Illegal Immigrants, Health Care, and Social Responsibility
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Illegal Immigrants,
Health Care, and
Social Responsibility
by JAMES DWYER
"Nationalists" argue that illegal immigrants have no claim to health benefits because people who
have no right to be in a country have no right to benefits in that country. "Humanists" say access to care is
a basic human right and should be provided to everyone, recognized citizens and illegal immigrants alike.
Neither view is adequate.
I
llegal immigrants form a large and disputed phenomenon of illegal immigration and adequately
group in many countries. Indeed, even the name reflects the complexity of moral thought. There may
is in dispute. People in this group are referred to be important ethical distinctions, for example,
as illegal immigrants, illegal aliens, irregular mi- among the following groups: U.S. citizens who lack
grants, undocumented workers, or, in French, as sans health insurance, undocumented workers who lack
papiers. Whatever they are called, their existence rais- health insurance in spite of working full time, med-
es an important ethical question: Do societies have ical visitors who fly to the United States as tourists in
an ethical responsibility to provide health care for order to obtain care at public hospitals, foreign citi-
them and to promote their health? zens who work abroad for subcontractors of Ameri-
This question often elicits two different answers. can firms, and foreign citizens who live in impover-
Some people—call them nationalists—say that the ished countries. I believe that we—U.S. citizens—
answer is obviously no. They argue that people who have ethical duties in all of these situations, but I see
have no right to be in a country should not have important differences in what these duties demand
rights to benefits in that country. Other people—call and how they are to be explained.
them humanists—say that the answer is obviously In this paper, I want to focus on the situation of
yes. They argue that all people should have access to illegal immigrants. I will discuss several different an-
health care. It's a basic human right. swers to the question about what ethical responsibil-
I think both these answers are off the mark. The ity we have to provide health care to illegal immi-
first focuses too narrowly on what we owe people grants. (I shall simply assume that societies have an
based on legal rules and formal citizenship. The ethical obligation to provide their own citizens with
other answer focuses too broadly, on what we owe a reasonably comprehensive package of health bene-
people qua human beings. We need a perspective fits.) The answers that I shall discuss tend to con-
that is in between, that adequately responds to the ceptualize the ethical issues in terms of individual
desert, professional ethics, or human rights. I want to
James Dwyer, "Illegal Immigrants, Health Care, and Social Responsi-
discuss the limitations of each of these approaches
bility," Hastings Center Report 34, no. 5 (2004): 34-41. and to offer an alternative. I shall approach the issues
HASTINGS CENTER REPORT January-February 2004in terms of social responsibility and
discuss the moral relevance of work.
In doing so, I tend to pull bioethics in ac© a s -fir©©
the direction of social ethics and po-
litical philosophy. That's the direction
I think it shotild be heading. But be-
fore I begin the ethical discussion, I to
need to say more about the phenom-
enon of illegal immigration.
oaiD lb©[n]©'i?D'Ss.
P eople have always moved around.
They have moved for political,
environmental, economic, and famil-
Africans in France. But the phenome- economy. In general, they have the
non is really much more diverse and worst jobs and work in the worst con-
ial reasons. They have tried to escape complex. Illegal immigrants come ditions in such sectors of the econo-
war, persecution, discrimination, from hundreds of countries and go my as agriculture, construction, man-
famine, environmental degradation, wherever they can get work. There are ufacturing, and the food industry.
poverty, and a variety of other prob- undocumented workers from Indone- They pick fruit, wash dishes, move
lems. They have tried to fmd places to sia in Malaysia, undocumented work- dirt, sew clothes, clean toilets.
build better lives, earn more money, ers from Haiti in the Dominican Re- Japan is a good example of this. In
and provide better support for their public, and undocumented workers the 1980s many foreign workers came
families. A strong sense of family re- from Myanmar in Thailand. Thai- to Japan from the Philippines, Thai-
sponsibility has always been an im- land is an interesting example because land, China, and other countries.
portant factor behind migration.' it is both a source of and a destination Yoshio Sugimoto summarizes the sit-
But while human migration is not for undocumented workers: while uation:
new, illegal immigration is, since only many people from poorer countries The unprecedented fiow of foreign
recently have nation-states tried to have gone to work in Thailand, many workers into Japan stemmed from the
control and regulate the flow of im- Thais have gone to work in richer situations in both the domestic and
migration. Societies have always tried countries. foreign labor markets.
