Eight chilling words appeared in a medical job posting listed last week in the online career center of JAMA, one of the most prestigious medical journals in the world. A large firm is seeking a doctor to be “lead physician” of a particular “facility.” But getting hired seems to require passing some sort of loyalty test: According to the original posting, applicants must be “philosophically committed to the objectives of the facility.” (The language of the ad was later revised to delete that line, but it still wants doctors to work “based on the company goals, objectives and philosophy.”)
The facility is the U.S. Immigration and Customs Enforcement detention center in Basile, La., owned by the Geo Group, a for-profit private contractor. The salary is $400,000 a year.
That salary is only one of this posting’s stranger aspects, given that it specifies a preference for general practitioners, a category of physician not likely to make anywhere close to that amount of money in most other settings. The posting does not require board certification, either, which is a common requirement in most such jobs and involves additional studying and passing a specialty-specific exam. It does note a requirement for “direct experience,” a term that is not defined. But the amount of experience is defined: “2 years … preferred.” That’s a short time practicing medicine for such a well-paid position.
The commitment to unstated “objectives” and “philosophy” is the most troubling part of the ad, though. Which objectives will the physician taking this job be committing to? The highest degree of medical quality and the protection of human rights? Or the implementation of the Trump administration’s inhumane and loathsome policies on immigration and asylum?
Any doctor who signs up to work in an ICE detention facility and commits “philosophically” to the mission there will face an ethical dilemma. As physicians, we swear to put patients’ well-being above any other consideration — to “first, do no harm.” The immigration policies the administration is carrying out now would make that extremely difficult. “Dual loyalty” can be a problem for doctors in any setting; our duties to our patients can conflict with our obligations to our employers. I teach this concept to medical students as a warning before they even begin their careers. But when a physician’s paycheck or job security ultimately derives from a prison operator, military establishment or government authority carrying out policies that themselves threaten to harm patients, the conflict becomes all the more severe.
In similar circumstances in the past, physicians have compromised themselves by enabling or even participating in practices like the forced feedings of prisoners or the administration of unnecessary medications, or by signing off on punishments such as solitary confinement or withholding food, water and necessary health care. Lapses of omission are also a risk, where doctors may recognize clear signs of abuse but neither record nor report them lest they jeopardize their own job security.
In other immigration detention facilities, we’ve seen adults and children in cages. People are living in filth, or sleep on cold, hard floors with no mattresses, no sunlight, insufficient food and poor access to clean water, toilets and hygiene products.
Geo Group, one of the largest for-profit private prison companies in the United States, is contracted by the federal government to manage and operate detention centers where people are held indefinitely pending resolution of their immigration claims. The firm is facing litigation brought by RAICES, a Texas nonprofit, that alleges that its employees allowed 13 children to be separated from their fathers in Karnes City, Tex., last summer. The lawsuit portrays a situation that any physician should find difficult to make a philosophical commitment to supporting: “GEO permitted armed men to forcibly remove the fathers from their rooms at the Karnes Detention Center by using bulletproof vests, shields, knee pads, boots, helmets, tear gas equipment and guns. Fathers screamed and cried loudly for their children. Others vomited blood and shook uncontrollably. Because GEO told the fathers that they would never see their sons again and all of the circumstances appeared to confirm it, one father attempted suicide.”
The litigation has no record of a doctor’s presence at this scene, or in the facility at the time, but I would tend to doubt that any “philosophically” vetted physician could have been counted on to intervene, help those suffering from the trauma of the separation or complain to supervisors about it.
(The Geo Group said in a statement after that lawsuit was filed that they “strongly deny the baseless allegations.” The company did not respond to a request for comment from The Washington Post until after this article was published. A spokesman said “we are deeply committed to delivering culturally responsive services in safe and humane environments and to treating everyone in our care with dignity and respect. This is the only commitment we expect from all of our employees, including our medical professionals." The statement continued: “We play no role in passing immigration laws, and we have never taken a position on immigration policies. As a service provider to the government, our only mission is to deliver the highest quality care in the most humane setting possible. That is all we ask our employees to commit to.”)
Acting in the patient’s best interest is the most fundamental tenet of medical ethics, professional duty and moral practice, so a job that requires the physician put the philosophy of the facility first — an immigration detention center run by a for-profit private company under harsh and inhumane orders from the government — runs counter to everything we doctors are told is our highest duty.
But there is also this quandary: The detainees in these centers absolutely need medical care. People in detention are always considered a high-risk and very vulnerable group. Those in immigration detention have suffered tremendously already before and during their journey to the United States and require trauma-informed care. They include children, pregnant women, detainees who are LGBTQ, ill, disabled, or those who suffer from mental illness or substance-use disorders.
Until they get out, nothing could be better for them, from a health-care perspective, than to have competent, compassionate, conflict-free physicians working with and for them on the inside.
But that is exactly why those eight words in the JAMA posting are such a red flag. They warn that ethical compromise is built into the hiring process, in the hopes of finding a doctor who is okay with that. Not everyone has been okay with what they’ve seen. In fact, doctors on the inside have been some of the best sources of information about what has been going on in these places — which is probably not what a “philosophically committed” doctor would do.
Whoever applies for this position should think back to their white coat ceremony. I hope they remember the Hippocratic oath they took; to “do no harm” also means not being complicit. I am not sure how exactly they’re supposed to prove their philosophical commitment during the interview — what to say, whether they’ll be required to spell out their politics on immigration. But whoever gets the job, I hope they have their fingers crossed when they’re answering.