Refugees Research Paper Example

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Abstract

The term “refugee” refers to an individual who has been granted legal asylum in a country of which they are not a citizen (although the term is used colloquially with a far broader meaning). This entry on refugees, however, situates the bioethical dilemmas relating to refugees within a broader understanding of forced displacement, asylum seeking, and migration. In particular, it focuses on the bioethical dilemmas relating to access to medication and healthcare for refugees, internally displaced persons, and asylum seekers; the triage decisions of states, humanitarian actors, and medical professionals at both macro and micro-levels; the dilemmas of health professionals involved in the asylum process; and, ﬁnally, the ethics of researchers conducting work on asylum and forced displacement.

Introduction

The ﬁeld of bioethics has not widely addressed questions around refugees, nor migrants in general. Verina Wild has noted that “the reluctance to discuss moral theories about duties towards migrants and the rights of these persons is paradigmatic of bioethics in general” (Wild 2012, p. 11). In fact there is no speciﬁc mention of refugees or migrants in the UNESCO Declaration on Bioethics and Human Rights. However, bioethical questions and dilemmas have critical relevance to refugee studies, and vice versa. Hence, this entry is an account of an emergent ﬁeld and outlines some key literature that has a powerful bearing on bioethical questions, even if not explicitly framed in terms of bioethics.

Furthermore, bioethical questions regarding refugees relate not only to the rights of refugees as deﬁned in national or international law but also to questions of whether rights accorded to refugees are ethical in contradistinction to other forcibly displaced (such as the internally displaced), asylum seeking, or migrant groups (in particular, undocumented migrants). Hence, this entry also includes reference to internally displaced as well as to asylum seekers and undocumented migrants.

The structure of this entry is as follows: it gives a brief overview of the development of the category of the “refugee” in the post-World War Two era and outlines the related categories noted above. The body of entry then focuses on the bioethical dilemmas around refugees, the asylum process, and forced displacement – situating this in relation to general questions around migration. The core of this entry is focused on healthcare and the role of health professionals in dealing with refugees, the displaced and the asylum process.

The History And Concept Of The Refugee

The contemporary system of international refugee law and institutions was established in the wake of the Second World War as a result of the millions displaced by the conﬂict (see UNHCR 2011). This led, in 1951, to the creation of the Ofﬁce of the United Nations High Commissioner for Refugees (UNHCR, later referred to as the UN Refugee Agency) and the signing of the Convention Relating to the Status of Refugees (“1951 Convention”).

The Convention deﬁnes a refugee as a person who “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.” (United Nations Conference of Plenipotentiaries on the Status of Refugees and Stateless Persons 1951). The 1951 Convention accords, among others, the following rights to refugees: the right to work; the right to housing, education, and public assistance; the right to freedom of movement and of religion; and protection against refoulement or expulsion to a country where the life of a refugee is threatened. Whereas the initial 1951 Convention applied to those displaced prior to 1951 in Europe, a later amendment called the 1967 Protocol removed these time and place based limitations.

The UNHCR makes a distinction between a refugee and a migrant deﬁning the latter as an individual who leaves his or her country not out of fear of persecution but for a variety of reasons (work or education among others) and who “continues to enjoy the protection of his or her own government even when abroad” (UNHCR 2011). However, decades of research have shown that the distinction between forced and voluntary migration is often blurred, and there may be a range of mixed motivations for migration (Van Hear 2011): while the UNHCR has acknowledged this blurring of categories, the juridical and normative distinctions between refugee and migrant persist and have critical implications for bioethics as will be addressed below.

One key arena in which UNHCR policy has shifted over recent decades has been to provide support for internally displaced persons (IDPs). IDPs are those who “have been forced or obliged to ﬂee or to leave their homes of places of habitual residence, in particular as a result of or in order to avoid the effects of armed conﬂict, situations of generalized violence, violations of human rights or natural or human-made disasters, and of have not crossed an internationally recognized state border” (Interagency Standing Committee, cited in Mendelsohn et al. 2014, p. 1).