to exclude people they viewed as un- Since illegal activities are difficult "Pull" factors within Japan includ-
desirable: criminals, people unable to to measure, and people are difficult to ed the ageing of the Japanese work-
support themselves, people with con- count, we do not know exactly how force and the accompanying shortage
tagious diseases, and certain ethnic or many people are illegal immigrants. of labor in unskilled, manual, and
racial groups. But only in the last The following estimates provide a physically demanding areas. In addi-
hundred years or so have states tried rough idea. The total number of ille- tion, the changing work ethic of
in a systematic way to control the gal immigrants in the U.S. is proba- Japanese youth has made it difficult
number and kinds of immigrants. bly between five and eight million. for employers to recruit them for this
In contrast, what the Athenian About 30-40 percent of these people type of work, which is described in
polis tried to control was not immi- entered the country legally, but over- terms of the three undesirable Ks (or
gration, but citizenship. Workers, stayed their visas. Of all the immi- Ds in English): kitanai (dirty), kitsui
merchants, and scholars came to grants in Europe, about one third are (difficult), and kiken (dangerous).
Athens from all over the Mediter- probably illegal immigrants. A small Under these circumstances, a number
ranean world. They were free to work, country like Israel has about 125,000 of employers found illegal migrants,
trade, and study in Athens, although foreign workers (not counting Pales- in particular from Asia, a remedy for
they were excluded from the rich po- tinians). About 50,000 of these are in their labor shortage.^ The pattern is
litical life that citizens enjoyed. Today, the country illegally.^ much the same in other countries.
political states try to control both cit- I believe that a sound ethical re- In the global economy, in which a
izenship and residency. sponse to the question of illegal im- company can shift its manufacturing
Modern attempts to control resi- migration requires some understand- base with relative ease to a country
dency are not remarkably effective. ing of the work that illegal immi- with cheaper labor, illegal immigrants
There are illegal immigrants residing grants do. Most undocumented often perform work that cannot be
and working all over the globe. When workers do the jobs that citizens often shifted overseas. Toilets have to be
people think about illegal immi- eschew. They do difficult and dis- cleaned, dishes have to be washed,
grants, they tend to focus on Mexi- agreeable work at low wages for small and children have to be watched local-
cans in the United States or North- firms in the informal sector of the ly. This local demand may help to ex-
January-February 2004 HASTINGS CENTER REPORTplain a relatively new trend: the femi- deceptive promises and felse accounts laws, but the deepest arguments for
nization of migration. Migrants used of jobs, then transport them under and against it remain very much alive.
to be predominantly young men, horrible and dangerous conditions. If Because they will probably surface
seeking work in areas such as agrictil- and when the immigrants arrive in again, at a different time or in differ-
ture and construction. But that pat- the destination country, they are con- ent place, it is worthwhile evaluating
tern is changing. More and more trolled by debt, threat, and force. the ethical frameworks that they as-
women migrants are employed in the Some become indentured servants, sume.
service sector as, for example, maids, working without pay for a period of The first argument put forward is
nannies, and health care aides. time. Others are controlled by physi- that illegal aliens should be denied
Women migrants are also em- cal threats or threats to expose their il- public benefits because they are in the
ployed as sex workers. The connec- legal status. A few are enslaved and country illegally. Although it is true
tion between commercial sex and ille- held as property. that illegal aliens have violated a law
gal immigration is quite striking. As Not all illegal immigrants are vic- by entering or remaining in the coun-
women in some societies have more tims, however, and an accurate ac- try, it is not clear what the moral im-
money, choices, schooling, and count of illegal immigration, even if plication of this point is. Nothing
power, they are unwilling to work as only sketched, must capture some of about access to health care follows
prostitutes. These societies seem to be its complexity. My task is to consider from the mere fact that illegal aliens
supplying their demands for commer- how well different ethical frameworks have violated a law. Many people
cial sex by using undocumented deal with that complexity. break many different laws. Whether a
workers from poorer countries. Be- violation of a law should disqualify
fore brothels were legalized in the A Syiatter of Desert people from public services probably
Netherlands, about 40 to 75 percent depends on the nature and purpose of
of the prostitutes who worked in Am- the services, the nature and the gravi-
sterdam were undocumented work-
ers. About 3,000 of the 7,000 prosti-
T he abstract ethical question of
whether societies have a responsi-
bility to provide health care for illegal
ty of the violation, and many other
matters.
