Physicians are pushing back against a recent job listing for a lead physician at a US Immigration and Customs Enforcement (ICE) detention center, saying the position requires physicians to betray their oath to act in their patients' best interest.

The GEO Group, a private contractor based in Boca Raton, Florida, posted the job listing on JAMA's career website. In it, the company asked applicants to demonstrate they are "philosophically committed to the objectives of the facility."

Dr Zackary Berger

Bioethicist Zackary Berger, MD, PhD, told Medscape Medical News a colleague originally sent him the JAMA job posting link with the tongue-in-cheek suggestion that he might be interested in applying for that job. Instead, he sent a letter to JAMA's editor in chief, Howard Bauchner, MD, and executive editor, Phil B. Fontanarosa, MD, MBA, on July 21 expressing his concern and asking them to remove the listing. Bauchner responded to him "pretty promptly" on July 22, saying that he does not review ads but would forward Berger's email to Thomas J. Easley, senior vice president and publisher of periodical publications for JAMA.

Easley wrote him on July 24 thanking him for his concern and telling him the job posting had been taken down; it was removed on July 23. Berger said he asked Easley whether JAMA "would accept future postings seeking physicians to work in ICE and CBP [US Customs and Border Protection] facilities," but he did not receive an answer. JAMA declined a request for comment from Medscape Medical News. ICE did not respond to a request for comment.

A similar job listing for the same detention center is available on the New England Journal of Medicine career website, seeking a "lead Physician managing and evaluating the medical program activities based on the company goals, objectives, and philosophy according to industry standards and contractual obligations." The job also requires applicants to be "philosophically committed to the objectives of the facility." The job listing was posted on June 28 but has now expired, according to the listing. The journal declined a request for comment.

The GEO Group currently has 69 job listings for physicians and other healthcare professionals for positions in detention and correctional facilities across the United States. As of July 26, the ICE detention facility in Basile, Louisiana, was looking for five healthcare professionals — a physician, a psychologist, a dentist, a registered nurse, and a licensed vocational nurse. The only physician job posting — for a primary care physician — was posted on July 22 and did not contain the wording referred to by Mishori.

"Loyalty Test"

Dr Ranit Mishori

Ranit Mishori, MD, MHS, from MedStar Georgetown University Hospital in Washington, DC, Physicians for Human Rights, and a contributor to Medscape Family Medicine, calls the requirement that applicants be "philosophically committed to the objectives of the facility" a "loyalty test" by which physicians are expected to put the company's best interest before that of their patients.

"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," Mishori writes in an editorial published July 22 in the Washington Post.

It is unclear whether the job listing was removed as a result of Mishori's editorial or the physician backlash.

Mishori goes on to say that the language of the ad was first changed to say that the GEO Group was looking for physicians to work "based on the company goals, objectives and philosophy" before it was later taken down.

Mishori is also suspicious of the $400,000 annual salary for a general practitioner, who would be unlikely to make that much money in another setting, and the preference for applicants with 2 years of direct experience. That's a short time practicing medicine for such a well-paid position, she writes. And it's much more than she makes, she said in a July 22 interview with National Public Radio.

The company also does not list board certification as a requirement or even a preference in the original ad, another fact that troubles Mishori, because board certification is generally an indication of a practitioner's competency.

Mishori asks which objectives that physician would 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?"

She says she warns medical students about this conflicting concept of "dual loyalty" to both an employer and patients. "[W]hen 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," Mishori explains.

Mishori also cautions about "lapses of omission," such as when a physician sees "clear signs of abuse" but does not record or report them because they are afraid of risking their own job security.

She says the GEO Group is being sued "by RAICES [Refugee and Immigrant Center for Education and Legal Services], a Texas nonprofit, that alleges that its employees allowed 13 children to be separated from their fathers in Karnes City, [Texas], last summer."

"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," according to Mishori.

The GEO Group denies Mishori's accusations, saying in a statement published July 24 in the Hill, "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, and for Professor Mishori to imply otherwise is shameful."

Stay Away in Protest or Be There to Help?

Berger is an associate professor at Johns Hopkins School of Medicine, core faculty at Johns Hopkins Berman Institute of Bioethics, and a staff physician at Esperanza Clinic Health Center, all in Baltimore, Maryland. This issue is important to him because some of his patients are immigrants, he said.

"Normally you don't hire a physician by their ideology or their political or mission belief, you just hire someone who's competent. This is highly politicized hiring, which is ethically highly suspect," Arthur Caplan, PhD, professor of bioethics in the Department of Population Health at New York University School of Medicine in New York City, told Medscape Medical News. Caplan is also a regular contributor to Medscape Business of Medicine.

Berger said many of his colleagues found it "depressing that a prestigious journal like JAMA should be helping ICE [find] doctors to do that work." A "minority" of his colleagues expressed the opinion that "it's better that there be doctors there, which I think gets it wrong."

For one thing, he explained, there is a legal remedy — freedom — to the situation these children and adults are in.

"There's a chance that an exceptional individual, put in that situation, would be able to make a positive change in the life of a child, but it seems really unlikely," he said.

But Caplan believes physicians can improve conditions for detainees in these detention centers. Anything anyone can do to help make the children's lives better would be worthwhile, he said. But physicians have to be willing to "blow the whistle, talk to anybody in Congress or the media who will listen about what's wrong, you have to fight for them."

Mishori urges physicians to remember that the "do no harm" concept in the Hippocratic oath also means not being "complicit" with actions that put their patients at risk. "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," she writes.

Editor's note: This article originally said that GEO Group is based in Baton Rouge, Louisiana. It is in Boca Raton, Florida.

Mishori is a contributor to Medscape Family Medicine. Caplan is a contributor to Medscape Business of Medicine.

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