A Question of Ethics: Ethics of Interacting with ICE

February 14, 2025 Pediatric clinicians have obligations to their patients and law enforcement. But it can be challenging to figure out how to navigate situations where these obligations conflict or where there is uncertainty about the right thing to do. This has increased with recent exectuive branch agendas. Dr. Alyssa Burgart is the Associate Director of Pediatric Bioethics at the Stanford Center for Biomedical Ethics, Medical Director of Ethics for the Stanford Medicine Children’s Health, and writes about ethics and culture in her substack Poppies & Propofol. She joins Dr. Wolfe to discuss the ethics of interacting with law enforcement, speficially immigration and customs enforcement (ICE).

Transcript

I’m your host, Dr. Kade Goepferd. Today’s segment, a Question of Ethics recognizes that pediatric clinicians do ethics every day. And our guest host, Dr. Ian Wolfe, director of ethics, offers helpful guidance for pediatric clinicians navigating those everyday ethical issues. Dr. Ian Wolfe: Welcome to A Question of Ethics. I’m your host Dr. Ian Wolfe, and with me today I have Dr. Alyssa Burgart, who is an anesthesiologist and bioethicist at Stanford. Today, Dr. Burgart and I will talk about the ethics of interacting with immigration. Alyssa, thanks for joining us. Dr. Alyssa Burgart: Thanks for having me, Ian. Dr. Ian Wolfe: In the past couple of years, there’s been a lot more consideration of what are the ethical implications or ethical considerations of clinicians engaging with either law enforcement, with other federal officials or even civil organizations such as school nurses dealing with patients within a district that might have different rules. You recently wrote on your newsletter Poppies and Propofol, which is available on Substack, about some guidance for clinicians dealing with immigration. Can you talk a little bit about what’s prompted you to discuss this? Dr. Alyssa Burgart: The issue of interacting with law enforcement, and this comes up in lots of different ways in hospital ethics, right now we’re talking about immigration law enforcement officers, but additionally, it’s very common for patients who are incarcerated to need medical care. And so it’s not unusual to have law enforcement officers potentially inside the hospital. And so it’s really important that clinicians understand what it is that they are obligated to do or not do and what it is that they’re voluntarily can choose to do or not do. One of the things that I think is so incredibly important is recognizing that all of us, to a degree, have been conditioned to believe that we need to obey law enforcement. And there are some reasons why you may want to obey law enforcement. It is important to recognize your rights and your patient’s rights so that you are not complying in ways that are absolutely voluntary, that may actually be giving up rights, services, safety of your patients without even knowing it. So just because a law enforcement officer asks you a question does not mean that you’re obligated to answer it. And so it’s really important right now, especially now that immigration agents have been the guidance for them to not enter places like hospitals, schools, churches, sensitive areas. Since that guidance has been lifted, there’s never been a better time for health care workers to be very clear on what are my obligations to my patients, what are my obligations to myself and my colleagues, and what are my obligations, if any, to law enforcement? Dr. Ian Wolfe: Yeah, I think that’s really important and just to say that it sort of transcends this idea of whether you agree or disagree with some of the laws or policies, but still impacts your practice and your ethical obligations to the patient. One example, I once read a case, and this is a pediatrics podcast. This was not a pediatrics case, but it displays I think an example of our deference to authority where a person was brought into the ER who was capacitated, meaning they could make decisions for themselves, they could answer questions, but had allegedly swallowed some drugs and the police officers were asking the hospital team to put in an NG tube and try to intervene to expel those drugs. And of course, the situation there is one that comes up against a request from a law enforcement agent, but gets in the way of patient ethics or sort of clinical ethics and patient rights. Is that correct? Dr. Alyssa Burgart: Absolutely. And part of that as well is was there a warrant to invade that person’s body in that way? And I’m just guessing based on the way that the story was sort of organized, probably not. And so it’s also a really important thing for clinicians to recognize that not only is it a reasonable thing to do, I would say it is something that you absolutely should do or escalate to someone who will, which is someone in law enforcement is asking you to do something, asking you to disclose information, saying, okay, well do you have a warrant or some sort of legal documentation. I’ve had a number of interactions regarding patients who are incarcerated where there will be someone from the prison who is insisting on certain limitations on the patient that are completely outside of our normal standard of care. There are going to be health care workers that are across the political spectrum that are going to have lots of feelings and beliefs about immigration, about how it is that our country should and should not respond to how it is that people enter this country. You can simultaneously be supportive, for example, of what ICE is doing. That may be something that as a health care worker is simultaneously something that you support. However, I would argue that those beliefs that fit within a political sphere within partisan beliefs should not supersede our obligation as health care workers directly to our patients. That’s one of those relationships that is just sacred. It is special and it supersedes many other obligations. It’s important to recognize that this is a distinction I think also that some folks are struggling with is again, this idea that you’re going to comply when you don’t have to. That is a choice. That is a choice to put the desires, the wishes, the requests of an immigration officer above that of your relationship to a patient. That is a