Migrants

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Migrants Health Care

• Donna Knapp van Bogaert
• Steve Biko Centre for Bioethics

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• In a world of global inequalities, discrimination
  and brutality, are states ethically obliged to
  open their boundaries as wide as is economically
  reasonable to migrants?
• Is migration a basic human right or should the
  claims made by migrants be overridden by the
  principle of national sovereignty - that the
  moral responsibility of states is only to their
  own citizens?

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Outline

• (Ask why health care resources are constrained -
  questions of adequate management of healthcare
  resources.)
• 1) Remark on migrants and national sovereignty
• 2) Consider the ethical mandates of impartiality
  and universality
• 3) Sketch out why medicine is a moral enterprise

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Migration Fundamental Moral Contradiction

• National Sovereignty versus Human Rights
• Conflicting rights and claims by those migrating
  from a country.
• Concerns of governments their citizens about
  the control of their borders and protection from
  both real and perceived threats.

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Migration Coercion

• Migration particular difficult complex issue
  because directly or indirectly, coercion is
  involved.
• Within countries, restrictions or redistribution
  of people involves the exercise of coercion.
• Across and between international borders coercion
  is also evident.
• Consider- Transport negotiations, refugee
  confinement camps, border police, employment of
  illegal migrants, payments to agents, etc.
• Coercion is always morally wrong because it shows
  no respect for persons.

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Ethics Universality Impartiality
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Ethics Universality Impartiality

• Post modernism, which disrupted the fabric of
  moderninity, still has not successfully removed
  the modernist idea of universality.
• While universal laws play themselves out in
  different venues and demands on place and agents,
  ultimate moral principles have long been regarded
  as inviolate across people.
• The Law may vary from time to time place to
  place
• Moral laws remain constant they are universal
  in that they apply consistently to all humans
  everywhere at any time in any place.

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Impartiality

• A corollary of universality, used in this way is
  (or should be) impartiality.
• It has long been a tenet of moral philosophy that
  moral principles and moral agents ought to be
  treat people in the same way.
• As we are human, so we are moral agents.

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Impartiality

• On this the two major contenders of modern moral
  theories agree
• In the Benthamite caucus everyone counts for one,
  no one for more than one
• Kants second formulation of the categorical
  imperative treating people as ends in
  themselves also promotes impartiality
• Respecting the rationality personified in others
  may require us to do different things for
  different people or with different people. But
  that is not a expression of our impartial respect
  for each and every other human.
• It is sometimes required that we treat different
  people differently but this does not equal a
  reduction in our obligation to respect the
  dignity and worth of others.

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Universality, Impartiality Duties to Others

• Arguably, at least, a significant characteristic
  of any moral theory is that universality and
  impartiality are embodied as basics in its moral
  code.
• In contrast to the impartiality of general moral
  laws, we all have special duties to some people
  that we do not have to others.
• General duties tell us how we should treat
  everyone, special duties vary from person to
  person.

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What is a Duty?

• A duty is an obligation to do or refrain from
  doing something
• If we have a duty to a person-then we are bound
  to (that) person in some respect and for some
  reason.
• We owe that person something and that person may
  hold a corresponding right or claim against us.

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General Special Duties

• There are some general duties" we have towards
  other humans merely because they are human.
• Over and above that, there are also special
  duties we have towards particular individuals
  just because they stand in a special relation to
  us.
• Amongst these are generally supposed to be
  special duties to our families and friends.
• Because we also have roles, special duties extend
  to e.g. our students our patients.
• Also amongst special duties we are told that we
  have special duties towards our countrymen.

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Special Duties

• Special duties bind particular people to
  particular other people.
• Just how this particularism of special duties
  fits in with the universality and impartiality of
  the general law is problematical.
• Some say that this is another branch of moral
  law.
• Some say that it is derivative in some way from
  more general moral laws.
• Others says that particularism marks the limits
  of our psychological capabilities for living up
  to the austere standards that the general moral
  law sets for us.

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Special Duties psychological note

• Questioning what we mean by special duties.
• When we consider what type of special treatment
  is due to those who stand in a special relations
  to us, ordinarily we envision this to be
  especially good treatment.

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Special Duties psychological note

• We want not the ordinary, but the very best for
  our families, friends, and compatriots.
• But if we interrogate the latter classification
  of those to whom we have special duties, we are
  obliged to admit that this is not completely
  true.
• It may well be a matter of degree.
• A particularist approach is interesting in that
  it has the further effect of compelling us
  reconsider the basis of our general duties to
  compatriots, with yet additional political
  consequences.

