The benefits most often cited of medical tourism (MT) relate to significant reductions in the cost of care reduced wait times access to physicians who are well trained and opportunities to relax in an exotic destination following the medical procedure. On the other hand issues around continuity of care postoperative follow-up possible negative impacts on the healthcare systems in both the departure as well as destination countries and concerns around the global commercialization of healthcare and market driven imperatives in medical decision-making are some examples that cause concern about this niche industry.
The topic of medical tourism (MT) from an ethical perspective is extensive and complex. As in healthcare generally MT is certainly not immune from ethical uncertainties and worries. There are multiple viewpoints (from patients physicians policy makers health economists and insurance agencies among others) on the appropriateness of MT as an option for healthcare. Nevertheless people traveled far and wide for centuries to seek treatment and healing therapies and continue to do so.
It is beyond the scope of this article to explore the many debatable dimensions of MT. The aims of this paper is to provide opportunities for reflection on the social responsibility of physicians in medical tourism and considerations for socially responsible approaches to healthcare worldwide.Why Social Responsibility? Since the inception of medicine physicians have embraced a fiduciary duty governing the healing relationship.
Physicians have accepted a responsibility to manage and protect the health of their patients with the utmost trust and confidence over and above self-interest. The fiduciary relationship is part of the internal morality of medicine founded on principles such as fidelity honesty compassion courage altruism and fairness.The concept of social responsibility is born from these principles and it is one that enables physicians to develop a public trust and a professional identity alongside a role of what it means to be a Doctor in society.
The World Health Organization suggests that physicians ought to also be mindful of medicines social accountability through which medical organizations are called to direct their education research and service activities in addressing the priority health concerns of the community region and/or nation that they have a mandate to serve particularly the more vulnerable and marginalized segments of the population.
Social responsibility emphasizes attention as to how society is structured examining who is systematically disadvantaged and working to eliminate social inequities and injustice in the interest of the common good. It requires a social conscience and an ethic of care and trust beyond individualism profit and private interests. Physicians are thereby called upon to positively influence necessary changes in healthcare systems to ensure that services are effective efficient equitable and sustainable.
Social responsibility is not simply a matter of charity but a moral commitment to the patient that has been developed over centuries within societies that advanced the conception of medicine as a profession.Many medical schools are giving more attention to developing future physicians understanding of professionalism and its obligations. Accepting the status of profession requires a public declaration to protect and advance the common good.
Protecting public interest is not seen as an option but an obligation that is entrusted to each and every physician individually and collectively. Hence the medical profession is given a remarkable social moral and political status in society and the designation of the title of Doctor. Physicians as designated professionals profess to give priority to the existential needs of the people they serve.
Physicians are required to maintain unusually high levels of expertise and skillfulness as well as virtuousness and trustworthiness. An occupation cannot simply claim professional status. That status must be granted by the public.Social responsibility is a pillar on which sophisticated democratic political systems are formed.
And although social responsibility is not the exclusive domain of medicine it highlights the fiduciary duty that distinguishes the medical profession from others and the particular attention medicine gives to the importance of preserving human dignity.
Medicines Respect for Human Dignity.
A cardinal principle in medicine is respect for human dignity. Physicians remain unequivocally committed to protecting their patients communities and society and preserving social physical psychological and cultural integrity. As part of their ethical commitment physicians consider two essential components in all of their medical decisions: (1) the selection and achievement of morally acceptable ends and (2) the morally acceptable means to those ends.
The first component is directed at defining acceptable ends in terms of the benefits of medical tourism for individuals communities and societies and for the advancement of medical knowledge and service. The second component is directed at ethically appropriate approaches to medical tourism.For example even in the most promising of MT initiatives universally accepted ethical guidelines specify that a person must not be deceived into participating in any activity through a promise of insincere benefits.
At the heart of what is ethically objectionable concerns the use of another human solely as a means toward even legitimate ends. It is unacceptable to treat persons solely as means (mere objects or things for personal gain) because doing so fails to respect their intrinsic human dignity and as a result impoverishes all of humanity.
The welfare and integrity of the individual must remain paramount in all human relationships. No one should be rendered vulnerable because of MT. Respect for human dignity is a defining feature of the physicians ethical obligation social responsibility and accountability.
Medical Tourism and Concern for Vulnerable Populations
Vulnerability includes a combination of social economic political environmental or biological conditions that prevent persons from protecting their own needs and interests. Vulnerable persons tend to experience worse health outcomes they face barriers to adequate healthcare they have higher rates of morbidity and mortality than the general population and they have little or no control over the conditions that contribute to their situation.
