The ethical physician encounters international medical travel

Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com The ethical physician encounters international medical travel G K D Crozier and Françoise Baylis J Med Ethics 2010 36: 297-301 originally published online May 3, 2010 doi: 10.1136/jme.2009.032789 Updated information and services can be found at: http://jme.bmj.com/content/36/5/297.full.html These include: References This article cites 13 articles, 3 of which can be accessed free at: http://jme.bmj.com/content/36/5/297.full.html#ref-list-1 Email alerting service Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Notes To order reprints of this article go to: http://jme.bmj.com/cgi/reprintform To subscribe to Journal of Medical Ethics go to: http://jme.bmj.com/subscriptions Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com Global medical ethics The ethical physician encounters international medical travel G K D Crozier,1 Françoise Baylis2 1 Department of Philosophy, Loyola University Chicago, Chicago, Illinois, USA 2 Novel Tech Ethics, Dalhousie University, Halifax, Nova Scotia, Canada Correspondence to Professor GKD, Crozier, Department of Philosophy, Loyola University Chicago, 1032 West Sheridan Road, Chicago, IL 60660, USA; g.crozier@gmail.com GC and FB were equal contributors. Received 24 August 2009 Revised 4 February 2010 Accepted 8 February 2010 ABSTRACT International medical travel occurs when patients cross national borders to purchase medical goods and services. On occasion, physicians in home countries will be the last point of domestic contact for patients seeking healthcare information before they travel abroad for care. When this is the case, physicians have a unique opportunity to inform patients about their options and help guide them towards ethical practices. This opportunity brings to the fore an important question: What role should physicians in more-developed home countries play in promoting or constraining international medical travel towards less-developed destination countries? In our view, critical attention to the decision spaces of patientsddefined by the personal circumstances, socio-cultural cues, and legal constraints that inform decision-makingdis a useful starting point for evaluating the proper response of physicians to various forms of international medical travel. International medical travel occurs when patients cross national borders to purchase medical goods and services. Discussions of international medical travel once tended to focus on patients travelling from less-developed to more-developed countries for safe, high-quality medical care not otherwise available in their home countries. Consider, for example, the highly publicised case of conjoined twins Lin and Win Htut1 who were separated at the Hospital for Sick Children in Canada because of insufficient medical expertise and limited financial resources in their home country of Burma.2 Subsequently, discussions of international medical travel turned to cases of patients travelling between equally developed countries for more accessible or more affordable care. For example, the bi-directional movement of patients between Canada and the US saw considerable attention in the media during the 1990s: Canadians travelling south to avoid waiting lists, and Americans travelling north for less costly healthcare. But now, with the ease of international communication, travel and marketing, international medical travel has become an increasingly attractive option for patients travelling from moredeveloped to less-developed countries. Often, this travel is for elective procedures such as laser eye surgery or cosmetic procedures. However, it can also be for procedures with considerable impact on quality of life and longevity, such as hip replacement surgery, kidney transplantation, or fertility treatment. Consider, for example, the case of Ranjit and Jagir Hayer, a 60-year-old Canadian couple of J Med Ethics 2010;36:297e301. doi:10.1136/jme.2009.032789 Indian origin. After having been denied access to fertility treatments in Canada, the Hayers travelled to India in the summer of 2008 where they procured eggs from a woman much younger than Mrs Hayer (possibly purchasing themda practice which is illegal in Canada). The fertilised eggs were transferred to Mrs Hayer, who then returned to Canada for the gestation and birth of twin boys, who were delivered prematurely in a Calgary hospital in February 2009.3 The high cost of maternal and neonatal care was paid for by the Canadian public healthcare system.4 This led many commentators to reflect on the benefits and harms of medical travel for both the individuals involved and for the healthcare system. THE SCOPE OF INTERNATIONAL MEDICAL TRAVEL We will start by suggesting some very basic ways of looking at the global industry of international medical travel in terms of the number of customers and the revenue reported for various countries. These figures suggest that this market is a significant one; however, as we will subsequently discuss, quantifying its extent in relative terms has proven challenging. A number of destination countries are actively cultivating the medical travel industry as a lever for economic growth. For example, Asian markets are growing at a rate of 20% per year, and