key: cord-1056336-2eo2jhoh
authors: Onarheim, Kristine Husøy; Wickramage, Kolitha; Ingleby, David; Subramani, Supriya; Miljeteig, Ingrid
title: Adopting an ethical approach to migration health policy, practice and research
date: 2021-07-28
journal: BMJ Glob Health
DOI: 10.1136/bmjgh-2021-006425
sha: 0f2ca8725a20bff60ba1a1d7d6cc8cd2309786c9
doc_id: 1056336
cord_uid: 2eo2jhoh

Migration health is affected by decision making at levels ranging from global to local, both within and beyond the health sector. These decisions impact seeking, entitlements, service delivery, policy making and knowledge production on migration health. It is key that ethical challenges faced by decision makers are recognised and addressed in research and data, clinical practice and policy making on migration health. An ethical approach can provide methods to identify ethical issues, frameworks for systematising information and suggesting ethically acceptable solutions, and guidance on procedural concerns and legitimate decision making processes. By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. Adopting an ethical approach to migration health benefits governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves. First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do through an ‘all things considered’ approach. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions – from ‘bedside rationing’ to collection of big data or in policy making – that can ensure that migrants’ interests are considered. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups. An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses.

that ethical challenges faced by decision makers are recognised and addressed in research and data, clinical practice and policy making on migration health. An ethical approach can provide methods to identify ethical issues, frameworks for systematising information and suggesting ethically acceptable solutions, and guidance on procedural concerns and legitimate decision making processes. By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. Adopting an ethical approach to migration health benefits governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves. First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do through an 'all things considered' approach. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions -from 'bedside rationing' to collection of big data or in policy making -that can ensure that migrants' interests are considered. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups. An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses.

The positive economic, scientific and cultural contributions made by international migrants to their countries of origin and destination are undeniable. [1] [2] [3] Nevertheless, politicised debates on migration health persist, concerning among other things health coverage (entitlements) and care delivery that is responsive to migrants' needs. 4 5 Our use of the term 'migration health' rather than 'migrant health' emphasises that migrants themselves are not the only people whose health may be affected by migration: their families' health, for example, can also be impacted both positively and negatively. Whether health systems and policies are inclusive and equitable for those affected by migration varies between countries and categories of migration, and is often linked to the legal and socioeconomic status of those who migrate. [6] [7] [8] The world's 271 million international migrants in 2019 (people living in a country different from the one they were born in) are a heterogeneous group, encompassing categories such as migrant workers (over 60% of all international migrants), families seeking reunification, international students, refugees, asylum seekers, trafficked persons and irregular (undocumented) migrants. 9 10 Migration can be a powerful determinant of health, acting through or alongside poverty, unfavourable living and working conditions, stigmatisation, 'othering' narratives or the 'healthy migrant effect'. 1 8 11-13 Failure to consider the interests of migrants in health policy making, including that concerned with COVID-19, 1 11 14-16 is at odds Summary box ► Against the background of politicised debates on migration health, decision makers navigate challenging ethical dilemmas and trade-offs in policy and practice relating to entitlements, service delivery, prevention and research. ► Adopting an ethical approach to migration health by applying ethical methods, frameworks and procedural guidance helps to clarify competing interests and values and to set priorities fairly. ► This can help governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves to mainstream migration health in decision making.

