New Ethical Perspectives on Medical Tourism in the Developing World

International travel for private medical services, commonly known as medical tourism, is perceived as a growing international trade practice in terms of patient numbers, expenditures, and geographic scope. A range of medical services are purchased by patients who travel abroad for care, including orthopaedic surgery, experimental treatments not available in the patient's home country, organ transplantation, and reproductive treatments.1 Medical tourists typically pay for these services out-of-pocket, and in this way this practice can be distinguished from cross-border health care that is planned and administered by national and regional health care systems.2 As medical tourism is understood as travel with the intention of receiving medical care, it is also separable from cases where travelers become sick while abroad and are forced to access medical care. Medical tourism is not a new phenomenon and has been practiced for thousands of years.3 Until recently, medical tourism was typically understood to involve two forms of travel. First, wealthy patients from high income countries and the Developing World would travel to high income countries with technologically advanced health care systems in order to access treatments and expertise not available in their home countries.4 Second, patients from the Developing World would travel regionally to other Developing World countries to access care and expertise not available in their home countries.5 More recently, attention has focused on a relatively new form of medical tourism: travel by patients from high income countries to private facilities targeting international patients in the Developed World. Prominent destinations for these patients include India, Thailand, Singapore, Costa Rica, and Mexico, but the number of Developing World countries and clinics participating in this practice is perceived to be growing quickly, even in the face of the recent global economic downturn. This special issue of Developing World Bioethics presents five articles highlighting some of the ethical concerns that have arisen in response to a medical tourism industry that actively seeks to recruit patients from high income nations to hospitals and clinics in the Developing World. Over the past several years, as awareness of this global health services practice has increased, scholars have noted a wide range of concerns with medical tourism, focusing on the potential impacts it holds for the populations of Developing World destinations for international patients, as well as health and safety concerns for the patients themselves.6 Ethical concerns for destination countries focus on the prospect of medical tourism worsening inequities in access to health care within the populations of these countries. As the facilities serving international patients are typically private and often charge prices for their services that are unaffordable to most members of the local population, the worry is that these clinics will be limited to serving relatively wealthy international patients and elites among the local population. These inequities may also result in worsening access to care in absolute terms if public subsidies are used to support these clinics, if they shift focus from preventive care for the local population to acute care for international patients, and if health human resources are drawn from the public sector to staff these private facilities.7 Meanwhile, proponents of medical tourism typically note the potential of this sector to cross-subsidize public health systems by bringing in new taxable revenue to the country and helping to retain workers who might have emigrated otherwise.8 The prospects of these potential positive effects outweighing the potential negative effects of medical tourism is uncertain and will likely depend on contextual differences, including regulatory measures and oversight that will vary highly between destination countries. The phenomenon of patients from high income countries traveling to the Developing World for care has been made possible by the widening availability of high technology equipment, Western-trained doctors, new facilities targeting these patients, and the spread of international accreditation standards. The Bumrungrad Hospital in Thailand, for example, has been described as being more like a hotel or mall than a hospital, with amenities designed to appeal to relatively wealthy patients from around the world. While many of these facilities are perceived and advertised as offering high quality care that is as good as or better than that available in the West, the quality of facilities is likely to be highly variable. Patients may have a difficult time deciding among facilities given a dearth of reliable information on patient outcomes internationally. Linguistic and regulatory differences further complicate this decision-making process, as does the prominence of industry-affiliated websites on the internet. While informed decision-making about care is always complicated for patients, the international dimension of medical tourism heightens this problem, underscoring the need for reliable information for these patients. Due to a lack of systematic data gathering, we cannot be certain whether patient outcomes for medical tourists are worse or better than those for patients seeking care domestically. Certainly, any answer to this question will vary by source and destination countries for medical tourists. Developing better information on patient outcomes is essential, however, not only for the sake of patient safety, but because these patients may face medical complications or exposure to infectious disease that will create new, and possibly inequitable and unethical, burdens for their home health