From the 1980s, the number of internally displaced persons escalated and eventually exceeded the number of global refugees. At the end of 2012, the UNHCR was caring for an estimated 15.5 million, out of a total of 28.8 million, internally displaced in comparison to 10.4 million refugees (UNHRC website).

In 2004, the United Nations Ofﬁce for the Coordination of Humanitarian Affairs issued the Guiding Principles of Internal Displacement which states, among other things, that internally displaced persons should have the same rights as other nationals in their country; be protected against forced repatriation and accorded the right to “return voluntarily, in safety and with dignity, to their homes or places of habitual residence, or to resettle voluntary in another part of the country” (UNOCHA, p. 14).

While the UNHCR has increasingly operated in IDP communities, there was no basis for IDP protection in international law until the African Union Convention for the Protection and Assistance of Internally Displaced Persons in Africa (“Kampala Convention”) of 2012 which provided the ﬁrst legally binding convention, ratiﬁed by 16 African states, on rights and protections to internally displaced communities. The Convention protects against arbitrary displacement based on ethnic, racial, or religious grounds and obliges states to provide protection and humanitarian assistance to IDPs in cooperation with international agencies (African Union 2012).

Hence, given that the UNHCR and other refugee agencies have been increasingly providing support to IDPs, that the Kampala Convention has enshrined similar protections and rights to IDPs as to refugees, and that the existential and humanitarian situations facing IDPs are similar to refugees (for instance in cases of encampment), the bioethical questions regarding refugees often relate closely to those of the internally displaced.

A ﬁnal conceptual distinction which is important here relates to the asylum process itself. An “asylum seeker” in contrast to a refugee is someone who has applied for refugee status but is awaiting consideration of his or her application or has been rejected but lodged an appeal. There is wide variability in the rights and protections accorded to asylum seekers across different states (for instance, relating to the right to work and socioeconomic support).

Increasingly, as will be discussed below, medical professionals have come to play a role in ascertaining the veracity of asylum claims which raises critical bioethical questions. When an asylum claim is rejected, the asylum seeker may be deported. Bioethical dilemmas of whether or not to accord rights and services to undocumented migrants reveals another, but related, issue.

The sections below focus on these issues starting with a brief assessment of the normative grounds shaping the bioethics of asylum and refuge.

The Bioethical Base For Healthcare Provision To Refugees

One of the key aims of the Universal Declaration on Bioethics and Human Rights is “to promote equitable access to medical, scientiﬁc and technological developments as well as the greatest possible ﬂow and the rapid sharing of knowledge concerning those developments and the sharing of beneﬁts, with particular attention to the needs of developing countries.” Although it is not stated explicitly, this creates a speciﬁc normative obligation to extend healthcare rights to refugees, asylum seekers, and undocumented migrants who are often excluded from them. As discussed above, while the 1951 Convention and the 1967 Protocol enshrine rights of assistance to refugees, the normative basis of the Universal Declaration on Bioethics and Human Rights suggests that this is too limited in excluding other forcibly displaced or migrant groups.

Wild and Heilinger (2014) note that key bioethical dilemmas around healthcare provision to asylum seekers arise from the tensions between the nation state’s duty to citizens and universal ethical and legal principles. They cite the Geneva Convention as providing a ground for medical ethics which does not discriminate. These authors argue for an ethical basis for the medical treatment to asylum seekers – but also to migrants in general – based on a “cosmopolitanism within borders.” This notion is derived from the ideas of a moral cosmopolitanism (a shared human community), social justice (based on equitable distribution of resources), and a legal cosmopolitanism (based on global governance and legal codes). These propositions – while requiring substantive global and economic changes – do reveal the ways in which bioethical considerations relating to asylum seekers and other migrant groups must be considered not simply at level of the patient-provider relations but also in relation to macro-processes in which nation states legislate the right to life and well-being based on considerations of nationality and citizenship which exist in tension with universal legal and normative frames. Bioethical considerations relating to healthcare provision to asylum seekers, refugees, and other migrants, under conditions of scarce resources, may be framed in terms of both macro and micro-levels of triage (cf. ten Have 2014), though the lines of these are often blurred. The bioethical dilemmas facing health workers on a micro or individual level may be contrasted to the dilemmas facing states and humanitarian groups when dealing with large numbers of forcibly displaced persons (for instance, in humanitarian emergencies). These different concerns are dealt with below.

