For physicians who treat undocumented patients, navigating the dichotomy between providing high-quality care and knowing that some available resources remain out of reach for the patient population is a difficult ethical challenge to tackle.

Some services, such as Medicaid and Affordable Care Act insurance subsidies, for example, may not be available to undocumented patients — even if they are eligible in every other way. In addition, services vary depending on the state and even the county. Clinicians have attempted to solve this ethical dilemma with workarounds.

“Because health care work is work that happens under pressure, using workarounds to manage workflow problems is a normal, if unofficial and semisecret, part of how work gets done,” wrote Nancy Berlinger, PhD, a research scholar at the Hastings Center in Garrison, New York. “Tailoring the chart to emphasize a patient’s eligibility for a resource or to de-emphasize factors detracting from eligibility, is one example.”

Continue Reading

Dr Berlinger goes on to outline the problems with using this kind of workaround, despite good intentions. For one, acting in secrecy contributes to the problem rather than seeking to address the issue at its core so that an approach can be made to remove the obstacles in place. Obtaining resources for undocumented patients through an “unofficial route” may actually have a negative effect on another group of people.

Related Articles

“An effort to promote justice risks introducing a new source of injustice,” wrote Dr Berlinger. “Greater transparency about how organizations address or could address these challenges using internal resources may help alleviate pressures that drive workaround behaviors.”


Berlinger N. Is it ethical to bend the rules for undocumented and other immigrant patients? AMA J Ethics. 2019;21(1):E100-E105.