tutes in Berlin are from Thailand. immigrants sometimes becomes a Consider one example of a viola-
Japan has over 150,00 foreign prosti- concrete political issue. Rising health tion of the law. People sometimes
tutes, most of them from Thailand, care costs, budget reduction pro- break tax laws by working off the
China, and the Philippines. Thailand grams, and feelings of resentment books. They do certain jobs for cash
has about 25,000 prostitutes from sometimes transform the ethical ques- in order to avoid paying taxes or los-
Myanmar.^ tion into a political debate. This has ing benefits. Moreover, this practice is
Even when prostitution is volun- happened several times in the United probably well quite common. I re-
tary, it is difficult and dangerous. States. In 1996, the Congress debated cendy asked students in two of my
Leah Platt notes that prostitution is and passed the "Illegal Immigration classes if they or anyone in their ex-
Reform and Immigrant Responsibili- tended family had earned money that
"a job without overtime pay, health ty Act." This law made all immigrants was not reported as taxable income.
insurance, or sick leave—and usu- ineligible for Medicaid, although it In one class, all but two students
ally without recourse against the did allow the federal government to raised their hands. In the other class,
abuses of one's employer, which reimburse states for emergency treat- every hand went up.
can include being required to have ment of illegal immigrants. No one has su^ested that health
sex without a condom and being
In 1994, the citizens of California care facilities deny care to people sus-
forced to turn tricks in order to
debated Proposition 187, an even pected of working off the books. But
work off crushing debts."'
more restrictive measure. This ballot undocumented work is also a viola-
And for some illegal immigrants, initiative proposed to deny publicly tion of the law. Furthermore, it in-
prostitution is not a voluntary choice. funded health care, social services, volves an issue of feirness because it
Some are deceived and delivered into and education to illegal immigrants. shifi:s burdens onto others and dimin-
prostitution. Others are coerced, their This law would have required pub- ishes funding for important purposes.
lives controlled by pimps, criminal licly funded health care facilities to Of course, working off the books and
gangs, and human trafiPickers. deny care, except in medical emer- working without a visa are not alike
Some of the worst moral offenses gencies, to people who could not in all respects. But without Rirther ar-
occur in the trafficking of human be- prove that they were U.S. citizens or gument, nothing much follows about
ings, but even here it is important to legal residents. whether it is right to deny benefits to
see a continuum of activities. Some- This proposition was approved by people who have violated a law.
times traffickers simply provide trans- 59 percent of the voters. It was never Proponents of restrictive measures
portation in exchange for payment. implemented because courts found also appeal to an argument that com-
Sometimes, they recruit people with that parts of it conflicted with other bines a particular conception of desert
3© HASTINGS CENTER REPORT January-February 2004with the need to make trade-offs.
Proponents of California's Proposi-
tion 187 stated that, "while our own
citizens and legal residents go wanti- A simple appeal to a comprehensive human right
ng, those who chose to enter our
country ILLEGALLY get royal treat- avoids hard questions about duties and priorities.
ment at the expense of the California
taxpayer."^ Proponents noted that the
legislature maintained programs that asked to give an award for the best low taxes but use the library quite
included free prenatal care for illegal student in chemistry, a narrow notion often. In thinking about the public li-
aliens but increased the amount that of desert is appropriate and useful. brary, we should consider questions
senior citizens must pay for prescrip- But publicly funded health care is dif- such as the following. What purposes
tion drugs. They then asked, "Why ferent and requires a broader view of does the library serve? Does it pro-
should we give more comfort and desert. mote education, provide opportunity,
consideration to illegal aliens than to The discussion of restrictive mea- and foster public life? Does it tend to
our own needy American citizens?" sures often focuses on desert, taxa- ameliorate or exacerbate social injus-
The rhetorical question is part of tion, and benefits. Proponents tend tice? Given the library's purposes,
the argument. I would restate the ar- to picture illegal immigrants as free who should count as its constituents
gument in the following way: Given riders who are taking advantage of or members? And what are the rights
the limited public budget for health public services without contributing and responsibilities of the library
care, U.S. citizens and legal residents to public funding. Opponents are users? In the following sections, I
are more deserving of benefits than quick to note that illegal immigrants shall consider analogous questions
are illegal aliens. This argument do pay taxes. They pay sales tax, gas about illegal immigrants and the so-
frames the issue as a choice between tax, and value-added tax. They often cial institutions that promote health.
competing goods in a situation of pay income tax and property tax. But
limited resources. do they pay enough tax to cover the A Matter of Professiona!
