Ms Mendez

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This case concerns a foreign domestic worker hospitalised for diagnosis and treatment of suspected pneumonia. Her health insurance coverage is likely to run out before she can be safely discharged, and her doctors are uncertain about this patient’s options and their responsibilities as advocates.

Ms Mendez: Providing good care to foreign workers

Jenny Mendez is a 23-year-old woman from the Philippines. For the past three years, she has been employed by the Seah family to care for their two young children, ages three and five, and to do housework. Two weeks ago, Ms Mendez began to feel unwell, and she soon developed a fever, cough, and muscle aches. Her employers gave her a few extra days off, which she spent resting in her bedroom in their flat. She returned to work, but still felt fatigued, with a nagging cough.

This morning, Ms Mendez told Mrs Seah, ‘I’m so sorry to bother you – I know you’ve got to get to work – but I’ve got a pain in my chest. It’s sharp – I can feel it when I take a breath.’

Mrs Seah said, ‘Oh, no, Jenny! I’ll drop you off at the emergency room. Let me call my mother to see if she can watch the children today. We’ll manage.’ Mrs Seah drove Ms Mendez to the nearest hospital, telling her, ‘Call me if there are any questions about your insurance. Good luck!’

After examining Ms Mendez and listening to the patient’s description of her symptoms, Dr Josiah, a medical registrar, says, ‘I’m going to admit you to hospital – you may have a severe case of pneumonia.’

‘Pneumonia! I thought I just had a bad cold. Can’t you just give me some medicine for it? I must get back to work.’

‘I understand that you’re worried, but we need to figure out what’s wrong. You need to see a lung specialist for a proper work-up.’

‘Okay, maybe I could come back and see the specialist a different day?’

‘Really, it’s best for you to be in hospital right now. I don’t want your lung to collapse.’

A nurse motions to Dr Josiah from the corridor.

‘I’ve got Mrs Seah on the phone – she wants to know when she can pick up her maid.’ Dr Josiah picks up the phone and introduces herself.

‘Is Jenny all right? Is she okay to come home by herself?’

‘Well, she’s resting right now…’

‘Resting’? Do you mean she’s really sick? Is something wrong?’

‘Mrs Seah, you did the right thing to bring Ms Mendez here this morning. I must go right now, but I’ll call you back later, okay?’

Dr Josiah goes back to Ms Mendez’s cubicle. She tells her patient, ‘Your employer just called – she wanted to know how you were doing.’

‘Oh no! Did you say anything? I hope not. I’m really worried about my job – they’re a nice family, but if I go to hospital how are they going to manage? They’ll find someone else. I know a maid who got fired when she got sick. And my insurance – what if it runs out?’

‘Look, you can’t look after little kids if you’ve got pneumonia. Just give me another minute, okay?’

Dr Josiah steps into the corridor to collect her thoughts. She finds foreign worker cases so stressful. What would be the harm in sending the patient home on a trial run of antibiotics, to help her hang onto her job? But is that good enough?

When the domestic helper falls ill

Commentary by Jacqueline Chin

A vulnerable patient

Jenny Mendez, the patient in this narrative, is a foreigner who is resident in Singapore and legally employed as a domestic helper in the Seah family. The case suggests that the family she works for are good employers, taking responsibility for her healthcare, and fulfilling their contractual obligation to purchase healthcare insurance for Ms Mendez. However, the insurance policy is likely to be adequate only for coverage of non-critical illnesses and short-term hospitalisations. Employer-purchased insurance typically would not secure Ms Mendez’s coverage for critical care or for rehabilitative hospitalisation. In addition, Ms Mendez’s residency in Singapore depends on her having an employment contract that remains current, and any termination of that contract while she recovers in hospital would render her an illegal overstayer in the country. It is highly likely that she found this job through a recruiting agency which would have loaned her a sum of money for her passage and charged to her a range of fees needed for fulfilling cross-border employment requirements. If so, Ms Mendez would therefore have had to use part of her salary to pay for these debts, and have very little savings of her own to cover the cost of medical care in a first-world country. It is unclear whether her employer is in any position to offer to pay for the cost of Ms Mendez’s treatment. As a work permit holder, Ms Mendez is eligible for government subsidised care in B1 and C class wards, but as a non-citizen, she is excluded from participation in Medifund. Any payments not covered by insurance put pressure on her employers and ultimately Ms Mendez herself. These uncertainties surrounding healthcare and employment can leave a migrant worker like Ms Mendez in a state of great anxiety whenever she becomes ill or injured. They also place Ms Mendez’s doctors in a difficult predicament. What should Dr Josiah do?