choice. It is not one that I recommend, but it is a choice. Dr. Ian Wolfe: So the tension that really exists there is what are ethical obligations to the patient and at what times might we either want to or have to or should even put your legal obligations over those, right. So we do have some times when we say override our obligations to protect privacy or even to restrict a patient’s autonomy. So when they’re a danger that of self for others, we might not allow them to leave the hospital or there’s processes set up for things like that, or we might have to override their right to privacy with the intention that protecting their safety is higher or protecting somebody else’s safety is higher. And so what you’re saying then is at this point immigration status or requests from immigration don’t meet that level of standard to override their right to privacy? Dr. Alyssa Burgart: Exactly. That’s not part of our mandated reporting requirements. For example, for abuse or for self-harm, like you’ve mentioned, those are not legally protected. Clients with immigration officers is not something that falls within that category where violating a patient’s privacy is justified. One thing I think is important to also recognize is there’s multiple layers here, right? There’s my individual relationship with a patient. There’s the choices that I make in terms of how do I protect my patient’s privacy? How can I be as minimally compliant with the law as possible or as minimally compliant with immigration officers as possible? But it’s also what’s happening in my unit, what’s happening in my organization? Has my organization made a commitment to protect patient privacy? That’s really important when we think about what is the ethical and moral community that we are creating in a hospital. Is it one that continues to value patients, which many hospitals claim is part of their mission statement, or is it one that’s going to promote health care worker vigilantism in terms of giving up patients for ulterior beliefs that are outside of that relationship with the patient? Dr. Ian Wolfe: A couple of things there I would say is on one hand there’s processes set up hopefully within an organization to deal with law enforcement requests. If a law enforcement agency shows up at the door of the hospital, obviously individual clinicians want to protect patient privacy. The organization should want to protect patient privacy, but also we exist within a society of laws. And so there should be processes set up to engage or how that law enforcement agency can engage with the hospital in mediating out those interests. Correct? Dr. Alyssa Burgart: Absolutely. And the issue of does your hospital have a policy and what kind of a policy does your hospital have is such an important question right now because I think a lot of hospitals are realizing, oh gosh, we have a policy for addressing police, but we actually haven’t created a policy that is in relation to the kinds of law enforcement that are involved in immigration issues. And that’s part of why in my piece, I highlighted work that’s come out of the Attorney General of California’s office providing model policies for hospitals to be able to put into place, and there’s certain aspects of that that are going to work best for people in California based on the laws that we have in the state where we work. However, there’s a lot of great things in there that can be modified and utilized in other states in order to again, be technically compliant with the law, and not override our obligations to our patients. Dr. Ian Wolfe: And there’s sort of a twofold thing there, which is that individual clinician obligation to patients and then that sort of organizational ethics of how do we promote community health? And there’s other considerations. I think that impact, especially in pediatrics, right, when there’s potentially something that may make parents hesitate to bring their child to the hospital. Dr. Alyssa Burgart: .. of mine who have large immigrant populations that they care for have seen a dramatic decrease in folks showing up to clinic. And for many families, they’re mixed. Maybe one of the parents is undocumented, one of them is documented. The children may or may not be documented or maybe other people in the family who have mixed immigrant status. And so it can be really scary for families to come in. And so oftentimes families are going to delay that care that their child really would benefit from having at the time that other kids we would expect to see in clinic. We’re absolutely going to see health consequences. Things that I think clinicians can do now and that people who are hospital administrators and social workers, unlike all the people who are part of hospital ecosystems, is to understand what are your rights as health care workers? What are your rights as a healthcare organization? What are your patient’s rights and how can we ensure that we are doing everything we can as individuals and as organizations to ensure that our patients have access to top-notch, excellent, safe care? We know that these immigration rates will negatively impact the families that seek care from us, the patients who need care from us. We need to be very concerned about our waiting rooms. It’s not even just the patients who are at risk. It’s their families who are coming to be there with their family members in the ICU. These are the folks that we depend on to be able to help bridge that care for our patients who are recovering. When they’re ready to leave the hospital, will they have a family to go home to? Dr. Ian Wolfe: So it seems like for an individual clinician, there’s a couple different ethical considerations. One, just being your individual obligations to the patient to protect their rights, and one of those being specifically right to privacy, and where it would be ethical to override that would be specifically when they’re at risk to themselves or others from a safety perspective, which this doesn’t seem to meet this standard. There’s also, it seems, like this idea of trustworthiness as public figures or in promoting community health. Dr. Alyssa Burgart: I want to make sure that we’re super explicit here. It’s really important to recognize as clinicians, absolutely, you have some mandated reporting obligations, you have some health and safety