restricted access To Discharge or Not to Discharge: Ethics of Care for an Undocumented Immigrant
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Brief Communication TO DISCHARGE OR NOT TO DISCHARGE: ETHICS OF CARE FOR AN UNDOCUMENTED IMMIGRANT Recent debate over undocumented immigrants' access to care has centered on cost. What this macro-level debate often ignores is the ethical dilemma presented to providers caring for undocumented immigrants . Providers are torn between their duty to the patient's welfare and their role as gatekeeper in the distribution of societal health care resources. One of the authors (Steven Asch) encountered such an ethical dilemma. As a house officer, he was instructed to discharge an undocumented woman in chronic renal failure without arranging follow-up dialysis. This dilemma led to a review of the basic ethical principles involved in balancing the needs of the undocumented patient , her physician, the hospital facility, and society at large. The Case Patient T was diagnosed with systemic lupus erythematosus (SLE) in 1985 at age 17 years in the outpatient clinic of our state university hospital. She received a course of immunosuppressive therapy; however , she failed to return for follow-up care as she had returned to Mexico to live with her family. In 1988, she presented again to the clinic with lupus nephritis and soon required admission for emergency dialysis. Although she had Medicaid, the dialysis unit affiliated with the hospital refused her as a chronic patient. The unit, which is institutionally distinct from the hospital, decided that T's undocumented status would soon jeopardize her insurance and thus her ability to pay for dialysis, leaving the unit with an unacceptable financial burden. The intern caring for T contacted other local dialysis units in an attempt to arrange follow-up but had no success. Authorities at the Mexican consulate stated that T, whose sister had died of SLE in Mexico, might qualify for dialysis at least until age 21. However, T refused repatriation Journal of Health Care for the Poor and Underserved · Vol. 6, No. 1 · 1995 4 To Discharge or Not to Discharge because she wished to remain with family members in the United States and because she feared the uncertainty of the Mexican government's promise. The intern was instructed by his attending physicians to discharge her with a list of local dialysis units so that she could arrange her own dialysis, although she was offered standard clinic follow-up and was told she would qualify for inpatient emergency dialysis when her condition so warranted. The house officer decided to refuse to discharge T, and another house officer wrote the discharge order. With difficulty, T found a dialysis center in another county. Ironically, T never lost her public insurance and continues to receive care. Case Analysis In weighing whether to discharge T without arranging dialysis, we focus on four key ethical principles: autonomy, nonmaleficence, beneficence , and justice. In T's case, these principles conflict at the individual, institutional, and societal levels. Autonomy. The principle of autonomy dictates that, in the absence of competing ethical principles, people ought to be able to choose their own courses of action free of coercion. The principle of fidelity, or promise keeping, can be derived from this principle because breaking a promise forces the promised to make decisions under false pretenses. At the individual level, discharging T constrains her autonomy. Within T's value system, the alternative—an uncertain promise of dialysis in Mexico—does not carry equivalent worth, although this worth must of course be balanced against competing institutional and societal interests. At the institutional level, discharging T compromises the house officer's autonomy by mandating that he or she do so against his or her wishes. The house officer must answer to an institution that supports his or her training and to an attending physician legally responsible for his or her actions.1 Yet health professionals need not follow moral imperatives of authority in the absence of compelling reasons." In our discussion of nonmaleficence and beneficence, we examine whether the hospital or society had such compelling reasons to override patient and physician autonomy. Autonomy's derivative principle of fidelity is even more troubling in T's case. In discharging T without arranging dialysis as he would for a paying patient, the physician has broken the promise implicit in the Hippocratic...