Immigration status is a social determinant of health, and its inclusion in medical records may facilitate care continuity for patients; however, documentation of immigration status may also expose patients to discrimination and stigmatization from physicians with anti-immigrant beliefs. In an AMA Journal of Ethics Case and Commentary article, authors Grace Kim, Uriel Sanchez Molina, and Altaf Saadi, MD, MSHPM, offered commentary on a specific case study and on the broader topic of medical record-keeping for immigrant patients, according to ethical, legal, and historical standards.
The authors considered the case of “Anna,” an 8-year-old Korean American experiencing anxiety in response to her mother’s status as an undocumented immigrant. Anna’s provider, Dr Lopez, considered documenting the mother’s immigration status as a means to facilitate referrals and adjust care to accommodate a major life stressor; however, he feared exposing the family to discrimination and risk for deportation, particularly in a time of increased anti-immigration sentiment and immigrant enforcement.
Although the primary ethical obligation of physicians is to provide quality care to all patients, the authors wrote, patient safety may be compromised if records are accessed by physicians with anti-immigrant beliefs or by immigration enforcement. The National Immigration Law Center and medical immigration advocates currently do not recommend documentation of immigration status. Even if physicians approach documentation through an “informed consent” process, they are not poised to fully explain the risks and benefits, particularly given the rapidly changing political climate.
Under the Health Insurance Portability and Accountability Act, disclosure of personal identifiable information, including immigration status, without patient consent is prohibited by law. Even so, documentation of immigration status still poses legal risks, particularly if immigration enforcement were to somehow access medical records. Although such a scenario remains theoretical as of the present, the United Kingdom has documented government sharing of National Health Service data with immigration authorities. As such, from a legal perspective, the authors recommended that physicians minimize such documentation. From a historical perspective, authors considered regulations developed in the 1980s regarding patient HIV status. Many states require written consent before HIV testing, and HIV status is more strongly protected than other components of medical records. Similarly, many states also restrict health insurers’ use of genetic information to prevent discrimination. The authors suggested that immigration status receive the same level of consideration as these other protected health measures.
The authors concluded that explicit documentation of patient immigration status should be minimized. Although disclosure of status could facilitate care, the legal risks to patient safety are too great to justify documentation as standard practice. Physicians have an obligation to provide the highest standard of care; in present times, the highest standard involves minimal documentation of sensitive information.
Kim G, Sanchez Molina U, Saadi A. Should immigration status information be included in a patient’s health record? AMA J Ethics. 2019;21(1):E8-E16.