Needs versus rights: moral understandings of primary care workers in Belgium regarding access to healthcare for undocumented migrants

Problem

The ambiguity of Belgium’s society towards undocumented immigrants becomes particularly tangible in the domain of healthcare. Belgium has a legal framework about who should account for medical services provided to individuals with a precarious immigration status. However, epidemiological findings show this legislation is poorly implemented. Bureaucratic obstacles, language barriers, chilling effects as well as a climate of fear are well-known factors that hinder undocumented migrants’ access to healthcare. Yet, the impact of the individual characteristics and more specifically the moral positions of service providers on the access to healthcare for undocumented migrants has so far been largely under investigated. In this paper we explore what health care workers in Belgium consider to be the criteria to help individuals with a precarious immigration status. This allows us to critically question common practice, intuitive understandings, and the relevance of deontological principles.

Approach

Ethnography, involving long term observations and building intimate ties with respondents, offers a valuable path to research how moral judgements are made on a daily basis. This approach advocates morality is best revealed in practice, by describing what morality is in real life daily interactions. Therefore, we currently perform participant observations in a community of undocumented migrants in Brussels to investigate the normative arguments that are used (not) to choose for a primary care worker as well as the negotiations to get access to clinical consultations. Besides this, we perform participant observation at the emergency department in Sint-Pieters hospital in Brussels to study the moral concepts healthcare workers use to negotiate dilemma's due to difficulties in access to healthcare. Based on this multi-site ethnographic research we identify indicators for different subject positions that are taken by health care workers.

Findings

Our findings show a gap between existing deontological theoretical models and clinical practice. Conceptions of ‘illegality’ shape people’s sense of responsibility towards undocumented migrants. Perceptions of vulnerability, intuitions about patient’s own responsibility, as well as differentiation in appeal and charitability of an illness, interfere with willingness to implement existing formalized procedures. This selectivity results in an informal hierarchy of ‘deservingness’ along multiple axes and evidently impacts on the access to health care services for undocumented migrants.

Consequences

The normative framework that is currently used regarding access to healthcare, is mainly guided by deontological, utilitarian and human rights perspectives. A care-ethics approach can furnish us with a more comprehensive understanding of how practices on allowing access to healthcare are related to specific ethical characteristics of care, as well as to broader moral values and norms. Starting from needs rather than rights, an ethics of care perspective allows to critically analyse how subjectivities are linked to normative theories and ideological conceptualizations of care in a context of global power imbalances.