Travel with Care: Ethical Dimensions of Health Tourism

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By Kristina Madarang Stahl

Kristina Madarang Stahl is a conservation biologist, wildlife rehabilitator, philanthropy professional, and freelance writer from Washington, DC. She earned both a Master of Science in Environmental Science & Policy and a Bachelor of Arts in French Language & Literature from Johns Hopkins University. As former Associate Director of Development for Georgetown University Medical Center, Kristina actively participated in the development of cutting-edge biomedical research, clinical trials, and education focused on neurology, neuroscience, pharmacology, endocrinology, veteran’s health, and clinical bioethics. Previous publications include articles in Georgetown Medicine Magazine. Kristina is currently a visiting biologist at Bear Sanctuary Prishtina in Kosovo.

If you have traveled to another country for medical care, you can count yourself among a rapidlygrowing number of health tourists. Our increasingly inter-connected world presents to us a wealth of options. Your passport is your ticket to nearly all of them. While most of today’s health tourists travel for aesthetic and wellness offerings such as weight loss management, dental care, and rehabilitation, a 2018 study by PricewaterhouseCoopers projects that pricier, riskier, and more invasive procedures such as cardiac surgery, orthopedic surgery, and oncology will grow in popularity, doubling the value of the over $70 billion global health tourism industry.

So where are health tourists getting treatment? Patients Beyond Borders reports Costa Rica, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey, and the United States as the top destinations for health tourism. And why are health tourists traveling? Some attractive health destinations, like Singapore and the United States, already have established booming tourism industries and significant public and private investments in their healthcare systems.

Some countries perform procedures that are unavailable in others. Take, for example, the CyberKnife radiotherapy treatment for cancer sought by Americans, Australians, and Romanians (among others) offered in Turkey by well-trained physicians at approximately half the cost of the same procedure in the United States. The average wait time for CyberKnife in Turkey is only four days.

With its reputation for affordability, quality of care, and use of state-of-the-art medical technology, Asia has historically been the prime destination for health tourists, particularly for cosmetic surgery. Asia is now being closely tailed by Greece and the United Arab Emirates. Perhaps by accident, America has joined the fray, with the most controversial example being the wave of Chinese women participating in birth tourism in Saipan to gain American citizenship for their children.

Patients most often become health tourists as a result of prohibitive costs or poor quality of care in their home country. Many researchers in literature detail major country-by-country price differences for procedures like liposuction and knee replacement. For example, a heart bypass operation costs about $123,000 in the USA, $14,000 in Poland, and $7,900 in India – a jarring comparison.  Patients in developing countries are faced with myriad challenges that push them to travel for their medical care. A 2016 report entitled “Recommendations of Policies for Healthcare System in the Republic of Kosovo” presents discouraging facts about corruption and bribery that pervade even the healthcare system in Kosovo. According to Julie Coleman of the Center for Research, Documentation, and Publication, Kosovo spends so little on healthcare that “only 15% of the population is in the healthcare insurance fund”; the remainder pay out-of-pocket, and often out-of-country. In fact, Kosovo’s citizens spend approximately 80 million euros abroad on medical treatment

Well-documented economic globalization has created long and complicated supply chains susceptible to corruption and human rights violations. The World Trade Organization has oversight over international trade, while nongovernmental organizations attempt to hold entities accountable using research, certification schemes, and public education

The globalization of healthcare needs similar structures. For example, Canada and Australia are major sources of health tourists, but neither country provides official guidance for patients or doctors. Health tourism destinations such as India leave accreditation of its medical centers to the Ministry of Tourism. Some argue that the source and destination countries should set complimentary regulations including acceptable standards of system quality, infrastructure, ethical buying, risk, and patient safety.

James Giordano, PhD, Chief of Neuroethics Studies and Scholar-in-Residence in the Pellegrino Center for Clinical Bioethics and Professor of Neurology and Biochemistry at Georgetown University provides answers to some of the most pressing ethical questions surrounding health tourism

Regarding the trajectory of health tourism, Giordano says “Without doubt, medical tourism— and research tourism—will increase during the coming decades, as biomedical science and technological enterprises become ever more multinational, and the relative parameters and policies regulating practices in different countries become more varied. This might encourage vigorous discussion and pursuit of guidelines that ensure patient safety and continuity of sound patient care in and between nations. Guidelines may establish minimum criteria for research efforts, and address the translation of research findings, tools, and methods to clinical care. Not a simple task, but it is important and necessary.”

Giordano advises today’s health tourist to “Seek assurances regarding the safety of any procedure. Has the technique been evaluated and demonstrated for safety and effectiveness in clinical use? What personnel resources and services are available during preparation, articulation, and recovery? Also, find out if care for any latent effects incurred by techniques administered outside of the United States would be treatable, and covered by insurance once the patient returns here. This is of particular concern if such techniques are not approved in the U.S., or if they or the follow-up care do not fall under an existing or accepted procedure code.”

Giordano supports a tri-partite ethical mission for health tourism. “First is the need to remain apace with developments in international biomedical research and its translation into medical practices that are viable and valuable for generating and sustaining research tourism and medical tourism.” He distinguishes international health, clinical, and translational research and education as imperative to this task.

“Second, it is important to know what types of medical treatments are being offered to medical tourists and what the manifest effects of such treatments might be. This knowledge helps to establish medical readiness for conditions that may be encountered in patients returning from treatments in other countries.”

Lastly, Giordano recommends “engaging in proactive discourse in international forums to address the scope and conduct of research and medical practices, with an aim to develop ethical guidelines and policies that will be important for safety and patient health.”

The convoluted nature of health tourism presents an arduous task. Its increased popularity has bubbled to the surface previously masked issues, such as failed healthcare systems and corruption in developed and developing countries alike. Its lack of oversight requires well-equipped regulatory bodies with resources dedicated to standardizing national regulations. Any industry growing at lightspeed demands responsible growth. As clinicians, caregivers, researchers, family members, watchdogs, policymakers, and patients ourselves, we are all stakeholders tasked with the safe and ethical development of health tourism.