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Table of Contents
PERSPECTIVE/VIEWPOINT
Year : 2022  |  Volume : 4  |  Issue : 2  |  Page : 94-100

The Physician's Role in Confronting Humanitarian Challenges: A Guide for Action


1 Department of Psychiatry and Behavioral Sciences, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
2 The Access Clinic, School of Medicine, University of California, Riverside, California, USA
3 Dimitri Alphosus is a pseudonym for an author who wishes to remain anonymous for personal and professional reasons. Any correspondence should be routed through Dr P. McPherson
4 Senior Counsel and Director of Education, Government Accountability Project, Washington DC, USA

Date of Submission29-Jun-2022
Date of Decision29-Jun-2022
Date of Acceptance30-Jun-2022
Date of Web Publication22-Aug-2022

Correspondence Address:
Dr. Jaime Guzman
Department of Psychiatry and Behavioral Sciences, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, Louisiana 71103
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_24_22

Rights and Permissions
  Abstract 


An increase in humanitarian challenges has resulted in an increased demand for mental health resources. Social psychiatrists face a clinical and moral imperative to study and treat mental disorders precipitated or impacted by sociocultural events. Immigration detention is but one example of a setting that can take a toll on the mental health of those detained. Psychiatrists working in detention settings do not have immunity from feeling overwhelmed and may suffer the effects of moral distress. Many question how to take action beyond direct clinical care. Here we present a case study on physician action to address the humanitarian crisis of family separation and family detention of immigrants at the US. Southern border. Subject matter and advisory committee experts for the US Department of Homeland Security were recruited to identify concerns and provide recommendations in this guide for action.

Keywords: Detention, humanitarian, immigration, moral distress, social psychiatry


How to cite this article:
Guzman J, Mcpherson P, Allen S, Alphosus D, Gold D. The Physician's Role in Confronting Humanitarian Challenges: A Guide for Action. World Soc Psychiatry 2022;4:94-100

How to cite this URL:
Guzman J, Mcpherson P, Allen S, Alphosus D, Gold D. The Physician's Role in Confronting Humanitarian Challenges: A Guide for Action. World Soc Psychiatry [serial online] 2022 [cited 2022 Sep 26];4:94-100. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/94/354182



”Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”

-Rudolf Virchow


  The Dilemma of Humanitarian Challenges Top


Psychiatrists know all too well the direct and indirect effects of humanitarian upheaval on the mental health of our patients. The science of epigenetics clearly connects toxic stress to an increased risk of mental and physical illness and to potentiating existing mental illness. Never has the skill of the social psychiatrist to study and treat mental disorders precipitated or impacted by sociocultural events been more critical.[1] The United Nations' Global Humanitarian Overview for 2022 highlights a record increase in the number of people impacted by humanitarian challenges with a record cost to address global challenges, estimated at 41 billion (US$) with 5 million for refugees from Ukraine alone.[2] With over 84 million refugees world-wide, the current need for mental health services is staggering and will be greater in the future as children who have suffered directly and indirectly mature.[3] In the face of such need, it is easy for physicians to feel overwhelmed and even powerless to take action beyond the provision of direct clinical care. These feelings intensify for those who bear witness to human rights violations and decide to take action. While professional ethics provide critical guidance, physicians confronting humanitarian challenges often find additional skills are needed. Here we provide a case study from physicians bearing witness to the humanitarian crisis of family separation and family detention of immigrants at the US. Southern border and the path of taking action to challenge government practices.


  A Case Study in Physician Action in United States Immigration Detention Top


The history of persons seeking refuge from persecution in America dates to the 1600's. Since 1875, the regulation of immigration has been a federal responsibility.[4] From the 1890's, the US Public Health Service has employed physicians to assess and treat persons immigrating to the United States. The early mandate for Public Health Service physicians was to identify individuals with contagious diseases, mental illness and intellectual disabilities.[5] The governmental roles of physicians have expanded over the last century to include screening for medical needs, the provision of clinical care to those held by the government, and the evaluation of health-care delivery systems. Here, we detail experience as subject matter and advisory committee experts for the US Department of Homeland Security (DHS) and the actions taken by these physicians when the government failed to act on expert recommendations.

For decades the US government has detained refugee families in locked facilities euphemistically deemed Family Residential Centers (FRCs). For the FRCs, the guidance for medical care is detailed in the Family Residential Standards and delivered by onsite medical teams of government public health personnel and private contractors.[6] The FRC health-care services are subject to periodic review by physicians contracted by the government as subject matter experts (SME) of health in detention. Over multiple administrations authors substance addiction (SA) and PM acted as medical and mental SMEs advising the DHS on compliance with federal standards and best practices for the care of detained families which included multiple in FRC facility inspections. On the recommendation of SMEs in 2014, the first FRC inspected was closed based on documented actual harms to children including weight loss, misdiagnoses due to lack of pediatric providers and absence of appropriate mental health services including trauma informed care to the at-risk population. While the recommendation to close that center was heeded, the administration subsequently opened new centers where similar problems were identified and documented by the SMEs.

