Friday, April 25, 2014

Responding to the Dream – Loyola Stritch School of Medicine & Dreamer Applicants

Dr. Martin Luther King, Jr.
Comments by Mark Kuczewski, PhD, delivered on a portion of Dr. King’s “I Have a Dream” speech as part of the Loyola Stritch School of Medicine celebration of the 50th Anniversary of the March on Washington.

“We have also come to this hallowed spot to remind America of the fierce urgency of now. This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism. Now is the time to rise from the dark and desolate valley of segregation to the sunlit path of racial justice. Now is the time to open the doors of opportunity to all of God’s children. Now is the time to lift our nation from the quicksands of racial injustice to the solid rock of brotherhood.” - Dr. Martin Luther King, Jr.

History is a funny thing. When we are living it, matters of right and wrong can seem unclear. People expect there to be two valid sides to each issue. Pro-slavery and anti-slavery, segregation and de-segregation, antimiscegenation and freedom to marry whom one loves have all been debated as if there are two sides and it was hard to definitely assert which position was correct.

But with the passage of history, as we examine the issues with the tincture of time, we see that there was always the just position v. injustice, prejudice, and discrimination. Because justice is so much clearer in retrospect, Dr. King has elsewhere spoken of the long arc of history and assured us that it bends toward justice. As a result, many counsel “going slow” in matters of social change. By going slowly, we might minimize hurt feelings and conflicts with those close to us. But, in this speech, Dr. King highlights the “fierce urgency of now” and asserts that “Now is the time to throw open the doors of opportunity to all God’s children.”

We have faced such a situation and have risen to the challenge of the NOW. We have thrown open the doors of Stritch to applicants who are known as Dreamers. They are undocumented immigrants who were brought to the United States as small children, were raised and educated here, and have become vital members of our society. They are Americans in every way but on paper. We have become the first medical school in the nation to declare that these people are welcome to apply and to compete on their merits for admission.

Most members of the Loyola community have been supportive of this decision and understand how history will judge. A few have been vociferously opposed and chosen to end their relationship with our community. However, a number of others have expressed disappointment that we were not more patient. They claim that to go first among medical schools is grandstanding and that we should just wait for immigration reform to be enacted by our government. Then we could allow these students to apply. What could be wrong with that counsel? Why isn’t that simply prudence?

We cannot wait for history. While going slow might seem prudent so as not to alienate members of our community who do not see the justice of our decision, we cannot do so for two reasons. First, each year that we do not throw open the doors of opportunity, we consign the medical careers of another group of these applicants to the scrap heap. Young people cannot wait forever but must move on with their lives. So, while we wait year after year, their talents would be lost to the medical profession and to the patients they would serve. We would not only fail the potentially successful applicants, but we would fail patients in need. Even more damning, there is no neutral place to which we could retreat while we waited for justice to prevail. If we didn’t throw open the door of opportunity, it would be our hands that continued to bolt that door. It would be us who continued to respond to the inquiries of Dreamers with nonsensical reasons as to why they could not apply. It would be us who continued to discriminate against fully qualified applicants. It would be us who were the purveyors of injustice. We will not do these things.

When you hear those powerful closing words of Dr. King’s speech, “Free at last! free at last! thank God Almighty, we are free at last!” know that the movement we commemorate today did not just free those who were oppressed. It made us all aware that we could also choose to be free from being the oppressor. We are free to treat all of our neighbors as God’s children. Thank God Almighty, we are free at last.

Mark G. Kuczewski, PhD, is the Director of the Neiswanger Institute for Bioethics and Chair, Department of Medical Education, Loyola University Chicago Stritch School of Medicine. Dr. Kuczewski teaches Clinical Bioethics and Organizational Ethics in Loyola's Online Bioethics Graduate Programs.

Tuesday, April 22, 2014

HealthCare & Immigration: A Summary to Accompany BioethxChat Twitter Event (4/21/14)

Mark Kuczewski, PhD
I recently did a TwitterChat sponsored by BioethxChat on the relationship of healthcare and immigration through a bioethical lens. Here is the transcript of that chat.

This was a great event and I hope self-explanatory. But Twitter’s 140 character limitation means things are expressed in such a condensed way that they might not always be clear. So, I provide the following summary as related to the four topics discussed.

Topic One asked about the Duty of Healthcare Providers to Treat all Patients without regard to Immigration Status – It’s hard to imagine a health-care provider discriminating on the basis of immigration status per se. However, immigration status is often relevant to a patient being uninsured and unable to secure resources that a citizen might have available. So, in some ways, an immigrant is simply another uninsured patient. However, because of their truncated eligibility, e.g., even a patient who has legal permanent resident status is not eligible for Medicaid until he or she is present in the US for five years. problems can arise for immigrant patients that do not arise for citizens. For instance, if the patient is uninsured and needs a stay at a long-term care facility after an acute hospitalization, the citizen can often get Medicaid to pay for the long-term care stay while an immigrant could be stuck in the hospital with no possibility of discharge to a more appropriate level of care. This raises the question of who is hurt when public policy restricts eligibility to access insurance based on immigration status.