There is something right and cost of the services they use? Or more Ethics
something wrong about this way of generally, are illegal immigrants a net
economic gain or a net economic loss
framing the issue. What is tight is the
idea that in all of life, individual and
political, we have to choose between
for society?
Instead of trying to answer the
S ome of the most vigorous respons-
es to restrictive measures have
come from those who consider the
competing goods. A society cannot economic question, I want to point issue within the framework of profes-
have everything: comprehensive and out a problem with the question it- sional ethics. Tal Ann Ziv and
universal health care, good public self The question about taxation and Bernard Lo, for example, argue that
schools, extensive public parks and benefits tends to portray society as a "cooperating with Proposition 187
beaches, public services, and very low private business venture. On the busi- would undermine professional
taxes. What is false is the idea that we ness model, investors should benefit ethics."^ In particular, they argue that
have to choose between basic health in proportion to the fiinds they put cooperating with this kind of restric-
care for illegal aliens and basic health into the venture. This may be an ap- tive measure is inconsistent with
care for citizens. Many other trade- propriate model for some business physicians' "ethical responsibilities to
offs are possible, including an in- ventures, but it is not an adequate protect the public health, care for
crease in public funding. model for all social institutions and persons in medical need, and respect
The narrow framework of the de- benefits. The business model is not patient confidentiality."*
bate pits poor citizens against illegal an adequate model for thinking Restrictive measures may indeed
aliens in a battle for health care re- about voting, legal defense, library have adverse effects on the public
sources. Within this framework, the services, minimum wages, occupa- health. For example, measures that
issue is posed as one of desert. Avoid- tional safety, and many other social deny care to illegal aliens, or make
ing the idea of desert is impossible. benefits. them afraid to seek care, could lead to
After all, justice is a matter of giving Consider my favorite social insti- an increase in tuberculosis. And
people their due—giving them what tution: the public library. The impor- physicians do have a professional
they deserve. But a narrow concep- tant question here is not whether obligation to oppose measures that
tion of desert seems most at home in some people use more library services would significantly harm the public
allocating partictilar goods that go be- than they pay for through taxation, health. But the public health argu-
yond basic needs, in situations where which is obviously true. Some people ment has a serious failing, if taken by
the criteria of achievement and effort pay relatively high taxes but never use itself It avoids the big issue of
are very clear. For example, if we are the library, while others pay relatively whether illegal immigrants should be
January-February 2004 HASTINGS CENTER REPORT 37considered part of the public and ethics. In their view, screening out il- responsibility to work to realize this
whether public institutions should legal aliens conflicts with physicians' idea.
serve their health needs. Instead of ethical responsibility to "care for per- There is something appealing and
appealing to an inclusive notion of sons in medical need."'^ plausible about this interpretation,
social justice, the argument suggests This claim is important, but am- but it too goes beyond professional
how the health of illegal immigrants biguous. It could mean simply that ethics. It has more to do with the na-
may influence citizens' health, and physicians have an obligation to at- ture of social justice and social insti-
then appeals to citizens' sense of pru- tend to anyone who presents to them tutions than with the nature of med-
dence. The appeal to prudence is not in need of emergency care. That ical practice. It makes an ethical claim
wrong, but it avoids the larger ethical seems right. It would be wrong not to based on a belief about social respon-
issues. stabilize and save someone in a med- sibility and an assumption that illegal
The second argument against ical emergency. It would be inhu- aliens are to be counted as members
Proposition 187 is that it restricts mane, even morally absurd, to let of society. I shall try to elaborate this
confidentiality in ways that are not someone die because her visa had ex- belief and assumption later.
