? Your post wreaks of xenophobia.

Let the flames begin.

Because americans can easily identify with an immigrant of european descent so that keeps them from calling white illegal immigrants "illegal". It is easier for them to look at a mexican and call him an illegal.

 

[hans19]

Is it ethical to report patients that are in the US illegally?

I'm interested in an ethical discussion. I'll state up front that I'm not a bleeding heart kind of doc willing to watch American medicine destroyed so we can be health care to the world.

Let the flames begin.

Funny how we physicians complain about how much paper work there is in medicine today. We complain that its not my job to be a social worker. It appears that some of us would jump at the chance to be an INS officer.
Last time I checked, the biggest threats to healthcare it was the insurance lobby and malpractice gone awry.

I will most certainly report suspected cases of child abuse, or a patient who threatens to hurt himself or others. But otherwise, doctors supposedly have a priveleged relationship with their patients. Patients need to be able to trust their doctors about all kinds very private information, not just pertaining to their health.

We certainly don't NEED to be health care to the world. But we can be healthcare to those in need in our own back yard, regardless of background.

We don't NEED to be health care to the rest of the world... but is it wrong to give medical aid to third world countries in need?
Are you tired of Tsunami victims bleeding us dry?

If you have problems for America providing healthcare to the rest of the world, do you have problems with the US being a police officer for the rest of the world?

'Let the flames begin'

 

[tonem]

Because americans can easily identify with an immigrant of european descent so that keeps them from calling white illegal immigrants "illegal". It is easier for them to look at a mexican and call him an illegal.

What about Americans that easily identify with Mexicans?

What happens when Ian or Sean or Gunter or Igor go around spreading plague and pesitilence because the'yre afraid of being deported...or is it just Carlos and Juan we're worried about?

 

[DrBowtie]

Ukrainians can't hop across a 4 foot fence and be in America.
It is natural to assume that most illegals are Mexican or Canadian since they have the easiest route to get into America.

 

[toughlife]

Ukrainians can't hop across a 4 foot fence and be in America.
It is natural to assume that most illegals are Mexican or Canadian since they have the easiest route to get into America.

very easy for europeans to get on a plane and come to america since many european citizens (at least from western europe) can hop on a plane and come to the US without a visa. All they need is to fill out the I-94 arrival/departure form while en route and voila!

For your credit, I do agree that among hispanics, mexicans make up the highest # of illegal aliens.

 

[allendo]

Well I from the great state of Texas! And a long long time ago we won the state from the mexicans, but apparently somewhere along the way the snuck back up on us. One day when I was teaching a group of hispanic children reproductive biology in a sheltered class(english deficient)(b/c they just swam across) they asked me if teenagers should be having babies??? I stated they should only have them if they can pay for them, and they said "Pay for what babies are FREEEEEEEE" What???? "Babies and doctors are FREEEEEEEE". Oh yeah that's why I'm going 100k in debt to deliver foreign illegal immigrants. Could I go to Mexico and get free medical care, I doubt it. I used to work at a hospital and the illegals would come in speaking zero english. But guess what they had a freakin medicaid card. Wait, they did know one word "Medicaid". What a convenient word to learn first, I wonder if Pedro taught them that one while they were in the desert. Now don't get me wrong I'm all about humanity. But they laws of nature will prevail every time. Thats why we have hunting seasons to make shure the population in a given area is controlled. If we keep letting them come across without making them pay for $hit! Where in the hell are we going to end up. They get better care than most Americans, the system is screwed up. They do help they agriculture system by harvesting products but we must have a limit on how many hop on over.

 

[edinOH]

Mexican physicians are better than American physicians because they are products of a morally superior third world country that is not tainted by the self important paternalism and decadence of capitalism. The only reason that the Mexican system can not deliver better care than the American system is that they are under the thumb of the imperialist jingoism of the United States. Ultimately the only way to bring true justice to the people of the third world is to completely socialize the entire economy of the US and redistribute all of that ill gotten wealth. The current administration and Halliburton are minions of Satan and must be tried in The Hague for war crimes and crimes against The World.

