Do Illegal Immigrants Have the Right to Receive U.S. Health Care?
Do Illegal Immigrants Have the Right to Receive U.S. Health Care?
Article by Albert Garcia
James Dwyer At Issue: What Rights Should Illegal Immigrants Have? Lori Newman Greenhaven Press
Viewpoint
Illegal immigrants form a large and disputed group in many countries. Indeed, even the name is in dispute. People in this group are referred to as illegal immigrants, illegal aliens, irregular migrants, undocumented workers, or, in French, as sans papiers. Whatever they are called, their existence raises an important ethical question: Do societies have an ethical responsibility to provide health care for them and to promote their health?
Medical Care for Illegals Is an Ethical Question
This question often elicits two different answers. Some people-call them nationalists-say that the answer is obviously no. They argue that people who have no right to be in a country should not have rights to benefits in that country. Other people-call them humanists-say that the answer is obviously yes. They argue that all people should have access to health care. It’s a basic human right.
I think both these answers are off the mark. The first focuses too narrowly on what we owe people based on legal rules and formal citizenship. The other answer focuses too broadly, on what we owe people qua human beings. We need a perspective that is in between, that adequately responds to the phenomenon of illegal immigration and adequately reflects the complexity of moral thought. There may be important ethical distinctions, for example, among the following groups: U.S. citizens who lack health insurance, undocumented workers who lack health insurance in spite of working full time, medical visitors who fly to the United States as tourists in order to obtain care at public hospitals, foreign citizens who work abroad for subcontractors of American firms, and foreign citizens who live in impoverished countries. I believe that we-U.S. citizens-have ethical duties in all of these situations, but I see
important differences in what these duties demand and how they are to be explained.
In this paper, I want to focus on the situation of illegal immigrants. I will discuss several different answers to the question about what ethical responsibility we have to provide health care to illegal immigrants….
I believe that a sound ethical response to the question of illegal immigration requires some understanding of the work that illegal immigrants do. Most undocumented workers do the jobs that citizens often eschew. They do difficult and disagreeable work at low wages for small firms in the informal sector of the economy. In general, they have the worst jobs and work in the worst conditions in such sectors of the economy as agriculture, construction, manufacturing, and the food industry. They pick fruit, wash dishes, move dirt, sew clothes, clean toilets….
A Matter of Desert
The abstract ethical question of whether societies have a responsibility to provide health care for illegal immigrants sometimes becomes a concrete political issue. Rising health care costs, budget reduction programs, and feelings of resentment sometimes transform the ethical question into a political debate. This has happened several times in the United States. In 1996, the Congress debated and passed the “Illegal Immigration Reform and Immigrant Responsibility Act.” This law made all immigrants ineligible for Medicaid, although it did allow the federal government to reimburse states for emergency treatment of illegal immigrants….
Although it is true that illegal aliens have violated a law by entering or remaining in the country, it is not clear what the moral implication of this point is. Nothing about access to health care follows from the mere fact that illegal aliens have violated a law. Many people break many different laws. Whether a violation of a law should disqualify people from public services probably depends on the nature and purpose of the services, the nature and the gravity of the violation, and many other matters.
Consider one example of a violation of the law. People sometimes break tax laws by working off the books. They do certain jobs for cash in order to avoid paying taxes or losing benefits. Moreover, this practice is probably well quite common. I recently asked students in two of my classes if they or anyone in their extended family had earned money that was not reported as taxable income. In one class, all but two students raised their hands. In the other class, every hand went up.
What is false is the idea that we have to choose between basic health care for illegal aliens and basic health care for citizens.
No one has suggested that health care facilities deny care to people suspected of working off the books. But undocumented work is also a violation of the law. Furthermore, it involves an issue of fairness because it shifts burdens onto others and diminishes funding for important purposes. Of course, working off the books and working without a visa are not alike in all respects. But without further argument, nothing much follows about whether it is right to deny benefits to people who have violated a law….
I would restate the argument in the following way: Given the limited public budget for health care, U.S. citizens and legal residents are more deserving of benefits than are illegal aliens. This argument frames the issue as a choice between competing goods in a situation of limited resources.
There is something right and something wrong about this way of framing the issue. What is right is the idea that in all of life, individual and political, we have to choose between competing goods. A society cannot have everything: comprehensive and universal health care, good public schools, extensive public parks and beaches, public services, and very low taxes. What is false is the idea that we have to choose between basic health care for illegal aliens and basic health care for citizens. Many other tradeoffs are possible, including an increase in public funding.
The narrow framework of the debate pits poor citizens against illegal aliens in a battle for health care resources. Within this framework, the issue is posed as one of desert [who is most deserving of receiving a benefit]. Avoiding the idea of desert is impossible. After all, justice is a matter of giving people their due-giving them what they deserve. But a narrow conception of desert seems most at home in allocating particular goods that go beyond basic needs, in situations where the criteria of achievement and effort are very clear. For example, if we are asked to give an award
for the best student in chemistry, a narrow notion of desert is appropriate and useful. But publicly funded health care
is different and requires a broader view of desert.
Measures that deny care to illegal aliens, or make them afraid to seek care, could lead to an increase in tuberculosis.
The discussion of restrictive measures often focuses on desert, taxation, and benefits. Proponents tend to picture illegal immigrants as free riders who are taking advantage of public services without contributing to public funding. Opponents are quick to note that illegal immigrants do pay taxes. They pay sales tax, gas tax, and value-added tax. They often pay income tax and property tax. But do they pay enough tax to cover the cost of the services they use? Or more generally, are illegal immigrants a net economic gain or a net economic loss for society?
Instead of trying to answer the economic question, I want to point out a problem with the question itself. The question about taxation and benefits tends to portray society as a private business venture. On the business model, investors should benefit in proportion to the funds they put into the venture. This may be an appropriate model for some business ventures, but it is not an adequate model for all social institutions and benefits. The business model is not an adequate model for thinking about voting, legal defense, library services, minimum wages, occupational safety, and many other social benefits….
A Matter of Professional Ethics
Some of the most vigorous responses to restrictive measures have come from those who consider the issue within the framework of professional ethics. Tal Ann Ziv and Bernard Lo, for example, argue [in the New England Journal of Medicine] that “cooperating with Proposition 187 [a proposal to deny health care to illegal immigrants in California] would undermine professional ethics.” In particular, they argue that cooperating with this kind of restrictive measure is inconsistent with physicians’ “ethical responsibilities to protect the public health, care for persons in medical need, and respect patient confidentiality.” Restrictive measures may indeed have adverse effects on the public health. For example, measures that deny care to illegal aliens, or make them afraid to seek care, could lead to an increase in tuberculosis. And physicians do have a professional obligation to oppose measures that would significantly harm the public health….
A Matter of Social Responsibility
Framing the issue in terms of social responsibility helps to highlight one of the most striking features of illegal immigration: the employment pattern within society. As I noted before, illegal immigrants often perform the worst work for the lowest wages. Illegal immigrants are part of a pattern that is older and deeper than the recent globalization of the economy. Societies have often used the most powerless and marginalized people to do the most disagreeable and difficult work. Societies have used slaves, indentured servants, castes, minorities, orphans, poor children, internal migrants, and foreign migrants. Of course, the pattern is not exactly the same in every society, nor even in every
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