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AMA Journal of Ethics

Rie Ohta, Clara Long
More people, including children and pregnant women, are being detained for longer periods in a patchwork of over 200 detention centers around the country, most of which are private facilities or county jails. Human Rights Watch has documented systemic medical care failures at these facilities, including incompetent treatment, which is linked to patient deaths. Clinicians working in these facilities face formidable obstacles to providing adequate care, two of which are the Department of Homeland Security's lack of reasonable alternatives to detention and insufficient staffing...
January 1, 2019: AMA Journal of Ethics
Rohail Kumar
This graphic narrative is a storybook drawn on sketch paper with graphite and charcoal pencils and scanned into Microsoft Word. Sofia represents children of undocumented families currently living in the United States who are being denied fundamental human rights including health care, education, shelter, and food.
January 1, 2019: AMA Journal of Ethics
Nora Hiriart Litz, Isha Marina Di Bartolo
In an exhibition called El Viaje de los NiƱos ( The Children's Journey ), members of the undocumented Mexican community in South Philadelphia created stories of their journey to the United States. With help from lead artist Nora Hiriart Litz, their experiences and thoughts on migration, family, love, loss, and hope are conveyed creatively via artwork.
January 1, 2019: AMA Journal of Ethics
Nancy Berlinger
Physicians and other health care professionals who work in hospitals and clinics serving low-income populations will encounter undocumented immigrants as patients, family members, community members, and persons whose health-related rights can be overlooked, imperiled, or difficult to use. The routine uncertainty arising in how to provide good care to patients who are excluded from key public insurance provisions, together with the desire to be a good advocate for this patient population, can give rise to so-called workarounds as problem-solving strategies...
January 1, 2019: AMA Journal of Ethics
Rachel Fabi
Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines...
January 1, 2019: AMA Journal of Ethics
Jonathan J Suarez
It is a tough road for undocumented immigrants with kidney disease. There are many barriers that these patients must overcome, which prevents them from receiving proper treatments to prevent or slow the progression of their kidney disease. Those who are dialysis dependent also face an uphill battle, as some states limit access to regular dialysis. This article describes specific struggles faced by undocumented immigrants with kidney disease and how some physicians have tried to guide their treatments. It also considers how these patients might be helped through health policy changes at the national level...
January 1, 2019: AMA Journal of Ethics
Mark G Kuczewski, Johana Mejias-Beck, Amy Blair
Clinicians whose practice includes a significant immigrant population report a climate of fear adversely affecting their current patients. Increased immigration enforcement targeting undocumented immigrants increases these patients' stress and negatively affects their willingness to seek medical care. To address these concerns, this article draws upon the literature and the authors' experience to develop guidance on sanctuary doctoring. These materials provide opportunities for patients to open a dialogue about their immigration concerns and can assist clinicians in connecting patients to networks and resources that can address their needs...
January 1, 2019: AMA Journal of Ethics
Rachel F Harbut
Accessing health care resources in the United States often proves to be a difficult task for vulnerable populations. Immigrants, in particular, face barriers and difficulties in obtaining continuous medical care, which negatively impacts both patients and clinicians. The AMA Code of Medical Ethics offers guidance on how physicians and health care systems can best support undocumented and lawfully present immigrants alike to promote the best possible care for all who need it.
January 1, 2019: AMA Journal of Ethics
Scott J Schweikart
A lawsuit filed in April 2018 alleges unlawful administration of psychotropic medications to detained immigrant children in US custody. The suit, under jurisdiction of the Flores Settlement Agreement of 1997, alleges misuse of psychotropic medication to chemically restrain and control immigrant children and prolong their detention. This article describes the legal scope of the suit and considers significant ethically and clinically relevant questions it poses.
January 1, 2019: AMA Journal of Ethics
Craig B Mousin
In 1989, the United Nations adopted the Convention on the Rights of the Child (CRC), which the United States provided significant guidance in drafting. The CRC focused on those under 18 years of age, recognizing the rights most other international conventions and declarations accorded to adults. This article explores the ethical and health implications of the United States' failure to ratify the CRC with an emphasis on refugees. Federal policies have led to separation of families, mass detention of children and families, and accelerated removal, revealing the United States' disregard for global concern about children and families...
January 1, 2019: AMA Journal of Ethics
Nancy Berlinger, Rachel L Zacharias
How to provide good care to uninsured undocumented immigrants who are broadly excluded from federally funded health benefits in the United States can raise ethical challenges for clinicians. The chilling effect of current immigration enforcement policies on health care access affects other immigrant populations and US citizens in mixed-status families. In the current political environment, students in health professions, house staff and other early career professionals, and teachers and mentors in health care settings that serve low-income immigrant populations need a shared understanding of how to provide good care under changing and challenging conditions...