On the recommendation of the SMEs, the DHS formed the FRC Advisory Committee in late 2015. The purpose of the committee was to develop and provide recommendations to DHS on subjects such as education, medical care, mental health care, legal process help, assistance with after care upon release from detention centers. The committee was composed of professionals including child and adolescent psychiatrists, lawyers, law enforcement and advocacy organizations. Individuals associated with the committee were appointed due to their professional expertise and experience with advocacy for minority populations. The Advisory Committee undertook a rigorous 10-month investigation which included visiting FRCs, examining documentation related to the individuals present at the facilities, reviewing protocols, and gaining an understanding legal procedure including relevant federal laws. The Advisory Committee Report included approximately 200 recommendations and proposed a standard of care for the government to utilize within the FRCs. The Civil Rights of Institutionalized Persons Act was cited within the recommendations due to its use in establishing a basis for care for families within these residential facilities. The Committee's primary recommendation was the renouncement of family detention.[7] Concern was noted for the well-understood mental and physical trauma placed on families during detention, compounded by the limited services available.[7] The Committee recommended proven alternatives to detention such as the integration of refugee families into communities with monitoring for families to fulfill their appointed court hearings.[8]

The primary recommendation for facility closure was not enacted. A variety of the Committee's recommendations were implemented, but facilities struggled to maintain them. The Advisory Committee received reports of continued medical and mental health emergencies not being attended to in an appropriate manner. The Committee expressed concern that the profit motive of the private prison companies managing the FRCs contributed to failures to meet the necessary standards of care to immigrant families.[7]

During the spring of 2018 the Trump administration implemented a zero-tolerance family separation immigration policy which forcibly separated more than 5000 children from their parents and announced plans to increase the detention of refugee families. The inhumanity of the zero-tolerance policy shocked the conscience of the world. Professional medical organizations denounced the practice and worldwide protests occurred. As SMEs, we questioned the ethics of our participation in a system that violated fundamental sanctity of the family and the dignity of children. It became clear that the evidence-based findings of the Advisory Committee were not resulting in changes that would adequately mitigate harm, and that Congress and the public were not well-informed regarding the dangers to children. The imminent threat of further harm to children and their families once in detention settings made it clear that our professional ethical duty was to take action beyond our traditional roles of submitting internal reports of our inspections and internal recommendations. Here we explore the ethical basis for action before offering guidance for others who may wish to heed a professional call to action.


  The Ethical Responsibility to Defend Human Dignity Top


Medicine is not merely a skilled trade, it is a profession and to many a calling or moral duty. Physicians have long been bound by an ethical code and a social contract which requires acting in the interests of the patient first and highlights our obligations to protect the public health. Respect for the dignity of the patient is a foundation of our profession.

Each human person possesses an intrinsic, inviolable dignity based upon the fact that personhood constitutes dignity. Dignity is not a token to be “granted” based on some subjective criteria created at the whim of an authority. Respect for human dignity and autonomy are integral to medical ethics and the practice of psychiatry. Professional organizations throughout the world provide codified forms of medical ethics delineating a framework for international human rights related to health and medicine grounded in the dignity of the human person. The four values of justice, autonomy, nonmaleficence, and beneficence are represented by the precept primum non nocere: First do no harm. These four values are critical to the practice of psychiatry and medicine overall. We propose that they are applicable to all human persons because of the intrinsic dignity each possesses.[9]

The German philosopher Martin Buber characterized relationships as I-Thou or I-It.[10] In the I-Thou relationship one's own humanity is reflected in the other, whereas the I-It relationship objectifies the other. The I-Thou relationship is the basis for an emphatic relationship that is transformative in existential and humanistic psychotherapies. The I-It relationship is antithetical to the ethical practice of psychiatry. One may not treat any person as only the means to an end, as an instrument or object, but must allow for the fact that he or she has distinct personal ends. The I-Thou relationship promotes the virtue of solidarity; human beings living and acting together in a community constituting the common good. Solidarity means a constant readiness to accept and realize one is in the community because there is a common kinship existing among all human persons throughout the world. Solidarity makes one look beyond his own share in the consideration of others' share within the common good. As a virtue, solidarity helps medical professionals see refugees and asylum seekers as their “brother, sister, or neighbor.” As systems lose solidarity and shift relationships to I-It, physicians often experience moral distress. As we advocate for all human beings to receive basic health and mental health care, we may need to foster solidarity through opposition, especially when it is clear that current practices are contrary to the common good, and hence, the dignity of the person. Health care as a basic human good– and ethical right-can demand the formation or strengthening interhuman solidarity through the attitude of opposition.

