by Gordon Nary
Gordon: When and where did you earn your doctorate in philosophy?
Mark: I received my Ph.D. from Duquesne University. Duquesne is a Catholic university located in Pittsburgh, Pennsylvania. The philosophy department was and remains very strong in Continental philosophy and also in the history of philosophy. For most of my time in graduate school, I thought I was going to be a scholar of Plato and Aristotle. When working on my dissertation, I was asked to teach a course on medical ethics for an extension program at a local hospital for nurses who were Registered Nurses (R.N.) and were working to achieve their Bachelors of Science degree in Nursing (B.S.N.). I was struck by their stories of wrestling with these issues at the bedside. They became my teachers about the clinical context of bioethics. I couldn’t imagine anything better than working with these kinds of students. I guess many of us hear our calling in unexpected places through the voices of others.
Gordon: You have a certification as a Healthcare Ethics Consultant. Please explain what that certification permits you to do.
Mark: While bioethics has an ancient pedigree going back to classical Greek figures, it is still fairly new as a professional discipline. Starting in the late 1980s, some hospitals began to offer ethics case consultation to their physicians and patients who had difficulty resolving an important ethical issue such as whether to continue death-delaying treatment. The ethics consultant was typically a clinician with some education, sometimes self-education, in clinical ethics. The consultant reviews the medical record, interviews the parties to the case, possibly convenes a meeting to facilitate consensus on a path forward, and makes recommendations in the medical record. As has happened with many professions in healthcare, ethics consultation initially had no required particular educational or training pathway. Anyone a hospital was willing to credential to perform ethics consultations did so.
Beginning in the 1990s, the American Society for Bioethics and Humanities (ASBH) began very deliberate work that defined the competencies for ethics consultants and eventually developed a standardized certification test that began being offered in 2019. Being a certified ethics consultant is now the standard among those conducting clinical ethics case consultation.
Gordon: What are some of the most challenging healthcare ethics issues?
Mark: The majority of requests for ethics consultation still involve end-of-life decisions. While these are “old news” from a societal standpoint, each person’s last days and death are of enormous concern to them and their family. Family members can be mistrustful and fear that the physicians are “giving up” too soon on their loved one. Thus, they sometimes insist on aggressive interventions that are bringing no benefit to the patient and may inflict unnecessary pain and suffering.
On a related note, we increasingly see patients who no longer have the capacity to make decisions for themselves but who have outlived their relatives and have no one to make decisions for them. Similarly, clinicians face ethical conundrums when there are not appropriate facilities available for patients when they are ready for discharge from the hospital.
For instance, there may not be a slot in a treatment program available for a person with a substance use disorder (an addiction) or a bed in a mental health treatment facility for a patient in a psychotic episode. Similarly, my interest in equity for patients who are undocumented immigrants was stimulated by the fact that it can be very difficult to find appropriate discharge placements for them when they require rehabilitation or long-term care. This has at times led to the troubling spectacle of forced medical repatriation.
Clinicians face great stress when it is not clear how they can meet their duties to promote the patient’s safety and well-being when they are ready for discharge from the hospital.
Gordon: Please share with our readers an overview of your work as Faculty Advisor at NHMA/LMSA.
Mark: When I arrived at the Stritch School of Medicine in 2000, two of the most striking things about it were (1) the large number of Irish Catholic medical students and faculty, and (2) the lack of diversity in our student body and faculty. Our university and medical school had done a wonderful job of living its mission to be welcoming institutions for the wave of European immigrants a century ago. Loyalty to the school ran strong among their descendants decades later. This was incredible and we could be proud of our identity as one of the few Catholic medical schools in the nation.
Unfortunately, we had not yet renewed that mission to the new generations of immigrants who were arriving in this country and needed a welcoming hand up. Among this new generation are many students of Latino/Hispanic heritage, i.e., students from cultures that are also renewing the Catholic Church in the United States. They needed to be able to recognize Stritch as their medical school. So, starting in 2007, I worked with the small number of Hispanic medical students at Stritch to found and develop our chapter of the Latino Medical Student Association (LMSA). The chapter has been very active in building a robust student-led medical Spanish program, serving as interpreters in our safety net clinic, and organizing educational events to promote cultural awareness in clinical care.
