International workshop: Health care provision for migrants: Comparing approaches to ethical challenges in Germany and the United Kingdom

Introduction

In 2015, over 1 million people fled to Europe either by sea or via the “Balkan route.” ¹ The sheer scale of this “Refugee Crisis” has highlighted important practical questions relating to the provision of health care to migrants and refugees within the European Union (EU) and the Schengen area. In addition, the massive number of persons seeking to reach Europe has drawn attention to the ongoing debate surrounding the extent of any health care entitlements held by migrants and the duties owed by European countries to non-citizen residents. Even prior to the refugee crisis, the expansion of the EU facilitated easier travel within and between member states, meaning that destination countries have been facing complex practical, legal, and ethical challenges regarding migrant health. These include the justifiable extent of, and ethical practice in, health surveillance and research, the limits of duties to migrants from within and outside the EU, the dissemination and sharing of health data between nations, and differences as regards health and medical expectations, concepts and beliefs. Given the importance of health and health care for the well-being of individuals, communities, and the wider public, the choices made by European countries in responding to these questions will have major consequences for all persons living in, or seeking to migrate to, Europe.

Conference goals, themes and design

In response to these issues, a workshop was convened by the Institute for Ethics, History and Theory of Medicine and the Institute for Sociology at LMU Munich. The conference was organized by three researchers: Katja Kuehlmeyer, Postdoctoral Fellow and lecturer, Corinna Klingler, research associate and PhD Candidate in Medical Ethics (both based in the Institute for Ethics, History and Theory of Medicine at LMU) and Dennis Odukoya, research associate and PhD Candidate in Sociology (based in the Institute for Sociology at LMU).

This workshop focused on a comparison of the approaches to ethical issues in migrant health in Germany and the UK, with the goal of exchanging knowledge, expertise, and best practice. The conference was organized around four key themes, to which participants addressed their papers:

Terminology and knowledge production: how do we talk about migrant health?

The workshop featured 14 papers by early career researchers (including the authors of this report) from a range of disciplines, as well as NGO workers, and medical professionals from 14 institutions in four countries. Each paper was followed by a short commentary by another workshop participant and an open discussion period involving all participants. In addition, six senior researchers from the fields of sociology, philosophy, public health, medical ethics and law gave lectures on issues relating to migrant health policies and health care provision. Three of these lectures were given in a public symposium, which complemented the broader workshop programme. The programme was further enhanced by an additional public panel discussion focusing on clinical ethics, as well as a visit to Munich’s largest refugee reception centre, “Bayernkaserne.” This site visit included a meeting with representatives of the Centre’s administrative and health care staff. Finally, workshop participants engaged in four group work sessions, as detailed below.

Conference structure

The first four days of the workshop addressed the four key themes of the conference devised by the organizers, with the final day focusing on a general review of the topics discussed, and planning of future collaborative work.

On Monday, 14 March, the conference was opened by a welcoming plenary, in which the conference organizers outlined the aims of the workshop. The theme of the first day – “Comparing Migrant Health (Care) Data” – focused on the ethics and practice of research on migrant health. It explored questions related to comparative social research, practical and ethical issues concerning data collection on marginalized populations and the impacts of different definitions and terminologies on the visibility and inclusion of migrants in health research, policy and planning.

Prof. Dr. Viola Burau from the Department of Political Science at Aarhus University, Denmark gave the first paper of the conference, “Comparative Health Policy,” laying the groundwork for the day. Using the framework of the OECD health care system typology, ² Prof. Burau offered a comparative analysis of the German statutory health insurance system and the British National Healthcare Service (NHS). The session closed with an exploration of the value of comparative health system analysis and potential solutions to the challenges and pitfalls of comparative research.

Following the energetic discussion which accompanied Prof. Bureau’s lecture, Suzanne Bruins and Lucy Jones from the NGO “Doctors of the World” offered insight into the impacts of British and German health policy on marginalized persons. Presenting data from their organization’s walk-in clinics in Munich and London, their paper, entitled “Migrants Without Access to the Regular Healthcare System: Consequences of Exclusion in London and Munich,” illustrated that despite their commitments to universal health coverage, both Germany and the UK exclude certain populations from publicly funded care. Importantly, exclusion mechanisms in each country differ, leading to differences in the groups most affected. The paper also highlighted the dire consequences of inadequate access to care for uninsured persons, particularly children, in both countries.

