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Ethical, Legal and Social Aspects
of Health Care for Migrants

Numerous important issues arise in relation to the health of, and health care for
(and by), migrants. Much of the commentary on the migrant ‘crisis’ and health
care has focused on the allocation of resources, with less discussion of the needs
of, and provision for, migrants. Presenting a comparative perspective on the UK
and Germany, this volume increases knowledge of a broad spectrum of chal-
lenges in health care provision for migrants.
‘Migration’ is deliberately understood in its broadest sense and includes not
only migrant patients but also migrant health care professionals. The book’s con-
tent is diverse, with insights from health care ethics, health care law, along with
clinical perspectives as well as perspectives from the social sciences. The collec-
tion provides normative reflections on current issues and presents data from em-
pirical studies. By informing researchers, politicians and health care practitioners
about approaches to challenges arising in health care provision for migrants, the
collection seeks to inform the development of adequate and ethically appropriate
strategies.

Katja Kuehlmeyer, Dr. rer. biol. hum., is Research Associate at the Institute of
Ethics, History and Theory of Medicine at LMU Munich. She works on various
topics at the intersection of psychology, health and ethics.

Corinna Klingler, MSc, has recently finished her doctoral research on integration
of migrant physicians in Germany and is currently working on translational bio-
ethics as a postdoctoral researcher at the QUEST Center of the Berlin Institute
of Health.

Richard Huxtable, LLB, MA, PhD, is Professor of Medical Ethics and Law
and Director of the Centre for Ethics in Medicine, University of Bristol, UK. He
works primarily on ethics and law at the end of life, surgical ethics, and clinical
ethics support.
Law and Migration
Series Editor: Satvinder S. Juss, King’s College London, UK

Migration and its subsets of refugee and asylum policy are rising up the policy
agenda at national and international level. Current controversies underline the
need for rational and informed debate of this widely misrepresented and little
understood area.
Law and Migration contributes to this debate by establishing an edited ­volume
series to encourage discussion and help to inform policy in this area. The series
provides a forum for leading new research principally from the Law and Legal
Studies area but also from related social sciences. The series is broad in scope,
covering a wide range of subjects and perspectives.

Bureaucracy, Law and Dystopia in the United Kingdom’s Asylum System

John R. Campbell

Children’s Rights and Refugee Law

Conceptualising Children within the Refugee Convention
Samantha Arnold

Law and Asylum

Space, Subject, Resistance
Simon Behrman

Ethical, Legal and Social Aspects of Health Care for Migrants:

Perspectives from the UK and Germany
Edited by Katja Kuehlmeyer, Corinna Klingler and Richard Huxtable

Environmental Change, Forced Displacement and International Law from

legal protection gaps to protection solutions
Isabel M. Borges

For more information about this series, please visit:

www.routledge.com/Law-and-Migration/book-series/LAWANDMIG
Ethical, Legal and Social
Aspects of Health Care for
Migrants
Perspectives from the UK and Germany

Edited by
Katja Kuehlmeyer,
Corinna Klingler and
Richard Huxtable
First published 2019
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
52 Vanderbilt Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa
business
© 2019 selection and editorial matter, Katja Kuehlmeyer, Corinna
Klingler and Richard Huxtable; individual chapters, the contributors
The right of Katja Kuehlmeyer, Corinna Klingler and Richard Huxtable
to be identified as the authors of the editorial material, and of the authors
for their individual chapters, has been asserted in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested

ISBN: 978-1-138-05654-1 (hbk)

ISBN: 978-1-315-16524-0 (ebk)
Typeset in Galliard
by codeMantra
Contents

List of tables and box ix

Notes on contributors xi
Foreword xv
S atvinder S . J uss

Preface xxi
Acknowledgements xxiii
List of abbreviations xxv

Introduction – ethical, legal and social aspects of

health care for migrants: perspectives from the UK
and Germany 1
K atja K uehlmeyer , C orinna K lingler and
R ichard H uxtable