The Dilemmas Of Health Workers

Under conditions where health policy discriminates against refugees, asylum seekers, and undocumented migrants, this often puts health workers under acute bioethical dilemmas: whether to act according to state policy or patient needs. As Wild (2012, p. 11) notes, “Health workers have found themselves in moral dilemmas, caught between the health needs of a migrant and ofﬁcial migrant policy.” However, the asylum process also creates bioethical dilemmas that extend beyond the therapeutic context.

Increasingly, at least in Europe, psychologists and medical professionals have become part of the process of ascertaining the truth of the narratives of persecution given by asylum seekers. Didier Fassin (2012) has documented this shift in France in recent decades where rates of acceptance of asylum seekers have been dropping, and medical proof of torture or persecution has increasingly become a requirement for the granting of refugee status. As he writes, “the asylum seekers’ accounts, long the only evidence testifying to their story and justifying their request, were no longer sufﬁcient to conﬁrm the truth of the alleged persecution. The body, which could have retained a trace of it, came to be seen as potentially providing tangible proofs” (Fassin 2012, p. 111) – in this new “regime of truth,” the expertise of the physician and psychologist become increasingly powerful.

While this condition is more a phenomenon in Europe as opposed to Africa where the involvement of medical professionals in asylum claims is rare, this does reveal an increasingly bioethical dimension to the asylum claims process itself. The diagnosis of medical professionals no longer simply relates to therapeutic or curative outcomes but actively shapes the outcome of asylum claims and hence the lives of those they diagnose. This raises profound bioethical questions about the part medical professionals take in the policing of borders and as gatekeepers to refugee status. Fassin frames this turn as “ethics put to the test” (2012, p. 118). This test facing both medical professionals and refugee support organizations may be framed as threefold: ﬁrst, producing medical examinations and certiﬁcation of possible torture victims risks exacerbating their trauma; second, it makes medical professionals complicit in the asylum and deportation regimes which many view us unjust or dysfunctional; and ﬁnally, this approach discredits the testimony of asylum seekers by making medical professionals an authority over them. The ethical dilemmas arising from the medicalization of the asylum process is framed poignantly by Fassin: “a modest element in the politics of asylum, the medical certiﬁcate can sometimes become the ﬁne thread on which the existence – both physical and psychic – of the asylum seekers hangs” (p. 129).

However, the bioethical dilemmas of health workers involved in the asylum process is not the only level at which bioethics must be understood in relation to forcibly displaced populations. Issues of global equity are also at stake. This is clearly illustrated in relation to the provision of life-saving medications to forcibly displaced populations and exempliﬁed by the provision of treatment for HIV/AIDS.

HIV/AIDS Treatment To Forcibly Displaced Populations

One of the key bioethical questions facing refugee and internally displaced populations, particularly in Africa, has been the provision of antiretroviral therapy (ART) for the treatment of HIV/AIDS. Antiretroviral therapy requires rigorous adherence to treatment; poor adherence and treatment breaks can lead to the development of drug resistance in the patient which can also be spread. Given the complexities of treatment, it was widely considered by states and medical professionals that provision of ART was unfeasible to forcibly displaced populations. However, these claims have been contested on both clinical and ethical grounds.