alone they could generate about US$4 billion annually by 2012.5 Half of this market is expected to be in India, where predicted revenue of US$2.2 billion by 20125 would represent roughly 1% of that country’s gross domestic product (GDP).i In an effort to capitalise on this potential market, India has established a visa specifically for medical travellers. Another Asian country that is a major destination point for medical travel is Thailand. According to the Kasikorn Research Center, which publishes statistics on hospitals in Thailand, 1.2 million foreigners were treated in Thai hospitals in 2005 generating an estimated revenue of $850 million US,6 roughly 0.5% of GDP. This revenue represents a large portion of the health industry in Thailand, where total expenditure on healthcare in 2005 represented only 4% of GDP, and private healthcare expenditure totalled only 1% of GDP.7 Although it is unclear what percentage of these patients travelled to Thailand for the main purpose of accessing medical care, large i The figures in this passage regarding percentage of country GDP derived from medical travel have been calculated from the cited figures of industry dollar value and on reports of country GDP published by the World Bank.7 297 Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com Global medical ethics institutions such as Bumrungrad Hospital and Samitijev Hospital have been aggressively promoting services for medical travellers. If we consider examples outside of Asia, the Czech Republic’s medical travel industry is reportedly worth over US$182 million, close to 1% of GDP. In all, 35 000 medical travellers visited Israel in 2009 and contributed US$100 million in revenue, close to 0.05% of GDP.8 Costa Rican healthcare professionals treated roughly 150 000 medical travellers in 2007, mostly for cosmetic and dental procedures.9 In 2007, 200 000 medical travellers sought treatment in Cuba.9 (Estimates on the dollar value of these markets are not available.) According to Medical Tourism Association president, Jonathan Edelheit, within this decade over half of US medical travellers will choose Latin American destination points, spending nearly US$40 billion per year in these countries alone by 2017.10 Given these basic figures, the industry in international medical travel clearly matters. It is expected that competition among countries for a share of this lucrative market will become increasingly fierce. But while these figures indicate that the international medical travel industry is significant, and will become increasingly so in the future, it is very difficult to quantify its importance in relative terms. Empirical information on the scope and financial importance of international medical travel is limited, and what information is available is generally subject to wide variations. For example, the 2008 Deloitte Medical Tourism Study11 estimates a massive industry, projecting that the US alone will send six million medical travellers abroad in 2010, which potentially represents lost revenue to US healthcare providers of just under US$16 billion. In sharp contrast, Ehrbech and colleagues, in a report prepared for the consulting firm McKinsey and Company12 estimate that the international medical travel industry is negligible in size, with as few as 60 000 travellers per year. The small number of medical travellers cited in the McKinsey report is due in no small part to the use of a highly restrictive definition of medical travel.13 For example, the study excludes outpatient procedures such as dentistry and some cosmetic procedures, which are very popular draws for ‘medical tourists’. Most researchers find it useful to include these cases in overall estimates, and thus conclude that this study significantly underestimates the size and significance of the medical travel industry. Given this limitation, the McKinsey report has garnered relatively little attention in either news reports or academic articles on medical travel. Meanwhile, although the accuracy of Deloitte’s estimates have been questioned by critics14dwho contest both the survey methodology and the background research on which the extrapolations were baseddthese estimates have been widely cited by influential media outlets such as the Economist and CNN. But wherein lies the truth about the size and influence of the international medical travel industry? In a 2006 publication, Carrera and Bridges15 estimated a global industry of US$500 billion per year. More recently, in 2009, Grail Research16 estimated that by 2012 the global market would be worth US$100 billion per year.17 These are impressive (and confusing) differences. In 2009, Youngman13 assessed the global industry at five million patients per year, considerably less than the six million patients per year from the US alone, originally estimated by Deloitte in their influential 2008 report. Deloitte’s follow-up 2009 Survey of Health Care Consumers is more conservative in its estimates of the size of the international medical travel industry of just over three million patients per 298 year from the US.18 ii Its 2008 publication Medical tourism: the Asian chapter was also more conservative, reporting that only half a million patients from the US travelled abroad for treatment in 2007.19 Empirical investigations