Following collaborative work in two break-out groups (detailed below), in the evening, participants enjoyed three public lectures on the theme “Challenges in the Health Care Provision for Migrants: A Comparison Between the UK and Germany.” These lectures took place at the Munich Center for Ethics at the Central Campus of LMU and further explored the questions raised and discussed throughout the first day of the conference.

The first lecture was given by Dr. Hiranthi Jiayaweera from the Center on Migration, Policy and Society (COMPAS) at the University of Oxford, UK. Dr. Jiayaweera’s lecture focused on the challenges related to the diversification of migration, the importance of considering the entire migration process from a global perspective, and the need to better account for the social determinants of migrants’ health. Using examples from her research in the UK, Dr. Jiayaweera illustrated the importance for health of migration-related factors beyond ethnicity such as nationality, length of residence and migration motive, noting the complex interaction between migration-related and other parameters such as education, occupation and gender. In ending, she made a case for the integration of the most vulnerable groups into mainstream services.

Following Dr. Jiayaweera’s lecture, Prof. Dr. Oliver Razum, head of the Department of Epidemiology and International Public Health at Bielefeld University, Germany, discussed the German perspective on the provision of health care to migrants. Starting with an outline of the recent history of Germany as a de-facto immigration country, Prof. Razum continued with an explanation of the effects of migration on health. Like Dr. Jiayaweera, he emphasized the importance of examining migrants’ health in the context of their personal circumstances and full life-course. Drawing on research conducted on migrants in Germany, Prof. Razum showed how migration can be associated with both favorable and adverse health outcomes, and how current restrictions on asylum seekers’ access to care increase, rather than reduce, overall health care costs.

Finally, Prof. Dr. Hella von Unger from the Institute for Sociology at LMU, Germany, presented results from a collaborative research project, “Changing Categories: Migrants in Epidemiological, Preventive and Legal Discourses on HIV and Tuberculosis – a Comparison of Germany and Great Britain.” Prof. Unger examined the shifting discourses about migrants and public health in epidemiological research in Germany and the UK. Notably, she pointed out the biopolitical effects of terminological choices in reifying assumed distinctions between social groups, solidifying perceptions of minority groups as homogenous entities and defining migrants as being either “a risk” or “at risk.” In calling attention to the ethics and politics of data collection and use and, consequently, to the importance of critical reflexivity in the health sciences, the talk provided a perfect conclusion to the day’s discussions.

The second day of the workshop (Tuesday, 15 March) explored questions relating to refugees’ and asylum seekers’ formal access to health care services, states’ international legal obligations and national policies and public health approaches to immigration and infectious disease control. Recently, Germany and the UK have employed very different approaches to the absorption and social integration of asylum seekers. Where Germany has welcomed a very large number of refugees, the UK has taken a far more isolationist position.

First, Sabine Klotz, a PhD candidate from Friedrich-Alexander University of Erlangen-Nuremberg presented her paper “Health for All? Exclusion and Debates in Terms of Access to Health Care for Asylum Seekers in Germany.” Sabine outlined international legal standards with regard to asylum seekers’ health rights, contrasting them with the ways in which health care provision for this group is de jure and de facto designed in Germany. The current debate on asylum seekers’ access to care in Germany, including justifications for inconsistencies with international law, was then examined through the lens of discourse analysis.

Following Sabine’s paper, Dennis Odukoya, workshop organizer and PhD candidate at LMU, presented research on medical screening in migration contexts in a paper entitled “The Screening of Migrants for Infectious Diseases: Challenging a Public Health Measure.” Dennis focused on a comparison of the divergent policies and practices concerning the screening of migrants across different areas in Germany and the UK. In questioning the medical effectiveness as well as ethical appropriateness of ongoing practices, he pointed to biopolitical factors for explaining the particular medical screening practices of migrants.

Next, Alice Verran, a physician general practitioner from Coventry, UK presented her research on “The Experiences and Perceptions of Family Planning of Female Chinese Asylum Seekers Living in the UK.” Alice presented the results of a qualitative study conducted with Chinese migrants in the UK about their understanding of, and attitudes towards various methods of contraception. The study showed how Chinese societal and cultural concepts influence patients’ contraceptive choices, thus also pointing to the importance of physician awareness and understanding of these norms in order to be able to provide effective and appropriate care and advice to patients.