My thoughts exactly. I feel so guilty for just being an american.

 

[allendo]

My thoughts exactly. I feel so guilty for just being an american.

I understand the Hallburton stuff, but the other? Really? Are you smoking crack? Every country has their problems and we can't solve them, look at Iraq.

 

[docB]

My thoughts exactly. I feel so guilty for just being an american.

Do you know that you're the first person who got the joke.

 

[MeganRose]

Is it ethical to report patients that are in the US illegally?

I'm interested in an ethical discussion. I'll state up front that I'm not a bleeding heart kind of doc willing to watch American medicine destroyed so we can be health care to the world.

Let the flames begin.

I agree with your sentiment in that I think that US taxes should be used for the care of US citizens. And I am a bit annoyed that I did without health insurance while other people without citizenship could walk in get treated. Still, I think that whoever made the point about malpractice and managed care causing a huge drain on the system is absolutely right. We're not INS officials-- the only thing that can resolve the problem is a change in policy. I cant help but wonder how ethical it is to play minuteman border patrol when we're supposed to be taking care of the patient.

btw-- I agree with you on the STD reporting. Hypocritical or unethical, I just couldnt live with myself if a patient blatantly refused to tell his mate and I did nothing to help his innocent mate--

 

[Anasazi23]

I feel like people are missing a fundamental underlying principle about this discussion. Some are quick to say that despite people's wrongs, there is a physician-patient privilage that is sacred, and that healthcare should be delivered without prejudice.

However, to go back to the rape/murder example, what about the healthcare of the victim? Which is worse: Heal a murderer or rapist to offend again while keeping silent, or heal and report that person, so that the SOB can stand trial for the harm in health and destruction of lives he has brought onto others?

I feel it's too simplistic to hang onto the "physician-patient privilage" argument without considering confounding factors.

P.S. Has anyone seen that expose cable that showed how Mexicans can come into the US illegally? There are literally miles of unpatrolled border with trails and nothing but a rickety chicken fence protecting the border, which is, of course, cut open for even easier access.

Here's the guide to illegal immigration. It's apparently real. I like the part that tells you not to hit your wife or girlfriend, because it could cause you to get deported to Mexico.

 

[allendo]

I feel like people are missing a fundamental underlying principle about this discussion. Some are quick to say that despite people's wrongs, there is a physician-patient privilage that is sacred, and that healthcare should be delivered without prejudice.

However, to go back to the rape/murder example, what about the healthcare of the victim? Which is worse: Heal a murderer or rapist to offend again while keeping silent, or heal and report that person, so that the SOB can stand trial for the harm in health and destruction of lives he has brought onto others?

I feel it's too simplistic to hang onto the "physician-patient privilage" argument without considering confounding factors.

P.S. Has anyone seen that expose cable that showed how Mexicans can come into the US illegally? There are literally miles of unpatrolled border with trails and nothing but a rickety chicken fence protecting the border, which is, of course, cut open for even easier access.

Here's the guide to illegal immigration. It's apparently real. I like the part that tells you not to hit your wife or girlfriend, because it could cause you to get deported to Mexico.

Exactly my point, that's why I'm glad to see the citizens of Arizona starting to patrol the boarders themselves!

 

[oompaloompa]

since other Texans brought up the serious immigrant healthcare problems, I thought I would throw in my .02 too. here in Houston, the county hospitals are simply deluged with hispanic immigrants(I say hispanic and not Mexican because they also come from Honduras, Guatemala, El Salvador, etc....) Predictably, the departments that are hardest hit are Ob-gyn and pediatrics. Generally, about 80% of Ob-gyn patients are Hispanic and only about 10-15% of those can speak English. We don't specifically know, but it's assumed most are illegal.(and no, we don't assume every hispanic patient is an illegal, we know this is Texas after all) In pediatrics, we have what's called the "sibling special." Even if only one child is actually sick, all 7-8 of the siblings are brought in as well, because, after all, it doesn't cost anything extra. I particularly love it when the sibling groups come to the pediatric ER, because what the American health system needs is $1200 worth of ER visits (cost before doctor sees them) on perfectly healthy kids.

