NEJM, February 13, 2014
Michael J. Young, M.Phil. (Petrie-Flom Academic Fellow), and Lisa Soleymani Lehmann, M.D., Ph.D.


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Quelino Jimenez came to the United States at 18 years of age, seeking work to provide financial support to his family of 11 in Mexico. Jimenez found a construction job in Chicago, where he worked without a legal work or residence permit for more than a year until he sustained injuries after a 20-ft fall on the job, which resulted in quadriplegia. He was admitted to a Chicago hospital, where he remained for months. No long-term care facility was willing to accept Jimenez as a patient. One day, he recounted, “They told me, 'Today you are going to your home.' . . . I wanted to say something, but I couldn't talk. I wanted to ask why.”1

Jimenez was subsequently discharged, by means of air ambulance, to a hospital in Oaxaca, Mexico. In the Oaxaca hospital, Jimenez had bedsores, two cardiac arrests, pneumonia, and sepsis. “I didn't want to come back [to Mexico],” he told family and reporters, “because here there's no medicine. . . . I need therapy, I need a lot of things they don't have.” On January 3, 2012, Jimenez died at 21 years of age.1

Jimenez's case offers a poignant glimpse into medical repatriation, the transfer of undocumented patients in need of subacute care to their country of origin.2 Although data on the prevalence and circumstances surrounding medical repatriation are limited, owing to insufficient documentation and reporting requirements, a recent report based on observational data indicates that there have been at least 800 cases of attempted or successful involuntary medical repatriation of undocumented immigrants in the United States alone.3 The relatively scant attention that this practice has received among medical professionals is striking, given that medical repatriation impinges on the core values that have shaped medicine as a moral enterprise.

We examine the ethical boundaries of medical repatriation, particularly as they relate to patients, health care providers, and hospitals, while recognizing the need for increased comprehensive reporting and data to uncover the nature and scope of this practice. After exploration and critical evaluation of the history and motivations behind medical repatriation, considerations against the practice are advanced. Drawing on the ethical dimensions of informed consent, equality, distributive justice, transparency, and trust, we assess the tension between medical repatriation and the ethical duties of health care providers. At this time of great change in health care and immigration policy, clarity about our ethical obligations to undocumented immigrants is crucial if we are to create systems that are not only efficient, coordinated, and technologically sophisticated but also equitable for those who are vulnerable. [...]

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