reporting obligations. Those don’t go away. But I have never once been like, wow, this patient is a risk to themselves or others, I should call immigration. Dr. Ian Wolfe: This came up one time doing a case, I think I wrote this up for American Nurse where it was this question of what do I do if I find out my patient has a warrant? Well, the first question there is, great. Is that going to promote their health interests by you calling to notify law enforcement? So the idea that a patient discloses that to you may impact their health or it may have some impact their health that you can assist with going forward, but that doesn’t promote their health interests by calling the police on them. Where I would say as a nurse, what you might do is say, Hey, this might promote your health if you maybe took care of this warrant or maybe sought remediation for it, right? Unless it was sort of a warrant for a violent crime where the safety of the public might be at risk, right? Those are very distinct things that we must remember. Dr. Alyssa Burgart: And again, because we’ve talked so much about privacy and the limits on that versus what are the positive aspects of it, we have a positive obligation. We have an affirmative duty to protect our patient’s privacy. With those few exceptions that we’ve talked about, we do not have a positive obligation to talk to ICE agents who show up at our hospitals. That is not an obligation. Because of that tendency to comply with authority figures, and I think there are lots of things about the ways that we are trained in health care that further complicate that relationship with authority, you do not have a positive obligation to comply with questions from ICE officers unless they have legal reasons to be there, they have provided a warrant. If you’re a random person in a health care organization, know who it is that you’re going to escalate that to because that is not your obligation to go through all that documentation and make sure that it is valid, appropriate for somebody from your organization to help you determine does this create any new obligations for you or not? So your standard duties to your patient, those are still there and those are positive obligations. They’re built into the policies of your hospitals. They’re built into federal law, they’re built into our state laws. And those are not on hold just because an immigration officer shows up in your care space. Dr. Ian Wolfe: And it really speaks to, I think what probably a lot of clinicians are feeling, which is uncertainty, fear, what am I supposed to do? And as you know in ethics, a lot of ethics in clinical health spaces is not because somebody’s doing something unethical, rather there’s competing tensions or uncertainty about what to do and significant distress because of that. And so, what I liked about your piece in Poppies and Propofol was really giving some of that concrete advice for individual clinicians. So suppose you are a clinician at a primary care pediatrics clinic. What kind of advice can we give to those individual clinicians to how to navigate an immigration agent coming into the clinic? Dr. Alyssa Burgart: One of the things that is super important is to recognize that immigration officers don’t have a right to be in your clinic space any more than any other visitor has in that space, whether it’s a clinic, whether it’s a hospital. If you have areas that are not open to the public, somebody might show up into your waiting room, but it certainly doesn’t mean that they have the right to go back into patient care areas. Your clinic, you can ask people to leave. You can say, if you don’t have a warrant to be here, you don’t have a warrant to search this area, I’m going to have to ask you to leave. And you do not need to answer additional questions that they have. You have a right to remain silent. Your patients have a right to remain silent. There is not an obligation to respond. It’s really important that if you’re running a clinic that your front desk staff knows, wow, do we have a policy on this issue? Do we have some guidance that’s written down? Because it can be very nerve wracking, of course, when someone from law enforcement, from any branch of law enforcement appears in your place of work. So just understanding, what is the expectation? How can I make sure that I understand what those expectations are? Who do I escalate these concerns to? Do I have a manager? Do I have a boss? Who is it that’s going to help us navigate this? Those are just a couple of really small things and always remembering patients come first. Patients come first. It is at the core of what we do and it’s not on hold because somebody showed up in your clinic who’s unusual. Dr. Ian Wolfe: And that’s really helpful advice. And you mentioned managers and leaders, and I kind of wanted to get to what can managers, clinic supervisors, or even in hospital leaders, what can they do both to prepare and help their staff, but also maybe prepare their clinics or units or what have you for dealing with this situation? Dr. Alyssa Burgart: Providing leader, just leadership, is an incredible opportunity right now. So for larger organizations that have a lot of administrators, now is a great time for those administrators to have a good handle on what are the obligations that the organization has, should be talking with their legal counsel to understand. Organizations don’t want their employees breaking the law either. And so how can they be clear with the people who work in that space to say, Hey, here’s what’s expected of you and here’s what we are going to do to protect you, to protect our patients. These are the things that we’re going to do to ensure that there is a safe working environment. Something that I know is really important to many of us, talked a little bit earlier about what does it mean to be in a moral community? What does it mean to have a well-developed ethical culture in an organization? And people who are in leadership roles have an incredibly important role to play there because without having leaders who are going to come out and say, Hey, we’ve seen that this executive order that’s come out, that these behaviors that have come out, we see that these are impacting our patients. We see that these are impacting our clinicians who are working here, other staff who