The doctor’s predicament

Dr Josiah has treated other foreign workers, and finds these cases ‘so stressful’. A patient in this situation is worried about many things – the cost of getting treatment and who pays for it, the security of her job, whether she will be able to continue to work and to send remittances to her family – and, understandably, may minimise her health problems. Will Mrs Seah, Ms Mendez’s concerned  employer, be in a position to pick up any costs that will not be covered by Ms Mendez’s insurance policy, or not? Given that Ms Mendez needs to be hospitalised for a full diagnostic work-up and for treatment that may include intravenous antibiotics and procedures to drain fluid from her chest cavity, will Mrs Seah preserve the patient’s job while she recovers, by taking on the challenging task of finding temporary substitute help that is in short supply in Singapore? Or will she discharge Ms Mendez and employ a new helper for her family? Dr Josiah knows that Ms Mendez’s concerns are real concerns.

With Ms Mendez’s consent, Dr Josiah can provide Mrs Seah with information about what is known about Ms Mendez’s condition, what tests she needs, and what the possible course of treatment and recovery will be. However, Ms Mendez is, as yet, unwilling to disclose any medical information to her employer and wishes only to return to work. Dr Josiah is unable to discharge Ms Mendez with her current condition, and must find a way to provide for the healthcare needs of her patient within the constraints imposed by her insurance.

Healthcare obligations to migrant workers

Should Dr Josiah treat Ms Mendez differently because she is a migrant worker? This question would hardly arise if Ms Mendez had adequate health insurance coverage, as many foreign professionals have through their employment contracts. Dr Josiah should be able to treat patients based on their medical needs, in accordance with standards of care, and should not have to practice in ways that increase patients’ vulnerability. Hospitals should recognise the challenges their physicians and other staff (including social workers) are likely to face in practising medicine with due care and beneficent concern. This may require hospital administrators to take up the issue of the cost of care with the relevant authorities responsible for migrant worker recruiting practices. Since migrant workers contribute in various ways towards a destination country’s diverse labour needs, the governments of benefitting countries have an ethical obligation to ensure that employment conditions protect the well-being of workers. The effectiveness of labour recruitment policies should include rather than compete with ethical requirements of welfare and fairness for workers. Hospital authorities should therefore work with government agencies to offer healthcare professionals, employers, and workers a more accurate understanding of how best to secure the healthcare needs of migrant workers.

Research from the US and other nations on the treatment of unauthorised migrants reveals that ‘safety-net’ hospitals that provide emergency treatment for these patients can come under financial pressure to take the ethically problematic step of ‘medically repatriating’ patients who lack the means to pay for care, by returning them to their home countries, which often lack good healthcare services, at the hospital’s own expense. Hospitals in Singapore may face similar pressures when the cost of a migrant worker’s healthcare exceeds the worker’s insurance coverage. However, it is crucial for hospital administrators to keep in mind that, in the case of a patient like Ms Mendez, her status as a worker with legal rights in Singapore guarantees both an ethical and legal obligation of due care to her that ultimately lies with the state whose policy concerning migrants includes both the private-insurance mandate and partial exclusion from the public system (exclusion from Medifund’s social safety net). In 2012, Singapore ratified the International Labour Organisation’s Convention C187, underscoring its commitment to workplace safety and health.

Dr Josiah’s responsibilities

When hospitals lack clear policy, this adds to ethical uncertainty in the clinical setting. Because migrant workers like Jenny Mendez may be inadequately insured for the care they need, hospitals should offer guidance to clinicians on what to do in these situations, and should develop policy that is informed by clinical perspectives. This includes a clear process for physicians and social workers who may need to collaborate with patients, and with employers, to clarify healthcare costs, and how these costs will be covered, when a migrant worker is underinsured relative to her healthcare needs.