Topic One also asked Is It Ethical to Prevent Undocumented Immigrants from Accessing the Insurance Exchanges? and whether this is just. Again, there is a very real way in which attitudes toward the lack of insurance among the undocumented resemble unhelpful biases toward the lack of insurance among citizens. That is, insurance is seen as something that benefits the covered individual only and therefore, is a privilege that one is not entitled to. If you don’t have it, you don’t have it.

1. The problem is that as a society we also hold and have codifed directly opposite premises. We believe in emergency care for all so that we don’t have people literally dying in the streets. We have enshrined this belief in the law that goes by the acronym EMTALA. So, the US ends up treating the uninsured in the ER in a costly way. Through widespread insurance, the US can work to prevent illness and deliver care more efficiently (We also then don’t end up with the problem of not being able to discharge patient to a more appropriate level of care that we noted above). And, by making the uninsured wait until their illness is an emergency, it potentially means that communicable disease will have spread. So, insuring uninsured members of our community makes good sense for the community. While some such as the ACP have argued that allowing the unsubsidized purchase on the exchanges is a good, I would argue that access to the new system of premium subsidies is entailed by the same reasoning. That is, the subsidies enable immigrants of low income to pay what they are able toward the insurance plan. This is far better than simply providing charity care through the ER. (I developed this position in a paper a couple of years ago Mark G. Kuczewski (2011) Who is My Neighbor? A Communitarian Analysis of Access to Health Care for Immigrants. Theoretical Medicine and Bioethics 32(4): 327-36.)

2. Medicare – While the considerations I’ve noted can equally apply to any mode of insurance including Medicare, that program has a symbolic place in the minds of many Americans as a program for elderly persons who paid into it for many years. As a result, it may be politically impossible to open this up to immigrants who arrived late in life and didn’t pay into this system. Considerations of expediency might mean that it would be easier to insure any immigrants who arrived as senior citizens through other channels.

Topic Two asked about whether Undocumented Immigrants (presumably young people called DREAMers) should be able to attend graduate medical and health science programs and what unique barriers might confront them.
Many of you might know that I have worked at the Loyola University Chicago Stritch School of Medicine to welcome DREAMers of DACA status to apply to our school and not consign them to some ill-fitting category such as considering them as international students (a category at most medical schools for which there is no institutional financial aid.

DACA status (the Deferred Action for Childhood Arrival program of the US Citizenship and Immigration Service) enables DREAMers who meet certain qualifications to receive two-year renewable deferrals of any action on their immigration status. They also receive a work permit and can apply for a social security number. This means that many state medical licensing boards (and presumably boards in other health professions) can license these individuals to practice. As such, it would be a terrible waste of talent to deny qualified individuals who meet admissions standards access to the health care professions. DREAMers of DACA status potentially can provide us a new source of bi-cultural, often bi-lingual talent to serve our increasingly diverse society.

Financial aid remains the single biggest barrier to utilizing this pool of talent. They are ineligible for any federal aid including federally-guaranteed student loans. Thus, alternative sources of financial aid must be sought (In Illinois, we worked to create a loan program tied to service to the underserved of our state for these students). (See also Mark G. Kuczewski, Linda Brubaker (2013) Medical Education as Mission: Why One Medical School Chose to Accept Dreamers, Hastings Center Report 2013;43(6): 21-24.

Topic Three asked If Medical Repatriation Can Ever be Ethical? There’s been a number of good articles written on this topic in recent years including one in the NEJM (Michael J. Young, Lisa Soleymani Lehmann, Undocumented Injustice? Medical Repatriation and the Ends of Health Care, NEJM, 2014; 370: 669-673. )

I made an argument a couple of years ago that I believe is correct. Namely, forced medical repatriation is always wrong. (Mark G. Kuczewski, Can Medical Repatriation Be Ethical? Establishing Best Practices. American Journal of Bioethics 2012;12(9): 1-5) If our hospitals engage in that practice, it will cause the immigrant community to avoid the hospital with all the negative consequences we know follow. That is, they won’t present until the illness has progressed and is harder and costlier to treat. Persons with infectious illnesses will continue to spread them rather than seek treatment. And, in general, it will undermine the caring ethos of our institutions. Some have argued to me that this should entail no medical repatriation period. However, I believe there are circumstances under which repatriation is actually the moral thing to do.