January 1, 2019: AMA Journal of Ethics
Robin E Canada
Different standards of care for undocumented Latino patients raises ethical questions for teachers and learners. This lack of parity can cause moral distress for both and prompts consideration of whether decisions made on a patient's behalf are ethical. Teaching advocacy and creating projects and partnerships to improve access and quality of care for this vulnerable population can help fight burnout and improve health outcomes.
January 1, 2019: AMA Journal of Ethics
Isha Marina Di Bartolo, Dominic Sisti
Undocumented immigrants are part of the health care workforce, whether they are eligible to work in the United States through the Deferred Action for Childhood Arrivals (DACA) program or other visa programs or permits. This case commentary considers whether-and if so, when-a clinician should reveal her immigration status to patients. After reviewing the literature on clinician self-disclosure, this commentary discusses how sharing immigration status could benefit the patient-particularly if the clinician has an immigration status that could interrupt care-but could also draw the focus away from the patient, possibly eroding trust between patient and physician...
January 1, 2019: AMA Journal of Ethics
Scott J Schweikart
In response to a case of an undocumented patient who was reported to immigration authorities, this commentary considers whether a patient's immigration status should be deemed protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. A legal argument, supported by clinical data, is offered that immigration status should be regarded as PHI not subject to valid exception for release without patient authorization. This argument concludes that covered entities (eg, hospitals and health care professionals) are legally precluded under the HIPAA Privacy Rule from disclosing a patient's immigration status...
January 1, 2019: AMA Journal of Ethics
Peter Ellis, Lydia S Dugdale
A challenge in caring for patients in resource-poor settings is the ethical discomfort and discouragement clinicians might experience when they're unable to provide optimal care due to lack of resources. This case, in which a resident is faced with rationalizing substandard care for certain classes of patients, probably represents the top of a slippery slope. This article argues that physicians should identify and advocate for optimal care for each patient. Moreover, physicians should advocate to improve the health system that allows for substandard care...
January 1, 2019: AMA Journal of Ethics
Ruth L Ackah, Rohini R Sigireddi, Bhamidipati V R Murthy
Numerous undocumented children in the United States with end-stage renal disease undergo kidney transplantation funded by charitable donation or state-sponsored Medicaid. However, when these funding sources expire by adulthood, most are unable to pay for follow-up appointments and immunosuppressive medications necessary for maintenance of their organ. The organs fail and patients are then left with the options of retransplantation or a lifetime of dialysis. The dilemma of retransplantation introduces many questions regarding justice and fairness...
January 1, 2019: AMA Journal of Ethics
Grace Kim, Uriel Sanchez Molina, Altaf Saadi
The documentation of immigration status in patient records poses a challenge to clinicians. On one hand, recording this social determinant of health can facilitate continuity of care and improved communication among clinicians. On the other, it might expose patients or their family members to immediate and unforeseen risks, such as being stigmatized and discriminated against by nonimmigrant-friendly clinicians or being exposed to immigration enforcement if staff contact immigration officials in violation of patient confidentiality...
January 1, 2019: AMA Journal of Ethics
Stephen P Wood
This first-person narrative describes some of the barriers to caring well for patients at the intersection of human trafficking and substance use disorder. I canvass some of the ethical considerations regarding these patients' autonomy and call for establishing and using evidence-based practice to manage these complex scenarios.
December 1, 2018: AMA Journal of Ethics
Kelsey Walsh
Resources from the American Medical Association (AMA) Archives facilitate historical consideration of how physicians' authority has been exercised in naming diseases, epidemics, and other health-related issues of national importance. Selected images emphasize physicians' roles in motivating public health initiatives through public service posters, advertisements, and minutes of the AMA House of Delegates meetings.
December 1, 2018: AMA Journal of Ethics
Marvin J H Lee
Addressing the question of how medicine should engage with people who consider their clinical disease condition to be importantly constitutive of their identity, this article focuses on one group-advocates for the fat acceptance (FA) or body positivity movement in American society. Drawing on philosophical analysis, I try to show that FA and physician communities represent different traditions within the larger culture and that whether obesity should be considered a disease is a culture battle. I argue that diseases (medical) and illnesses (cultural) are 2 different designations of clinical symptoms and that both disease and illness designations can change over time or be uncertain...
December 1, 2018: AMA Journal of Ethics
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