In the light of the interdependent relationship between Ms Mendez and Mrs Seah, and the ways in which the worker-employer relationship differs from a familial relationship, Dr Josiah and medical social workers should also be prepared to support productive communication between them. This may include reassuring Ms Mendez that her needs as the patient have greatest priority, and that she will not have to figure everything out on her own while she is sick, while explaining to her that some level of discussion with her employer about issues relevant to the cost of her care is probably inevitable. A social worker with expert knowledge of healthcare insurance for migrant workers may be well-placed to facilitate communication between Ms Mendez and Mrs Seah. In advocating for her patient, Dr Josiah might also encourage Mrs Seah to exercise compassion and concern for her worker’s welfare. An unpreventable serious illness has brought the real face of her hard-pressed domestic helper’s vulnerabilities into sharp focus. It is a case that has systemic and global dimensions that each individual found in its web can assist in unravelling.


Commentary by Chin, Jacqueline, ‘When the domestic helper falls ill’, in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),

The right to medical privacy and confidentiality

Commentary by Calvin W. L. Ho

The employment relationship between a foreign domestic worker (FDW) and his or her employer is not directly regulated by legislation, but by contract. There will usually be a written employment contract between the FDW and the employer, and (from 1 December 2012) a safety agreement among the FDW, the employer, and the employment agency.

When a FDW falls ill, the employer may expect that he or she has the right to be informed of the employee’s medical condition. However, such expectations are inconsistent with the ethical and legal responsibilities of healthcare workers, because FDWs have the same legal rights concerning medical privacy and confidentiality as do citizens and other residents of Singapore. In this commentary, we consider the right to medical privacy and confidentiality of an FDW.

Right to Medical Privacy

As a patient, Ms Mendez has a right to medical privacy. This means that Ms Mendez has a right to decide on medical treatment and care for herself, without undue interference from others. Dr Josiah and her healthcare team have both an ethical and legal obligation to adequately inform Ms Mendez about her medical condition and treatment options in order to enable her to participate in decisions about her medical treatment, management, and care.

Right to Medical Confidentiality

Medical information pertaining to Ms Mendez’s diagnosis, treatment, and care should not be disclosed without her explicit consent. Although the diagnosis of certain medical conditions (such as pneumococcal disease) will require a designated authority to be notified (as would be the case with any patient), her right to medical confidentiality is to be safeguarded in all other respects. There may also be considerations in the public interest for disclosure to be made without the patient’s consent. (In Ms Mendez’s case, this is a possibility; if she has pneumonia or tuberculosis, there is a risk of infection.) Even so, the patient’s consent should be sought before disclosing any medical information to her employer.

Healthcare workers should be mindful that their duty to observe medical confidentiality is owed to the patient alone. While a third party, such as an employer in this case, may have an interest in knowing about the patient’s medical situation, this party has no automatic right to the information. In this respect, healthcare workers (especially doctors and nurses) are advocates for their patients, and should remind employers of their patients’ right to medical privacy and confidentiality, even if the employers are responsible for the costs of their employees’ medical needs.

As the employer, Mrs Seah is contractually responsible for Ms Mendez’s medical needs. This means that Mrs Seah will have to meet the cost of Ms Mendez’s medical care, including hospitalisation, in accordance with Ministry of Manpower requirements. Even under such an arrangement, Ms Mendez is nevertheless entitled to her rights to medical privacy and confidentiality.


Commentary by Ho, Calvin W. L., ‘The right to medical privacy and confidentiality', in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),

The physician’s responsibility to the sick migrant worker

Clinical perspective by Tan Chi Chiu

Ms Mendez has been diagnosed with a pneumonia of sufficient severity for Dr Josiah to recommend in-patient treatment, likely with antibiotics and, if there is a pleural effusion, the possibility of needing a pleural tap. Since Dr Josiah made the diagnosis after only a clinical examination and apparently before any chest x-ray was done, it may be assumed that she discovered significant clinical signs of pneumonia and possible pleural effusion.

Ms Mendez is still ambulant and not apparently in any respiratory distress. Also, she is a young, otherwise fit woman without any antecedent systemic illnesses such as heart disease or diabetes mellitus. Her risk profile is quite good. Nonetheless, a significant pneumonia must be treated aggressively and the patient monitored closely in order to prevent deterioration or complications, such as total pneumonia of one lung, contagion of the other lung leading to bilateral pneumonia which is hugely life threatening, fluid in the pleural space sufficient to cause respiratory distress, or septicaemia with the risk of multi-organ damage or failure. Once allowed to deteriorate, intensive care may well be necessary to save the patient. Pneumonia is one of the top causes of death in Singapore, and its danger cannot be minimised.