A foundation of medical ethics is the principle that the physician's duty to act in the best interest of the patient.[11],[12],[13],[14] Medical associations across the world address dual loyalty conflicts with regard to professional autonomy in the face of government pressure. Physicians have an affirmative responsibility to act when the consequences of laws or policies conflict with the best interests of the patient, and they must intervene to stop cruel, inhuman and degrading treatment of their patient. They must also act to protect the public health and have duties to intervene when the health and safety of their patient, especially if the patient is a child, are threatened.[15] In addition, some professional medical associations back the principle of medical autonomy explicitly with support for whistleblowers.[16]


  From Ethics to Action and Recommendations for Success Top


In 2018, the news of children being forcibly separated from parents and the images of children sleeping on the floor of crowded cages shook us to our cores. The dangers to short and long-term mental and physical health posed by the detention of young children, even with a parent, are well established by decades of clinical research.[17],[18],[19],[20] Based on the clear and significant dangers posed to children by detention, organized medicine, including the American Academy of Pediatrics (AAP) and the American Medical Association (AMA), opposed the detention of children in immigration facilities.[21] Worse, we knew as SMEs that the conditions in the detention facilities were inadequate to meet the needs of this already traumatized population and would pose imminent harm.

After the initial disbelief and rage began to recede, we knew we had a duty to act, but found no practice guidelines or professional statements to guide us in practical terms on how to proceed. Health-care professionals are trained first and foremost to treat and advocate for individual patients. The process of exercising the responsibilities to speak out against harmful policies and practices is foreign to most clinicians, including those who work within settings known to carry high risk of harms to their patients such as jails, prisons, immigration detention centers, prisoner of war settings or even locked psychiatric wards.

In our case, on the advice of specialized legal counsel with a pro bono nonprofit legal program, we first exhausted all internal mechanisms to communicate our urgent warnings of imminent dangers to the health and safety of children and their families by writing to the head of our unit, the Office of Civil Rights and Civil Liberties at DHS, documenting our concerns in detail. We followed this by filing a complaint with the Office of the Inspector General of DHS. When those efforts failed to result in a timely response, we made legally protected disclosures to Congress, followed later by strategic appearances in the press. Our calls for action were echoed and amplified by professional medical groups (organized medicine), medical advocacy groups, and our disclosures were cited in strategic litigation efforts undertaken by others on behalf of detainees and their families.

Based on lessons learned through our experience, we offer recommendations for action for physicians who may find themselves in similar positions where a professional ethical duty to act is complicated by substantial barriers or professional risks.

Define a clear objective or goal in the context of professional duties

The first recommendation is to consider the desired result of acting within a framework of professionalism and professional medical ethics. Analyze the reasons for acting as well as loyalties, obligations and biases. Then, identify a clear and specific tangible goal that will guide all efforts. In the cases discussed here, physicians hoped for an end to the detention of children. Recognizing that ending detention was a lofty, and perhaps long-term goal, physicians offered additional remedies for government consideration. Considering a range of results allows for multiple successes. With a range of possible outcomes, messaging must be carefully considered to avoid diluting the primary goal. Such messaging was handled deftly in the Advisory Committee's Report which placed ending family detention front and center, repeating this message while advising additional necessary remedies.

Assess risks

The second recommendation is to realistically assess risks of acting. Risks include harm to professional reputation even when the physician is acting consistent with professional ethics. Physicians may fear retaliation in the form of job loss, marginalization or violence in the workplace, and even legal prosecution; for example, those who work in US. Detention settings often sign nondisclosure agreements. The physician must also carefully consider the possibility of adverse consequences to other colleagues, witnesses, or even the people they are trying to protect. Given these very real concerns, the second step in acting is to assess the risk of an initial disclosure and to reassess risk at each stage of action. Risk tolerance will vary among individuals and for a given individual depending on the stage of one's life and career.