of the international medical travel industry can be expected to continue to produce divergent conclusions. For one thing, as mentioned above, there is no consensus on the definition of medical travel. Additionally, researchers vary with respect to the types of evidence they draw upon, consequently producing different results. For example, some statistics might be skewed by subtle political manipulations, such as over-inflated figures from a country or hospital that wants to promote itself as a destination point for international medical travel. As Youngman13 writes: “A typical example last year was an Asian country, where one week one minister stood up and said his country had 100 000 medical tourists, while the next week saw another minister claiming it was 200 000. almost every official figure is flawed. They are often badly collected, imperfectly collated and spun to infinity. Some hospitals inflate figures by counting the number of patient visits rather than number of patients.” In light of variations in data about the scope of the industry and the consequent opaqueness of the effects of various aspects of this industry, how can individual physicians in home countries make headway in promoting ethical markets and restricting unethical ones? PATIENT DECISION SPACES On occasion, physicians in home countries will be the last point of domestic contact for patients seeking healthcare information before they travel abroad for care. When this is the case, physicians have a unique opportunity to inform patients about their options and help guide them towards ethical practices.iii This opportunity brings to the fore an important question: what role should physicians in more-developed home countries play in promoting or constraining international medical travel towards less-developed destination countries? In our view, a useful starting point for evaluating the proper response of physicians to various forms of international medical travel is critical attention to patients’ decision spaces. An agent’s decision space is characterised by the extent of various categories of constraints, such as personal (including financial) circumstances, socia-cultural cues, and legal constraintsdthat inform decision-making20 21 We explore some of these decision spaces, as might be described by identifiable patients and/or discerned by their physicians, in an effort to better understand when physicians should attempt to facilitate medical travel for their patients, and when as a matter of professional ethics they should actively dissuade their patients from travelling abroad for medical treatment. There are various dimensions to each patient’s decision space, including the degree of necessity of a desired medical procedure, the cost of the procedure relative to the patient’s available income, as well as legal and socio-cultural constraints on the availability of the procedure. While there are many decision spaces in which patients opt to engage in international medical ii Of 4001 survey respondents, 1% reported having travelled outside the US to access medical services. The figure of 3.05 million US medical travellers is based on this figure and on a US population in 2009 of roughly 305 million. iii Physicians are not the only healthcare providers who may have an opportunity to discuss the ethics of international medical travel with prospective travellers. In many cases, nurses, technicians, and others will be better situated to share relevant information with, and glean the relevant information from, patients. J Med Ethics 2010;36:297e301. doi:10.1136/jme.2009.032789 Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com Global medical ethics travel, we focus on four broad categories of such spaces which are among the most likely to be encountered by, and raise ethical questions for, physicians in more-developed home countries. These are situations where patients pursue: A. Elective procedures that are expensive in their home country, and which are available at a fraction of the cost in destination countries; B. Medically necessary procedures for which there are long domestic waiting lists; C. Medical interventions unavailable in their home country because they have not yet been shown to be safe and effective; and D. Medical interventions that are illegal in their home country because they harmfully exploit vulnerable third-parties. Each of these categories of patient decision spaces raises a different set of ethical considerations, and may demand a different response from physicians. Of course, a particular patient’s decision space may fall into more than one of these categories, but for clarity we have chosen to discuss them as though they were isolated. Price Many of the cases of international medical travel that physicians in home countries will encounter occur in the context of significant cost differentials between home and destination countries. Some popular ‘elective’ proceduresdsuch as cosmetic surgery22 and dental care23dare prohibitively expensive for many in more-developed countries such as the US, Canada and the UK, and can be accessed at a fraction of the cost in lessdeveloped countries such as Thailand, the Czech Republic and Tunisia. All other things being equal, this seems to be a fairly innocuous form of medical travel. If so, the most