Our chapter also played a pivotal role in our school when Stritch became the first medical school in the nation to openly welcome applications from undocumented students who were eligible for the Deferred Action for Childhood Arrivals (DACA) program.
Many of the LMSA students conducted educational forums to raise understanding among their peers and prepare the community to build pride in this step that our school was taking. It was very moving for me to watch as students shared their family’s stories that included the struggles of family members and friends who were undocumented to normalize this situation.
While we sometimes use the word “transformative” too easily, this experience of sharing experience and vulnerability has changed our community. It called us back to the best in our values and traditions as a Jesuit, Catholic medical school.
Gordon: You have served as Director of the Neiswanger Institute for Bioethics since July 2000. What is the Institute’s mission and what are some of the more challenging issues that you have addressed?
Mark: Our bioethics institute was founded to promote the Jesuit and Catholic ideals of social justice and care for the person in healthcare. As with most academic entities, we live our mission through teaching, scholarship, and service. We were early adopters of online education and opened our online Master of Arts in Bioethics program in 2002 and later added a doctoral program. These online efforts were meant to support the kind of professionals who first called me to bioethics in their work at the bedside and as mission leaders for their hospital systems. We have also integrated ethics throughout the medical school curriculum and our faculty produce a significant body of scholarship each year. We serve Loyola University Health System by conducting clinical case consultations and the issues we encounter often give rise to our scholarly investigations.
I have already mentioned some of the clinical ethics issues that we often face. But I think what has come to distinguish the Neiswanger Institute is our effort to accompany our students who face unique challenges. First, we have been at the center of Stritch’s efforts to matriculate and support qualified applicants who are DACA recipients.
Accompaniment has meant fostering a supportive community that provides connection through so much uncertainty and the stress created by federal attempts at rescinding DACA, court challenges, and the ongoing slanderous anti-immigrant political rhetoric. Similarly, my colleague Professor Emily Anderson created, in partnership with the only Catholic University in Ukraine, a fellows program a number of years ago that utilizes our online educational capabilities to train healthcare professionals in Ukraine in bioethics. Since the Russian invasion of Ukraine, we have worked with these fellows to accompany them educationally, emotionally and spiritually as they have at times faced displacement and a variety of clinical ethical challenges. These two efforts at accompaniment are outside the usual aspirations of academic life but are central to the Jesuit educational ideal of cura personalis.
Gordon: You have authored many articles and spoken on issues related to undocumented immigrants and healthcare. Please provide an overview of the podcast “Undocumented Patients: Two Journeys”
Mark: Johana Mejias-Beck, M.D., was one of the first DACA recipients to matriculate to the Stritch School of Medicine. She is now an attending physician who is board certified in both internal medicine and pediatrics. In this podcast, she describes her journey as an undocumented young person struggling to get an education and become a doctor. In the podcast, we talk about how our respective paths intersected to develop the DACA-friendly community at the Stritch School of Medicine and to develop the Sanctuary Doctoring program that helps physicians to address the needs of their undocumented patients.
Dr. Mejias-Beck is an amazing person and physician and it was such an honor to engage with her in this discussion. Moreover, this discussion enabled me to talk a little bit about this work as a vocation, i.e., a calling. As a spiritual person and Catholic, I believe that our vocations unfold over time in response to the needs of others. I spent most of my career as a scholarly generalist and had no particular interest in immigrants or immigrant patients.
More than 15 years ago, some clinical cases involving patients who were undocumented immigrants caught my attention and I developed an interest beyond anything I could explain. I devoted all the time and energy I could find to learning about their plight and the historical, social, and legal context of U.S. immigration. I think too often we ignore these longings of the soul in favor of what we are “supposed” to be doing. But St. Ignatius Loyola counsels us to listen to our desires and discern what is holy in them.
Just as I heard my first calling to bioethics in the voices of those nurses taking an extension course with me, I eventually heard my next calling in the ambitions of incredible undocumented young people to be doctors.