A balanced risk assessment includes considering protections for any planned action. In the United States through a complicated patchwork of whistleblower laws, disclosures regarding possible waste, fraud, abuse and threats to public health and safety are protected; some legal protections may even supersede nondisclosure agreements. Directive 2019/1937 offers similar protections for those who work for public or private organizations with the European Union.[22] In 2018, having exhausted all internal options including filing a complaint with the US. DHS Office of the Inspector General, PM and SA made protected disclosures regarding the harms of family detention to Congress. Those disclosures helped bring needed attention to the dangers of the family detention program. Some actions, including participation on an Advisory Committee, may be relatively risk free. Still such action requires a substantial time commitment which may not be supported by all employers.

Build a supportive team

The third recommendation is to build your core team. Ideally, the core team will include like-minded colleagues. Acting with even one colleague can greatly reduce the stress of taking a stand against power. Prior to acting, experts can assist in risk management and crafting strong messaging. In order to be effective in bringing about change, the physician must act in concert with a team of experienced professionals including lawyers, ethicists and professional organizations. Speaking out, particularly in national security settings, carries risks to the professionals making disclosures, including the risk of retaliation, loss of employment and damage to professional reputation, so guidance by experienced attorneys is essential. As the ultimate goal is to be effective in bringing about changes to the policies and practices that threaten public health and safety, the strategic wisdom of those experienced helping employees make public interest disclosures is vital. Before making the protected disclosure to Congress, PM and SA consulted with attorneys with expertise in whistleblower laws. In addition, they also reached out to their own professional organizations seeking support prior to making the disclosures.

Whistleblower attorneys helped advise the physicians about their rights, risks and options, then helped guide them through the legal process of properly making a legally protected disclosure. The legal experts considered the specific factual and legal context and informed by our goals, helped craft a legal and advocacy strategy which included exhausting all internal mechanisms for action. When the disclosures to Congress had been submitted, within 2 weeks of public reports of those disclosures, fourteen national medical professional organizations signed a letter in support of the medical expert's concerns regarding family detention. An online petition by a physician's human rights group in support of the disclosures and concerns about family detention followed and gathered thousands of signatures from medical professionals across the country.

Identify and mobilize allies

The fourth recommendation is to widen the circle of influence by finding allies. While the initial disclosures did result in attention to the risks of family detention, in the early period following the disclosures they did not result in any changes in the program. Strategic interactions with national and international media, after evaluating legal rights and risks, became another tool that was employed. Effective interaction with the press is another area where most health professionals feel ill-prepared, particularly when the issue is clouded by political divisions. Media training and consultations are useful in supporting physicians in dealing with the press.

After the FRC Advisory Committee completed its investigation and provided recommendations to DHS, presentations at conferences informed the medical and advocacy communities of the findings and garnered support to improve advocacy for refugee population. Multiple organizations agreed with closure of family residential facilities, but fell short of providing official statements of disapproval toward detention facilities. However, after strong reception of approval by the AAP and patient advocacy organizations, additional medical organizations followed, including the American Psychiatric Association, Amercian Medical Association, and the American College of Physicians.

The disclosures by the medical experts about the dangers of family detention were also widely cited in legal filings including cases being brought strategically by advocates for the immigration detainees aiming to effect changes in policy to mitigate harms through the courts. Strategic litigation is another tool to bring about change in settings where public health and safety are under threat. Scholarly articles and legal filings have cited the Report of the DHS Advisory Committee on FRCs hundreds of times.

Prepare to remain engaged over time

Finally, physicians taking action for change are warned to prepare for a long fight. Perhaps psychiatrists know that change requires action and change is a process. The process from moral outrage to vision to action to outcome occurs in fits and starts. The core team, as well as the physician's family and practice, must be prepared to ride the waves. In today's world of instant access to news, care must be taken to craft a message that can be tailored to the news cycle of the moment. This requires readiness to answer media requests, pen articles or letters, and rally professional organizations; tasks that are near impossible without your core team and allies. The long fight will include frustrations and victories. Frustrations are opportunities to reassess the message with the core team and to consider new allies who will bring new perspectives and avenues for action. New allies may include well-established organizations or colleagues who wish to follow your path. The importance of educating physicians for advocacy work is critical.

The COVID-19 pandemic has tested health-care systems around the world, creating special issues for patient care in detention settings and a new opportunity for physician advocacy. The increased risk of infection for refugees and staff in detention settings is well-documented[23] as are the increased mental health, medical, and socioeconomic vulnerabilities.[24],[25] With media reports of solitary confinement being used for quarantine, lack of sanitary conditions, and rising infection rates, advocates renewed calls for ending family detention as well as calling for a comprehensive COVID plan for immigration detention settings.[25],[26] Pivoting quickly to keep the original goal (ending family detention) relevant in light of the issue of the day (the pandemic) is an important strategy for long term advocacy.


