Mark G. Kuczewski, PhD, of the Loyola University Chicago Stritch School of Medicine presented at the April 22 Bioethics for Breakfast session, offering perspectives and insight on the topic “Caring with and for undocumented physicians and patients.” Bioethics for Breakfast is generously sponsored by Hall, Render, Killian, Heath & Lyman.
The session addressed the contributions of undocumented immigrants to our communities in the United States, including those of DACA (Deferred Action for Childhood Arrivals) physicians, to our healthcare system; the limits that exclusionary practices place on the contributions of undocumented immigrants to our healthcare system; and approaches to facilitating better care of undocumented immigrants in the healthcare system.
Dr. Kuczewski shared facts about undocumented immigrants in the U.S.: they number approximately 10-12 million, approximately two-thirds have lived in the U.S. for more than 10 years, they cannot buy a full-priced policy on an ACA exchange, they commit crimes at lower rates than U.S. citizens, an increasing percentage are of Asian origin, and there are fewer in the U.S. now than in 2010. He pointed out that excluding these individuals from obtaining health insurance through the Affordable Care Act ends up harming the overall pool of people in the insurance marketplace.
Dr. Kuczewski also explained how U.S. immigration policies have changed since the Clinton administration and now those policies have created barriers to entering the U.S. lawfully and with authorization, with regard to application rules and the quota system.
“This is a people issue,” said Dr. Kuczewski, adding that the stable population of 10-12 million undocumented immigrants in the U.S. have healthcare needs, and need to be able to seek care. Using the example of someone in need of kidney dialysis, he pointed out that the usual route of getting Medicare coverage is not an option because federal benefits are not available to undocumented immigrants. Dr. Kuczewski highlighted the importance of hospitals and clinics caring for undocumented patients and advocating for them, in order to foster trust over fear, and in turn help to avoid negative impacts on public health.
Finally, Dr. Kuczewski discussed the challenges for DACA recipients who matriculate through medical school while being ineligible for federal student loans. The discussion portion of the session explored the importance of educating people, including politicians, on revisions to the ACA, and avenues for advocacy work for schools and universities, students, medical professionals, and instructors. Related resources are linked below.
Open access article: Kuczewski MG, Mejias-Beck J, Blair A. Good Sanctuary Doctoring for Undocumented Patients. AMA Journal of Ethics. 2019;21(1):E78-85. DOI: 10.1001/amajethics.2019.78.
Mark G. Kuczewski, PhD Mark G. Kuczewski, PhD, is the Fr. Michael I. English, S.J., Professor of Medical Ethics and the director of the Neiswanger Institute for Bioethics at the Loyola University Chicago Stritch School of Medicine. Mark is a past president of the American Society for Bioethics and Humanities (ASBH) and a Fellow of the Hastings Center. He has been engaged in bedside clinical ethics issues for more than 25 years. For the last decade, he has been an articulate spokesperson for the just and equitable treatment of immigrant patients. He created the Sanctuary Doctor website with Drs. Johana Mejias-Beck and Amy Blair to assist clinicians in supporting immigrant patients. He led the effort to make the Stritch School of Medicine the first medical school in the nation to openly welcome applicants who are DACA recipients.
About Bioethics for Breakfast: In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Bioethics and Social Justice to partner on a bioethics seminar series. The Center and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
This post is a part of our Bioethics in the News series. For more information, click here.
By Joel Maurer, MD
In February 2013 while visiting the University of California-Riverside, I presented a program on how to best prepare for medical school. As Assistant Dean for Admissions, I’d given this talk numerous times, and as such felt comfortable addressing questions from premed audiences. It was at that point I encountered a moment of awkwardness….
“Dr. Maurer, does your medical school consider applications from undocumented students?”
I’d previously addressed questions about citizenship on many occasions, but never quite in the context of the question at hand. Thoughts began to race through my head… “Undocumented, as in illegal alien? Attending our colleges and universities? Really?” I suddenly suspected that the response that CHM will only consider US citizens, Canadians, and permanent residents wasn’t the answer this student (and perhaps a few others) was looking for. It then hit me that there is something going on in American higher education that I was not aware of. I needed an education about this, and quick!