In a review article on the status of ART provision to refugee and displaced populations, Mendelsohn et al. (2014) make an argument that “moral, legal, and public health principles, in combination with recent evidence, provide a clear rationale for sustainable treatment provision and adequate support for refugees and IDPs” (2014, p. 1). They point out that refugee and IDP populations have been widely excluded from National Strategic Plans for responses to HIV/AIDS and that states often argue that providing ART to refugee populations will provide a “pull factor” for refugees not returning to their countries of origin. They pose four central arguments for the provision of ART to refugee and IDP groups: ﬁrst, there is now signiﬁcant clinical evidence for successful treatment and viral suppression to these groups; second, that principles of fairness and equity should include refugee and IDP populations in ART rollout even under conditions of scarce resources; third, that these populations should be included in treatment interventions based on the principles of the right to health and access to essential medicines; and fourth there is a basis in international law for securing the right to treatment including the 1951 Convention. Hence, while they do not frame their arguments within an explicitly bioethical frame, there are clear bioethical consequences of their arguments, in particular, relating to equal access to health technologies and the inclusion of refugee and IDP populations in treatment programs based on ethical, legal, and public health grounds. While these bioethical questions have been most prominently raised with reference to HIV/AIDS treatments, the implications of this debate certainly applies more broadly to health and treatment access to refugee and forcibly displaced populations. Another instance where decisions around macro-triage relate to forcibly displaced populations are in cases of large-scale, conﬂict-induced displacement.

The Bioethics Of Wide-Scale Displacement And Complex Emergencies

While the ﬁeld of refugee bioethics is inchoate, a signiﬁcant and related emergent ﬁeld is that of “disaster bioethics” (see Mathúna et al. 2014). It would be a mistake to conﬂate refugees with disasters in the ﬁeld of bioethics as while many refugees or forcibly displaced persons who may live in disaster-affected situations or be caused to migrate as a result of conﬂict, many refugees may actually live in relatively stable situations in countries of asylum and even refugee camps may be sedentary and stable. In addition, there is no international legal framework for those displaced by disasters per se (such as natural disasters), unless they be as a result of conﬂict or persecution.

Nonetheless, the ﬁeld of “disaster bioethics” certainly has some signiﬁcant implications and applications to questions of bioethics and forced displacement. In particular, in disaster situations in which resources are constrained and the situation volatile, in such cases, rather than an ethical focus on the individual, “disasters lead to a greater focus on the rights and care of populations” (Mathúna et al. 2014, p. 5). Under such conditions, signiﬁcant ethical issues arise around issues of resource utilization (and whether health professionals can undertake tasks they are not fully qualiﬁed for in the absence of expertise), political alliances in order to access victims, and triage.

The element of disaster bioethics with particular application to refugee and displaced populations is that of the “complex emergency” mostly caused by human violence. As Henk ten Have notes, these are “primarily political events requiring long-term assistance” (2014, p. 18). Complex emergencies invariably involve displacements which give rise to either refugee or internally displaced populations. These require ethical decisions regarding the triage of individual patients by healthcare workers, but also cases of “macro-triage” (Ten Have 2014) which are decisions about where resources are to be allocated and why to one disaster setting and not another. These humanitarian bioethical decisions involve ethical and political questions regarding whether an emphasis is placed by humanitarian actors on justice, equity, and political resolution or on simply saving lives and providing medical care (Fassin 2012; Ten Have 2014). These aims may be contradictory under conditions where armies may forcibly displace populations in counterinsurgency strategies and humanitarian support may be viewed as complicit in sustained conﬂict and forced displacement (see Branch 2008).

A ﬁnal and acute bioethical issue is whether to put refugees into camps or allow them to self-settle. As Wim Van Damme (1995) has asked “Do Refugees Belong in Camps?” Camps, although they may provide convenient points for the distribution of food aid and certain medical technologies (such as vaccinations), may have a number of adverse health and psychosocial consequences on their populations as well as facilitating the spread of communicable diseases such as cholera and potentially leading to malnutrition as a result of limited agricultural production and reliance on food support (see Harrell-Bond 1998; Van Damme 1995). Van Damme (1995) has argued that the association between forced displacement and encampment is widespread in refugee policy but that self-settlement (i.e., when the forcibly displaced are allowed to settle into host communities) should always be considered when feasible as evidence indicates this policy can be more beneﬁcial to the forcibly displaced.