However............
I do feel the need to point out some very powerful motivation for these immigrant patients. All too often, we've received kids that can be called nothing less than victims of Mexican healthcare. Horrible post-surgical abscesses from simple procedures like appendectomies, mutilating scars from "surgeons" giving questionable procedures in the first place. One woman had been given regular antibiotic shots for her lupus. Honestly, people. Many ob-gyn patients we've recieved made a mad dash to the border because of horror stories related to the Mexican healthcare system. I know it has been mentioned in this forum that Mexican doctors are just as good as American doctors. I will have to respectfully disagree. While I am sure there are many excellent physicians in Mexico and other 3rd world countries, there are no levels or standards in place. ON THE WHOLE the level of care for the average citizen is poor. It is a very unfortunate situation and I have great pity on those just want what's BEST for their children, and lets face it: the BEST(no contest) care 'round these parts is AMERICAN care. So I think its best that we do what we can to keep up the benevolence as much we can without it hurting our own citizens. But make no mistake, that's what it is, BENEVOLENCE, not duty.

 

[gtb]

Since when did illegal come to mean illegal Mexican? Why not an illegal Canadian? Or Ukranian?
BTW, how can you tell a Mexican or anyone else is illegal in the first place? By the way he/she looks? Your post wreaks of xenophobia.

Well . . .
Technically xenophobia would include both a fear of Mexicans, along with a fear of Canadians and Ukranians. A specific racist bent however might include only Mexicans. In my case, you are quite right that my concern is illegal Mexican nationals occupying beds in the hospital. In Denver this is (and has been) an overwhelming issue, not just because of unrecovered costs, but also because of bed availability in the MICU, SICU, NICU, and even the general wards. Not just a hypothetical problem, but at times, an honest to goodness lack of space for American citizens and legal residents.

As for identification, check out the identification section of the online medical records. If a legal resident, inevitably there will be a social security number in the patient identification section. For illegals, there is sometimes a SSN, so it doesn't help identify them. But given the patient is SSO, and there is no SSN, you begin to wonder. So, I frequently ask whether they are able to access the indigent health care programs available for legal residents. If the answer is no, then I tell them about the programs that are available for illegal Mexican nationals. Then I ask whether they are interested in getting more information about these programs. If the answer is yes, then my conclusion is that the patient is in the US illegally. Is it 100% specific? No. Does it convence me? Yes.

However the topic of my interest i, "exactly how does reporting illegals violate medical ethics?" Remember, if one patient suffers because of another patient's criminal activities, then the issue of ethics becomes more complicated. And I have seen legal residents suffer by delayed care. So am I obligated by medical ethics to report illegal aliens to diminish the rish of harm to other patients?

 

[doc05]

Well . . .
However the topic of my interest i, "exactly how does reporting illegals violate medical ethics?" Remember, if one patient suffers because of another patient's criminal activities, then the issue of ethics becomes more complicated. And I have seen legal residents suffer by delayed care. So am I obligated by medical ethics to report illegal aliens to diminish the rish of harm to other patients?

Interesting take on this issue. The "harm" in this case is too much of a stretch and is not directly attributable to the patient's illegal immigrant status. After all, legal residents suffer "delayed care" any time the ED is busy -- busy because there are lots of sick patients (illegal or not is irrelevant).

If the "illegals" had green cards, would that make them any less sick? Of course not; they would still be in the ED, and the others would still "suffer" delayed care.

I'm still awfully curious as to why you'd ever want to report the illegals, anyway. Are you a physician or an INS official?

 

[docB]

This thread has brought up an interesting and important question. How much duty does an individual physician have to the "public good" at the expense of a patient. Before Tarasoff there was none. That is why Tarasoff was so shocking to the docs around when it came down (Tarasoff was the court decision that said you have to tell someone if a pt plans to kill them). We all grew up with it so we are used to the idea that the doctor pt relationship has limits. As the health care system continues to crumble doctors are going to be forced, more and more, to be agents for the system in terms of rationing, exclusion and so forth. For an example see the thread on the EM board "Trouble on the EM Horizon" that talks about excluding nonemergent patients from the ER. I'm not in favor of all this but it's coming and sooner than we think.

