The Emergency Medical Treatment and Active Labor Act in 1986 was intended to bring an end to incidents of “patient dumping.” However, due to the conflation of various federal legislative provisions, hospitals faced with the prospect of long‐term unreimbursed care of an immigrant patient, whether legally present in the United States or not, are in some cases having such patients transported to another country. These transfers are often being effectuated without patient consent. After an overview of the flaws in the (...) legal system that have effectively encouraged such patient transfers, this essay uses a clinical case to demonstrate how physicians can collaborate with an interdisciplinary team and with family members to ensure that the best interests of immigrant patients are met. Finally, the essay calls on physicians to advocate for the development of hospital policies and practices that will protect patients from international patient dumping. (shrink)

The American Journal of Bioethics, Volume 12, Issue 9, Page W1-W3, September 2012.

Hospitals in the United States have been engaging in the practice of returning immigrant patients, usually undocumented immigrant patients, to their country of origin when the patient has long-term medical needs for which no reimbursement is available. I argue that for such an action to be ethical, it must be done in accordance with the mission and values of hospitals. I describe three standards that an individual instance of repatriation must meet to be ethical: (1) patient best interests, (2) medical (...) due diligence, and (3) informed consent. I argue that these should form the basis for best practices in regard to medical repatriation for all hospitals in the United States. (shrink)

Both the USA and Europe limit access to care by undocumented immigrants. In the debate over what level of access to confer to IMs, there are various public policy rationales operating either explicitly, or below the surface, ranging from minimalist humanitarianism to full cosmopolitan equality, with several intermediate positions between these two poles. This article informs the international debate by providing a conceptual mapping of these underlying policy rationales. Each position is based on different lines of reasoning or bodies of (...) evidence, and each leads to somewhat different conclusions about the extent to which IMs should have access to different types of health care. It is unlikely that broad consensus will be achieved in this ongoing debate. However, by articulating the ethical, legal, pragmatic and conceptual reasons to support or oppose various positions, we hope to help determine where in the landscape of reasoned argument various positions lie, and how each position might be best supported or refuted. In particular, we see in this debate an illustration of Michael Walzer’s classic analysis of competing spheres of justice. Various positions depend to a considerable extent on whether their advocates approach this issue from the health policy sphere rather than the sphere of immigration policy, or whether they attempt to blend the two spheres. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. Legal, professional, and ethical norms prohibit physician and acute care hospital “dumping” of these patients. However, limitless use of hospital resources for indefinite stays is untenable. In the absence of hospital policy addressing this specific issue, the availability of financial support will be determined by health care professionals' willingness to (...) advocate for the patient and negotiate with hospital administrators and the ability and willingness of administrators to authorize the use of hospital resources. We propose five mid-level ethical principles to guide advocacy and administrative decision-making about provision of financial support for post-acute care for those patients who cannot afford it. We use two actual, de-identified cases to illustrate how these principles can be used to make reasoned, consistent decisions about the provision of post-acute financial support. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. The care of these patients contributes to the rising costs of health care and will remain largely unaffected by the Affordable Care Act. For example, some resources may be available for treatment of undocumented persons, but Medicaid enrollment is unavailable for this population. Even where patients have access to Medicaid, (...) it takes up to three months between applying for and actually receiving Medicaid benefits. During that time, patients may be ready for hospital discharge. However, post-acute care facilities have no financial incentive or legal obligation to accept patients with no insurance or only pending Medicaid coverage. (shrink)

The American Journal of Bioethics, Volume 12, Issue 9, Page 9-11, September 2012.