In the afternoon, the workshop relocated to the “Bayernkaserne,” Munich’s largest refugee reception centre. Here, representatives of the local administration, Dr. Werner Schimana, head of the Municipal Council for Health and Environment, and Vreni Steinack, Commissioner for Migration and Health at the same office, showed part of the facilities, explained the intake procedure for new arrivals and provided an overview of their work and the Munich municipality’s approach to migrants’ and asylum seekers’ absorption, integration and health.

The third day of the workshop, Wednesday, 16 March, explored the arguments for and against providing publicly funded health care to migrants and provided in-depth analyses of the philosophical, conceptual and practical considerations at play. Two questions emerged as fundamentally important to such debates: (a) the question of migrants’ deservingness for health resources and (b) the questions of who should have responsibility for the costs of provision.

In the first session of the day, Nora Gottlieb, postdoctoral researcher from Ben-Gurion University, Israel, and Peter West-Oram, senior research fellow at Christian-Albrechts-University, Germany, gave papers exploring the distinctions often drawn between migrants and citizens as justifications for excluding the former from publicly funded health services. Nora’s paper, “Beyond Rights and Wrongs: Suggestions for an Ethical Discussion on Migrants’ Access to Care,” presented empirical data on the different, context-specific ways in which policy-makers in Germany and Israel define and justify (un)deservingness for publicly funded healthcare. Based on her findings, Nora noted that the universalistic, egalitarian assumptions which ground most ethical discourses in public health are not fully expressed by migrant health policies in Germany and Israel, which assume certain exclusions and inequities to be the “fair” policy solution. In response to these incommensurabilities, the paper drew on ethical theory to make three suggestions to pragmatically move the ethical debate on migrants’ access to health care to more fruitful grounds.

Peter’s paper, “Reconceptualising ‘Migrant’ and ‘Public’ Health: From Self-interest to Solidarity,” focused on assumptions common to many discussions of “migrant health” – that migrants and citizens have distinct interests which are often in conflict, making resource allocation decisions into zero-sum games, where for migrants to benefit, citizens must lose out. In criticizing these assumptions, Peter’s paper suggested that citizens have an interest in protecting the health of migrants, and that this interest may provide the catalyst for broader solidarity between the two groups, where difference and distance had previously been assumed.

In the day’s second session, Jan-Ole Reichardt, research associate at the University of Münster, and Wajima Safi, a physician working at the University Hospital in Erlangen, discussed questions of justice relating to the distribution of scarce resources for health. Jan-Ole’s paper, “Public Health Care Provision for “Paperless”: Should we Pay and Let Them Stay?”, examined the difficulties of meeting the health needs of undocumented migrants. The paper noted that, in Germany, undocumented migrants who realize their formal entitlement to publicly funded medical treatment run the risk of being reported to the authorities. In exploring this issue, Jan-Ole examined the costs and benefits of instantiating anonymous health registration cards for migrants, in order to enable them to seek care free of fear from detention and/or deportation.

Wajima’s paper, “Distribution of Donor Organs to Non-Residents in Germany: Residency is Challenging Responsibility,” addressed a similar concern, focusing more specifically on the allocation of donor organs to migrants and refugees. Given the chronic shortage of donor organs for transplantation in Europe, the provision of organs to migrants and refugees for transplantation is controversial. Wajima offered an overview of current legislation and insights into donation practice and her paper then explored the nature of the objections to provision of donor organs to migrants, as well as the arguments for equitable provision.

In the first afternoon session, Dr. Verina Wild, postdoctoral researcher at LMU and senior teaching and research associate at the University of Zurich, examined existing ethical frameworks which could serve as grounds for migrant health rights claims. Her lecture, “Access to Health Care for Migrants: Exploring Ethical Justifications From Minimal Care to Universal Access,” examined a range of arguments given to justify migrants’ access to care. In doing so, Dr. Wild offered a cosmopolitan argument for guaranteeing migrants access to care, as well as arguments based on international law and human rights, and emphasized the importance of providing an ethical justification for migrant access to health services.