Part I
Migrants’ health in Germany and the UK 19

1 Health of migrants and ethnic minorities in Germany:

reflecting on normative agendas 21
Oliver R a z um and J udith W enner

2 The health of migrants in the UK: evidence and

implications for health care 33
H iranthi J ayaweera

3 Bearing witness: observations of the health of people

without access to the regular health care system
in Médecins du Monde’s health care and advocacy
programmes in London and Munich 47
L ucy Jones , A nna M iller , S abine F ü rst, C arolin B ader
and L ea G elfert
vi Contents
4 Dynamics of informal exclusion: migrants’ health as
experienced in the City Lab Bochum 57
C hristiane Falge

Part II
Migrants’ access to health care 77

5 Migrants’ right to health in international and

European human rights law: can it still unfold
its integrative dynamic in an era of restrictive
immigration policies? 79
A mrei M ü ller

6 Entitlements to social health benefits for asylum

seekers and refugees in Germany 100
M arkus K altenborn

7 Access and entitlements for migrants and visitors to

the UK in the English National Health Service 112
S arah S teele and C ormac Devlin

8 The right to health for all? Debates surrounding access

to health care for asylum seekers in Germany 125
S abine K lot z

Part III
(Re)constructing migrants in health research 145

9 Questioning categorisation practices: ‘migrants’ and

‘ethnic groups’ in public health classification(s) 147
P enelope S cott and H ella von U nger

10 Culturally sensitive palliative care research: what

should we do with ‘those people’, or what should we
do with ourselves? 162
P iret Paal

11 Using superdiversity as a lens to view migrant health:

reflections on ethical and practical implications of an
exploratory study involving community researchers 175
A ntje L indenmeyer
 Contents vii
Part IV
Navigating pluralism in health care 189

12 Challenges in the provision of mental health care

for refugees in Germany: a socially and culturally
sensitive approach to psychological counselling and
psychotherapy 191
K erstin H ein and B arbara A bdallah - S teinkopff

13 Female genital alteration in the UK: a failure of

pluralism and intersectionality 207
A rianne S hahvisi

14 Integration, identity and elite migrants: capturing the

perspectives of overseas-trained South Asian doctors in
the UK 224
Y asmin G ha z ala Farooq

15 How to support migrant physicians in navigating

through an unfamiliar health care system: findings
from a qualitative interview study 241
C orinna K lingler and G eorg M arckmann

16 Migrants, pluralism and end-of-life decision-making

for children with life-limiting illness: perspectives on
the case of Josip 259
K atja K uehlmeyer and M onika F ü hrer

Commentary 1: The ethical implications of interculturality

in paediatric palliative medicine 262
I lhan I lk I lic

Commentary 2: Migration, bioethics, pluralism 267

R ichard H uxtable

Commentary 3: Universalism versus particularism in

clinical ethics: a coherentist perspective 272
G eorg M arckmann

Index 283
List of tables and box

Tables
4.1 Results from the vulnerability assessment 66
4.2 Biological and physiological vulnerability 67
11.1 Description of the study participants 180
14.1 Ethnic, gender and religious attributes of participants related
to the case study areas 227
15.1 Description of the sample 244
15.2 Desired support strategies for migrant physicians 251

Box
16.1 Principle-based model of ethical case discussion
(cf. McCullough & Ashton 1994; Marckmann & Mayer 2009) 275
Notes on contributors

Editors
Richard Huxtable, LLB, MA, PhD, is Professor of Medical Ethics and Law and
Director of the Centre for Ethics in Medicine, University of Bristol, UK.
He works primarily on ethics and law at the end of life, surgical ethics, and
clinical ethics support.
Corinna Klingler, MSc, has recently finished her doctoral research on integration
of migrant physicians in Germany and is currently working on translational
bioethics as a postdoctoral researcher at the QUEST Centre of the Berlin
Institute of Health.
Katja Kuehlmeyer, Dr. rer. biol. hum., is Research Associate at the Institute of
Ethics, History and Theory of Medicine at LMU Munich. She works on var-
ious topics at the intersection of psychology, health and ethics.

