Modern medicine’s ability to save life – to keep people alive who would once have died – gives rise to an increasing number of ethical dilemmas. An article in a recent edition of the New England Journal of Medicine discusses the case of Quelino Jimenez, a Mexican illegal immigrant who was employed as a construction worker in Chicago. He had a fall that rendered him tetraplegic; after emergency treatment to stabilize his condition, and some time in the hospital, he was repatriated against his will to Mexico, where, aged 21, he died because of a lack of medical care.
Jimenez, like the majority of the 11 million illegal immigrants in the Unites States, was uninsured. The law already prescribes that hospitals receiving Medicare funding must provide emergency care to anyone in need of it, without discrimination as to legal or insurance status. However, they are not under obligation to provide, nor will they be reimbursed for providing, long-term care for those who need it. Looking after tetraplegics is expensive and consumes much time and effort. Hospitals will therefore be anxious to transfer them (and the costs) elsewhere.
It is an elementary principle of medical ethics that doctors are not permitted to sort patients into deserving sheep and undeserving goats when providing treatment for them: they are supposed to do their best for everyone, prince or prisoner. The best for Quelino Jimenez was certainly not to be returned to conditions in which, only too predictably, he would be medically neglected.
The authors of the article about the case (and, by implication, others like it) argue that to have sent him back was unethical because it was against his will, and therefore infringed his right to autonomy; that it was against the fundamental moral injunction for doctors to treat all patients equally irrespective of their legal status or moral qualities, and thus a threat to that very injunction as a whole; that it was against the principles of distributive justice, expressed in the article as follows:
Insofar as the duties of justice issue from a universal recognition of the equality of all persons and take as their aim the optimization of opportunity for the least privileged, the repatriation of vulnerable patients to places where opportunities for health and social mobility are less guaranteed represents a powerful injustice…. and finally that it would have the unintended effect of reducing public trust in doctors because it would give the impression that economic arguments trumped purely medical ones.
Since space is limited, let me just deal with the argument from distributive justice, whose premise is unexamined. The authors do not believe in global distributive justice, for if they did it would be unlikely that the United States disposed of the means to save Quelino Jimenez’s life in the first place. Thus they implicitly believe it is right for each society to treat people medically according to their means. But was Quelino Jimenez a member of American society or not?
The authors argue that he was, because (like most illegal immigrants) he worked there and was “deeply embedded” in it. Supposing, however, that he had not been a construction worker, but a drug-dealer who had arrived in the country on the very day of his accident? Would that have changed the obligations of the hospital and medical profession towards him? Ex hypothesi the latter are not supposed to consider the moral or legal status of their patients, such as their “embeddedness” in society or otherwise. And yet one feels that this is absurd, indeed morally destructive. Life makes it hard to be consistent.
If Quelino Jimenez had been my patient, I would have fought tooth and nail on his behalf – for kindness’ and decency’s sake, and hang the consequences.