Hospitals as places of sanctuaryBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2178 (Published 17 May 2018) Cite this as: BMJ 2018;361:k2178
- Altaf Saadi, neurologist1,
- Martin McKee, professor of European Public Health
- 1National Clinician Scholars Program, University of California Los Angeles, California, USA
- 2London School of Hygiene and Tropical Medicine, London, UK
- Correspondence to: A Saadi
Migration has become one of the greatest challenges of the early 21st century. The British and American governments have intensified efforts to find and deport people believed to be in the country without authorisation. Health professionals find themselves in an ethical dilemma between their duty to provide care to patients and their governments’ political agendas. But though both countries pursue the same objective, they are doing so in different ways, each with implications for health professionals.
In the US, immigration enforcement is largely in the hands of Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP). Since the 2017 presidential inauguration, enforcement at or near health facilities has increased, although both organisations’ internal policies deem hospitals to be “sensitive locations,” where immigration enforcement is to be avoided.1 High profile cases have contributed to a climate of fear that creates anxiety and hopelessness among immigrants, who fear detention and deportation of themselves or members of their community.2 Efforts by health professionals have focused on how to reduce fear and on ensuring that all immigrants feel safe when accessing necessary healthcare services. One approach has been to avoid collection of data on immigration status.
The UK has taken a different approach. It has forced health workers to become enforcers. They must demand evidence of immigration status before providing hospital treatment,3 contributing to what ministers describe as a “hostile environment” in which evidence must be produced to take up employment, find accommodation, and much else, a process that has been described as “weaponising paperwork.”4 Anyone failing to comply faces possible financial penalties. Such measures have been difficult to impose in the US, with its combination of federal safeguards on privacy and local measures. The designation of “sanctuary” cities or states, for example, attempts to protect immigrants by limiting local and federal cooperation on immigration enforcement.
Care without fear
The ethical arguments against any measure that deters people in need from seeking treatment are enshrined in the Hippocratic oath. The public health arguments are many: people with preventable or chronic conditions risk delays that may worsen their condition and increase visits to emergency departments, and those with untreated infectious diseases may spread them. The associated fear has also been shown to be harmful, with recent research in the US linking worry about deportation with raised cardiovascular risk factors, while a large ICE raid was associated with reduced birth weight among Latina mothers.56 Evidence is also growing of psychological damage not only to those who are deported but also their families,7 and those from the same ethnic group who are citizens.8
Faced with official hostility and indifference, health professionals in both countries have organised to oppose policies that threaten patients. In the UK, Docs Not Cops has publicised abuses,9 and Doctors of the World provides care for those afraid to access the NHS, such as victims of the 2017 fire at Grenfell Tower.10 They have had some success, with the government climbing down on some of its plans to share NHS data with the immigration authorities,11 aided by an extremely critical report by the House of Commons Health and Social Care Committee.12 However, these non-profit organisations are limited in what they can do, and NHS hospitals continue to display posters reminding people that they must prove their status before obtaining care, symbolising a culture—whether intended or not—that those who have any uncertainty about their status should stay away.
Health professionals in the US have adopted the concept of “sanctuary hospitals” and “sanctuary doctoring.”13 The San Francisco Department of Health promotes a welcoming culture with statements and signage that declare, “You’re Safe Here!”14 and New York City Health and Hospitals issued an “open letter to immigrant New Yorkers” as part of a “Seek Care Without Fear” message reassuring immigrant patients.15 Other healthcare facilities have implemented written policies that restrict cooperation with ICE to a minimum, train staff not to provide information without a court warrant, and distribute leaflets to patients educating about their rights. In some states, such as California, they have been supported by legislation that limits hospitals’ ability to collaborate with federal agencies such as ICE.
International transfer of ideas is inevitably constrained by context—in particular, differing constitutional, legal, and cultural situations. However, for British health professionals, the concept of a “sanctuary hospital” or “sanctuary doctoring” should have considerable attraction, saying to everyone in need of care that they are welcome, they will be treated regardless of their status, and that, while those treating them may be forced to comply with intrusive and oppressive laws, they will do so to the least extent possible. Similarly, US health professionals can learn from, and feel bolstered by, their British counterparts’ campaigns to restore medical ethical principles and values of compassion and a right to healthcare, regardless of background.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.