  Challenges to Action Top


In 2001, the AMA House of Delegates adopted a Declaration of Professional Responsibility for physicians. The Declaration admonishes physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” Multiple medical organizations endorse physician professional responsibility for medical advocacy with many physicians answering the call.[27] However, a survey was completed 2004 that demonstrated only one fourth of US. Physicians reported political participation, apart from voting, on local health issues.[28] In addition, it has been shown that physicians have less civic participation compared to the general public. The question remains what barriers continue to limit physician participation with medical advocacy for vulnerable populations even though there is a defined professional responsibility?

Time and financial pressures may be barriers to action, particularly for early career physicians. Medical advocacy for vulnerable populations tends to not be equitable to billable clinical hours within a physician's specialty, which may result in a monetary loss. Time will be a limiting factor for physicians just like any other person. Time and financial pressures can create conflict between balancing family, personal, and professional goals. Although all physicians recite the Hippocratic Oath and adhere to practicing medicine to the best of their ability, physicians are human with independent values and lives. There will be times that individual needs may supersede public need.

Medical advocacy with refugee populations may be viewed by some as having a political undertone. Psychiatrists may have concerns that addressing public policy or other issues with political implications might affect the physician-patient relationship, including transference or even impacting patient privacy, particularly for persons in detention settings. The reality is that medicine and politics are not mutually exclusive. As Virchow, the father of social medicine, stated “Medicine is a social science and politics is nothing else but medicine on a large scale.”[29] While some physicians do not believe they have a role or expertise with public issues, physicians do have a unique perspective, experience, and expertise that can be helpful to the general public and particularly for advocacy for vulnerable populations on issues related to health and well-being. The public holds physicians in high regard.[30] The privilege of practicing medicine comes with responsibilities to individual patients and society at large. Social psychiatry values action over introspection in recognizing the impact of systems on the individual in addition to the traditional emphasis on the psychiatrist-patient relationship. Medical education widely recognizes social determinants of health; however, training in social medicine skills, including structural competency, allyship, accompaniment, and activism are often lacking, as are standards and expectations for residency training.[31]

Fear of repercussion in the form of legal or professional involvement has been speculated to be another potential barrier. One of the difficult aspects of tracking repercussion is the wide variety offorms it can take, which may limit observation from a macro perspective. Examples include unrenewed contracts, increased work duties, removal from leadership positions, termination, as well as many other possibilities that may be more subtle. Immigration within the United States continues to remain a controversial topic, with many people having divided views. Despite physicians having a professional responsibility to continue medical advocacy for this population, hospitals that are affiliated with large corporations may not share similar values. For example, a private prison corporation serving refugees was the target of public outcry after advertising for doctors interested in practicing in accordance with “the company goals, objectives and philosophy.”[32]A lack of employer support or employer harassment can have a chilling effect on physician willingness to take action, especially with more physicians being employees within systems. Autonomy appears to be diminishing with modern medicine.


  Concluding Remarks Top


Physicians from around the world have used their medical expertise to speak out against the detention of migrant children. In 2021, the use of family detention in immigration settings was eventually largely eliminated in the United States.[33] Through the actions of many, including the contributions of our coordinated efforts involving carefully crafted legal disclosures to Congress with the guidance of legal counsel, the engagement with medical professional organizations, and the amplification of messages by advocacy organizations and the press, physicians have made significant headway in confronting the humanitarian challenge posed by family detention. While we celebrate this victory, room for future advocacy remains. Detention of migrant children is still occurring in other settings, and we remain vigilant that the practice of family detention may resurface under the pressure of politics and migration trends. Many children who have suffered family separation and detention will require mental health care. Providing care and advocating for access to a coordinated system of care for all children with mental health needs is a responsibility we face daily by taking actions to promote health and foster a better life for children.

The importance of clinical competence is widely understood to be essential to the practice of medicine. Less appreciated is the fact that clinical competence alone is not sufficient to meet the obligations of the profession. Physicians often find themselves in positions where policies and practices of institutions or governments come into conflict with the public health or with individual patients under their care. Negotiating such conflicts can be complex, but the ethical principles of the profession of medicine serve as guideposts. Professional consultation with ethicists and legal experts can provide additional help. Support from organized medicine for physicians who do act in the interest of their patients and public health is essential. The aforementioned recommendations to promote action for medical advocacy, defining a clear goal or objective, assessing risks, building a supportive team, identification of allies and preparation of engagement over time, can assist in providing guidance. Physicians will continue to confront competing obligations to government or employers and their duties to patients and the public health. Therefore, medical education must do more to prepare physicians with the knowledge and skills needed to negotiate those conflicts. Ultimately, the profession's ability to maintain the confidence of the public is at stake.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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