Illegal immigrants form a large and disputed group in many countries. Indeed, even the name is in dispute. People in this group are referred to as illegal immigrants, illegal aliens, irregular migrants, undocumented workers, or, in French, as sans papiers. Whatever they are called, their existence raises an important ethical question: Do societies have an ethical responsibility to provide health care for them and to promote their health?
This question often elicits two different answers. Some people--call them nationalists--say that the answer is obviously no. They argue that people who have no right to be in a country should not have rights to benefits in that country. Other people--call them humanists--say that the answer is obviously yes. They argue that all people should have access to health care. It's a basic human right.
I think both these answers are off the mark. The first focuses too narrowly on what we owe people based on legal rules and formal citizenship. The other answer focuses too broadly, on what we owe people qua human beings. We need a perspective that is in between, that adequately responds to the phenomenon of illegal immigration and adequately reflects the complexity of moral thought. There may be important ethical distinctions, for example, among the following groups: U.S. citizens who lack health insurance, undocumented workers who lack health insurance in spite of working full time, medical visitors who fly to the United States as tourists in order to obtain care at public hospitals, foreign citizens who work abroad for subcontractors of American firms, and foreign citizens who live in impoverished countries. I believe that we--U.S. citizens--have ethical duties in all of these situations, but I see important differences in what these duties demand and how they are to be explained.
In this paper, I want to focus on the situation of illegal immigrants. I will discuss several different answers to the question about what ethical responsibility we have to provide health care to illegal immigrants. (I shall simply assume that societies have an ethical obligation to provide their own citizens with a reasonably comprehensive package of health benefits.) The answers that I shall discuss tend to conceptualize the ethical issues in terms of individual desert, professional ethics, or human rights. I want to discuss the limitations of each of these approaches and to offer an alternative. I shall approach the issues in terms of social responsibility and discuss the moral relevance of work. In doing so, I tend to pull bioethics in the direction of social ethics and political philosophy. That's the direction I think it should be heading. But before I begin the ethical discussion, I need to say more about the phenomenon of illegal immigration.
People have always moved around. They have moved for political, environmental, economic, and familial reasons. They have tried to escape war, persecution, discrimination, famine, environmental degradation, poverty, and a variety of other problems. They have tried to find places to build better lives, earn more money, and provide better support for their families. A strong sense of family responsibility has always been an important factor behind migration. (1)
But while human migration is not new, illegal immigration is, since only recently have nation-states tried to control and regulate the flow of immigration. Societies have always tried to exclude people they viewed as undesirable: criminals, people unable to support themselves, people with contagious diseases, and certain ethnic or racial groups. But only in the last hundred years or so have states tried in a systematic way to control the number and kinds of immigrants.
In contrast, what the Athenian polis tried to control was not immigration, but citizenship. Workers, merchants, and scholars came to Athens from all over the Mediterranean world. …