A health care professional holding the scale of justice, representing the ethical considerations in medical practice. Image by gabrielhrech/freepik.
Michael Allen is a biology major with a minor in public health. He is a 2025-26 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are his own.
To hide, or confide? This is the decision many people have to make when deciding whether to receive medical attention. Recent reporting on the killing of Alex Pretti, a 37-year-old VA ICU nurse shot during an encounter involving federal immigration agents, has intensified public scrutiny of how enforcement decisions unfold under stress, and how those events shape community trust. Hospitals rely on the public’s confidence that they can seek care without the fear of consequences. As immigration enforcement becomes increasingly involved in or near health care settings, fear can erode that confidence, deteriorating the quality of care for patients and reliability of hospitals as safe institutions. The erosion of trust doesn’t just affect patients; it also creates situations where clinicians feel ethically responsible for protecting patients while constrained by policies or legalities. The ethical question for health care is not partisan: when immigration enforcement and health care collide, what does clinicians’ duty to “do no harm” require of staff and institutions?
What is Moral Distress?
Hospitals are built to be places of care, but when enforcement pressures enter the clinical space, clinicians can be pulled between protecting patient welfare while also complying with institutional rules and legal authority. When enforcement-related disruptions deter care or destabilize clinical spaces, they can create preventable harms, harms that institutions have ethical responsibilities to minimize. Yet, at the ground level, individual clinicians often cannot prevent those harms as they are required to comply. The gap between what a clinician believes is ethically right and what protocols allow is what bioethicists call moral distress.
I’ve felt a version of this in prehospital care, when an underage patient communicated discomfort about a discharge plan, but our protocols constrained what I could do in the moment. Even after looping in my supervisor and attempting to contact an alternate guardian, I ultimately had to follow the required legal process. The lingering question in my mind was not clinical. It was ethical. What do you do when your responsibility to protect a patient conflicts with your responsibility to follow protocol?
What Does ICE in or Near Hospitals Mean for Practice?
Now, you may be thinking: Aren’t hospitals protected? Can enforcement officers just go in and arrest people? Until January 20, 2025, DHS guidelines discouraged enforcement actions in or around “protected areas,” including hospitals. However, on that date, Acting DHS Secretary Benjamine Huffman rescinded the 2021 Guidelines for Enforcement Actions in or Near Protected Areas memorandum, meaning many previously-protected spaces, including hospitals, were no longer designated as protected. In practice, this shift increased uncertainty for patients and staff, and can heighten fears about seeking care or speaking freely. In response, the American College of Emergency Physicians (ACEP) and Office of the Attorney General (OAG) emphasized that hospitals should prepare in advance by establishing clear internal response plans, protecting patient rights and safety, documenting the incident, and complying with valid legal processes while minimizing disruptions to care.
On December 31, 2025, a patient arrived at the Hennepin County Medical Center (HCMC) in Minneapolis seeking medical care. Community organizers stated that ICE officers later entered the hospital without a judicial warrant and stayed while care was being provided. According to reporting by Sahan Journal, Unidos MN said, “ICE officers entered the hospital without a warrant to arrest the patient, and sat at the patient’s bedside for approximately 28 hours while medical staff provided care.” Advocates also described the patient being treated as someone in custody, such as limited family access and restraints during the hospitalization, creating tensions for other patients who were receiving care nearby. CBS Minnesota similarly reported organizers’ claims that the patient was handcuffed to the bed without a judicial warrant, and that the officers left only after being confronted by elected officials. Even without discussing the facts of the case, the ethical tensions are clear as the bedside environment becomes contested between patient privacy and legal fears. For clinicians, this clash creates role conflict, a duty to “do no harm” and protect the patient’s welfare while navigating protocols and power structures they do not control. These conditions can create moral distress and increase the risk of preventable harm.
Who is Affected?
The duty to “do no harm” stems from the principle of nonmaleficience in the Principlism ethical framework. It requires professionals to avoid causing harm and minimize risk, ensuring patient well-being is a priority. In clinical practice, nonmaleficence is often understood as avoiding physical harm, but it also applies to more indirect harm, like clinical conditions that interfere with privacy, communication, comfort, or willingness to seek help. To understand how that harm manifests, we have to zoom out from the single case and look at the broader effects of enforcement in clinical settings.
When people believe a hospital visit could expose them, or someone they love, to risk, they may skip visits, let disease go unchecked, or disclose less than they otherwise would. A study found that rises in local immigration enforcement activity, measured by per capita I-247 requests, were associated with lower rates of seeking care among Hispanic adults in the US. As many patients feel that the “risks from detention and deportation may outweigh the cost of forgone care,” many have outright stopped seeking medical attention. This pattern extends to children and families as well. Another study reported a 43.3% and 34.5% decrease in completed primary care visits among undocumented children and adults, respectively, during periods of heightened anti-immigrant rhetoric from 2015 through 2018. The growing fear of hospitals reshapes health care behavior in ways that are potentially harmful. This pattern continues today; a 2025 survey found that since January 2025, 40% of immigrant adults overall and 77% of likely undocumented immigrants reported negative health impacts due to immigration-related worries.
These impacts also reach providers. Clinicians can experience moral distress when they believe patient care is compromised, but feel powerless and morally cornered by policy or protocol. In a conversation with me, nurse Hannah Warnecke captured the exhaustion: “when you have to act against your morals constantly, it gets to you.” Over time, that pressure can accumulate into emotional exhaustion and negatively affect clinical performance, especially when staff repeatedly internalize that care is unsatisfactory with limited power to change the conditions causing it. Additionally, because enforcement situations can involve unclear or inconsistently followed rules, they can also create the kind of moral ambiguity that makes moral distress even harder to resolve.
Practical Recommendations
If nonmaleficence requires minimizing foreseeable harm, then hospitals cannot treat enforcement encounters as rare occasions handled ad hoc by whoever happens to be on shift. Nonmaleficence requires that the ethical response is to establish clear protocols, protect privacy, and reduce moral distress.
Firstly, there should also be a trained liaison in every institution as the only point of contact to interact with immigration officers and to verify documentation through appropriate channels. The ACEP guidelines emphasize how responses to immigration enforcement requests depend on various factors, so narrowing and consolidating communication to trained personnel helps safeguard patient privacy and keep care teams focused on care.
Secondly, hospitals should proactively protect the care environment by clarifying public and private areas, and limiting enforcement presence in treatment spaces when possible. The National Immigration Law Center stresses the importance of maintaining trust and knowing rights and obligations so staff can protect patients while responding appropriately to immigration enforcement.
Thirdly, hospitals should recognize and treat moral distress as a safety issue. After enforcement-related incidents, implement optional debriefs, consultations, mentorship, or support to reduce moral distress as much as possible and process what happened so that they can return to patient care without carrying unresolved ethical stress.
These recommendations won’t completely erase the effect of enforcement activity in or around hospitals, but they can reduce predictable harms by replacing improvisation with clear procedures that emphasize patient trust while also reducing moral distress in clinicians.
To hide, or confide? This is the decision many people have to make when deciding whether to receive medical attention, and too many have understandably chosen to hide. When immigration enforcement and health care collide, the harm is not only in the immediate disruption of care, but also in the downstream effects that change who feels safe asking for help. If “do no harm” is taken seriously, hospitals must treat preparedness as an ethical obligation. A hospital cannot control forces outside its walls, but it can choose whether its policies reduce harm, or compound it.