Large segments of the global population find it difficult to access adequate healthcare and are thereby rendered increasingly vulnerable. Hence most physicians will generally agree that basic healthcare should be equitably distributed.Indeed various socioeconomic professional and political factors influence decision making about how healthcare ought to be structured and distributed in society.
Moreover health outcomes are influenced not only by access to care but also by issues such as education housing food security employment social capital poverty social exclusion and lifestyle. We know that there are persistent increases in morbidity and mortality as social position decreases.So what does this have to do with medical tourism? Because of the way it is structured MT is regarded as a health service available mainly to people who are more privileged and who have the means to access healthcare.
MT physicians work in some of the most sophisticated healthcare clinics around the world. Some of these clinics are located in settings where large segments of the population have little hope for receiving any healthcare at all. MT may inappropriately consume desperately needed resources for improved health delivery in the countries it is offered.
At the same time there is ongoing debate around the locus of social responsibility and accountability for ensuring equitable access to healthcare and for addressing the broader determinants of health affecting vulnerable populations. One possible approach toward addressing issues affecting equitable access to care is for the MT industry to consider the concept of social offsets as a social responsibility in medical tourism.
Social Offsetting Negative Impacts of MT
There is ongoing debate on whether healthcare is a human right and related issues of affordability effectiveness efficiency and accessibility. Universal healthcare is certainly desirable yet fraught with concerns of it being a very expensive proposition almost to the point where financial costs could overwhelm benefits depending on how systems are structured.It has been effectively argued by others that striving for universal access to healthcare is not akin to communism or socialism.
It is in fact a socioeconomic investment toward creating a healthier world citizenry the outcomes of which benefit everyone. We know a great deal about the determinants of health and about the impacts of globalization on the distribution of wealth and health within and between nations. What is needed is a mechanism to link these forces for the greater good.
Like the impact of greenhouse gases on our atmosphere the commons we all share MT can pose significant direct and indirect negative social and ethical impacts on the local national and/or global commons. Just as the concepts of carbon offsets and comprehensive environmental impact assessments of new developments has now been widely embraced as feasible processes the concept of social offsets proposes a potentially viable response toward reducing health inequities possibly created by the medical tourism market.
A certain percentage of revenues from MT could be set aside toward creating a comprehensive primary care system for vulnerable populations. The MT industry could fund measures to mitigate the negative impacts on local health systems and local citizens who might be disadvantaged by medical tourism. In other words not having wealth or social status should not necessarily serve to marginalize people from attaining optimal health and healthcare.
Working to enable equity and social justice can become both an objective toward social responsibility as well as a moral foundation on which the MT industry and physicians who choose to serve the industry base their work. Efforts would seek to reduce systematic disparities in health between people who are at different levels of socioeconomic positions in society.
Socially responsible approaches would begin to partially address some of the worrisome elements of MT that become more pronounced within the context of the social arrangements that influence the distribution of the services available.Some questions for physicians patients and the MT industry to consider
- What is my/my organizations social responsibility as a participant in medical tourism (MT)?
- Does participation in MT contribute in any manner to undermining fairness in the conditions that affect equitable access to healthcare healthcare seeking behaviours and health outcomes of local populations? If so how can I help to ensure fairness?
- Do economic imperatives supersede social responsibility and professional obligations in MT? If so how can I help to advance socially accountable practices?
- Do people in certain social circumstances enjoy the benefits of MT at the expense of others? If so what can I do to ensure human dignity?
- Does my participation in MT compromise the social accountability standards set forth by the World Health Organization? If so how can I work to ensure an ethically sustainable approach?
Dialogue around these questions are likely to be more effective and fruitful if there is a genuine willingness to understand and ultimately resolve differences in opinions through a cooperative discussion and toward a consensus moral view among all of the different stakeholders.
About The Author
Dr. Dharamsi is a professor with the Faculty of Medicine at the University of British Columbia (UBC). He served as the Associate Director (2005-2010) with the UBC Centre for International Health. He leads the Global Health Network at the UBC Liu Centre for Global Issues and serves as the Global Health liaison with the UBC College of Health Disciplines. His teaching and research focus on social responsibility and accountability in healthcare health advocacy medical education and global health ethics. Prior to joining UBC he worked to implement an innovative health promotion and early childhood development initiative in Kenya Tanzania and Uganda through the Aga Khan Development Network. His work has been featured on a Canadian television documentary series The Global Villagers which follows Canadians who work to promote peace and development around the world.