In some cases, a return to a prior community is in the patient’s best interests. US citizens sometimes return to other states when they are sick and need to be near family. Similarly, immigrants who come to the US for work but become unable to work owing to illness or injury may find that they would prefer to be near familial support systems that are in their country of birth. Furthermore, dying patients may also wish to be near their loved ones. So, I believe that with certain ethical safeguards, i.e., we seek the informed consent of the patient or appropriate surrogate decision maker and the repatriation can be seen to be in the patient’s best interests on some reasonable interpretation of those interests, repatriation can be ethical.
Finally, I was asked how Immigration Policy as it relates to healthcare can relate to concepts such as human rights and social justice. I see the health care question as a subspecies of the larger question of social justice (I am far more comfortable with social justice language but I think it can be translated to human rights thinking.). Social justice is about treating people as if they have worth (dignity) and so treating them fairly. This means enabling them to participate fully in the life of the community. Healthcare provides a condition for full participation.

The immigration debate has failed to see the issue in perspective. We are an increasingly globalized world with rather free trade. Capital, i.e., investment and profit, flows more easily across borders than ever before. But, we have not allowed labor to flow with similar ease. This can create untenable and unlivable situations for many people and cause them to cross borders without authorization.

The United States is an aging society with a workforce that has needed supplementation both from many workers at the lower level of the workforce and those with very high education and skills. We have been more responsive at the high end of the spectrum although even there one could say that many more workers are needed. In a sense, our immigration laws are like a broken traffic light that is stuck on stop. In the end, we usually thank those who after a time, cautiously proceed through the broken light.

Once people have lived in a community and contributed to it, they also gain a kind of equity interest in that community and are entitled to full participation. This is the need for immigration reform. Of course, as we have seen, there is a kind of regressive thinking that does not simply infect the immigration debate but the health insurance debate as well. That thinking sees the US as having a finite set of goods and that allowing access to them, e.g., health care, diminishes the pool for others who are more deserving. This kind of thinking fails to see that we can use access to promote the contributions of all to the common good of our communities and our society.

Mark Kuczewski, PhD, is the Director of the Neiswanger Institute for Bioethics and Chair, Department of Medical Education, Loyola University Chicago Stritch School of Medicine. Dr. Kuczewski teaches Clinical Bioethics and Organizational Ethics in Loyola's Online Bioethics Graduate Programs.

Monday, April 7, 2014

On Holy Ground

Ruth Sanborn, MA
Last month I had the privilege to participate in a two-day Advanced Clinical Ethics Skills (ACES) workshop at the Maywood campus of Loyola University Chicago with three of my fellow graduate students. Participation in this workshop was a key requirement to completing the “Special Topics” course by the same name that we are enrolled in. One of the foundational goals of the course, and more specifically of the ACES workshop, was to provide us the opportunity to improve and refine our skills by participating in clinical ethics consultation simulations. In nearly three years as a community member on an Ethics Committee close to home, I have participated in only a small handful of ethics consultations. I have never been the lead ethics consultant, much less the only ethics consultant. The experience of leading three simulations, and observing my classmates as they lead their ethics consultation simulations, was incredibly valuable to my own formation as an ethicist. The faculty, fellow students, and simulation participants were generous and honest in their evaluations after each simulation. Their feedback and critiques became tools I was able to draw upon in subsequent simulations.

As I chatted with my 83-year old dad in his dining room the other day, I realized that the ACES workshop experience of three weeks ago continues to gift me with learning and insights. After my mother passed away 4-1/2 years ago, my dad named me as his legally recognized health care decision maker in the event he is not able to speak for himself. Dad has experienced some significant medical crises since mom passed away but, like the Phoenix, he has risen from the ashes. Mindful that this will not always be the case, and that he has probably spent time re-evaluating his preferences in light of these crises, I endeavored to explore what his current end-of-life wishes are. I used the details and challenges presented in one of the simulation cases to guide our conversation. I prompted Dad with “what ifs”. As he pondered and responded, and I waited quietly and patiently listened. It was a tender and respectful conversation; it was priceless. It demonstrated the depth of trust my dad has gifted to me. Even more, it served as a reminder of the holy ground on which we bioethics consultants stand when we are invited into the sacred space of patients and families who must make difficult health care decisions.

Ruth Sanborn, MA, is a full-time instructor of ethics for the Religious Studies Department of Mount St. Mary's College in Los Angeles. She is a student in the Doctorate in Bioethics graduate program at Loyola University Chicago.

The Neiswanger Institute for Bioethics recently conducted their Advanced Clinical Ethics Skills course during a three-day intensive experience in the clinical skills center on the campus of Loyola University Chicago. This blended course provided an opportunity for their advanced graduate students to improve and refine their clinical ethics skills. The focus of the course was for students to develop their own portfolios for quality attestation. Students practiced consultation skills, evaluated the performance of others and received feedback from faculty reviewers.