Throughout the early 21st century, Congress attempted numerous times to pass the DREAM Act (Development, Relief, and Education for Alien Minors). Its intent was to provide protection from deportation of individuals who had come to the US illegally as children (under the age of 15), graduated from a US high school or received their GED, and had lived here continuously for at least 5 years.
On August 15, 2012, US Citizenship and Immigration Services started accepting applications under executive order of the President for his new Deferred Action for Childhood Arrivals (DACA) program, in which qualifying individuals are given legal renewable protection from deportation every two years. To qualify, applicants must: arrive to the US before age 16; live here continuously since July 15, 2007; be under age 31 in June 2012; demonstrate completion of high school or a GED; and be without conviction of a felony or serious misdemeanor.
Most DACA enrollees come from Mexico and other Latin American countries. Approximately 2 million people qualify or potentially qualify for DACA, most living in California and Texas. In Michigan, approximately 15,000 people would potentially qualify or have enrolled for DACA. DACA enrollees can get a driver’s license, work permits, and social security numbers (meaning that they can pursue medical residencyand become employed). They can take the MCAT and all US medical licensing exams. In states with the highest numbers of undocumented DACA potentials, there are no laws prohibiting their medical licensure.
65,000 undocumented students graduate from high school annually. The right to this education was granted in 1982 when the Supreme Court ruled that undocumented children could not be denied a K-12 education. It is less clear how many undocumented students attend college. Estimates in California suggest that 10-20% of undocumented students who graduate from high school enroll in college. With a national graduation rate of 59%, this would translate into roughly 3,800—7,600 undocumented college graduates nationally.
According to the Undocumented Student Guide to College, the following schools are considered DACA-friendly: Western Michigan University, Michigan Technological University, Hope College, University of Detroit, Eastern Michigan University, Olivet College, Marygrove College, and Grand Valley State University. Eastern Michigan University, Wayne State University, and the University of Michigan recently began offering in-state tuition to undocumented students meeting Michigan residency requirements. Michigan State University does not offer in-state tuition to undocumented or DACA enrolled matriculants.
Michigan State University’s College of Human Medicine is committed to educating exemplary physicians and scholars, discovering and disseminating new knowledge, and providing service at home and abroad. We enhance our communities by providing outstanding primary and specialty care, promoting the dignity and inclusion of all people, and responding to the needs of the medically underserved.
I believe it is no mistake that “responding to the needs of the medically underserved” is the last component of our mission—it leaves a lasting impression. Undocumented students are civically engaged and give back to their communities. Coming from underrepresented backgrounds in medicine, they are likely to return to their communities—low income, doctor shortage areas—and serve as primary care physicians.
Immigration remains highly problematic and politicized. And my point is not to initiate commentary about how to solve the problem of illegal immigration by those who were brought to our country as children beyond their own will, raised in American society, speak the dominant language, and educated in our public schools. My personal ethics, though, compel me to want to help these people if for no other reason than their personal merits and potential to our society (or even for what I believe is our profession’s duty of beneficence and the value of social justice).
I have since received a handful in inquiries from DACA students in Michigan asking us to accept their application to medical school. If we believe that DACA enrollees possess value in our society, giving them the opportunity to apply to medical school is the first step in recognizing this potential. If we continue the status quo, we risk trying to defend a mission statement in light of an admissions policy that is selective and rejects inclusiveness. If we change our current policy, we risk scrutiny and support from certain aspects of the public. The issues are complex to say the least. Shouldn’t we, though, as a college and institution be grappling with this? It appears that others in Michigan have (and are moving onward). At a minimum, this is an issue that we can no longer ignore. I hope that our institution is having this conversation. If asked, I know what position I and my conscious would take.
Balderas-Medina Anaya Y, del Rosario M, Doyle LH, Hayes-Bautista DE. Undocumented students pursuing medical education: The implications of Deferred Action for Childhood Arrivals (DACA). Academic Medicine. 2014 Dec; 89(12):1599-602. http://www.ncbi.nlm.nih.gov/pubmed/25093382.
Joel Maurer, MD, is Assistant Dean of Admissions in the College of Human Medicine and Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Biology at Michigan State University. All opinions expressed in this article are his own.
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