justified. It requires health care facili- pired. But a claim that physicians Let me sum up my main points so
ties to report people suspected of have an enduring obligation to pro- far. Political measures that restrict
being in the country illegally and to vide emergency care is consistent medical care for illegal immigrants
disclose additional information to au- with measures like Proposition 187 often involve violations of profession-
thorities. Ziv and Lo argue that and the 1996 federal law. al ethics, and health care professionals
"Proposition 187 fails to provide the The claim might also mean that should oppose such measures. But
usual ethical justifications for overrid- the selection of patients should be the framework of professional ethics
ing patient confidentiality."' Report- based only on medical need, never on is not adequate for thinking about
ing a patient's "immigration status such factors as nationality, residency, the larger ethical issues. It fails to illu-
serves no medical or public health immigration status, or ability to pay. minate the obligation to provide
purpose, involves no medical exper- This is a very strong claim. It means medical care. Furthermore, it fails to
tise, and is not a routine part of med- that all private practice is morally consider factors such as work and
ical care."'" Thus this restriction on wrong. It means that most national housing that may have a profound
confidentiality is a serious violation of health care systems are too restrictive. impact on health. In the next two
professional ethics. It means that transplant lists for or- sections I shall consider broader
But if restrictive measures work as gans donated in a particular country frameworks and discourses.
designed, issues of confidentiality should be open to everyone in the
may not even arise. Illegal aliens will world. It might even mean that olf Hiomatu Roglhtls
be deterred from seeking medical care physicians have an ethical responsibil-
or will be screened out before they see
a doctor. Thus the issue of screening
may be more important than the
ity to relocate to places where the
medical need is the greatest. I shall
say more about the strong claim in
T o deal with the issue of health
care and illegal immigrants,
some adopt a humanistic framework
issue of confidentiality. First, if the the next section. Here I just want to and employ a discourse of human
screening is carried out, it should not note one point. This claim goes well rights. They tend to emphasize the
be by physicians, because it is not beyond professional ethics. It is an right of all human beings to medical
their role to act as agents for the po- ethical claim that seems to be based treatment, as well as the common hu-
lice or the immigration service. Pro- on a belief about the nature of human manity of aliens and citizens, point-
fessional ethics requires some separa- needs and human rights. ing to the arbitrary nature of national
tion of social roles, and terrible things Finally, Ziv and Lo's claim about borders.
have happened when physicians have physicians' responsibility to care for National borders can seem arbi-
become agents of political regimes. people in medical need might be trary. Distinctions based on national
The bigger issue, though, is not who stronger than the claim about emer- borders seem even more arbitrary
should do the screening, but whether gency care but weaker than the uni- when one studies how borders were
it should be done at all. versal claim. Perhaps we should inter- established and the disparities in
Ziv and Lo note that "clerks will pret it to mean that it is wrong to wealth and health that exist between
probably screen patients for their im- turn patients away when society has countries. Since it doesn't seem just
migration status, just as they current- no other provisions and institutions that some people should be disad-
ly screen them for their insurance sta- to provide them with basic care. The vantaged by arbitrary boundaries, it
tus."" They object to this arrange- idea then is that society should pro- may also seem that people should
ment, and they argue that physicians vide all members with basic health have the right to emigrate from wher-
bear some responsibility for arrange- care and that physicians have some ever they are and to immigrate to
ments that conflict with professional wherever they wish. But does this fol-
HASTINGS CENTER REPORT January-February 2004low from the fact that national bor-
ders can be seen as arbitrary?
John Rawls thinks not. He writes:
It does not follow from the fact
that boundaries are historically ar-
bitrary that their role in the Law of
Peoples cannot be justified. On
the contrary, to fix on their arbi-
trariness is to fix on the wrong
thing. In the absence of a world
state, there must be boundaries of
some kind, which when viewed in
isolation will seem arbitrary, and
depend to some degree on histori- medicine, we still need a plan for
cal circumstances.'3 possibilities. He says that to "tear
ensuring equal access to care. As
down the walls of the state is not. . .