systems.9 The five articles showcased in this special issue of Developing World Bioethics help to enhance our understanding of the ethical dimensions of medical tourism, a growing form of globalization that impacts populations in both the Developed World that are destinations for medical tourists and patients in high income countries traveling to the Developed World in search of care. The first two of these articles, by Kristin Smith and Glenn Cohen focus on the economic and regulatory systems that have enabled the expansion of medical tourism and that must be modified if the ethical problems associated with the industry are to be addressed. In her article, Kristen Smith highlights and critiques the neoliberal rationale for medical tourism. She argues that a neoliberal discourse encourages hard currency flows into Developing World economies, increasing the gross domestic product of these countries and therefore their wealth. Focusing on the case of India as a leading medical tourism destination, Smith contends that the neoliberal discourse fails to take account of the negative impacts of the expansion of the private medical tourism sector on equity in Developing World countries. By focusing on the aggregate economic gains made possible by this practice and the increased options for ‘medical refugees’ from high income countries, an important aspect of the debate around the impacts of medical tourism is ignored. Smith argues that future research into medical tourism should emphasize the equity impacts of this practice and work toward identifying those populations that will be made worse off in absolute and/or relative terms to the potential beneficiaries of this practice. Glenn Cohen explores regulatory options to control medical tourism both in patients' home countries and in destination nations in the Developed and Developing Worlds. Cohen notes that regulatory responses by patients' home countries are more readily available for government-prompted forms of cross-border care than in cases where patients initiate travel and pay for it out-of-pocket as medical tourists. As Cohen argues, however, a wide range of potential responses by patients' home countries are available to regulate different stakeholders in medical tourism and for different procedures, such as paid surrogacy and organ transplantation. In destination countries, the regulatory question is seemingly more straightforward as these countries can simply choose to limit certain forms of medical tourism or outlaw the practice altogether. However, the allure of potential financial gains from this industry will make it difficult for countries to ban some forms of medical tourism altogether. Moreover, regulatory reforms aimed at mitigating the potential negative effects of this practice may also be difficult to implement given that patients can simply choose to patronize facilities in countries with ‘loose’ regulatory environments. Multilateral agreements can circumvent this problem, but Cohen argues that the political will to develop these agreements is likely lacking. The creation of professional norms within the industry is desirable and may be more likely to develop in order to protect the reputation of the industry, but Cohen notes that these norms are not likely to be effective in controlling bad actors in the industry. Cohen's discussion is helpful for assessing the range of regulatory options available to home and destination nations participating in medical tourism. It importantly helps to ground discussion of the ethical problems associated with medical tourism in a meaningful understanding of the options for effective policy responses to these problems. The remaining three articles, by Leigh Turner, Edna Einsiedel and Hannah Adamson, and Gillian Crozier and Dominique Martin each discuss specific forms of medical tourism. Focused discussions of this kind are important as international travel for necessary care, elective care, experimental treatments, reproductive services, and organ transplantation all raise distinct ethical issues. These studies help to avoid generalization about the ethical terrain of medical tourism and also, in the case of Turner and Einsiedel and Adamson, present empirical data to help further explore these insights. Leigh Turner describes a series of 26 cases of morbidity among patients seeking cosmetic or bariatric surgery abroad spanning from 1993-2011. While Turner does not use these cases to argue that medical tourism results in greater levels of complications and morbidity for patients or lower quality of care than can be found in their home countries, these cases do reinforce the need for reflection on means of protecting the safety and welfare of patients engaging in medical tourism. These cases, Turner argues, demonstrate the need for better tracking of clinical outcomes of patients traveling overseas for cosmetic and bariatric surgeries in order to understand the effects of medical tourism on patient safety and to design interventions to improve outcomes. As Turner notes, a large number of these case reports resulted from surgeries that took place in Mexico and the Dominican Republic. While this result may simply reflect reporting biases from the sources Turner used, it also demonstrates that certain destination countries and procedures are likely to develop good and bad reputations for safety. Successful investment in medical tourism, then, is dependent on reputational factors outside of the control of any single clinic or even country, a point that should give pause to countries seeking to invest public resources into this sector. Edna Einsiedel and Hannah Adamson discuss the ethical issues surrounding stem cell tourism; that is, international travel for stem cell treatments that are typically not available in the patient's