The final session on Wednesday afternoon featured a public panel discussion entitled “Pluralism, Culture and Religion in End-of-Life Decisions for Terminally Ill Children,” which took place at the Hospital of the LMU Munich. The panel explored the specific details of one particular case, presented by Dr. Kathrin Knochel, Medical Doctor at the Center for Pediatric Palliative Medicine at the children's hospital of LMU Munich, Großhadern, in which a specialized home pediatric palliative care-team struggled in the provision of intercultural pediatric palliative care. In addressing this case, the members of the panel discussed questions relating to the role of culture, language barriers, and differing expectations and values. The panel comprised Prof. Dr. Monika Führer, Head of the Coordination Center for Pediatric Palliative Care, LMU Children’s Hospital, Prof. Dr. Richard Huxtable, Director of the Centre for Ethics in Medicine at the University of Bristol, UK, Prof. Dr. Ilhan Ilkilic from the Department of History of Medicine and Ethics at Istanbul University, Turkey and Member of the German Ethics Council and Prof. Dr. Georg Marckmann, Head of the Institute for Ethics, History and Theory of Medicine of LMU, Germany.

The penultimate day of the conference, Thursday, 17 March, featured six participant papers which addressed informal access barriers to health care. Papers under this workshop theme examined the impact of socio-cultural and linguistic differences on health care policy-making, provision, and research. These papers explored the effects of informal, and sometimes even unnoticed, socio-cultural discrepancies and conflicts in health care, the consequences of failure to account for these phenomena, and possible responses to it.

Arianne Shahvisi, lecturer at the University of Sussex, the UK opened the day with her paper “FGM and Cultural Pluralism: Racism, Sexism, and Hypocrisy.” Starting out from a specific case, the paper illustrated the confusion among UK medical practitioners over their legal and ethical obligations as regards Female Genital Mutilation (FGM). To scrutinize the conflicting logics and assumptions underlying current UK law on non-therapeutic genital surgery, Arianne juxtaposed regulations on FGM, male circumcision and female cosmetic genital surgery. The analysis revealed inconsistencies that are incompatible with bioethical principles. Consequently, Arianne closed with suggestions for policy reform that would align the respective legal frameworks with each other and with core principles of medical ethics.

She was followed by Antje Lindenmeyer, lecturer at the University of Birmingham, whose paper, “Using Superdiversity as a Lens to View Migrant Health,” commented on the heterogeneity of migrant and refugee groups in the UK, for example, with regards to socio-economic status, age, and gender. Antje noted that this “superdiversity” has rendered researchers’ traditional views of diversity, which took membership in a migrant community to be the only key identifier of persons, insufficient. Using examples from two distinct studies, Antje’s paper offered suggestions on how migrant health research can better accommodate superdiverse societies.

Next, Rebecca Ehata, postdoctoral researcher at the University of Oxford, presented her research (conducted with Tamsyn Eida, a Freelance Researcher working at T4SE Cooperative Limited) on how to overcome those barriers to health care that mobile EU citizens continue to face within the EU, despite their legal entitlements. Her paper, “Beyond Formal Inclusion: Addressing Barriers to Healthcare for EU Migrants in the UK,” described a particular intervention aimed at improving Polish nationals’ access to an NHS smoking cessation program. In considering successes, failures and lessons learnt, the paper considered several important issues for public health service provision, including whether and under what circumstances should migrant health care services be incorporated into “mainstream” provision? When and to what extent should migrant health care interventions be separate and tailored to meet particular needs? And how can the unequal resource allocation implied in tailored approaches be justified?

Yael Peled, postdoctoral research fellow at McGill University, Canada, finished the morning session with her paper “Healthcare Provision for Migrants: (Mis)managing Language Barriers.” Yael pointed out that language barriers are among the crucial challenges to equitable health care provision faced by migrants, both in multilingual and presumptively monolingual societies. She further noted that, in so far as language is not only a medium of communication, but also a repository of cultural knowledge and marker of identity, insufficient linguistic accommodation may lead to “epistemic injustices”; such as when a patient’s credibility is questioned due to his/her accent. Given the impossibility of eliminating language barriers, the paper made suggestions towards a better management of language barriers such as metalinguistic awareness, epistemic humility and the reconceptualization of languages as “linguistic repertoires.”