with widespread calls to address migration health anchored in public health considerations, economic arguments and human rights obligations. 1 2 17 Migration health may also be impacted by decisions made in non-health sectors dealing with immigration, education, the labour market, housing or home affairs. 11 18-21 ADOPTING AN ETHICAL APPROACH TO ADVANCING MIGRATION HEALTH Migration health is affected by decisions made at levels ranging from global to local, both within and beyond the health sector. 11 18 19 These decisions impact issues such as healthcare seeking, entitlements, service delivery, policy making and knowledge production on migration health. It is key that ethical questions faced by decision makers are recognised and addressed in efforts to tackle the persisting challenges in migration health (exemplified in table 1 ). An ethical approach can provide methods to identify ethical issues, 22 frameworks for systematising information and suggesting ethically acceptable solutions, 23 and guidance on procedural concerns and legitimate decision making processes. 24 By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. 20 In seeking transparent justification towards the best alternatives, ethics can assist in holding decision makers to account. 25 Based on the ethical question that is at stake, the most relevant ethical guidance and tools should be used. Ongoing debates around the 'right' ethical approach demonstrate that decision makers should critically reflect on their choice of framework or method. 26 For instance, principles used in clinical reasoning at a healthcare centre 27 28 may differ from those emphasised by policy makers during a public health emergency. 29 When facing real-life dilemmas on migration health decision makers should use various sources and frameworks. 20 23 24 In examining the dilemmas decision makers face on migration health (table 1) , one may ask what the added value of an ethics approach is relative to the existing rightsbased, public health and economic arguments. 17 30 31 These approaches have different strengths and limitations; they put forward both intrinsic and instrumental arguments BMJ Global Health for mainstreaming migration health issues. Like human rights, ethics are concerned with dignity, equality and concern for vulnerable groups. 22 30 32 33 Historically, human rights conventions have evolved as a framework for regulating the actions of governments, whereas ethics concerns 'specific actions, values, interests and relationships of individual health workers, researchers and organisations'. 30 Human rights are formulated in broad, somewhat abstract terms, leaving open the precise way in which they should be implemented in the complex reality of practice 'on the ground'. An ethical approach, which explicitly recognises and discusses the values and norms at stake, equips its users with analytic tools and guidance on dealing with challenging dilemmas. 25 26 Ethical and human rights approaches overlap in the sense that they both proceed from fundamental moral values, but they differ in the uses to which they are typically put. 30 With its concern for the impacts on all affected parties, and a special focus on vulnerable individuals and groups, an ethical approach can help ensure that policies are fair and accountable. 20 22 34 Unacceptable living conditions in refugee camps and migrant workers' accommodation, precarious employment and dangerous working conditions, failure to include migrants in public health measures (eg, in relation to and 'one size fits all' approaches to health service delivery all suggest that attention for migrants' interests is not currently mainstreamed into policy making on health. 1 11 14 15 Ethical scrutiny and procedural guidance can assist in highlighting practices and policies that contradict the fundamental principles of medical ethics, public health and human rights. 30 35 Principles of ethics, such as doing no harm, respect for self-determination and concern for the worse-off, provide a normative foundation for evaluating dilemmas and balancing diverging concerns on migration health. 22 34 36 By systematically bringing into focus affected parties, benefits and burdens, conflicts of interests and values at stake regarding a potential decision, an ethical assessment can guide stakeholders at different levels on the ethically most justifiable solution. 22 An ethical approach provides decision makers with tools to evaluate different alternatives 'all things considered', for example, when collecting migration health data or deciding how to care for a migrant patient. There are multiple analytical tools and procedural methods for systematising and discussing ethical arguments and solutions and we do not argue for or apply a specific ethics approach here. 23 24 34 37 We examine how ethical perspectives and analytical approaches in general can advance research, practice and policy making on migration health.

In responding to recent efforts to promote more research and better data on migration health, 38 39 a number of ethical challenges arise (table 1). In meeting these, research should be carried out 'with' migrants rather than 'on' them, through meaningful participation. 40 Existing standards for research ethics such as the Declaration of Helsinki offer guidance regarding participation, autonomy, informed consent, conflicts of interest and the benefits and harms of research in the field of migration health. 41 The lack of robust, standardised data and the politicisation of the language used to discuss migration emphasise the importance of ethical scrutiny in knowledge production. 38 42 In response to data gaps concerning migration health, the Global Commission on International Migration recommended including information on country of citizenship, birth and previous residence and incorporating standardised migration-related questions in existing data collection. 43 However, this can raise unexamined ethical questions regarding the collection and use of such data. In the UK, for example, health data on undocumented migrants have been reported to the Home Office, which runs counter to the ethical principles of autonomy and confidentiality. 22 41 44 An increasingly important source of information is 'big data,' which is harvested from digital sources such as the use of internet, mobile phone or social media. 45 While big data opens new opportunities for understanding human behaviour, traditional research ethics protection (especially for vulnerable groups) is not present in its collection and use. [45] [46] [47] In a refugee camp in Greece researchers found that most individuals pass at least four identification and registration points before settling in to a temporary camp: this compromises privacy, informed consent and data protection. 46 The dividing line between public and private data is blurred. The increasing number and diversity of data systems and actors must be supplemented by efforts to secure data protection and privacy rights and to obtain meaningful informed consent. 45 