She is also a potential danger to the family and the children under her care, as well as the wider community if she carries an infective agent that is easily transmissible. If she has pneumococcus bacteria, for example, this may lead to pneumonia or meningitis in those she comes into contact with. Children and persons who are elderly, with diabetes mellitus or other reasons for immune suppression, are particularly susceptible. It is also not yet clear that she does not have tuberculosis, a diagnosis that must be on the list of possibilities in view of her origin. Pre-employment health screening may not have picked up an indolent or dormant TB infection that has subsequently flared up. This too would be of enormous public health concern. So from the public health standpoint, it is also important for a serious case of pneumonia to be properly diagnosed and managed in an institution.

From the patient’s and employer’s point of view, the two most important considerations are firstly whether the insurance policy for the foreign domestic worker (FDW) is sufficient to cover the cost of hospitalised care, and secondly how the family will cope with the absence of the maid during her time of convalescence. FDWs are required to be covered to at least $15,000 per year. They pay private rates for all hospital ward classes in restructured public institutions with full reimbursement for C and B2 class ward charges at nonsubsidized rates and all other charges at private rates to the yearly limit. If a FDW or employer opts for a higher ward class or care at a private hospital, the insurance company will pro-rate their reimbursement according to a pre-defined formula (see example). Such provisions may well be sufficient for a brief period of hospitalisation, such as this is likely to be, provided the pneumonia is caught and arrested early enough.

The employer of Ms Mendez appears to be caring and responsible and may well pay any out-of-pocket balance, although this has yet to be determined. Whether the family can cope with the absence of their maid during her hospitalisation is unclear, but from the narrative it does seem as though Mrs Seah tends to give priority to the welfare of Ms Mendez and seems quite accommodating in making last-minute arrangements.

Dr Josiah’s first responsibility is to the secure the welfare of her patient. She has decided that Ms Mendez must be admitted, but now she must figure out how to convince the patient. As patient confidentiality must be maintained, any discussion with the employer first requires that she obtains Ms Mendez’s consent to discuss her case with Mrs Seah, who has already made contact by phone. It is Dr Josiah’s responsibility to ensure that Ms Mendez has sufficient information about her illness, prognosis and need for treatment, for her to understand the urgency of her situation as well as the risk she poses to the family should she return to work without being adequately treated. It is likely that only then will she agree to let Dr Josiah discuss things with Mrs Seah.

Because there is a public safety issue here, medical confidentiality is not absolute, but must take into account the interests of the public. Therefore, in the hypothetical situation where Ms Mendez is adamant that she does not wish to disclose any information to Mrs Seah and wants to sign an ‘at own risk’ discharge form to go back to work, considerations of the family’s safety may allow Dr Josiah to breach confidentiality and inform Mrs Seah without Ms Mendez’s consent. This would be ethically and legally defensible.

Assuming that Ms Mendez is persuaded as to the seriousness of the situation and agrees to involve Mrs Seah, then Dr Josiah should give Mrs Seah the information necessary for her to make decisions about her support for Ms Mendez. Dr Josiah may bring the medical social worker into the discussion if necessary. However, ultimately Dr Josiah’s first responsibility is to treat Ms Mendez, and she should not be diverted from this task by a discussion with an employer that may become protracted. It is important to note that if Ms Mendez is amenable to being hospitalised, her employer may not decide otherwise. The decision rests with the patient and her doctor alone. If there is a risk of the employer terminating the employment of the FDW, then further assistance may be required from the FDW’s agency as well as from the various non-profit organisations that can assist. Hospitals here do not have a policy of ‘medical repatriation’, which is inhumane, although there may be internal policies guiding how FDW are managed. However, it is not the role of the doctor to get involved in all of this. Dr Josiah should have no doubt that she must advocate for her patient under all circumstances to ensure that her welfare is preserved, and she must fulfil her first obligation, which is to adequately treat her patient.


Clinical Perspective by Tan, Chi Chiu, ‘The physician’s responsibility to the sick migrant worker', in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),