Authors
Barbara Abdallah-Steinkopff is working as Psychotherapist at REFUGIO
Munich, Germany, a centre for counselling and treatment for refugees and
victims of torture. She is furthermore providing education and training in
different institutions concerning psychotherapy of post-traumatic stress dis-
orders, intercultural psychotherapy and cooperation with interpreters in the
psychotherapy of refugees.
Carolin Bader is Advisor for domestic missions at Ärzte der Welt/Doctors of
the World Germany, responsible for quality and strategy with regards to con-
tent and at the intersection to advocacy, media and communication. She has a
background in cultural anthropology, sociology and gender studies.
Cormac Devlin has just completed his undergraduate degree in Law at Jesus
College in the University of Cambridge, UK. He is particularly interested in
immigration law and its intersection with health care policy and LGBT+ issues.
Christiane Falge, Prof. Dr., is Professor of Health and Diversity at the Univer-
sity of Applied Health Sciences, Bochum, Germany. She conducted her PhD
at the Max Planck Institute for Social Anthropology in Halle.
xii Notes on contributors
Yasmin Ghazala Farooq, Ph.D., is Lecturer in Social Statistics at the
­University of Manchester, UK. She completed her PhD at the University of
Manchester, UK in 2014. Her research interests include migration, ­identity,
ethnicity, race and health inequalities. Her doctoral research focussed on
the migration and identity experiences of overseas-trained South Asian
­doctors in the UK.
Monika Führer, Prof. Dr., is Pediatrician specialized in oncology, hematology
and palliative medicine, Professor for Pediatric Palliative Medicine and head
of the Pediatric Palliative Medicine Centre at LMU Munich, Germany. Her
research interests are advance care planning and end-of-life decisions, social
support and meaning in life in Pediatric Palliative Care.
Sabine Fürst is Head of Domestic Programs at Ärzte der Welt/Doctors of the
World Germany since 2014, overseeing all projects in Hamburg, Stuttgart,
Munich and Berlin. She worked for many years in international development
cooperation in South Africa and Sudan, among others.
Lea Gelfert is a student of Political Sciences and Sociology and has worked as
assistant for Ärzte der Welt/Doctors of the World Germany since April 2017.
Kerstin Hein, Dr. Phil, has a degree in Psychology from the Universidad
Diego Portales in Santiago de Chile and a doctoral degree in Psychology and
­Sociology from LMU Munich, Germany. She is currently research coordi-
nator at the Centre for Paediatric Palliative Medicine at LMU Munich and a
parent trainer at REFUGIO Munich, Germany.
Hiranthi Jayaweera, Dr., is Research Associate at the School of Anthropology,
University of Oxford, UK. She has long-standing research and policy inter-
ests in migrant health, in the UK, Europe and globally, and has written and
presented extensively on this topic.
Lucy Jones is Director of Programmes at Doctors of the World UK, leading the
programmes team and policy and advocacy work since 2013.
Markus Kaltenborn, Prof. Dr., is teaching Public Law at the Faculty of Law
of Ruhr-University Bochum, Germany. He is Director of the Institute of
­Development Research and Development Politics (IEE) at Ruhr University
Bochum. His main areas of research are Health Law, Social Security Law, the
Law of Development Cooperation and Human Rights Law.
Sabine Klotz studied Polictical Science at the Frierich-Alexander University
Erlangen-­Nürnberg. She is currently working as a coordinator of the gradu-
ate program “Human Rights and Ethics in Medicine for the Ederly” at the
Friedrich-Alexander Universität Erlangen Nürnberg, Germany.
Antje Lindenmeyer, Dr., is Lecturer in Qualitative Methods at the University
of Birmingham. Her main field of research is the experience of health, illness
 Notes on contributors xiii