country of origin. While this lack of local access sometimes results from insufficient technology and expertise to offer these treatments or their high price, in many cases regulations against offering experimental treatments are the source of this inaccessibility. The authors estimate that over 700 clinics worldwide, most of which are in the Developing World, offer experimental stem cell treatments, taking advantage of ease of travel and globalization to allow patients to circumvent local restrictions. Einsidel and Adamson report on five focus groups they led with Canadians in order to better understand these citizens' willingness to engage in stem cell tourism. Hope and desperation have been cited as key factors that were thought to potentially motivate patients to travel internationally to access experimental treatments, and the citizens they spoke with reported that they would consider accessing these treatments themselves under similar circumstances despite awareness of health and safety risks associated with going abroad for experimental medical care. While improved regulation and governance would help to address the safety issues raised by stem cell tourism as it is currently practiced, the authors note that this practice is likely to continue to grow. As with Turner's discussion of morbidity in cosmetic and bariatric surgery, the sensational health and safety concerns associated with experimental stem cell treatments may influence perceptions of medical tourism more widely, with impacts on its viability even in countries with relatively strong regulations of this industry. Finally, Gillian Crozier and Dominique Martin consider travel for reproductive services that include the use of paid surrogacy or purchase of human ova. Payments for these services raise a number of ethical concerns. These worries are particularly heightened in cases where there are large socioeconomic gaps between those participating, as is typical when patients from high income countries travel to the Developing World for these exchanges. In response to these concerns, the authors consider two policy alternatives. First, the national self-sufficiency model aims to make countries self-sufficient in terms of the reproductive needs of their members, thus reducing the push factors toward international travel for these services without banning the practice. Second, the regulated market model focuses on providing additional benefits to women in the Developing World participating in these exchanges in order to reduce the negative and enhance the positive effects of this practice. As the authors note, these models have conflicting objectives but do overlap in many ways that offer a path forward toward policy action that could help reduce some of the ethical concerns associated with these forms of reproductive travel. In this way, this article complements Cohen's work by offering a case-specific and pragmatic regulatory response to the expanding practice of medical tourism. The articles included in this collection offer many new and important ethical insights into the growing practice of medical tourism in the Developing World. While each considered different aspects of medical tourism, there were indeed some commonalities. One was the simultaneous consideration of both individual actors, and most particularly the medical tourists themselves, and the wider structures of medical tourism. For example, while Turner's article presented the cases of individual medical tourists, his discussion engages with larger regulatory issues and other industry dimensions. While Smith's article is focused on the large-scale issue of the neoliberal discourse that surrounds medical tourism, she gives consideration to the needs of individual citizens in destination countries. This common thread in the collection points to the importance of research on the ethical issues associated with medical tourism in the Developing World to consider the local and global along with the perspectives of individual actors and the global structures against which their actions are framed. The consideration of these multiple perspectives, as contained in the current five articles, is essential to develop insights that contribute to our current understanding of the ethical issues raised by medical tourism. Another commonality across many of the articles was a concern for the safety of medical tourists. While the articles did not focus on new threats to patient safety, they typically linked their findings to implications for patients' health and safety. This common theme is important in light of considering emerging research directions, as it highlights the potential for ethics research to offer new insights into health and safety issues and how these issues might be shaped by either the actions of individual actors or the structures that shape this global health services industry. The findings and discussions shared in this Developing World Bioethics special collection point to the fact that much remains to be learned about medical tourism. New empirical insights need to be brought forth in order to assist with assessing the practicality of the types of conceptual arguments put forth by Cohen and Crozier and Martin about mitigating the potential harms of medical tourism or instilling regulatory frameworks. Such empirical insights need to be coupled with the development of new ethical argumentation around the harms and benefits of both the industry and the practice of patients traveling to Developing World countries for private medical care. This argumentation will benefit from acknowledging the diversity of practices, places, and actors that make up this industry, as was so well done by the contributors to this collection, which may result in ‘one size fits all’ solutions being rendered ineffective.