Immigration: Pragmatism & ProphecyMark Kuczewski, PhD

Loyola University Chicago1. Three common scenarios involving undocumented patients:

a. DREAMer M.D.s – Loyola Stritch breaks ground (Fall 2012)b. Forced Medical Repatriationc. Access to Health Insurance

2. Each best resolved by treating patient/person as full member of community rather than truncating participation. (Preservation of values of community institutions; recasting concept of benefit)

3. Through participation, community’s equity interest in person grows and vice versa.

4. Prophetic Role of Catholic Health Care

Loyola University Chicago Neiswanger Institute for Bioethics & Health Policy

www.bioethics.luc.edu

Mark G. Kuczewski, PhD Bioethicist

• Former President American Society for Bioethics & Humanities (ASBH)

• Chair, Department of Medical Education

• Interests include End-of-Life Care, Spirituality & culture in medicine, Communitarian & Case-based ethics

An e-mail arrived . . .(May 2011)

A professor at a Jesuit university enquired of the medical school prospects for his student Clara:•3.94 GPA•Pre-Med double major in Biology & Spanish•Strong volunteer & service record•Does not have an authorized immigration status, i.e., is a DREAMer

DREAMer M.D.s: Typical DREAMer Students

• Born outside the United States• Brought to the U.S. at a young age (< 16 yrs.)• Lived in U.S. more than 5 years• Commonly bi-lingual and bi-cultural• Sometimes university educated (High School

Diploma/GED is significant)• “Americans in every way but one: On paper”

Why Clara Interested Stritch . . .

Day 1DREAMERS of DACA Status Welcome

www.stritch.luc.edu/daca

DREAMers

• Financing of Medical Education – Illinois Finance Authority (IFA) – “no taxpayer dollars”

• Larger problem of educational financing for DREAMers

• Dreamers & DACA – “Liminal legality” Implications for Future of U.S.

• “Makers” v. “Takers”

The Prophetic Voice of Catholic Philosophical Anthropology

Human beings are

• Intrinsically valuable beings - dignity

• Laboring animals – in a global economy; capital flows across borders but labor is artificially restricted

• Social animals with cultures – God’s self-revelation

• Political animals – entitled to participate in self-governance

Respecting our nature means

Welcoming the participation of all persons in the life of the community and society (i.e., hospitality, solidarity, social justice).

Uninformed & Sinful Attitudes about Immigrants

• They take our jobs & depress wages by working for so little.

• They are free loaders: They come here for benefits/handouts, e.g., welfare, health care, education

• They refuse to assimilate, e.g., they won’t learn English.

• They have no right to be here and should stay in their own countries & the undocumented are law breakers

• Conclusion: In essence, they are ungrateful thieves by taking what does not belong to them. They are the “undeserving poor” i.e., “Takers”

Policy Flows from Sinful Attitudes

• Prohibit or restrict any and all “benefits” to immigrants in general, but especially to undocumented immigrants, e.g., (a) Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996; (b) Affordable Care Act – Ineligibility issues; Further restrictive amendments offered; © Proposals to limit EMTALA-related benefits

• Any immigration reform is accompanied by increased penalties on immigrants and employers; Immigration Reform & Control Act 1986 (Simpson – Mazzoli)

Affordable Care Act

LOYOLA UNIVERSITY CHICAGO Stritch School of Medicine

Reduces uninsured from approximately 50 million to 15-20 million by (a) Subsidized individual purchase and (b) Medicaid expansion

Individual Purchase on Exchanges

Indiv Purchase on Exchanges w/ subsidies

ExpandedMedicaid

Immigrants > 5 Yrs Yes Yes Yes

Immigrants < 5 Yrs Yes Yes NO

DREAMers (DACA) NO NO NO

Undocumented Immigrants

NO NO NO

Insurance as Community Benefit

• EMTALA – community does not want people “dying in the streets.”

• Insurance enables delivery of care to be efficient, effective, rational; benefits community by minimizing cost, containing contagion, fostering opportunity

• ACA (exchanges, subsidies, Medicaid exp.) enable community members to participate in payment to extent possible and assume responsibility for health

The Prophetic Example of Catholic Health Care in an Unjust World

• No Forced Medical Repatriation Jeopardizes our hospitals’ identity as caring, efficient, promoters of

public health Best Practice in Medical Repatriation = Informed Consent + Best

interest

• Treatment Consonant with Standard for Uninsured Patients Ex: Dialysis/kidney transplant v. Liver transplant Creativity & Shared Responsibility – with community, with local

providers

“Welcoming the Stranger Among Us: Unity in Diversity” (USCCB 2000)

1. Rejection of anti-immigrant posture

2. Welcoming stance– Understanding cultures as hospitality

3. Acknowledgment that current immigrants are predominantly Catholic

4. Advocacy – (a) Legalization of maximum number of

undocumented

(b) Change of 1996 laws – IIRIRA & PRWORA

5. Ministry Outreach – Catholic health ministry

What Catholic Hospitals Are Doing

LOYOLA UNIVERSITY CHICAGO HEALTH SCIENCES DIVISION

Cultural Hospitality • Interpreter programs

• Patient navigators

• Written materials – incl. consent forms, discharge instructions; attention to “low literacy” needs;

• Signage

• Masses

• Staff education programs (diversity committees)

• Build staff diversity

• Cultural celebrations – Feast of Our Lady of Guadelupe

• Bilingual baby showers

• Offer English as a Second Language classes (ESL)

Medical Hospitality

• Health screening programs for seasonal workers

• Develop community-wide provider consortium

• Find medical home for undocumented

• Mobile units deployed to appropriate areas

• Health promoter programs (promotoras de salud)

• Full-time advocate for immigrant community

Argument for Permanent Inclusion

1. Duty to steward, not waste, resources; common good; People are naturally makers; exclusion turns them into takers

2. Globalization of Economy: Presence of large numbers of contributors in community suggest needs to be filled; needs are more objective than policy by fiat.

3. Globalization of IndifferenceE-mail: mkuczew@luc.edu

@mkuczew

References• DREAMERS of DACA Status Welcome www.stritch.luc.edu/daca

• Kuczewski MG, Brubaker L. (2014) Medical Education for “Dreamers”: Barriers and Opportunities for Undocumented Immigrants. Academic Medicine 89(12): 1593-1598.

• Kuczewski MG, Brubaker L. Accepting Undocumented Immigrants: How We became the "Medical School of Dreams" and Dreamers. Academic Medicine Blog

• Kuczewski MG, Cassidy T. (2013) Health Care for Our Immigrant Neighbors: The Need for Justice and Hospitality. Health Care Ethics USA 21(3): 8- 16.

• Kuczewski MG. Can Medical Repatriation Be Ethical? Establishing Best Practices. American Journal of Bioethics 2012;12(9): 1-5.

• Kuczewski MG. Who is My Neighbor? A Communitarian Analysis of Access to Health Care for Immigrants. Theoretical Medicine and Bioethics 2011;32(4): 327-336

E-mail: mkuczew@luc.edu

@mkuczew

Church Documents

• St. John Paul II (1999) Ecclesia In America

• USCCB (2000) Welcoming the Stranger Among Us: Unity in Diversity

• Catholic Bishops of Mexico & the United States (2003) Strangers No Longer: Together on the Journey of Hope

• Pope Francis Homily at Lampedusa

• Cardinal Sean O’Malley, OFM, Homily at the Border