study after study shows the power
Even if boundaries depend on histor- to create a world without walls, but
of effective therapies to alter the
ical circumstances, a defined territory rather to create a thousand petty
course of infectious disease, we
may allow a people to form a govern- fortresses."" Without state regulation
should be increasingly reluctant to
ment that acts as their agent in a fair of immigration, local communities
reserve these therapies for the af-
and effective way. A defined territory may become more exclusionary,
fiuent, low-incidence regions of
may allow a people to form a govern- parochial, and xenophobic. Walzer
the world where most medical re-
ment that enables them to take re- also notes another possibility: "The
sources are concentrated. Excel-
sponsibility for the natural environ- fortresses, too, could be torn down:
lence without equity looms as the
ment, promote the well-being of the all that is necessary is a global state
chief human-rights dilemma of
human population, deal with social sufficiently powerful to overwhelm
health care in the 21st century.'^
problems, and cultivate just political the local communities. Then the re-
institutions.'"^ sult would be . . . a world of radically I too am critical of the gross inequal-
From functions like these, govern- deracinated men and women.""" ities in health within countries and
ments derive a qualified right to regu- Of course, the humanist need not between countries, but here I only
late immigration. This right is not an be committed to an abstract position want to make explicit the framework
unlimited right of communal self-de- about open borders. The humanist and discourse of Farmer's critique.
termination. Societies do not have a might accept that states have a quali- His critique appeals to two ideas:
right to protect institutions and ways fied right to regulate immigration, that there is a lack of proportion be-
of life that are deeply unjust. Further- but insist that all states must respect tween the medical resources and the
more, even when a society has a right the human rights of all immigrants— burden of disease and that there is a
to regulate immigration, there are legal and illegal. That idea makes a lot human right to equal access.
ethical questions about whether and of sense, although much depends on What is wrong with the claim that
how the society should exercise that how we specify the content of human equal access to health care is a human
right. And there are ethical questions rights. right? First, to claim something as a
about how immigrants should be The idea that all human beings right is more of a conclusion than an
treated in that society. should have equal access to all benefi- argument. Such claims function more
The committed humanist, who cial health care is often used to cri- to summarize a position than to fur-
begins with reflections on the arbi- tique both national and international ther moral discussion. A quick and
trary nature of national boundaries, arrangements. In an editorial in the simple appeal to a comprehensive
sometimes reaches the same conclu- New England Journal of Medicine, right avoids all the hard questions
sion as the global capitalist: that all Paul Farmer refiects on the number about duties and priorities. When
restrictions on labor mobility are un- of people who go untreated for dis- faced with grave injustices and huge
justified. In their different ways, both eases such as tuberculosis and HIV. inequalities, claiming that all human
the humanist and the capitalist deval- He writes: beings have a right to health care is
ue distinctions based on political easy. Specifying the kind of care to
Prevention is, of course, always
community. To be sure, there is much which people are entitled is harder.
preferable to treatment. But epi-
to criticize about existing political Specifying duties is harder yet. And
demics of treatable infectious dis-
communities, but we need to be cau- getting those duties institutionalized
eases should remind us that al-
tious about some of the alternatives. is hardest of all.
though science has revolutionized
Michael Walzer warns us about two
January-February 2004 HASTINGS CENTER REPORTIn addition to the general prob- tern that is older and deeper than the employers who violate even the basic
lems with claims about rights, a recent globalization of the economy. standards of a decent society.
problem more specific to the issue of Societies have often used the most We need to take responsibility for
illegal immigration exists. Since a powerless and marginalized people to preventing the old pattern from con-
claim based on a human right is a do the most disagreeable and difficult tinuing, and the key idea is that of
claim based on people's common hu- work. Societies have used slaves, in- "taking responsibility." It is not the
manity, it tends to collapse distinc- dentured servants, castes, minorities, same as legal accountability, which
tions between people. Yet for certain orphans, poor children, internal mi- leads one to think about determining
purposes, it may be important to grants, and foreign migrants. Of causation, proving intention or negli-
make distinctions and emphasize dif- course, the pattern is not exactly the gence, examining excuses, apportion-
ferent responsibilities. We may owe same in every society, nor even in ing blame, and assigning costs. Tak-
different things to, for example, the every industry within a society, but ing responsibiliry is more about see-
poor undocumented worker in our the similarities are striking. ing patterns and problems, examining
country, the middle-class visitor who I see the use of illegal immigrants background conditions, not passing
needs dialysis, the prince who wants as the contemporary form of the old the buck, and responding in appro-
a transplant, people enmeshed in the pattern. But it is not a natural phe- priate ways. A society need not bear
global economy, and the most mar- nomenon beyond human control. It fiiU causal responsibility in order to
ginalized people in poor countries. is the result of laws, norms, institu- assume social responsibility.