appropriate response may be to leave this category of travel to the free marketd un-facilitated and unencumbered. As with all medical travel, however, we should be concerned about the socio-economic consequences of various markets for third parties. For example, clinics and hospitals abroad may be less selective about the efficacy and quality of care, ultimately burdening the individual patient or the home country’s public healthcare system with significant costs in corrective and follow-up procedures. Also, some markets may negatively affect access to medical interventions for non-consumers in both home and destination countries. We discuss these, and other, important confounding factors below. Waiting lists Another category of patient decision spaces includes situations wherein patients’ access to necessary medical procedures, such as orthopaedic surgery or cancer treatments, is constrained by long waiting lists.24 For example, consider the case of Mr Dolinsky who, in the spring of 2007, travelled to India for hip surgery. Mr Dolinsky was in serious pain because of osteoarthritis and was unwilling to wait a year in Canada for the recommended hip resurfacing procedure.25 All other things being equal, physicians should facilitate this category of medical travel when patients’ needs cannot be efficiently addressed in the home country. It is preferable that patients access medical procedures that can significantly improve their quality of life in a timely fashion. Additionally, to the extent that medical travel shortens the queue in home countries, it is desirable for patients to go abroad. Collaterally, medical travel might ease pressure on public care waiting lists by moving some of the patients to a different system, without at J Med Ethics 2010;36:297e301. doi:10.1136/jme.2009.032789 the same time removing physicians from the public system of home countries. On a larger socio-political scale, in some cases, home countries might even be obligated to fund travel for medically necessary interventions so that all citizens can access them without incurring debt: for example, where the capacity to supply a particular service lags behind a spike in demand for this service. Additionallydexcepting in cases such as rare procedures, where there is benefit in promoting regional specialisationsdhome countries should simultaneously be working to shorten domestic waiting lists for medically necessary procedures so that patients are not forced to go abroad for them. For those nations that are committed to government-funded universal healthcare, there is an obligation to ensure that international travel for medically necessary procedures does not become the status quo. Unproven medical interventions When medical travel is undertaken for the purpose of accessing unproven medical interventions, physicians may be warranted in adopting a more interventionist response. For example, it has recently been reported that UK children with congenitally underdeveloped optic nerves have travelled to China for unproven and costly stem cell transplantation. Belfast couple Darren and Wilma Clarke paid £30 000 for their 3-year-old daughter Dakota to receive six injections of stem cells. She obtained these injections in February 2009 in Qingdao, northeast China.26 Welsh couple Joanna and Anthony Clark paid £40 000 for their 16-month-old son Joshua to receive a stem cell transplant in April 2009 in Hangzhou, near Shanghai.27 Stem cell transplantations such as these are not permitted in the UK because they are deemed unsafe and ineffective. The concern with medical travel for unproven interventions is the risk of serious harm to patientsda risk recently reported in relation to another case involving stem cell transplantation where “an Israeli boy developed benign tumours in the brain and spinal cord after being injected with foetal neural cells at a Moscow clinic in Russia.”28 International medical travel for “unproven stem-cell treatments that lack appropriate oversight or patient monitoring or use poorly characterised cells” is explicitly condemned by the International Society for Stem Cell Research.29 Beyond a concern about harm, there are concerns about false hope and exploitation. A commitment to patient autonomy dictates that if patients understand and freely consent to purchase a desired medical procedure, we ought not to interfere with their plans. But what about the vulnerable positions in which these patients and their families often find themselves? They may be subject to tremendous pressures to exhaust all available means to cure the illness in question, thus rendering them easy marks for exploitation. Even if physicians should not directly intervene by preventing travel for unproven interventions sought by competent patients, this does not mean that they should support it. Arguably, at the very least, physicians should deter patients from seeking unproven procedures abroad (through education and counselling), when there is good reason to believe that the sought after interventions are likely to do more harm than good. With the cases cited above, the ethical challenges are greater by virtue of the fact that the procedures in question were performed on children. Considerations of patient autonomy are considerably more complicated when the patient is a child and the purchaser is a guardian who may be exposing her child to harm. In such situations, a stronger interventionist approach might be warranted. 