and health care. She has a strong interest in the impact of migration on these
experiences including health care encounters and everyday practices.
Ilhan Ilkilic, MD, PhD, has studied medicine, philosophy, Islamic science and
oriental philology in Istanbul, Turkey and Bochum and Tübingen, Germany.
He is currently Director of the Department of History of Medicine and Eth-
ics at the Istanbul University Faculty of Medicine and Director of the Insti-
tute for Health Sciences of Istanbul University, Turkey.
Georg Marckmann, Prof. Dr., MPH, is Professor of medical ethics and Di-
rector of the Institute of Ethics, History and Theory of Medicine at LMU
Munich, Germany. He studied medicine and philosophy at the University of
Tübingen, Germany, and received a master’s degree in Public Health from
Harvard School of Public Health, Boston, MA, USA. His main research in-
terests include ethical issues in end-of-life care, clinical ethics consultation,
distributive justice in health care, and public health ethics.
Anna Miller is Policy and Advocacy Manager at Doctors of the World UK,
overseeing programmes to strengthen the right to health care in the UK. She
has a background in policy and campaigning work on the right to justice,
housing and health care.
Amrei Müller, Dr, is currently a Leverhulme Trust early career researcher at the
School of Law, Health & Human Rights Unit, Queen’s University Belfast,
United Kingdom. Her research interests lie in the area of human rights law
and international humanitarian law, in particular the right to health, the pro-
tection of access to health care in times of armed conflict and the law of the
European Convention on Human Rights.
Piret Paal, Dr., is researcher and facilitator for WHO Collaborating Centre in
Nursing Research and Education, Institute of Nursing Sciences and Practice
at the Paracelsus Medical University Salzburg. She is a member of steering
groups on spiritual and palliative care education at the European Association
of Palliative Care.
Oliver Razum, Prof. Dr., is full Professor and Dean of the School of Pub-
lic Health, Bielefeld University, Germany. He also heads the Department of
­Epidemiology & International Public Health. His main research field is social
epidemiology with a particular focus on the health of immigrants, and on the
role of contextual factors in the production of health inequalities.
Penelope Scott, Ph.D., is guest researcher at the Institute of Sociology,
LMU Munich, Germany. She has ­researched and published in the field of
ethnic minority and im/migrant health in the UK and Germany.
Arianne Shahvisi, Ph.D., is Lecturer in Ethics at the Brighton & Sussex Med-
ical School, UK. She received her Ph.D. from the University of Cambridge,
UK in 2013. She has research interests in the philosophy of science and
xiv Notes on contributors
applied ethics, with current projects focusing on reproductive ethics and
social epistemology.
Sarah Steele, Dr., is the Deputy Director of the Intellectual Forum at Jesus Col-
lege in the University of Cambridge, UK. She is also a Senior Research Asso-
ciate, focusing on themes and problems of interest to communities across the
world at the interface of public health and law, and an Affiliated Researcher at
the Department of Politics and International Studies.
Hella von Unger, Prof. Dr., is Professor of Sociology at LMU Munich,
Germany. Her areas of expertise are qualitative methodologies, participatory
research and research ethics in particular concerning research on health and
illness, migration and ethnicity.
Judith Wenner is researcher at the Department of Epidemiology and Inter-
national Public Health at the School of Public Health, Bielefeld University,
Germany. She works on health inequality, access to health care and migration.
Currently she is conducting a study on access to health care for refugees.
Foreword
Satvinder S. Juss

