- Email: [email protected]
Prenatal care to future citizens
ETHICS
Prenatal Care to Future Citizens Beatriz E. Juncadella, MS II Brody School of Medicine at East Carolina University, Greenville, North Carolina The goal of the North Carolina Medicaid program for pregnant women is to “reduce infant deaths in North Carolina by providing early and regular prenatal care, support services to pregnant women, and family planning referrals among others.”1 This program is targeted to help residents of North Carolina of limited resources needing extra help and support during their pregnancy. Yet, being pregnant, of limited resources, and a resident of the state are not the only criteria required to receive this social service. Among those individuals excluded from receiving this benefit are documented legal immigrants not possessing a permanent resident card (“green card”). Some of these residents have been living legally in North Carolina for years, active participants in the life and economy of the state as consumers, producers, and taxpayers. According to section 3405 of the Medicaid Manual, immigrants are qualified to receive full Medicaid coverage only if they possess a green card for at least 5 years or more; all other legal immigrants are viewed as “illegal” for purposes of Medicaid assistance and, thus, only qualify for emergency Medicaid services—the day of delivery if vaginal, and not more than 4 days if C-section. They are excluded from receiving financial help for any type of preventive, early prenatal care. Furthermore, the main beneficiary of such a program is the unborn child—a future United States citizen. “For the little child in you we want to see you through,”1 states the cover of the Medicaid informational pamphlet. If the concern is for the unborn child, why are the future children of immigrant women denied assistance for their prenatal care? I believe that the policy denying assistance to legal immigrant pregnant women is unjust, impractical, and morally unsound. Denying assistance to legal immigrant pregnant women interferes with the principle of reciprocity as distributive justice. Most legal immigrants, with the exceptions of those holding visas not allowing employment, such as student and tourist visas, are authorized to work in the United States, and they pay the same state and federal income taxes as do citizens. According to a report by the American Civil Liberties Union, when immigrants participate in the United States economy, they create more jobs than they fill.2 Their contribution to state and federal funds demands in return access to society’s benefits. The state has a reciprocal obligation to provide assistance to those
Correspondence: Inquiries to Willem A. Landman, DPhil, Department of Medical Humanities, Brody School of Medicine at ECU, 600 Moye Blvd., Greenville, NC 27858
individuals paying to receive such assistance. As reasoned by Chief Justice Warren Burger, “for purposes of allocating its finite resources, a state has legitimate reason to differentiate between persons who are lawfully in the state and those who are unlawfully there.”2 One might recognize the distinction that some people make for an illegal immigrant working without paying taxes; yet, I cannot understand differentiating between a legal immigrant with a “green card” and one without one, when both reside in the state and pay the same taxes. Furthermore, legal immigrants participate not only in the economics of the state, but they are also integral members of society. Unlike a tourist, who is just visiting for a short time, many legal immigrants consider the United States their home—those waiting for confirmation of their political asylum or permanent residence status. Their evident social, cultural, and economical participation in the life of the community should be sufficient to allow these women to share in society’s benefits.2 Denying entitled assistance to legal immigrant women who are residents of North Carolina, on the sole basis of not possessing a “green card,” is downright exploitation. Another argument against this policy is that it offends the formal principle of justice; “treat equals equally; unequals unequally” (D. B. Resnik, lecture, East Carolina University School of Medicine, September 9, 1999) As mentioned previously, the primary focus of prenatal care is the unborn child, not the pregnant woman. Regardless of the legal status of the mother, a fetus is not a citizen under the law. Citizenship is acquired at birth; therefore, an unborn child, whether of a citizen or a noncitizen, has the same legal status. Furthermore, both fetuses would have the same potential benefits from receiving prenatal care and the same potential harms from not receiving it. Treating fetuses differently violates the fairness provision of distributive justice—impartiality. Providing prenatal care to the unborn child of a citizen and not to that of a noncitizen implies that the former is more important or better than the latter, and this violates fairness. Finally, the denial of assistance for prenatal care to future United States citizens may impose a greater and unnecessary economic burden on taxpayers.2 The most important period for the normal physical and mental development of a child is prenatally. Early and regular prenatal care decreases the risks of delivering low birthweight, premature children. It also reduces
CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/00/$20.00 PII S0149-7944(00)00189-6
161
the risks of physical and mental prenatal injuries and long-term disabilities. If any of these infants, as United States citizens, suffer a preventable prenatal injury, they are eligible for full social welfare the rest of their lives. Why decide to pay more later rather than less now? It is obvious that helping pregnant immigrant women provide prenatal care for their unborn children is in the long run more economically efficient and humane than denying this help and addressing the child’s health complications after birth.2 Furthermore, having healthy citizens is “socially useful and cost-effective since it benefits the current generation of adults who, when aged, will need to be supported by a healthy, stable, and productive work force.”3 It is almost unquestionable that the current North Carolina Medicaid policy, which denies assistance to legal immigrant women for the prenatal care of their unborn children, insults justice and morality, and it needs to be reformed. A possible argument against providing such assistance to legal immigrant women might be based on the availability of scarce social services, even for United States citizens. Opponents might argue that the United States government has a greater duty to its citizens than to its legal immigrants. Yet, permanent resident aliens, one class of noncitizens, are allowed to enjoy almost all of the benefits of society, with the exception of voting and holding
162
public offices.2 What distinguishes permanent resident aliens from other legal immigrants is a piece of paper (a “green card”). Moreover, the one benefiting the most from prenatal care is the unborn child—a future United States citizen. Why refuse to help future citizens have a better chance at life, and an equal opportunity of competing? I believe that no justification exists for denying assistance to pregnant women on the basis of not possessing a “green card.” Principles of justice, utility, and humanity demand that prenatal care be made available to the future citizens of the United States.
REFERENCES 1. Baby Love Program [brochure]. Greenville, NC: Pitt
County Health Department, 1997. 2. De Ville K. Parties to the social contract? Justice, Proposi-
tion 187 and health care for undocumented immigrants. Trends Health Care Law Ethics 1995;10(1–2):113–117. 3. Kopelman L. Children: health care and research issues. In:
The encyclopedia of bioethics. New York: Macmillan, 1995: 363–368.
CURRENT SURGERY • Volume 57/Number 2 • March/April 2000
Prenatal Care to Future Citizens Beatriz E. Juncadella, MS II Brody School of Medicine at East Carolina University, Greenville, North Carolina The goal of the North Carolina Medicaid program for pregnant women is to “reduce infant deaths in North Carolina by providing early and regular prenatal care, support services to pregnant women, and family planning referrals among others.”1 This program is targeted to help residents of North Carolina of limited resources needing extra help and support during their pregnancy. Yet, being pregnant, of limited resources, and a resident of the state are not the only criteria required to receive this social service. Among those individuals excluded from receiving this benefit are documented legal immigrants not possessing a permanent resident card (“green card”). Some of these residents have been living legally in North Carolina for years, active participants in the life and economy of the state as consumers, producers, and taxpayers. According to section 3405 of the Medicaid Manual, immigrants are qualified to receive full Medicaid coverage only if they possess a green card for at least 5 years or more; all other legal immigrants are viewed as “illegal” for purposes of Medicaid assistance and, thus, only qualify for emergency Medicaid services—the day of delivery if vaginal, and not more than 4 days if C-section. They are excluded from receiving financial help for any type of preventive, early prenatal care. Furthermore, the main beneficiary of such a program is the unborn child—a future United States citizen. “For the little child in you we want to see you through,”1 states the cover of the Medicaid informational pamphlet. If the concern is for the unborn child, why are the future children of immigrant women denied assistance for their prenatal care? I believe that the policy denying assistance to legal immigrant pregnant women is unjust, impractical, and morally unsound. Denying assistance to legal immigrant pregnant women interferes with the principle of reciprocity as distributive justice. Most legal immigrants, with the exceptions of those holding visas not allowing employment, such as student and tourist visas, are authorized to work in the United States, and they pay the same state and federal income taxes as do citizens. According to a report by the American Civil Liberties Union, when immigrants participate in the United States economy, they create more jobs than they fill.2 Their contribution to state and federal funds demands in return access to society’s benefits. The state has a reciprocal obligation to provide assistance to those