 

[hans19]

Well . . . A specific racist bent however might include only Mexicans.

Then consider yourself a racist.

GTB, things must be different in Colorado, where apparently all Mexicans are illegal.
I'm a Texan. Where I'm from, there are many new immigrants from Mexico. But there are also many Mexican-Americans that have been here for generations-- long before my family got here.

Heck, even some of my best friends growing up were 'Mexicans'. You don't need to tell me what I do and don't need to know about Mexicans.


BTW Are you a doctor or vigilante first?

If a guy comes in bleeding to death after a shoot out with cops do you refuse to treat him? Earlier in my training, I treated prisoners, some of which were known to me to be rapists and murderers. I have also treated other physicians, priests, soccer moms... you name it.
I don't ask my patients to prove their worth to me before I treat them.
I wear white coat to work, not a black robe. As a doctor, its not my duty to judge people. I hope some day you can learn to do the same.

 

[gtb]

Then consider yourself a racist.

Ah. First I'm a xenophobe. Then a racist. Please make up your mind, xenophobe, racist, maybe both? I'm so far beyond concern for somebody blindly labeling me anything, including a racist. You have, on first glance at least, seemed to run out of logical gas, and thrown out the 'R' word. Part of the question I proposed is in fact suppose to evoke a discussion of our role as physicians. Like it or not, I am an MD. Part of my role as an MD, as I see it, is to explore the changing dynamics of medicine in our society.

My interest is in ethical and philosophical discussion. You're throwing around epithets is not a productive strategy for engaging other physicians in exploring this challenging issue.

 

[hans19]

Ah. First I'm a xenophobe. Then a racist. Please make up your mind, xenophobe, racist, maybe both?

My interest is in ethical and philosophical discussion. You're throwing around epithets is not a productive strategy for engaging other physicians in exploring this challenging issue.

On the contrary, I have been engaging you in a 'philosophical' discussion. I make the following assertions:
1. YOU are a racist-- by your own admission. See your previous post.
2. By your line of reasoning we should refuse to treat criminal (illegal aliens) because spending resources treating criminals is compromising care for citizens and legal residents. This is flawed reasoning.


1. You are singling out a single ethnic group Mexicans, and categorically calling them illegals, seems racist to me. You have made a blanket assumption about an entire group of people. That is racist.

2. Please clarify your view. First you assert that it reporting a crime commited by a patient is more important than respecting the doctor-patient relationship. Do you realize that this is a breech of trust which may dissuade the person from seeking medical attention in the future?

In your subsequent posts, you begin to say that caring for criminals (in this case illegal immigrants) is compromising care for citizens and residents. Treating criminals is then wrong because it takes away from the level of care that citizens and residents will receive.
The next step in your line of reasoning is to refuse to care for criminals, or 'illegal Mexicans' as you state.

Do I understand you correctly? You would rather treat a patient based on their citizenship or by their legal standing in society than based on a patients medical need? If a person was seriously injured in a car accident, you would rather not treat them if they were in this country illegally, because treating them compromises care for citizens?

By extension, would you refuse to treat a prisoner? By your reasoning are you asserting that a person that has broken the law is less worthy of medical treatment, regardless of his level of need- which I find objectionable.

You say devoting resources to noncitizens and nonresidents compromises the benefits receieved by our own citizens, and is thus wrong.

Do you feel that giving aid to non-citizen Tsunami victims was a bad idea? After all, that money that went to Tsunami victims could have been spent on US citizens?

As far as compromise of care goes, what you fail to realize is that the rich citizens in this country will always have the best health care, regardless of how many Mexicans immigrate (legally or illegally). The working poor in this country (This includes illegal aliens as well as poor citizens) will continue, for the forseeable future, receive substandard health care. This is regardless of the number of Mexicans that immigrate to this country. Does the fact that there are less illegal aliens in the country make the heart failure drugs, statins, and anti rheumatic drugs any more affordable for the poor elderly?