299 Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com Global medical ethics Legal prohibitions When patients’ decision spaces are characterised by the illegality of the desired procedure in the home countrydin particular because the procedure is exploitativedthis raises a different set of ethical considerations. These situations include medical interventions such as transplantation involving the purchase of a kidney30 or fertility treatments involving payment for ova.31 Consider medical travel to Pakistan by patients from countries such as Saudi Arabia, Kosovo, Turkey and Bulgaria for the purchase and transplantation of human kidneys. Despite the fact that the sale of organs is legally prohibited in Pakistan, this country remains a leading destination for foreigners seeking to purchase kidneys. In June of 2009, the Supreme Court of Pakistan confirmed that the sale of kidneys for transplantation continues despite the legal prohibition.32 A kidney patient might be tempted to go abroad for transplant surgery because of the shortage of kidneys in her country of origin, which results from domestic legal prohibition on the buying and selling of organs. Home country governmental prohibitions on the commodification of kidneys (and other human bodily resources) are motivated in part by a desire to protect members of vulnerable groups from exploitation. Surely the exploitation of destination-country organ providers is no more ethically acceptable than would be the exploitation of home-country organ providers. Therefore, when home-country legislation prohibits a certain medical practice in order to protect vulnerable persons, there is an ethical obligation to engage in serious conversation and counsellingdand possibly also to deter patients from travelling abroaddin an effort to prevent the exportation of harmful exploitation. Now some might argue that in situations where the domestically prohibited activity is not illegal in the destination country a softer approach to dissuading patients may be warranted. Perhaps, but this assessment will depend upon a careful analysis of the nature of the activity that is legally prohibited in the home country. Activities that are prohibited in an effort to protect the vulnerable from exploitation are decidedly different from activities that are prohibited on the basis of presumed social mores and customs. An example of the latter is the legal prohibition in Italy on access to fertility treatment for those who are not legally married heterosexual couples. If common law partners, single women, lesbian couples, or others who do not fit the description of ‘legally married heterosexual couples’ want to access fertility treatment in a foreign country where such treatment is legally available to them, there might be few grounds on which to deter patients from travelling abroad. The same might not be true with respect to medical travel for ova sales and surrogacy contracts where women in the destination countriesdfor example, India and the USdare at risk of exploitation. CONFOUNDING FACTORS There are a variety of ethically relevant considerations that are not captured in the analysis provided thus far. These include the potential costs to the health of travellers,33 the internal ‘care drain’ of healthcare professionals from public and rural hospitals to private and urban hospitals that do not service the public healthcare needs of the domestic populations, and the undermining of public healthcare systems in home and destination countries by challenging the core value of equal access to healthcare. To say the least, many of these considerations are highly complex. For example, while international medical travel motivated by a desire to avoid long waiting lists might be ethically uncontroversial from a patient perspective, especially when the patient 300 is wealthy and willing to pay for the travel, the ethics assessment is somewhat more complicated from a health-systems perspective. To the extent that international medical travel shortens the queue for medical procedures in home countries, it is desirable for patients to go abroad. In this way, international medical travel eases pressure on public care waiting lists by moving some of the patients to a different system, without at the same time removing healthcare providers from the public system. But this strategy for shortening wait lists is ethically problematicdespecially when the procedures are medically necessary (as opposed to elective) and the cost of the medical travel must be borne by the patients. At a minimum, this introduces an advantage for the wealthy who can buy their way off the waiting list. Now for some, this is not ethically problematic; there are many things the rich can buy that the poor must do without. But for those who believe in governmentfunded healthcare, this is a significant ethical issuedmedical travel for necessary medical treatment undermines a core value of equal access. From another perspective, it is worth considering the impact of medical travel on access to healthcare for local patients in resource-poor destination countries, when the effort and energy of local healthcare