“A modest thoughtfulness”
Authors: Iona Heath
Journal: BMJ (2008)

In March 2007 the UK Home Office published Enforcing the Rules: A Strategy to Ensure and Enforce Compliance with our Immigration Laws, to “ensure that living illegally becomes ever more uncomfortable and constrained until they leave or are removed.”

This followed the Department of Health consultation document Proposals to Exclude Overseas Visitors from Eligibility to Free NHS Primary Medical Services,published in May 2004. The results of the public consultation have never been published, but over the intervening nearly four years the rhetoric has shifted from the need to curb the perceived abuses of “health tourism” to an apparently deliberate intention to make the lives of people who have been refused asylum intolerable.

No one knows exactly how many refused asylum seekers are living in the United Kingdom, but the National Audit Office’s estimate in 2005 was between 155 000 and 283 500. Some people have been wrongly refused. Appeals against decisions have a high rate of success (more than 40% for Somali, Eritrean, and Zimbabwean nationals in 2006), indicating that the original processes were flawed. Increasing the limits on the availability of legal expertise and support are only likely to compound this. Some people cannot return to their country of origin because they are unable to obtain travel documents or because they remain genuinely fearful for their safety. People become trapped in a state of limbo—unable to work, without access to financial support, and subject to a government policy of deliberate destitution. They have no access to hospital care other than in an emergency and are pursued by debt collectors if they inadvertently accept hospital treatment. 

Now the proposal is that they should also be refused access to primary care services. The government apparently cannot afford to track and remove refused asylum seekers and so adopts these policies to try to force people to leave out of desperation. In a release made under the Freedom of Information Act, dated 9 February 2007, the Home Office disclosed the extraordinarily ugly concept of “destitution plus.” The physical effects of destitution are not deemed to constitute illness, and the concept of destitution plus is used to insist on another cause of illness or disability in addition to the effects of destitution before any support can be given:

Adult asylum seekers who have a need for care and attention due to age, illness or disability which has not arisen solely from destitution or the physical effects of destitution are supported by local authorities under section 21 of the National Assistance Act 1948.

All doctors know that destitution is incompatible with any recognised definition of physical and mental health and that the very notion of destitution plus completely misrepresents the nature of illness.

Article 25 of the 1948 United Nations Universal Declaration of Human Rights states that all people have the right to a standard of living adequate for the health and wellbeing of themselves and their family, including food, clothing, housing, and medical care and necessary social services. It does not read “everyone except refused asylum seekers.” Article 3 of the European Convention on Human Rights prohibits the use of torture or inhumane or degrading treatment or punishment. And yet the UK government is pursuing a policy of deliberate destitution of refused asylum seekers, arguing that any more humane policy would act as a “pull factor” for further migration. Giving evidence to the parliamentary joint committee on human rights, the immigration minister, Liam Byrne, could cite no evidence for the existence of such a pull factor but claimed to have arrived at its existence “on the basis of logic.”

Government policy that fails to respect human rights also threatens to compromise the ethical code of doctors. In the UK this is laid out in the General Medical Council’s Duties of a Doctor:

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must make the care of your patient your first concern.

Again, this does not say “unless your patient is a refused asylum seeker.” The government also seems to expect doctors to help to police the immigration system, insisting in Enforcing the Rules that

we will make it easier for employers, healthcare workers, local authorities, government agencies and service providers like banks to access information more easily and determine whether people are here legally and entitled to services.

Doctors working in the NHS have been educated within a tradition of universality and equity that stretches back to the inception of the service in 1948. What is shocking about the current proposals is that they are not primarily about recovering costs but about denying access and refusing treatment. Policy has been disconnected from ethics. Doctors have clear responsibilities to work with government to promote public health and have responsibilities as agents of distributive social justice through decisions about who should be entitled to state benefits and whose healthcare needs should be prioritised at the expense of others. However, obliging doctors to take part in enforcing repressive political policy has an infamous history that is almost always associated with demonisation of a group that can be described as “other,” as in Nazi Germany, in South Africa under apartheid, and in the treatment of the minority Kurdish population in Turkey. Doctors in all these settings have had their commitment to ethical practice challenged at a very fundamental level. Some have colluded; others have resisted with immense courage. Never before have doctors working in the NHS been asked to face anything even remotely similar.

The lives of many refused asylum seekers substantiate what the writer W G Sebald described as “the marks of pain which . . . trace countless fine lines through history.” Albert Camus defines the appropriate response as

the job of keeping alive, through the apocalyptic historical vista that stretches before us, a modest thoughtfulness which, without pretending to solve everything, will constantly be prepared to give some human meaning to everyday life.

For doctors, that modest thoughtfulness should perhaps begin with supporting “Still human still here,” the campaign to end destitution of refused asylum seekers (www.stillhuman.org.uk).

Obliging doctors to take part in enforcing repressive political policy has an infamous history that is almost always associated with demonisation of a group that can be described as “other”