are working here, and here’s the guidance that we have put together so that we take away that lack of clarity, that uncertainty that you mentioned earlier. It creates cognitive dissonance, it creates an inability for people to know what to do. Health care is hard. There is wild stuff that comes up every single day when you’re in clinical practice. And so to have this completely unusual new issue come up in such a profound way can be very destabilizing. And so leaders have a great opportunity to really support their staff, support patients by making sure that folks understand and have clarity around doing the right thing will be supported. Dr. Ian Wolfe: You kind of alluded to this a little bit and talking about from the leader stepping up to the organizational leaders, so from what managers and leaders within the clinical spaces, but talking a little bit about what organizational leaders can do, both I think for their staff, which you mentioned too, but also for the community. Why is that messaging so important in that aspect? Dr. Alyssa Burgart: It’s multidimensional, right? So if you’re a manager and you have not yet heard from your hospital or clinic leadership about what to do if ICE shows up at your hospital, they’re not serving your needs. They need to hear from you. Reach out to those folks and say, Hey, we are really looking for clarity on how we can protect our patients. What are we doing as an organization? And for patients? Like I said, we have so many of our immigrant families and mixed immigration families, they’re not coming to the hospital, they’re not coming to clinic, they’re not going to be getting those vaccinations, they’re not going to be getting those well child checks. They’re not going to be getting those concerning symptoms looked at. So when families can at least get some messaging somewhere, whether it’s directly from the clinicians in the office, if it’s from the organizational leaders from multidimensions, how is it that we can ensure that families know that it’s safe to come to the hospital or safe to come to the clinic? Now, let’s be honest, there are going to be hospitals that are probably going to be a little less safe than others, especially if you have lack of organizational clarity around what clinicians should and should not do. Because there will be clinicians who say, you know what? I think immigration is bad and I don’t want immigrants to be here. Whatever. That’s going to support some vigilantism in terms of self-selecting, who’s going to prioritize their beliefs around immigration versus their direct obligations to patients? Dr. Ian Wolfe: Yeah, it’s really important and just that’s why we noted earlier, I think just to say that whether you agree with us or not is sort of beside the point. The point is really ethical obligations and as currently stands as well, patients federally protected rights to privacy. And so really making that distinction, I think in clarity for leaders to their staff is important to say, this isn’t a political spectrum issue. This is a issue between obligations to law enforcement and our obligations to patients and really making that distinct. Dr. Alyssa Burgart: And I think that if you’re a clinician who feels a really strong deep value to law and order, I understand it. That’s something that’s really important to certain people. Being compliant with your patient’s privacy rights, honoring your legal ethical duties to protect patient privacy. That is law and order. Complying unnecessarily over complying with requests from law enforcement is actually beyond compliance. That is doing more than the law has asked you to do. And it is in violation of something that you are directly responsible for control. Dr. Ian Wolfe: Right? And one thing to consider too, in those spaces that law and order is often about good processes. And so clinics and hospitals often have those processes established, and whether it’s through then your security and risk departments, but also that’s why warrants and things like that also exist, right as good process. And so to override that process is itself sort of an act of unlawfulness in a way. Dr. Alyssa Burgart: And there’s only certain states right now that require health care providers to request any information about immigration. Otherwise that’s a choice. And so if you’re somebody where you’re like, oh, if I knew that my patient was an undocumented immigrant, I might have a harder time balancing my responsibilities, maybe you shouldn’t ask because you actually probably don’t need to know. Dr. Ian Wolfe: Again, centering back on the patient of what is in their health interests and what things might both be necessary to help them with their health interests, but also what might promote their health interests. And I think those are good things to consider. Dr. Alyssa Burgart: Putting our patients first is always the right choice. Doing what’s right for our patients, doing what’s safe for our patients. That is always going to be the right choice. Dr. Ian Wolfe: Alyssa, thank you so much for talking with us. And I want to point folks to your Poppies and Propofol newsletter on Substack, which I think provides some really important information and guidance on both what clinicians can do, what leaders can do, and what organizations can do. And also, as we talked about, just with these times, it can be fairly distressing for clinical staff trying to do the right thing, often being uncertain about what that right thing to do is. And you also have another newsletter called The Moral Injury Clinic, which provides some really good tools, I think both for individuals but also for leaders and educators to try to help staff and clinicians through times like this. Dr. Alyssa Burgart: Thank you. Listen, we’re human beings. We’re ethical creatures. There’s always going to be moral dimensions to what we do, and there’s a lot of moral stress in what we do. It doesn’t have to become distress and injury. And like you said earlier about processes, when we have plans, when we have processes, when we have mechanisms to support each other through doing this incredibly wonderful, challenging work, then we can have the resilience to be able to do it moving forward. Dr. Ian Wolfe: It was a pleasure talking to you today, Alyssa. Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.