The politics of migration confront health workers with a minefield of ethical dilemmas (table 1) . 20 In settings where undocumented migrants have restricted access to health services, health workers become 'street-level bureaucrats' navigating legal regulations, medical needs and ethical obligations. 48 With limited options available for an undocumented migrant, healthcare workers may have to provide second-best options or carefully adapt the information they provide to the patient. 49 50 To be an ethical practitioner, how should one act in encounters with migrants when policies deny them access to affordable health services? How should one document medical findings when medical evidence may play a key role in the assessment of asylum applications? 51 Medical training should emphasise migration health dilemmas and provide ethical guidance on navigating the competing demands of legal regulations, politics and health workers' conscience and duty to treat. 52 In addition to overdue discussions on the ethical dimensions of such questions, 4 5 clinical guidance and appropriate BMJ Global Health ethics training is needed to support health workers handling these ethical challenges. 53 

A central debate in public health ethics focus on population health priorities from the standpoint of justice. 35 These discussions are relevant for policy making on migration health concerning health coverage (table 1) . 4 20 Which services should be provided to whom, and how much should they pay for them? Should all migrants have access to all types of diagnostics and treatment, including expensive new drugs, lengthy drug rehabilitation programmes, in vitro fertilisation and organ transplants? The answers to these questions may depend on evidence, interests and values at stake. Some may weight concerns for services that are costeffective (economic argument) or benefit population health (public health argument), whereas others may argue that access must be ensured for everyone (human rights argument). 4 5 Applying a public health ethics approach involves analysis of different concerns and examination of distributional impacts. 26 35 54 A relevant ethical framework developed by the WHO, Making fair choices towards Universal Health Coverage, provides guidance on setting priorities at population level. 23 To promote fairness it is recommended that priority is given to health maximisation, the worse-off and providing financial risk protection. Balancing these concerns, in particularly when they conflict, can be challenging, such as seen when countries decide on inclusivity and payment for health services for undocumented migrants. 4 Application of public health ethics frameworks, building on theories of justice and 'all things considered' approaches, can promote fairness in policy making on migration health. 35

What are the benefits for governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves of adopting an ethical approach to migration health? First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do. Following an 'all things considered' approach, ethics is concerned with everyone affected, which makes inclusion of concerns for migrants and their families standard practice. It is ethically unacceptable to share health information or data about an individual migrant which might be used as a reason for denying access or for deportation. 55 With a concern for the worse-off and doing no harm, it is ethically unacceptable to not to provide necessary health services for a worse-off migrant. 4 22 Application of an ethics approach can reveal unfair and unacceptable practices and assist in ending these. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions-from 'bedside rationing' 56 to collection of big data or in policy making-that can ensure that migrants' interests are considered. 20 23 37 41 57 Unless an ethical approach is adopted in migration health, governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves will be left without much-needed support in everyday decision making. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups in policy formulation, programme design and implementation. 24 40 These advancements of the migration health agenda assist all decision makers in mainstreaming concerns for migrants. 22 23 41 An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses. 14 15 58 Examining and reframing migration health through an ethical perspective will incorporate a focus into decision making on what is the best thing to do 'all things considered', towards a new normal where concerns for migrants are standard practice. As a litmus test, we ask whether global, national and local preparations for the next pandemic are responsive to the health needs of migrants?