Rather than claiming an essential- tions, habits, and conditions in soci- Why should society take responsi-
ly limitless right, it makes more sense ety, and of the conditions in the bility for people it tried to keep out of
to recognize a modest core of human world at large. It is a social construc- its territory, for people who are not
rights and to supplement those rights tion that we could try to reconstruct. social members? Because in many re-
with a robust account of social re- Some might object that no one spects illegal immigrants are social
sponsibility, social justice, and inter- forces illegal immigrants to take unsa- members. Although they are not citi-
national justice. I do not know if vory jobs and that they can return zens or legal residents, they may be
there is a principled way to delineate home if they wish. This objection is diligent workers, good neighbors,
exactly what should be included in too simple. Although most undocu- concerned parents, and active partici-
the core of human rights.'* But even a mented workers made a voluntary pants in community life. They are
short list of circumscribed rights choice to go to another country, they workers, involved in complex
would have important consequences often had inadequate information schemes of social co-operation. Many
if societies took responsibility for try- and dismal alternatives, and volun- of the most exploited workers
ing to protect everyone from viola- tary return is not an attractive option in the industrial revolution—chil-
tions of these rights. Illegal immi- when they have substantial debts and dren, women, men without proper-
grants are sometimes killed in trans- poor earning potential at home. More ty—^were also not full citizens, but
port, physically or sexually abused, importantly, even a fully informed they were vulnerable people, doing
held as slaves, kept in indentured and voluntary choice does not settle ofi:en undesirable work, for whom so-
servitude, forced to work in occupa- the question of social justice and re- ciety needed to take some responsibil-
tions, and denied personal property. sponsibility. We have gone through ity. Undocumented workers' similar
These are clear violations of what this debate before. As the industrial role in society is one reason that the
should be recognized as human revolution developed, many people social responsibility to care for them
rights. But this core of recognized agreed to work under horrible condi- is different from the responsibility to
rights should be supplemented with tions in shops, factories, and mines. care for medical visitors.
an account of social justice and re- Yet most societies eventually saw that If a given society had the ethical
sponsibility. freedom of contract was a limited conviction and political will, it could
part of a larger social ethic. They ac- develop practical measures to trans-
A MaUer of SocoaD cepted a responsibility to address con- form the worst aspects of some work,
ditions of work and to empower empower the most disadvantaged
workers, at least in basic ways. Decent workers, and shape the background
TP'raming the issue in terms of social societies now try to regulate child conditions in which the labor market
JL responsibility helps to highlight labor, workplace safety, minimum operates. The interests of the worst-
one of the most striking features of il- rates of pay, workers' rights to union- off citizens and the interests of illegal
legal immigration: the employment ize, background conditions, and immigrants need not be opposed.
pattern within society. As I noted be- much more. But because of their ille- Practical measures may raise labor
fore, illegal immigrants ofi:en perform gal status, undocumented workers are costs and increase the price of goods
the worst work for the lowest wages. often unable to challenge or report and services, as they should. We
Illegal immigrants are part of a pat- should not rely on undocumented
HASTINGS CENTER REPORT January-February 2004workers to keep down prices on nize work so as to give workers more ReiFerences
everything from strawberries to sex. voice, power, and opportunity to de- 1. See P. Warshall, "Human Flow," Whole
I can already hear the objection. velop their capacities; and (3) connect Earth 108 (2002): 39-43.
"What you propose is a perfect recipe labor to unions, associations, and 2. These statistics are taken from the fol-
for increasing illegal immigration. All communities in ways that increase so- lowing sources: U.S. Immigration and
the practical measures that you sug- cial respect for all workers. I cannot Naturalization Service, "Illegal Alien
gest would encourage more illegal im- justify these claims in this paper, but I Resident Population," available at
migration." Whether improving the want to note how they are connected http://www.ins.gov/graphics/aboutins/
statistics/illegalalien/illegal.pdf, accessed
situation of the worst-off workers will to health care. Providing health care October 1, 2002; B. Ghosh, Huddled Mass-
increase illegal immigration is a com- for all workers and their families is a es and Uncertain Shores (The Hague: Mati-
plex empirical question. The answer very good way to improve the benefit nus Nijhoff Publishers, 1998); L. Platt,
probably depends on many factors. that workers receive for the worst "The Working Caste," The American
But even if transforming the worst forms of work, to render workers less Prospect 13, Part 8 (2001): 32-36.