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Particularist

• Morally, what matters is not nationality per se.
• What matters is instead some further feature that
  is only contingently and imperfectly associated
  with a shared nationality.
• Such a characteristic (or characteristics) may
  sometimes be found in migrants as well as our
  fellow citizens.
• When this dynamic is unpacked, we will find we
  have duties toward migrants that are similar in
  their moral basis, and perhaps in their strength,
  to the ties we ordinarily acknowledge toward our
  fellow citizens.

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Non-Nationals

• At least in some ways, we are obliged to be more
  careful not less in our treatment of non
  nationals that we are in the treatment of our own
  citizens.
• At least some of our general duties to those
  beyond our borders and to migrants within them
  are sometimes more compelling, morally speaking,
  than to at least some of our special duties to
  our fellow citizens.

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Moral Basis of Healthcare Practice
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• Medicine is not only a science, it is an art.
  Science is primarily analytic, art primarily
  synthetic. Medicine is likely to remain an art,
  however hard we may try to make it more and more
  scientific, and however much we may attempt to
  master its scientific contents. For medicine
  deals not with impersonal atoms, elements or
  plants with tropisms but with humans.
  (Ackerknecht 1982xvii)

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Moral Basis of Healthcare Practice

• Health care is a human activity limited by the
  human experience as finite beings.
• Health care practice is an attempt to apply
  empirical data which may no respond favorably to
  the laws of medical science. The end of medicine,
  its justifying principle is in the final analysis
  a moral one the good of the person seeking
  help (Pellegrino Thomasma 2000).
• Three moral groundings

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1) Unequal Power Trust in the Patient Health
Care Professional (HCP) Relationship

• Intrinsic nature of illness because it is
  illness is a universal phenomenon that makes
  healthcare a special activity.
• This state engages the virtue of trust from the
  patient upon the healthcare worker.
• Vulnerability of patient as uniquely dependent,
  anxious, and liable for exploitation.
• Sick persons must bare their weaknesses, reveal
  intimacies of body mind.

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2) Characteristic of Medical Knowledge

• Healthcare knowledge is not proprietary.
• Acquired through privilege of education.
• Society sanctions certain invasions of privacy in
  the name of medicine e.g. dissecting bodies,
  participation in care of sick, research with
  human participants to ensure society has
  trained healthcare personnel.
• Medical knowledge not private in the sense that
  medical knowledge is held in trust for the good
  of the sick.

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3) Ineradicable Moral Complicity of the HCP in
Whatever Happens to the Patient.

• Implicit moral complicity necessary for healing
  process to be achieved.
• The HCP is therefore de facto a moral accomplice
  in whatever is done for good or ill to the
  patients.
• The obligation to serve the patients good cannot
  be overridden by any third party such as ones
  employer, the state, fiscal policy or the law
  (Pellegrino Thomasma 200042-98).

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Duty of Easy Rescue

• Emergency care In the professional opinion of
  the health care clinician is immediately
  necessary.
• Migrants should not be allowed to die or suffer
  serious harm when we are easily able to prevent
  it.

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Post Script

• If there are moral rights which, unlike legal
  rights, are universal timeless and, if access
  to health care is considered a human right, who
  then is considered 'human enough' to have that
  right?

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References

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  Self-Determination Moral Foundations for
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  (4).
• Goodin, RE. 1988. What is so special about our
  fellow countrymen? Ethics, (98)663-686
• Landau. LB. 2006. Transplants and Transients
  Idioms of Belonging and Dislocation in
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• Noonan, J. 2007. Social Conflict and the Life
  Ground of Value. Philosophy Today, ( 51) 4.
• Pellegrino, ED. 1979. Toward a reconstruction of
  medical morality the primacy of the act of
  profession and the fact of illness. Journal of
  Medicine and Philosophy, 3 (1) 32-56.
• Pellegrino, ED Thomasma DC. 1993. The Virtues
  in Medical Practice. NY Oxford University Press.
  
• Pellegrino ED. 1999. The Commodification of
  Medical and Health Care The Moral Consequences
  of a Paradigm Shift from a Professional to a
  Market Ethic. The Journal of Medicine and
  Philosophy , 24 (3) 243-266.

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Thank you Donna.VanBogaert_at_wits.ac.za