I have said before, our biggest problems as doctors are medical malpractice and the insurance industry nickel and diming us.

As far as the patient end perspective, Mexican immigrants will not the affect the level of care rich citizens receive. Poor citizens will have substandard care because they can't afford it, more so than competition for health care services by 'illegals'. Besides, I hope that as a doctor, your decisions to render care will be based on a patients level of need rather than their citizenship or legal status (criminals).

Yes, you are an MD and I am engaging you in a debate.

 

[ERMudPhud]

Well . . .
In Denver this is (and has been) an overwhelming issue, not just because of unrecovered costs, but also because of bed availability in the MICU, SICU, NICU, and even the general wards. Not just a hypothetical problem, but at times, an honest to goodness lack of space for American citizens and legal residents.

As for identification, check out the identification section of the online medical records. If a legal resident, inevitably there will be a social security number in the patient identification section. For illegals, there is sometimes a SSN, so it doesn't help identify them. But given the patient is SSO, and there is no SSN, you begin to wonder. So, I frequently ask whether they are able to access the indigent health care programs available for legal residents. If the answer is no, then I tell them about the programs that are available for illegal Mexican nationals. Then I ask whether they are interested in getting more information about these programs. If the answer is yes, then my conclusion is that the patient is in the US illegally. Is it 100% specific? No. Does it convence me? Yes.

However the topic of my interest i, "exactly how does reporting illegals violate medical ethics?" Remember, if one patient suffers because of another patient's criminal activities, then the issue of ethics becomes more complicated. And I have seen legal residents suffer by delayed care. So am I obligated by medical ethics to report illegal aliens to diminish the rish of harm to other patients?

I was going to ignore this whole thread until I saw you using Denver as an example. Denver is hardly drowning under a deluge of illegal aliens. I've worked at most of the hospitals in town including Denver Health and University. Sure DH and University have started turning away uninsured but even most of those aren't even hispanic much less illegal. Go ask the administrators at DH or university how much uncompensated care they are actually providing to illegals. Both institutions have significant losses from treating the uninsured but I'd like to see statistics documenting what percent of that is from illegals before you start claiming that the illegals are reducing care for citizens. Despite these losses both institutions are doing well enough to fund large new additions recently. Most of the hospitals in town have empty beds because they won't hire enough nurses to staff them and one hospital closed entirely for lack of business so its not like tax-paying American citizens are sitting on the curb waiting for a bed to open up.

So, back to your hypothetical illegal alien detection algorithm. Assuming you do this, very quickly the word will spread amongst the illegals that if you admit you need a referal to programs set up for the illegals you wil be deported. Now your system will result in the harm of hundreds if not thousands of illegals (including their kids) who will be afraid to avail themselves of charitable services set up for them. Using your own utilitarian arguments your decision to deport one illegal has harmed thousands of patients

A second more personal negative result will be the inevitable hispanic patient who will be offended by your labeling them illegal and report you to the state medical board. I suspect that the Colorado medical board would frown on your hobby as an INS agent.

Is it ethical to report illegals? I guess your conscience will have to decide but don't rationalize your xenophobia (or whatever) using a rather dubious utilitarian argument that you are making things better for citizen patients.

 

[ERMudPhud]

And I am a bit annoyed that I did without health insurance while other people without citizenship could walk in get treated.

Actually, without insurance you could "walk right in and get treated" like anyone else who lacks insurance legal or illegal. In fact if you were in Colorado and uninsured you would qualify for a number of services and referrals that illegals couldn't get. Illegals generally get only treatment and stabilization of emergent conditions. You would be surprised how little that entails. Illegal dialysis patients get dialyzed only every few weeks when they are so acidotic, hyperkalemic or fluid overloaded that they can barely live. Cancer patients might get their hypercalcemia or other life threatening complication treated but they rarely get chemo. There was a famous case in Denver a few years back where the community raised hundreds of thousands of dollars for treatment for a young girl with cancer after Childrens refused to give her definitive treatment. I'm not saying these institutions are wrong to deny all but the most emergent care but don't assume that the illegals are getting the best we have to offer or even what we might consider standard of care. These observations are somewhat state dependent. While working in NYC I saw illegals getting everything up to and including transplants.