work and empowering the worst-off vulnerable, and to express social and 3. Y. Sumimoto, An Introduction to
Japanese Society (Cambridge: Cambridge
workers leads to an increase in illegal communal respect for them. These University Press, 1997), 187.
immigration, countries should take are good reasons for providing health 4. These statistics are taken from the fol-
those steps. Although we have a right care for all workers, documented and lowing sources: L. Platt, "Regulating the
to regulate immigration, considera- undocumented alike. And they ex- Clobal Brothel," The American Prospect,
tions of justice constrain the ways we press ethical concerns that are not Special Supplement, Summer 2001: 10-14;
can pursue that aim. A society might captured by talking about human Ghosh, Huddled Masses and Uncertain
Shores, 27; P. Phongpaichit, "Trafficking in
also decrease illegal immigration by rights, public health, or the rights of
People in Thailand," in Illegal Immigration
decriminalizing the killing of illegal citizens. and Commercial Sex, ed. P Williams (Lon-
immigrants, but no one thinks that don: Frank Cass, 1999), 89-90.
would be a reasonable and ethical so- DoscussDomi 5. Platt, Regulating the Global Brothel, 11.
cial policy. Nor do I think that the 6. This and the following quotations
old pattern of using marginalized Thave examined the frameworks that are from the California Ballot
people is a reasonable and ethical way A are employed in discussions about Pamphlet, 1994, available at
to regulate immigration. http://www.holmes.uchastings.edu/cgi-
illegal immigrants and health care. I bin/starfmder/5640/calprop/txt, accessed
I have left out of my account the argued against conceptualizing the is- September 30, 2002.
very point with which I began, name- sues in terms of desert, professional 7. T.A. Ziv and B. Lo, "Denial of Care to
ly, health and health care, and I ethics, or even human rights. Al- Illegal Immigrants," NE]M 332 (1995):
ended up talking about work and so- though all of these concepts highlight 1095-1098.
cial responsibility. Surely work and something important, they tend to be 8. Ibid., 1096.
social responsibility are at the heart of too narrow or too broad. And because 9. Ibid., 1097.
the matter. Where then does health they provide the wrong perspective, 10. Ibid.
care fit in? they fail to focus attention on the 11. Ibid., 1096.
Good health care can, among crux of the matter. 12. Ibid.
other things, prevent death and suf- I have suggested that the issues 13. J. Rawls, The Law of Peoples (Cam-
fering, promote health and well- should be framed in terms of social bridge, Mass.: Harvard University Press,
1999), 39.
being, respond to basic needs and justice and social responsibility. I real-
14. Compare Rawls, The Law of Peoples,
vulnerabilities, express care and soli- ize that I did not fully justify my view, 8.
darity, contribute to equality of op- and that other people may give a dif- 15. M. Walzer, Spheres of Justice (New
portunity, monitor social problems ferent account of what social justice York: Basic Books, 1983), 39.
(such as child abuse or pesticide expo- requires. But I had a different aim. I 16. Ibid.
sure), and accomplish other impor- did not want to convince everyone of 17. P. Farmer, "The Major Infectious
tant aims. But health care is just one the rectitude of my account, but to Diseases in the World-To Treat or Not to
means, and not always the most effec- shift the discussion into the realm of Treat?" NEJMiA'j (2001): 208-210.
tive means, to these ends. To focus social justice and responsibility. 18. Compare Rawls, The Law ofPeoples,
on access to and payment of health 79-80.
care is to focus our ethical concern Acknowledgments
too narrowly.
I would like to thank the following
I believe that societies that attract people for their comments and encour-
illegal immigrants should pursue poli- agement: Jean Maria Arrigo, Solomon
cies and practices that (1) improve the Benatar, Les Chuang, Ruth Macklin,
pay for and conditions of the worst Sara Ruddick, William Ruddick, Mark
forms of work; (2) structure and orga- Wicclair, and Daniel Wilder.
January-February 2004 HASTINGS CENTER REPORTYou can also read