One of the most tantalizing myths of our time is that Europe’s migration crisis
is the result of the large number of their arrivals. It is true that in 2013 the figure
stood at 1.3 million, but that upsurge was because of the Syrian war. The truth
is closer to home. Public hostility to immigrants has been caused by a breakdown
in trust, and in social disengagement, as well as the political disaffection, which
arose exactly a decade ago, after the global financial crisis in 2008. Two distinct
consequences arose from this. First, there was the unleashing of populist forces
on both the far left and the far right, so that leaders from across the political
divide were able to rise, such as the Labour Party’s Jeremy Corbyn in the UK
and Pablo Iglesias from the anti-austerity Podemos party in Spain, to Matteo
Salvini, the leader of the Anti-Immigrant League, and Luigi Di Maio of the Five
Star Movement in Italy. Second, and more worryingly, there arose a flagrant
and unashamed attack on the liberal ideal from within the liberal order itself as
demonstrated by the election to power of populists such as Donald Trump and
Victor Orban with an outright rejection of the time-honoured liberal values of
tolerance, diversity, and human rights that had begun to take shape.
It is this which shaped public hostility to migrants. Not the immigrants them-
selves who just became an easy scapegoat. In fact, all the evidence is that in coun-
tries where there are high levels of institutional trust, low levels of corruption,
sound economies and most importantly a high level of social cohesion – which
does include immigrants as well – there is markedly less anti-immigrant senti-
ment. In short, dislike of immigrants has little to do with the immigrants them-
selves. This is why this study by leading experts in the field of health care for
migrants is so timely and important. The authors, Katja Kuehlmeyer, Corinna
Klingler and Richard Huxtable, do not just make it clear that the exclusion of
specific migrant groups from public health care is ethically unacceptable (noting
that several public health ethicists eschew such restrictions critically) but they
even pose the question whether a restrictive policy actually saves costs, thus
rendering this study indispensable to today’s financially strapped policy-makers.
It is often forgotten that in one of the most defining decisions in the UK,1 con-
cerning a 30-year old Ugandan asylum seeker threatened with expulsion had a
“tragic complication” in the words of the Judge in the country’s apex court, Lord
Nicholson, in that she “suffer(ed) from advanced HIV/AIDS (‘full blown AIDS’,
in the old terminology).”2 When she arrived in the UK “she was very poorly” and
xvi Foreword
“within hours she was admitted to Guy’s Hospital”3 in London, where, “as a result
of modern drugs and skilled medical treatment over a lengthy period, including a
prolonged course of systematic chemotherapy,” she was “now much better.”4 How-
ever, as a failed asylum seeker, Lord Nichols recognised her, “cruel reality” that if she
“returns to Uganda her ability to obtain the necessary medication is problematic” so
that, “her position will be similar to having a life-support machine switched off.”5
Whilst recognizing that, “[a]s everyone knows, the prevalence of AIDS world-
wide, particularly in southern Africa, is a present-day human tragedy on an im-
mense scale”,6 Lord Nichols was clear that the European Convention of Human
Rights 1950 did “not require contracting states to undertake the obligation of
providing aliens indefinitely with medical treatment lacking in their home coun-
tries.”7 In short, for those seeking to remain in a host country, “[i]f their appli-
cations are refused, the improvement in their medical condition brought about
by this interim medical treatment, and the prospect of serious or fatal relapse
on expulsion, cannot make expulsion inhuman treatment …”8 In so deciding
the UK’s apex court reversed the decision of the fact-finding tribunal of first
instance, which had found in favour of the Ugandan asylum seeker and urged
that she be not removed from the jurisdiction.
Another judge, Lord Hope, also was all too acutely aware that such a decision
would have “profound consequences” for this Ugandan asylum seeker, because
“[t]he prospects of her surviving for more than a year or two if she is returned
to Uganda are bleak” so that “she will face an early death after a period of acute
physical and mental suffering.” 9 He was clear, nevertheless, that “[t]he func-
tion of a judge in a case of this kind, however, is not to issue decisions based
on sympathy.” Rather, “judges must examine the law in a way that suppresses
emotion of all kinds” because “[t]he position that they must adopt is an austere
one.” This is because ultimately the question at hand was “about the extent of
the obligations under Article 3 of the European Convention on Human Rights”
and “about the treaty obligations of the contracting states” and whether “the
contracting parties would have accepted and agreed to be bound by” an obliga-
tion to treat, perhaps indefinitely, the sick and ailing who happen to reach our
shores from aboard or arrive at our airport terminals with no right to remain.
No one, looking at the anxious scrutiny displayed by the judges and language
deployed by them, can fail to be struck by how difficult they found the decision
to be made in this case. And, lest it be thought that the decision was wrong in
law, it was entirely upheld by the European Court of Human Rights in Stras-
bourg10 some three years later. Yet, what this seminal immigrant medical health
case demonstrates, however, the limits of the law specifically and of public policy
more generally in the two most advanced economies of the European Union,
namely, the UK and Germany, which the authors of this volume set out to ex-
amine, when it comes to the provision of medical health.
It is often said about the western conception of human rights that they are
‘negative’ rights in that they enjoin the State from refraining from interfering
with, and impinging upon, the integrity of the individual, thereby making for
the efficient running of the Capitalist system. Western rights are not gener-
ally ‘positive’ so as to require the alleviation of poverty of the masses as that
 Foreword xvii
would require the expenditure of money and resources. States, so the argument
runs, do not willingly inflict poverty on their people (though the decade long
­European Union policy of ‘austerity’ makes one wonder!), but they do willingly
torture their citizens, which is why it is correct to envision rights in this ‘nega-
tive’ sense. This, however, overlooks the fact that the right to vote, upon which
western democracy is predicated, is very much a ‘positive’ right in that it entails
costs on the part of the State every time people go to the polls.
It is against the background of such ambiguities and uncertainties that this
laudable tome by Katja Kuehlmeyer, Corinna Klingler and Richard Huxtable
aptly titled, Ethical, Legal and Social Aspects of Health Care for Migrants, is both
so welcome and so timely, written with the erudition, expertise and objectivity,
which policy-makers, state officials and lawyers will benefit from. What the au-
thors do is to consider migrants’ health, their need for and uptake of public health
care, and their health care entitlements. Their focus is on Germany and the UK
because both countries have a longstanding experience of migration, both have to
deal with issues relating to immigrant and immigrant-sensitive health; both have
had to deal with having to regulate migrants’ access to and uptake of health care;
and both are increasingly conscious of the need to ensure the provision of cul-
turally sensitive health care in societies that are now pluralistic. Although many
books have been usefully written on the rights of migrants, this is one of the few
to focus on the pressing question of the health needs of immigrants. The authors
tell us why this is so vitally important when they explain (at p. 3) that

