Sanctuary Doctoring

In my previous post I shared an episode in the life of the Syrian asylum seekers, the Guevaras, where a member of their party became injured. They were reluctant to seek medical assistance with the, what turned out to be well founded, fear that the Red Cross would hand them in to the authorities. This got me thinking about the role of the medical professional when it comes to helping asylum seekers and refugees (displaced individuals in general) without documentation. In this post I’ll discuss some of the ethical considerations, the intersection between societal and individual care, and some approaches to caring for vulnerable individuals

Ethical Considerations

Using the four pillars approach, the healthcare professional can be seen as adhering to beneficence and non maleficence by providing healthcare to asylum seekers. It is well documented that alongside physical aliments, psychiatric conditions are rampant among such populations and can be aggravated by antagonizing interactions with the medical profession- therefore it is beneficent to treat the patient in a manner which is considerate to the traumatic experiences accumulated through the process of displacement.Such an interaction can build trust between the patient and practitioner, setting up the framework for the patients to engage with the doctor in a stronger therapeutic alliance to result in better care. This also has the knock on effect of them being more likely to approach medical services for treatment in future scenarios. In this sense the doctor is non maleficent, as they are preventing potential harm. Either way whether the patient wants to be treated or not, the doctor must respect their autonomy.Can this respect for patient autonomy extend to their desire for legal immunity? I would posit yes, in deference to a broader understanding of the universal ‘right to health’.

The Universal Right to Health

The right to health, in the sense I am to talk of it, must be understood holistically. The surface level supply of medical treatment, ie through clinical practice (from critical ‘warzone’ care to longer term infrastructures such as hospitals), still stands and is implementable through organisations such as MSF or The White Helmets. However an individual’s health is affected by socioeconomic factors- such as societal pressures of living in camps or even worse detention centers: insecurity, trauma, malnutrition to name but a few – and it is with this understanding of health that it is proposed we must frame this right.

This is where healthcare becomes political, precipitating the notion of a ‘hybrid methodology’ . In order to treat the patient the doctor must also address the wider social factors which are contributing to their ill health such as financial insecurity, family responsibilities and societal ostracization. This is not to say, for example, that physicians should pack up their clinics and jump on the streets to advocate for their patient’s right to remain in the country- rather it is the implementation of ‘cultural competency’ in their practice, by paying attention to social determinants of health when composing and delivering treatment plans.

Methodologies

Striking the balance between professional integrity and advocating for a patient who is undocumented or displaced is difficult to execute in reality. However during my research I came across the concept of ‘Sanctuary Doctoring’ which aims to reconcile this:

The sanctuary doctoring approach combines the emotional support of an empathetic physician-patient relationship with patient empowerment by supporting patient networking and identifying helpful actions the patient can take

AMA J Ethics. 2019;21(1):E78-85. doi: 10.1001/amajethics.2019.78.

Patient empowerment is broken down further subcategories

Dialogue: There can be a lack of common ground between physician and patient, and a lack of constructive experiences with the healthcare profession can result in a slithered relationship from which follows a hesitant sharing of information or acceptance of treatment. The paper suggests clear signposting ‘utilizing written materials, signage, and wearable buttons that transmit a clear message to patients that they are welcome to raise immigration-related concerns’, so individuals know that the clinic is a safe space for them to navigate and interact with.

Reassurance: If a patient signals a desire to discuss their immigration status, the physician must be in a position to provide reassurance to feelings of shame, isolation or trepidation. The paper suggests ‘contextualizing the patient’s situation helps the patient to see his or her situation as commonplace. Physicians can simply address a sense of isolation by saying, for example, “Many people are going through similar struggles right now. You are not alone.” Explaining that there are medical reasons why physicians wish to discuss these matters can contextualize and normalize this conversation.‘ Furthermore,as the Guevaras were concerned about the disclosure of their immigration status, the paper suggest that doctors should also reassure patients that they would respect following confidentiality protocols.

Resources: Directing patients towards accessing legal resources ( preferably non private reputable NGO organisations), and network building opportunities continues to implement the patient’s experiences and concerns in the development of the treatment plan. ‘By identifying these local resources and listing them in the brochure, clinicians would be offering a great service.’

Emergency Plan: ‘People who fear sudden detention and deportation might live with a myriad of related fears concerning, for example, what will happen to their children in such an event. It would be beyond the scope of most physicians to help the patient develop a comprehensive emergency plan

‘Sanctuary Doctoring’ is underscored by a ‘Capabilities Approach’ ( Martha Nussbaum). With the aim to promote human capability, this approach encourages vulnerable patients to reflect on what they are able to do and to be, with the knowledge of the existing resources available to them. Crucially this fosters self awareness, building the foundation for sustainable treatment.

Conclusion

It is abhorrent know that a construction as arbitrary as political borders prevents people accessing high quality healthcare and I agree that it is truly an

‘imaginary divide between upholding societal values and promoting patient beneficence’

(Asgary and Smith 2013)

In clinical practice I can imagine that navigating laws, and situational nuance is far more complicated than I’ve presented with my limited real life experience, however I hope that at some point in the future i’ll be able to provide that dimension. If you wish to add anything that I have missed, or share personal experiences please do leave a comment.

Bibliography

https://journalofethics.ama-assn.org/article/ama-policies-and-code-medical-ethics-opinions-related-health-care-patients-who-are-immigrants/2019-01

https://journalofethics.ama-assn.org/article/how-should-health-care-professionals-address-social-determinants-refugee-health/2019-03

https://www.tandfonline.com/doi/abs/10.1080/15265161.2013.794885

https://www.tandfonline.com/doi/abs/10.1080/15265161.2013.794879

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1753-6405.2009.00336.x

https://onlinelibrary.wiley.com/doi/full/10.1111/bioe.12473

https://bjgp.org/content/59/567/765

https://www.aafp.org/fpm/2017/0700/p21.html

https://www.latimes.com/world-nation/story/2020-05-25/asylum-seekers-keep-border-clinic-open-during-pandemic

https://journalofethics.ama-assn.org/article/good-sanctuary-doctoring-undocumented-patients/2019-01

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