 

[AlternateSome1]

because (1) the criminal acts are ongoing, and you've every reason to believe it will happen again; and (2)the victims are minors, you must act in their best interest, which means reporting to the authorities. Remember domestic abuse is not reportable, since the victims are adults and hence can decide whether to report on their own.

Though it doesn't sit well with me either, you cannot simply report a criminal act that a patient tells you about, except in certain exceptional circumstances and generally under subpoena. Otherwise doctor-patient confidentiality goes out the window. Remember how history is 90% of the diagnosis? -- there goes the 90%.

Title 18 U.S.C. § 4 Misprision of felony. Whoever, having knowledge of the actual commission of a felony cognizable by a court of the United States, conceals and does not as soon as possible make known the same to some judge or other person in civil or military authority under the United States, shall be fined not more than $500 or imprisoned not more than three years, or both.

You should, therefore, report murders and other felonies or risk 3 years in jail.

 

[MeganRose]

ERMudPhud--
My senior year of college in NC, I didnt have health care and I went to the ED bc I was having really bad ab pain. From one visit 4 hr visit, I received a dx of IBS and bills that I only just two years ago finished paying off. Could I have qualified for a program? Maybe. But I dont feel right making someone else pay for a bill that I incurred. Maybe more my problem than theirs, but I guess my biggest problem is the ease with which some people (illegals and not) use these services and view them as a right, not a privilege... Anywho, I am originally from Denver (Centennial) and I have to agree with you-- Denver definitely isn't drowning under illegals. A visit to San Antonio where I'm at might give him some perspective.

At any rate, I still say there is no true ethical dilemma. We were tasked with patient care-- not policing the patient population. When a physician begins to police as gtb suggests, I think the real ethical dilemma is the time lost that the dr spent trying to figure out if a particular patient was legal (and the inevitable judgements that could affect the level of care that patient receives) as well as the time spent calling INS. Granted, this is just my 3rd yr of medical school, but it seems that there are a million different other things related to patient care that should be occupying one's time. If one feels so passionate about this issue I think that it makes more logical sense to pursue it on a legislative/activist level instead of making unilateral decisions about reporting practices...

 

[pseudoknot]

Title 18 U.S.C. § 4 Misprision of felony. Whoever, having knowledge of the actual commission of a felony cognizable by a court of the United States, conceals and does not as soon as possible make known the same to some judge or other person in civil or military authority under the United States, shall be fined not more than $500 or imprisoned not more than three years, or both.

You should, therefore, report murders and other felonies or risk 3 years in jail.

"This statute has been contrued, however, to require both knowledge of a crime and some affirmative act of concealment or participation."
Bratton v. United States, 73 F.2d 795 (CA10 1934); United States v. Farrar, 38 F.2d 515, 516 (Mass.), aff'd on other grounds, 281 U.S. 624, 50 S.Ct. 425, 74 L.Ed. 1078 (1930); United States v. Norman, 391 F.2d 212 (CA6), cert. denied, 390 U.S. 1014, 88 S.Ct. 1265, 20 L.Ed.2d 163 (1968); Lancey v. United States, 356 F.2d 407 (CA9), cert. denied, 385 U.S. 922, 87 S.Ct. 234, 17 L.Ed.2d 145 (1966). Cf. Marbury v. Brooks, 7 Wheat. 556, 575, 5 L.Ed. 522 (1822) (Marshall, C.J).

 

[Pingu]

While working in NYC I saw illegals getting everything up to and including transplants.

The problem I have with illegals receiving care is that we have millions of American taxpayers who are uninsured and not receiving care. The child health insurance programs get cut back while we continue to provide care to illegal immigrants. I think we need to handle our own business before we go about trying to provide for the rest of the world. Especially with transplants, I mean, that's a finite resource and should go to someone who has taken the steps to become an American citizen. If they have a green card, whatever, but if they are in the country and have not registered themselves with the government, then they should not receive benefits.

