Role of Hospital Ethics Boards in the Care of Immigration Detainees

Immigration detention is the fastest growing form of incarceration in the U.S., with over 300,000 immigrants detained annually and over 30,000 detainees held at any one time. These detainees are held in a heterogeneous mix of over 450 public and private jails, prisons and detention centers, all of which must have a system in place for transferring detainees to a nearby hospital when they become ill or require specialized care. These hospitals are reimbursed based on terms of a contract with ICE or another part of the Department of Homeland Security, the Division of Immigration Health Services (DIHS). Our involvement in advocating for improved medical care for approximately 50 individual detainees over two years has revealed several common challenges for hospitals in providing care to detainees. Medical staff may confront issues during admission or clinic visits including access to shackled patients, lack of privacy during examination, limited medical records from referring detention centers and necessity for prior approval from ICE/DIHS for some types of medical care. In addition, hospital staff may have concerns about the availability of follow up diagnostic testing, care and medications that stem from a detainees' initial visit. Particular challenges are apparent for visits relating to cancer and HIV. We have reported on several deaths among detainees who were denied testing or care originally ordered by a hospital consultant. In one instance, a detainee with a bleeding penile lesion was seen by a urologist who recommended a biopsy, which was denied by ICE/DIHS as elective. This detainee later died of metastatic penile cancer. In other instances, ICE personnel have approached hospital staff to elicit immigration status about patients, resulting in arrest of patients by ICE. In discussing these issues with hospitals, we have learned that many are unaware of the conditions of their contract with ICE. We advocate participation of the ethics board in any discussion of initiating or reviewing a hospital contract with ICE. Because these contracts generally grant medical decision making to hospital medical staff, they could be more precisely worded to promote humane, ethical care and include references to follow-up testing and care for detainees. Hospital ethics boards are uniquely resourced to review the terms of care provided to ICE detainees and make recommendations to ensure ethical care for detainees and advocate for continuity of care or testing initiated in their institutions.