providers is directed at the needs of foreign travellers. On the one hand, the medical travel industry threatens to exacerbate the internal ‘care drain’ by acceleration the depletion of an already scarce supply of healthcare providers from the critical public healthcare sector. On the other hand, this market could provide a means for attracting, retaining, and training doctors and nurses who might otherwise seek employment abroad. Additionally, the funds that medical travellers pay to hospitals, clinics and medical professionals can, in some cases, be used to subsidise the healthcare of local populationsdfor example, with the dedication of a percentage of hospital beds to patients within the public healthcare system. For resource-poor destination countries that are experiencing a shortage of medical resources and healthcare providers, medical travel has the potential to either help or harm their public healthcare systems. CONCLUSION It is easy to empathise with those who are (potential) international medical travellers. They want timely and affordable medical interventions that are not readily available to them domestically. In many cases the patients believe the desired interventions will allow them to lead the kinds of lives they envision for themselves and will significantly benefit their health. In a smaller number of cases, the patients see international medical travel as their only hope of survival. Chastising or punishing patients for travelling abroad is not the right response, but this leaves unanswered two pivotal questions: when, if ever, should patients participate in international medical travel, and when, if ever, should physicians facilitate or hinder their efforts to do so? In an ideal world, governments with publicly funded healthcare systems should organise their systems to provide needed healthcare for all citizens at home. In the real world, this is not always possible, however, which accounts for the burgeoning international industry in medical travel. All things considered, physicians should not inhibit their patients’ access to international medical travel where the decision spaces of the travelling patients are characterised by relative expense (A) or by long domestic wait lists (B). Beyond this, one might even argue that physicians should facilitate such travel by offering appropriate referrals and directing patients to J Med Ethics 2010;36:297e301. doi:10.1136/jme.2009.032789 Downloaded from jme.bmj.com on May 6, 2010 - Published by group.bmj.com Global medical ethics appropriate educational resources. At the same time, physicians should advocate for policy and practice changes in their home country, so that medically necessary services are controlled by the domestic public healthcare system for the benefit of all citizens. This is especially important given the underlying belief with most publicly funded healthcare systems; namely, that healthcare should be provided in a timely fashion on the basis of need, not ability to pay. Matters are notably different, however, when the international medical travel involves the element of harmful exploitation. Where the patient decision space is characterised by domestic bans on unproven medical interventions (C) or medical interventions that are domestically illegal because they take advantage of vulnerable third parties (D), a more restrictive approach is warranted. Where the potential victims of the harmful exploitation are the patients themselves, as in (C), the role of the physician may legitimately involve directive counselling aimed at dissuading the patient from travelling. At the very least, however, patients should be provided with full information about potential harms and available alternatives. When vulnerable third parties are the potential victims, as in (C) where the patients are children, or (D), the physician’s efforts at discouraging international medical travel should be all the more assertive. International medical travel is an ethically challenging aspect of globalisation. In our view, consideration of patient decision spaces is a useful analytical tool for illuminating the moral dimensions of medical travel, particularly in light of the scarcity of robust empirical data on various aspects of this burgeoning industry. It may also be a useful approach for physicians in deciding whether to facilitate or hinder patient efforts to engage in international medical travel. The four categories of decision spaces discussed in this article raise different ethical considerations; the weightiest of these concern the pursuit of interventions that are unproven (C), or illegal in the home country (D). Ultimately, in these contexts, the home country’s obligation to protect its citizens from unnecessary harm and to promote the health and safety of vulnerable persons in source and destination countries are ethical considerations that must be given priority. Acknowledgements This research was developed, in part, under the Canadian Institutes of Health Research (CIHR) grant ’Ethics of Health Research and Policy’. For insightful feedback on drafts of this essay, the authors are grateful to the members of the Novel Tech Ethics research team, especially Andrew Fenton, and also to Jim Sabin and David Badcott. 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