I went to medical school in San Antonio, which is a very good example of the abuses of the system. I recall one patient who came to the ob clinic with her mother at 39 5/7 weeks. She wanted to know why she was not in labor yet. She was a mexican national (some of whom are very wealthy) and her and her mother were completely decked out in designer clothing. When we stated that to do an ultrasound they would have to pay up front they began throwing a fit. If you can carry a two thousand dollar prada bag, you can pay for a 150 dollar ultrasound. But for many mexican women, their goal is to get across the border and have a baby, which will give the baby citizenship status and thus allow the mother to stay in the us.

Frankly, I think it is ridiculous that we allow what goes on in mexico to occur. Many of the people are oppressed and the power and money are in the hands of a few corrupt despots. If we made more of an effort to support change in mexico, perhaps there would be a reason for its people to stay there. I mean, you don't see canadians fleeing across the border, do you?

 

[gtb]

Wow! My hope is you are not so quick to form medical conclusions with such limited data, as you are about my motives and intentions. I really hate to once again to point to a dictionary, but please refer to the following generally accepted definition of racist.

Racist:
[n] *a person with a prejudiced belief that one race is superior to others
[adj] *discriminatory especially on the basis of race or religion
[adj] *based on racial intolerance; "racist

Of course the key word in this definition is in fact the very root of the word, "race." Nothing in this thread has remotely touched upon race or even ethnicity. Nationality, yes. But not race.

How about this? What if you recognized your patient as Joseph Mengele (hypothetical of course given he is dead). So, here's this horrible individual, in the United States illegally. He has never committed any crime on American soil, and is likely not likely to ever again commit a crime. Would you report him?

Refusing to treat has never been mentioned in this thread, so your statement is irrelevant to the discussion.

Your state that, "this is a breech of trust which may dissuade the person from seeking medical attention in the future." I'm curious what my ethical responsibilities are for trust. Obviously everything revealed to me of medical relavence is legally protected, but what about medically irrelavent topics? There is this remarkably vague concept of physician-patient relationship, and I know it is passed down as a legacy idea, but what does it include. As discussed before, I don't feel obliged to protect a child abuser.

I agree that the threat of deportation might be enough to keep a patient away from a clinic. Public health concerns mentioned in a previous post are for me the most compelling reason that this is not a good idea. Although I go back to my premise that American medicine is not significantly better than medicine in Mexico. And while a patient might not seek care in an American facility, why would they be dissuaded from seeking care back in Mexico?

I generally don't care for slippery slope arguments. Seems to me that they come from a last desperate gasp of reasoning. Kind of like ending an argument by saying, "Your mama." You state, "The next step in your line of reasoning is to refuse to care for criminals, or 'illegal Mexicans' as you state." I remind you that this thread is not discussing to treat or not to treat. I have no hesitation to treat anyone that presents.

No offense, but for the remainder of this thread, I'll instead focus on my original post, ethics.

Regards

 

[vigils]

Well I from the great state of Texas! And a long long time ago we won the state from the mexicans ... I used to work at a hospital and the illegals would come in speaking zero english ... I'm all about humanity. But they laws of nature will prevail every time ... If we keep letting them come across without making them pay for $hit! ... They do help they agriculture system by harvesting products but we must have a limit on how many hop on over.

Racist, pure racist. I wish you were born just south of the border growing up turning tortillas instead "getting screwed by all non-americans." You're an a hole. It is so interesting to think of suck a concept as winning a state. Hooray, we won Texas! Like back one hundred years ago we played monopoly and struck it rich on a dice roll. I'm suprised you don't realize that Texas originally declared its independence from not just Mexico but the united states also. It's just such a crazy idea to think that a person can be qualitatively "illegal" just for the fact he was not born in this country. And what the hell laws of nature are you talking about.

Medical care is not a comodity that is bought and traded, it is a service that is provided. It can not be held back until someone has paid an arbitrary amibiguous debt to society. Everyone regardless of their background, language or culture deserves equal health care services.

I hope you get hit by a drunk driver tonight, then how great is your $hithead life going to be.