Medical tourism: Ethical pitfalls of seeking health care overseas

Care provided in 'settings of exploitation'

A patient on a transplant waiting list learns she can quickly and less expensively obtain the organ she needs — in Thailand. Another person plans to go to Brazil for affordable plastic surgery. While both are legal, is either ethical? And should their American physicians encourage or discourage the practice of "medical tourism?"

Medical tourism, or traveling outside one's own country to obtain health care procedures, is not new. Some experts say it began hundreds of years ago, when wealthy Romans traveled to Germany and other countries to seek healing waters at spas; the modern version of medical tourism saw its first real boom when would-be parents in Europe began traveling to Italy and Belgium to obtain in-vitro fertilization and other assisted reproduction therapies that were either difficult or impossible to obtain in their home countries.

As health care has advanced and borders have opened in more and more countries, some developing nations have realized a huge profit to be made by funding hospitals and attracting international patients willing to pay for care.

Nathan Cortez, JD, assistant professor of law at Southern Methodist University in Dallas, has written on the subject of medical tourism, and says one of the great unknowns is how extensive the trend is. Reliable data on the number of American citizens traveling outside the country for medical care are not always easy to find, he points out.

Article reports on medical tourism

His forthcoming article in the Indiana Law Journal1 states that in 2003, an estimated 350,000 patients from various countries traveled to Cuba, India, Jordan, Malaysia, Singapore, and Thailand for medical care. In 2006, more than 55,000 Americans visited Bumrungrad Hospital in Bangkok for medical care. The Confederation of Indian Industry says that medical tourism in India alone is a $300 million business and could grow to $2 billion by 2012.

While it is legal for Americans to travel overseas for medical care, medical and legal experts say the ethics of the medical tourism phenomenon are murkier.

Traveling for transplants decried

Among the most desperate medical tourists are those in need of lifesaving organ transplants. That category of medical travel, according to transplant ethicists, is the least ethically defensible.

The Richmond, VA-based United Network for Organ Sharing (UNOS), which regulates and monitors organ donations and transplants in the United States, and the UNOS Ethics Committee recently restated the organization's condemnation of transplant tourism.

"It is the position of the Ethics Committee that participation in such a practice cannot be defended on ethical or current empirical grounds," the committee stated, with UNOS President Sue McDiarmid, MD, adding, "[W]e cannot condone a practice that fundamentally violates human rights and exploits human vulnerability."

Michael Shapiro, MD, FACS, chief of organ transplantation at Hackensack University Medical Center and a member of the UNOS ethics panel, says from an ethical point of view, "the biggest of the issues with transplant tourism is that, almost always, the tourism takes place in a setting of exploitation."

"We heard at the last UNOS ethics meeting [in September] that maybe the country of Columbia legitimately has an excess of deceased organ donors, and people are going there and getting on a [waiting] list, just as we allow foreigners to come to the United States and get on our deceased donor list," Shapiro says.

"But most transplant tourism to other countries is for living donors, and in those cases, the donors are almost without exception desperately poor; are never paid the market rate — if you can determine a market rate — for the organs; and are not getting first-world medical care either at the time of the donation or after their donations; and are probably not getting a true informed consent."

The UNOS Ethics Committee, in its statement to the UNOS board in September, said, "Transplant tourism typically operates in countries where the rule of law is absent, or incompletely enforced. The practice of transplant tourism, by design, manifestly undermines the ethical principle of non-malfeasance."

At a meeting of the World Health Organization on travel tourism in early 2007, attendees were told that in some villages in Pakistan, as many as half of the residents have only one kidney because they have sold the other as a transplant for a wealthy person, often from another country.

Until living donors receive the treatment and disclosure that we expect under American transplant rules, Shapiro says, "it's reasonable for us in the United States — and for the whole world community — to say, 'This is not an ethical practice.'"

So what do U.S. doctors say to patients who are badly in need of transplants and want to travel overseas to get them?

"Certainly our recommendation is to dissuade people from doing it, and to point out that donors are being exploited. Frankly, some recipients respond to that, and some don't," says Shapiro. "I understand that. If my daughter needed a heart and couldn't get one, I might be less concerned about the ethical implications and more concerned about her life. But I don't think health professionals should recommend that their patients do that."

An even more likely scenario — and one that Shapiro himself has faced — is when a transplant surgeon's patient shows up in the emergency department "with a huge gaping, infected wound" following an overseas transplant.

"What do you do when they go to Pakistan for an organ, and then show up in your ER saying, 'Here, take care of me?'" he asks. "Then you're stuck. We're physicians, and we're obligated to care for them in the emergency setting.