On Thursday afternoon, in the final early career researcher session of the workshop, Yasmin Farooq from the University of Derby, and Corinna Klingler, workshop organizer and PhD candidate at LMU, presented papers examining the professional experiences of migrant physicians. Yasmin’s paper, “Integration, Identity, and Elite Migrants: Capturing the Perspective of Overseas-trained South Asian Doctors,” offered insight into the professional expectations and experiences of migrant physicians in the UK. In doing so, Yasmin focused specifically on the experiences of South Asian physicians in the UK, noting the seemingly contradictory experiences of privilege, first, as a physician in a position of significant social status, and, second, marginalization as a migrant in a sometimes hostile social and professional context – an issue which workshop participants found particularly interesting, and which fostered much debate.

Following Yasmin’s paper, Corinna Klingler also explored issues relating to migrant physicians in her paper “Migrant Physicians, Setting-specific Knowledge and Responsibility.” Focusing on the professional, moral, and legal expectations countries might have of migrant physicians, Corinna’s paper examined the extent to which liability can be assigned to migrant physicians in cases where patients are harmed due to limited setting-specific competencies, e.g. language capacities. In the absence of adequate support, Corinna argued, it is unreasonable to hold (migrant) physicians solely responsible for poor treatment outcomes when they may have lacked the capacity to avoid harmful outcomes due to institutional failures.

Friday, 18 March, the final day of the workshop, began with the last of the senior researchers’ presentations, given by Prof. Dr. med. Alena Buyx, head of the Division of Biomedical Ethics at Christian-Albrecht-University at Kiel, and member of the German Medical Ethics Council. Under the title “Getting Ethics into Policy,” Prof. Buyx described her own experience working with British (the Nuffield Council) and German (Medical Association Central Ethics Commission (ZEKO)) research and policy organizations, setting out the structures and approaches of these organizations, and offering advice to participants on how to effectively shape public policy. Topics of particular interest to participants included the ways in which academic ethics research influences policy in different national contexts, the different standards adopted by Germany and the UK, and approaches to becoming involved in ethics and policy development and clinical research.

Group discussions, outcomes, and future direction

Throughout the workshop, participants had daily opportunities to engage in smaller group discussions addressing the following questions:

What are ethically acceptable ways to deal with challenges in health care provision for migrants?

The goal of this group work was to continue the discussions surrounding the individual workshop papers, draw out common issues, and share best practice. On the final day of the conference, the two groups were able to share the results of their respective discussions, in order to identify areas for further ongoing collaborative work.

In conjunction with the broader program and the extensive informal conversations which took place throughout the week, these structured discussions enabled participants to explore the key themes of the workshop in more detail, and consider possible solutions to the profoundly complex ethical issues surrounding migrant health care. Amongst the many issues discussed, four were of particular interest to participants: first, participants noted the importance of acknowledging and responding to the informal barriers which often prevent migrants’ equal access to care, even when formal barriers are absent. In particular, participants emphasized the need to ensure that health care providers are aware of, and trained to overcome, these informal barriers. Second, questions pertaining to universally accessible basic health care were of particular importance to conference participants, both in terms of how to present such provision as a desirable policy goal to reluctant destination countries, and of how it may be achieved and justified in resource-constrained contexts. Third, questions relating to the plausibility, or possibility, of establishing universally acceptable ethical norms in health care were an ongoing point of discussion throughout the workshop. One group in particular dedicated significant attention to the possible impacts of unreflective acceptance of supposedly universal moral norms. In discussing these impacts, participants noted the importance of making decisions in a way which acknowledges and respects different, potentially conflicting, ethical standards, based on open dialogue. Fourth, and perhaps most fittingly given the goals of the conference, participants emphasized the importance of sharing best practices across disciplinary, professional, and national boundaries, and of promoting open and inclusive dialogues in order to effectively protect all persons from deprivations of health.

These discussions provided a fitting end to a productive, informative, and highly enjoyable week. The workshop provided an excellent opportunity to explore a range of complex ideas in a series of lively and constructive debates and to collaborate on issues of great importance. Given the success of the workshop and the scale and importance of the issues discussed, participants and organizers are committed to maintaining and expanding the research network it created, and to future collaborative projects in research, publication, and practice.