However, the ways in which bioethics applies to refugee and asylum seeking populations are not simply in conditions of active conﬂict or refugee camps but also apply to peaceful settings. In particular, one area of intense bioethical and political contestation relates to the frequent drowning of migrants en route via boat from North Africa to Europe – this has prompted humanitarian responses to save migrants but also a backlash against these humanitarian responses (see Ticktin 2011). This phenomena gained global publicity when in October 2013, over 300 migrants, mainly Eritreans, died when the boat they used to travel to Europe sank off the Italian island of Lampedusa. In response, the Italian government launched a program Mare Nostrum to patrol the Mediterranean Sea which it claims saved more than a hundred thousand lives. However, by late 2014 there were moves to abandon this program due to lack of widespread support in Europe with a number of states supporting the focus only on monitoring European borders through its border force (Frontex) with no explicit mandate for search and rescue (Robinson 2014). This raises an explicit bioethical question whether states are obligated to save migrants (many of whom may be seeking asylum) who are attempting to enter into their countries illegally. Bioethical questions hence extend beyond simply provision of healthcare to refugees.

Research Bioethics

Related to all of the above is the bioethical role of research, both biomedical and social, on forcibly displaced and migrant populations. In recent years, these ethical and political questions have been pressing. This was illustrated by the “Verona Declaration” adopted on 10 September 2009 at the 6th European Congress on Tropical Medicine and International Health and 1st Mediterranean Conference on Migration and Travel Health organized by the Federation of European Societies for Tropical Medicine and International Health (2009) which stated that

We express our deep concern for the legislation and policies adopted by European countries with respect to migrant people. We underline that all policies and regulations that directly and indirectly put at risk the life of people and hamper their access to health, represent not only a clear violation of International human rights conventions and almost all national Constitutions, but also a public health threat.

We call the governments of European countries to develop joint policies with respect to migration, making sure that these are not in violation of the fundamental human rights and particularly the right to health. We also call the academic and research institutions and civil society to continue to play a role in monitoring the health and social conditions of migrants and refugees, including any measures that discriminate against this population and which may adversely affect their health and well-being.

This declaration reveals an expressly bioethical call for medical researchers to play a role in monitoring access to healthcare for migrants and refugees but also to monitor discriminatory policies adopted by their governments.

The ethical concern with alleviating the suffering of refugee populations, while at the same time adhering to standards of academic rigor, is a continual ethical concern with refugee research that crosses both the medical and social sciences. As Jacobsen and Landau have argued, there is a “dual imperative” with refugee research: ﬁrst, “to satisfy the demands of academic and peers” and, second, “that the knowledge and understanding work generates are used to protect refugees and inﬂuence institutions like governments and the UN” (2013, p. 186). Given that many refugees would have been exposed to extreme forms of persecution and depradation, there is an ethical concern that they cannot simply be the object of academic study and that refugee research must also be conducted in ways to ensure comparative analysis and policy relevance.

Conclusion

The ﬁeld of bioethics is still undeveloped in relation to refugee and other forcibly displaced and migrant populations. However, as this entry has shown, bioethical dilemmas and concerns relate to these populations across multiple spatial and geographical scales: from patient-provider relations, to the global distributions of medicines, and to both peaceful and disaster settings. The category of the “refugee” in international law may also be analyzed as a bioethical problem when it provides rights to refugees in contrast to other migrants, including those seeking asylum. Bioethics as a universal normative frame, as expressed by the UNESCO declaration, both provides a normative foundation for expanding healthcare beyond the frames of citizenship but also reveals the limitations of international refugee law. However, that refugees and migrants are not mentioned in the UNESCO declaration and are widely ignored in bioethics as an academic discipline shows that the ﬁeld of bioethics itself can learn much from refugee studies: this engagement is, however, yet to come.

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