"That doesn't mean, however, that once the emergency is over you can't say, 'What you did was despicable, and I think you need to find another transplant professional.' Until they find another doctor, though, you're stuck with caring for them."

Shapiro says he doesn't see lots of patients who've traveled overseas for transplants, but there's a "steady trickle" of them. He expects that travelers to the worst offender, China — which was charged by international health bodies with essentially executing prisoners when matching donors were needed — will continue to be minimal, at least as long as pressure is on by the international community and the upcoming Olympic games keeps a spotlight on the country.

Some cases of transplant tourism are less ethically questionable, he says. In the case of foreign-born Americans with relatives in other countries, it is sometimes easier to travel to those countries to obtain matching transplants from relatives than to bring the relatives to the United States in the post-9/11 atmosphere.

Reasons for travel vary

Cortez says a physician's response to a patient who wants to travel overseas for medical care is probably determined by the facts of the case.

"Why is the patient going overseas? Is it a life-threatening problem that no one in the United States will pay for? Did they lose insurance coverage and are paying out of pocket?" Cortez asks. "Another thing to consider is the procedure itself. Is it something widely performed and medically acceptable, or is it a treatment that is banned by law or regulation or considered unethical in the United States?"

Cost, health care economists have written, is a driving force behind most medical tourism. Cortez writes that world health experts estimate a $10,000 knee replacement in the United States can be had for $1,500 in Hungary or India; a coronary artery bypass graft that costs $35,000 in the United States costs less than $9,000 in India or Thailand.

Another ethical consideration is patient autonomy: Does a patient's right to pursue a procedure in a place where it is not banned make it acceptable?

"The counter-argument is that we might not want patients leaving the United State to get morally or ethically questionable treatments in other countries, because the concern is that countries are offering more and more really dangerous, morally questionable procedures to attract patients — a 'race to the bottom,'" he suggests.

On the other hand, patients in the United States are finding that procedures that they can't afford here — joint surgery, neurological surgery, cosmetic surgery — can be affordably done overseas in hospitals that meet or exceed U.S. hospital standards, says Cortez.

"It's tricky for a U.S. physician if a patient asks if he or she should go overseas because you don't know if the hospital is reputable, with a U.S.-trained and accredited staff, or if it's a less reputable facility," he continues. "From a physician's perspective, he or she would be concerned that the patient is going overseas without fully appreciating the risks or the recovery period or aftercare."

"If a patient asks for [his or her doctor's] opinion, it's really a crapshoot. From a lawyer's perspective, I would urge the patient to do his or her homework, but I would be hesitant to endorse a physician or facility unless I had specific knowledge of their quality."

If a physician is concerned that a patient's decision to travel overseas for care will result in complications that the doctor will then have to take care of when the patient returns, "the physician would probably be justified in trying to terminate the doctor-patient relationship," Cortez suggests.

Another developing layer to medical tourism is determining what recourse patients have if something goes wrong. Other countries' malpractice and liability courses are not like those in the United States, and can take years to navigate if there is, in fact, any recourse.

"Can you sue a foreign health care provider in a U.S. court? Can you sue the medical tourism brokers? Can you sue your doctor if he or she recommended a foreign provider?" says Cortez, adding that all are potential risks for traveling patients.

Neilish Patel, co-CEO of HealthCare Tourism International, a California-based nonprofit that accredits foreign health care providers and some travel brokers, says physicians in the United States are slow to warm to the idea of patients traveling abroad for care.

"Globalization in health care has hit so recently, and a lot of older, more traditional physicians and dentists believe patients should stay in local areas, and that health care should be a relationship-building modality," says Patel.

Reference

  1. Cortez N. Patients without borders: The emerging global market for patients and the evolution of modern health care. Indiana Law Journal 2008;83. Abstract and draft available at http://papers.ssrn.com.

Sources

For more information, contact:

  • Nathan Cortez, JD, assistant professor of law, Southern Methodist University, Dallas, TX. Phone: (214) 768-1002. E-mail: ncortez@smu.edu.
  • Neilish Patel, co-CEO, HealthCare Tourism International Inc. Phone: (650) 468-3631. E-mail: neil.patel@healthcaretrip.org.
  • Michael E. Shapiro, MD, FACS, chief, organ transplantation, Hackensack University Medical Center; associate professor of surgery, New Jersey Medical School/ University of Medicine and Dentistry, New Jersey. E-mail: MShapiro@humed.com.