Gordon: Please provide an overview of governmental ethical responsibilities to immigrants and refugees.
Mark: Sustenance, dignity, and justice. Generally speaking, most new arrivals need little support. Many have family or established communities that quickly absorb and support them. However, when migrants arrive from a nation such as Venezuela that has little history of migration to the U.S., shelter, food, and basic medical attention is needed for the short term. The government has a duty to treat them like the victims of a natural disaster who have lost everything.
The short-term response can also respect the dignity of the person by providing the conditions to become self-sustaining, e.g., rapid access to work permits. And, in the long-term, justice requires that they have access to fair legal processes and are provided the opportunity to understand and participate in those processes, e.g., legal assistance. Unfortunately, our governmental response to migrants often focuses on expediting removal and creating such undesirable conditions that even persons facing danger and starvation will not come here. As a result, we leave the short-term care for newly arriving asylum seekers to cash-strapped local governments; it takes months to receive a work permit even for those who are clearly eligible, our legal processes are baroque, and they have no right to legal assistance.
Gordon: When government leaders use barbed wire shields to prevent migrants crossing rivers that result in death, could they be considered as an accomplice to murder on an ethical standard?
Mark: Government leaders have long taken actions that have foreseeably led to the deaths of migrants to the United States. For instance, since the early 2000’s, U.S. Customs and Border Protection (CBP) has focused resources on fortifying urban areas on the U.S.–Mexican border. This has had the effect of pushing migrants who are trying to cross into ever more remote areas of the desert, leading to many deaths each year. The recent efforts by the Governor of Texas to fortify the river have resulted in more visible deaths and made us more aware of the culpability involved.
I would not describe this situation as murder since there is not an active action taken to kill an identifiable human being. But creating conditions that one knows will result in the deaths of some numbers of persons, can be termed a depraved indifference to human life. And, of course, from a Gospel point of view, to impose hardships, possibly resulting in death, on people who have fled their homes because of danger or starvation is simply cruel and evil. It is a kind of systemic assault on one’s neighbors, the proverbial “least of my brothers.”
Gordon: What five recommendations do you have to reduce the migrant challenges in the United States.
Mark: First, I think we Catholics have a special duty to stand up to the false witness that is born against our immigrant neighbors. Many slander immigrants with accusations that they come to the United States to take government benefits, commit crimes, and somehow live off the citizenry. Of course, nothing is further from the truth. The current wave of immigrants to the United States, like all the waves before them, are young, industrious, and entrepreneurial. They infuse life into a society that is aging and would have a shrinking population and economy without new arrivals. We all have a duty to testify to the truth.
Second, workers need work permits. It makes no sense to admit asylum seekers to the country and make them wait months for a work permit. Work permits should be issued as part of the initial processing so that new arrivals can become self-sufficient as soon as possible.
Third, the federal government needs to develop a FEMA-like structure to support cities to which significant numbers of asylum-seekers have been bused. The only “migrant crisis” we face is a short-term challenge of sheltering and feeding new arrivals until they are permitted to work and can secure housing. We know how to do this as we have methods that are employed after natural disasters by our Federal Emergency Management Agency. But we are currently leaving cities to do this on an ad hoc basis and it strains their limited resources and expertise.
Fourth, we must simply be far more generous with < > providing Temporary Protected Status to persons who present from nations that are failing to support their population and in providing pathways to citizenship for those who have been here and contributed to our society for many years. Providing more discretion to immigration judges to grant legal permanent resident status (also known as a “green card”) would make the system somewhat more equitable.
Fifth, in the long run, we need major reforms to our immigration laws that recognize that the goal of immigration law is not to discourage migrants from coming to the United States but to provide an orderly and fair process to contribute to our society that takes into account current economic, social, and global realities. Chief among these reforms should be a perpetual DREAM Act. That is, every person who was brought here as a minor, has lived here more than five years and is a contributor to our society should have the opportunities to work lawfully and continue their education without fear of deportation. For that, they need a pathway to citizenship.
Gordon: Thank you for an exceptional interview.