[p]eople value their health for various reasons but, foremost, health has an
instrumental value, as it is a prerequisite to pursuing ‘the innumerable pro-
jects of life that we are all involved with’” and not least because, “All hu-
mans are vulnerable to suffering…

Given this premise they are, “convinced that, ethically, there is in principle no good
reason for treating (literally and figuratively) migrants and non-migrants differ-
ently at least with regard to health care. Inadequate treatment of migrants can
be variously conceived as a failure of solidarity, injustice, or a violation of human
rights, such as the right to health” (at p. 5) thus making the reading of this volume
by a wider readership ever more compelling. This is because few immigration
works are as well focused as this one on the ethics of the debate.
Yet this is exactly what has been done in the case-law. Notwithstanding the
fact that some two decades ago Lord Hope urged that judges must “not to
issue decisions based on sympathy” and Lord Nicholls concluded that the Eu-
ropean Convention of Human Rights 1950 did “not require contracting states
to undertake the obligation of providing aliens indefinitely with medical treat-
ment …” the issue is being revisited again by the courts. This is a telling re-
minder that ultimately it is the humane approach to the resolution of social and
political problems that triumphs. In December 2016 the Grand Chamber of the
European Court of Human Rights, in a case brought against the Belgium gov-
ernment,11 decided to impose a much lower threshold than had been imposed in
2005 in the case of the Ugandan asylum seeker. In terms, it made it clear that,
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