Cross-border travel for healthcare is not immune from ethical considerations. Apart from obvious concerns of costs, risks and quality of care, a very real issue emerging in research is the ethical consequences of medical tourism. The Simon Fraser University Medical Tourism Research Group consists of a team of five researchers who have published many academic papers addressing this subject. They have indicated that patients may not be aware of these ethical concerns and ongoing education is important. These ethical concerns revolve around effects on the home country, on the patient and on the destination country.
When discussing medical ethics and the medical tourism industry we must first discard the sensational and the absurd. Horror stories of illegal organ donors and non-licensed surgery in questionable facilities are atrocities and are obviously unethical, illegal and universally condemned. The issues that need to be explored are the legitimate questions that can arise from any medical service and how they affect both the patient specifically and healthcare in general.
The physician’s ethical obligation to the patient is usually obvious to do no harm and do their best for the patient. The other partners in healthcare also have obligations. The patient has the theoretical social responsibility to maintain health and reduce burden on society to a minimum.
This concept is emphasized to a greater degree in a socialized health system. Finally, society and government carry the obligation to care for the sick and reduce public health risks. These three facets of ethics need to be considered in the medical tourism model.
The Potential of Burden on the Patient’s Home Country
In a recent publication in the British Medical Journal, a Canadian-based team conducted a focus group with health professionals dealing with the ethical concerns of medical tourism. Because Canada has socialized medicine and a national health insurance system, it is not surprising that some
Medical tourism for the classes, but missionary care for the masses.
of the major questions posed were the effect of late-arising complications burdening the national health system and the risk of introducing new antibiotic resistance infections to the home country. Further concerns identified regarded the potential for discontinuity of medical records for the medical traveller and the legitimacy of informed consent at a distance if the patient does not have complete information about the host country before arrival.
The Patients Ethical Perception
The ethical arguments over medical tourism can also have a bearing on the patient’s decision to seek care overseas. Each patient has his or her own ethical considerations justifying health travel. Patients often find it necessary to seek healthcare elsewhere because of the unethical situation in their home health system; be it inflated costs, the inability to obtain insurance or prolonged waiting lists for procedures.
Effects of Medical Tourism on Local Healthcare
Another frequent issue discussed in medical ethical research is the effect of medical tourism on the host nation. A paper in the World Hospital Health Service journal of 2011 discussed that limited expenditures in local healthcare infrastructure and development with concurrent investment targeted for medical tourism can lead to unequal access of health resources in developing nations.
By contractual arrangement, a portion of earnings from medical tourism contribute to the national health plan’s revenues and healthcare programs of this small nation.
The Harvard Pilgrim Health Ethics Advisory Group spoke about “brain drain” diverting medical talent way from the local population toward medical tourism markets. These issues have been summarized with the often spoken axiom, “Medical tourism for the classes, but missionary care for the masses.”
An Incommensurable Justice System
The legal system in the destination country can also be a significant concern. The lack of malpractice insurance or difficulty in initiating civil action in some destination countries may lead to an undesirable situation for the travelling patient.
An Industry Responds
The best solution in avoiding these dilemmas is information. There is a wealth of information available. Both the patient and the facilitator need to ask questions to avoid these ethical impediments. Providers need to furnish answers to these issues with absolute transparency.
Many international hospitals are accredited through agencies, such as the Joint Commission and Accreditation Canada. This is a great first step. Other information that should be available and sought including outcome data, such as complication rate, infection rate (including antibiotic resistance patterns), medical record-keeping and language, malpractice insurance and health professional licensing.
An ideal medical tourism product should offer complication and infection rates lower than the patient’s home country. In addition, they should be able to provide a complete medical record in the language of the patient’s choice. The medical tourism operator in addition to accreditation should hold malpractice and liability insurance and have in place policies and procedures to ensure qualifications of staff.
Recognizing the uniqueness of medical tourism, a separate accreditation system ensuring transparency and standards is now in the development phase. These initiatives could incorporate an ethical assessment, which is already seen in other sectors, such as in some mutual funds and in some consumer-imported products that have approval for social responsibility and sustainable merit, such as Fair Trade and other such programs for products originating from developing nations.
Finally not all developing nations are seen as draining from the local healthcare assets to the medical tourism sector. In some cases, the medical tourism initiatives contribute to local healthcare by providing expertise, economic stimulation and resources that might not be available.
In the Turks and Caicos Islands located south of the Bahamas, medical tourism services are provided in a state-of- the-art accredited facility operated in a private-public partnership between the local government and InterHealth Canada since 2010.
In addition to private care, such as medical tourism, this project also functions as the hospital to provide local residents comprehensive emergency, primary and secondary care as part of a national health insurance plan.
By contractual arrangement, a portion of earnings from medical tourism contribute to the national health plan’s revenues and healthcare programs of this small nation, providing services that would otherwise be unavailable locally.
Singapore has evolved into an important medical hub of the Southeast Asia and Asia-Pacific regions. With a relatively small population, the surge in medical tourism has allowed the healthcare system to exploit economies of scale and obtain equipment and expertise that benefit the local population as well. It can be argued that the medical tourism prevents loss of medical experts moving to other developed nations.
Indonesia has also initiated medical tourism in an effort to improve local hospitals. Medical tourism is argued to improve infrastructure, increase competition and decrease outbound medical tourism of the nation.
As the medical tourism industry continues to grow, new challenges, such as the ethics of cross-border health arise, and the industry continues to respond to these issues with research, information and initiatives.
About the Author
Dr. J. F. LeMoine is a Canadian orthopedic surgeon and director of Prime Sports Medicine. He is presently director and consultant for Prime Sports Medicine and Orthopedics in the Turks and Caicos Islands, which is a short direct flight from many American and Canadian cities. His expertise is in shoulder and knee arthroscopy. He assists medical tourists from North America seeking expert care from a North American surgeon in a hospital with North American accreditation and operated by a Canadian company in one of the top tourist destinations in the Caribbean. He accomplishes this without requiring extensive travel or concerns about foreign language, currency or health systems.