Correspondence: Inquiries to Willem A. Landman, DPhil, Department of Medical Humanities, Brody School of Medicine at ECU, 600 Moye Blvd., Greenville, NC 27858
individuals paying to receive such assistance. As reasoned by Chief Justice Warren Burger, “for purposes of allocating its finite resources, a state has legitimate reason to differentiate between persons who are lawfully in the state and those who are unlawfully there.”2 One might recognize the distinction that some people make for an illegal immigrant working without paying taxes; yet, I cannot understand differentiating between a legal immigrant with a “green card” and one without one, when both reside in the state and pay the same taxes. Furthermore, legal immigrants participate not only in the economics of the state, but they are also integral members of society. Unlike a tourist, who is just visiting for a short time, many legal immigrants consider the United States their home—those waiting for confirmation of their political asylum or permanent residence status. Their evident social, cultural, and economical participation in the life of the community should be sufficient to allow these women to share in society’s benefits.2 Denying entitled assistance to legal immigrant women who are residents of North Carolina, on the sole basis of not possessing a “green card,” is downright exploitation. Another argument against this policy is that it offends the formal principle of justice; “treat equals equally; unequals unequally” (D. B. Resnik, lecture, East Carolina University School of Medicine, September 9, 1999) As mentioned previously, the primary focus of prenatal care is the unborn child, not the pregnant woman. Regardless of the legal status of the mother, a fetus is not a citizen under the law. Citizenship is acquired at birth; therefore, an unborn child, whether of a citizen or a noncitizen, has the same legal status. Furthermore, both fetuses would have the same potential benefits from receiving prenatal care and the same potential harms from not receiving it. Treating fetuses differently violates the fairness provision of distributive justice—impartiality. Providing prenatal care to the unborn child of a citizen and not to that of a noncitizen implies that the former is more important or better than the latter, and this violates fairness. Finally, the denial of assistance for prenatal care to future United States citizens may impose a greater and unnecessary economic burden on taxpayers.2 The most important period for the normal physical and mental development of a child is prenatally. Early and regular prenatal care decreases the risks of delivering low birthweight, premature children. It also reduces
CURRENT SURGERY • © 2000 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/00/$20.00 PII S0149-7944(00)00189-6
161
the risks of physical and mental prenatal injuries and long-term disabilities. If any of these infants, as United States citizens, suffer a preventable prenatal injury, they are eligible for full social welfare the rest of their lives. Why decide to pay more later rather than less now? It is obvious that helping pregnant immigrant women provide prenatal care for their unborn children is in the long run more economically efficient and humane than denying this help and addressing the child’s health complications after birth.2 Furthermore, having healthy citizens is “socially useful and cost-effective since it benefits the current generation of adults who, when aged, will need to be supported by a healthy, stable, and productive work force.”3 It is almost unquestionable that the current North Carolina Medicaid policy, which denies assistance to legal immigrant women for the prenatal care of their unborn children, insults justice and morality, and it needs to be reformed. A possible argument against providing such assistance to legal immigrant women might be based on the availability of scarce social services, even for United States citizens. Opponents might argue that the United States government has a greater duty to its citizens than to its legal immigrants. Yet, permanent resident aliens, one class of noncitizens, are allowed to enjoy almost all of the benefits of society, with the exception of voting and holding
162
public offices.2 What distinguishes permanent resident aliens from other legal immigrants is a piece of paper (a “green card”). Moreover, the one benefiting the most from prenatal care is the unborn child—a future United States citizen. Why refuse to help future citizens have a better chance at life, and an equal opportunity of competing? I believe that no justification exists for denying assistance to pregnant women on the basis of not possessing a “green card.” Principles of justice, utility, and humanity demand that prenatal care be made available to the future citizens of the United States.
REFERENCES 1. Baby Love Program [brochure]. Greenville, NC: Pitt
County Health Department, 1997. 2. De Ville K. Parties to the social contract? Justice, Proposi-
tion 187 and health care for undocumented immigrants. Trends Health Care Law Ethics 1995;10(1–2):113–117. 3. Kopelman L. Children: health care and research issues. In:
The encyclopedia of bioethics. New York: Macmillan, 1995: 363–368.
CURRENT SURGERY • Volume 57/Number 2 • March/April 2000