Twitter Kristine Husøy Onarheim @Krionarheim Contributors KHO, KW and IM had the initial idea. KHO prepared the first draft. The analysis was developed and revised in collaboration between KHO, KW, DI, SS and IM. All authors read and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: KHO and IM have volunteered as medical doctors providing care by, or in association with, a healthcare centre for undocumented migrants in Bergen, Norway.

The UCL-Lancet Commission on migration and health: the health of a world on the move

Migration and health: a global public health research priority

Is migration good for the economy?

Towards universal health coverage: including undocumented migrants

Healthcare is not universal if undocumented migrants are excluded

The MIPEX health strand: a longitudinal, mixed-methods survey of policies on migrant health in 38 countries

Moving upstream: changing policy scripts on migrant and ethnic minority health

Immigration as a social determinant of health

Improving the health of migrants

United Nations, Department of Economic and Social Affairs, Population Division. International Migrant Stock

Effects of non-healthtargeted policies on migrant health: a systematic review and metaanalysis

Our health and theirs: forced migration, othering, and public health

Migration and health in an increasingly diverse

Refugee and migrant health in the COVID-19 response

Global call to action for inclusion of migrants and refugees in the COVID-19 response

European Centre for Disease Prevention and Control. Reducing COVID-19 transmission and strengthening vaccine uptake among migrant populations in the EU/EEA -3

International covenant on economic, social and cultural rights

Advancing health in migration governance, and migration in health governance

Building alliances for the global governance of migration and health

Migration KK. Health, and ethics

The political origins of health inequity: prospects for change

Principles of Biomedical Ethics.6 edt

Making fair choices on the path to universal health coverage: final report of the who consultative group on equity and universal health coverage. Geneva: World Health Organization

Accountability for Reasonableness

Ethical frameworks in public health decisionmaking: defending a value-based and pluralist approach

The evolution of public health ethics frameworks: systematic review of moral values and norms in public health policy

A framework for rationing by clinical judgment

An ethical framework for allocating scarce inpatient medications for COVID-19 in the US

Using a public health ethics framework to Unpick discrimination in COVID-19 responses

Human rights and ethics in public health

Global Health Priority-Setting: Beyond Cost-Effectiveness

Will international human rights subsume medical ethics? Intersections in the UNESCO universal bioethics Declaration

Method and Moral Justification

First do no harm" revisited

The development of the CoRE-Values framework as an aid to ethical decision-making

Data and research to inform global policy: the global compact for safe, orderly and regular migration

Bibliometric analysis of global migration health research in peer-reviewed literature

Ethical issues across the spectrum of migration and health research. migration and health: a research methods Handbook

Wma Declaration of Helsinki -ethical principles for medical research involving human subjects

Xenophobia toward refugees and other forced migrants. Waterloo, Canada: Centre for International Governance Innovation & World Refugee Council

Migrants count five steps toward better migration data: report of the Commission on international migration data for development research and policy

Creating a 'hostile environment for migrants': the British government's use of health service data to restrict immigration is a very bad idea

Navigating the Ethics of Big Data in Public Health

Digital Identity in the Migration & Refugee Context: Italy case study

Big Data for Migration Alliance -BD4M

Street-level bureaucracy : dilemmas of the individual in public services

Developing the ethical framework of end-stage kidney disease care: from practice to policy

Når helsevesenet blir en del av migrasjonskontrollenetiske og praktiske dilemmaer for helsepersonell (When healthcare becomes part of migration control -ethical and practical dilemmas for healthcare professionals)

Medical doctors commissioned by institutions that regulate and control migration in Sweden: implications for public health ethics, policy and practice

Exploring the perceived medical ethics and law training needs of UK Foundation doctors

Experiences of primary care professionals providing healthcare to recently arrived migrants: a qualitative study

Migration: a core public health ethics issue

Still not welcome -HIV-related travel restrictions UNAIDS UNDP

Fair resource allocation and rationing at the bedside

The signal code: ethical obligations for humanitarian information activities. Cambridge: Harvard Humanitarian Initiative

Health equity considerations in COVID-19: geospatial network analysis of the COVID-19 outbreak in the migrant population in Singapore