Medical Tourism:Medical and Ethical

ConsiderationsSharon A. (“Shari”) Falkenheimer,MA (Bioethics), MD, MPH, FAsMA

Academy of FellowsCenter for Bioethics & Human Dignity

Trinity International University

Deerfield, IL

Disclosure InformationDisclosure Information8484thth Annual AsMA Scientific Meeting Annual AsMA Scientific Meeting

Sharon A. Falkenheimer, MA, MD, MPHSharon A. Falkenheimer, MA, MD, MPH

I have no financial relationships to I have no financial relationships to disclose.disclose.

I will not discuss off-label use and/or I will not discuss off-label use and/or investigational use in my presentation.investigational use in my presentation.

Overview

Definition Medical Tourism

Today Medical

Considerations Ethical

Considerations Summary and

Recommendations

What is Medical Tourism?What is Medical Tourism? ““Intentionally leav(ing … one’s) country Intentionally leav(ing … one’s) country

of residence outside of established of residence outside of established cross-border care arrangements … (to cross-border care arrangements … (to seek) non-emergency medical seek) non-emergency medical interventions … abroad”interventions … abroad”

Typically includes staying abroad for at Typically includes staying abroad for at least part of the recovery periodleast part of the recovery period

Sightseeing and tourism often added Sightseeing and tourism often added on to tripon to trip

Crooks et al. BMC Health Services Research 2010, 10:266, p. 3.

Medical TourismMedical Tourism

Traditionally Traditionally from 2/3 world to from 2/3 world to the more the more developed worlddeveloped world

Increasingly the Increasingly the reversereverse

Magnitude of Magnitude of Medical Tourism*Medical Tourism*

1.6 million/year from North 1.6 million/year from North AmericaAmerica

> 1 million/year to > 1 million/year to Thailand, Hungary, India, Thailand, Hungary, India, and Singaporeand Singapore

*Estimates for 2012; Rogers et al Clin Infect Dis. 2011 Jul 1;53(1): 51)

Medical Tourism Today:PlanetHospital

http://www.trustlink.org/Photos.aspx?ID=205844252&ImageID=C8tmjSCUz0Y=

http://www.trustlink.org/Reviews/PlanetHospital-205844252

PlanetHospital

80 hospital network: US, Europe, Latin 80 hospital network: US, Europe, Latin America (including Cuba), Turkey, Australia, America (including Cuba), Turkey, Australia, South and East AsiaSouth and East Asia

240 “affordable” procedures with prices 240 “affordable” procedures with prices listed by physician and location (and more listed by physician and location (and more may be available upon request)may be available upon request)

http://www.planethospital.com/

PlanetHospital ““At PlanetHospital, we believe in borderless At PlanetHospital, we believe in borderless

medicine and patient empowerment.”medicine and patient empowerment.” ““A+ Rated with Better Business Bureau”A+ Rated with Better Business Bureau” ““Five Star Rating with Trustlink”Five Star Rating with Trustlink” Inquiry with personal contact information Inquiry with personal contact information

required for other but informationrequired for other but information Books flights and hotels and provides Books flights and hotels and provides

concierge servicesconcierge services

http://www.planethospital.com/

PlanetHospital

““At PlanetHospital, you speak to a real At PlanetHospital, you speak to a real doctor not a salesperson ...”*doctor not a salesperson ...”*

Doctor “discusses your situation with you… Doctor “discusses your situation with you… then sends the films and info to dozens of then sends the films and info to dozens of surgeons all over the world. Surgeons that surgeons all over the world. Surgeons that feel they are qualified ... they send you (all feel they are qualified ... they send you (all inclusive) quotes … (for) the procedure”**inclusive) quotes … (for) the procedure”**

*http://www.planethospital.com** http://www.trustlink.org/Reviews/PlanetHospital-205844252

Advantages: To Patients Increased choice for patientsIncreased choice for patients Increased therapeutic Increased therapeutic

optionsoptions Healthcare cost savingsHealthcare cost savings Convenience of Convenience of

arrangementsarrangements Personalized carePersonalized care International travel and International travel and

tourism opportunitytourism opportunity

Advantages: To Host CountryAdvantages: To Host Country

May help address the health May help address the health professional “brain drain”professional “brain drain”

Spurs healthcare facilities to Spurs healthcare facilities to ensure high standard of careensure high standard of care• Accreditation of facilityAccreditation of facility• Board certification of staff Board certification of staff

Increased healthcare incomeIncreased healthcare income

http://www.crcpress.com/product/isbn/9781439813140

UncertaintiesUncertainties Impact on level of Impact on level of

and access to care and access to care for citizens of host for citizens of host nation*nation*

Sustainability of Sustainability of low costs in host low costs in host nations as their nations as their economies improveeconomies improve

*Pocock and Phua Globalization and Health 2011, 7:12, p.3

http://www.abc-clio.com/product.aspx?isbn=0-313-39936-0

Disadvantages/Risks to PatientsDisadvantages/Risks to Patients

Reliability of information Reliability of information sourcessources

Uncertain legal recourse in Uncertain legal recourse in event of mishap event of mishap /complications/complications

Distance from family and Distance from family and friendsfriends

Language issuesLanguage issues Cultural differences (in Cultural differences (in

disclosure, etc.)disclosure, etc.) http://www.hamiltonbook.com/the-complete-idiots-guide-to-medical-tourism

Medical ConsiderationsMedical Considerations Standards of careStandards of care Level of training of staffLevel of training of staff Availability of unapproved medical Availability of unapproved medical

proceduresprocedures Continuity of care and recordsContinuity of care and records Management of complications after returnManagement of complications after return Exposure to endemic diseasesExposure to endemic diseases Availability of adequate, safe blood supplyAvailability of adequate, safe blood supply

Medical Considerations Introduction of new multiply-Introduction of new multiply-

resistant organisms to home arearesistant organisms to home area

Trans-National Movement of New Delhi Metallo-Beta-Lactamase-Producing Organisms

Rogers BA et al, Clin Infect Dis. 2011 Jul 1;53(1):49–56.

Travel SafetyTravel Safety

Cardiovascular Contraindications to Cardiovascular Contraindications to Commercial Airline FlightCommercial Airline Flight

Uncomplicated MI within 2–3 weeksUncomplicated MI within 2–3 weeks Complicated MI within 6 weeksComplicated MI within 6 weeks Unstable anginaUnstable angina CHF, severe, decompensatedCHF, severe, decompensated Uncontrolled hypertensionUncontrolled hypertension CABG within 10–14 daysCABG within 10–14 days CVA within 2 weeksCVA within 2 weeks Uncontrolled ventricular or SV TachacardiaUncontrolled ventricular or SV Tachacardia Eisenmenger syndromeEisenmenger syndrome Severe symptomatic valvular heart diseaseSevere symptomatic valvular heart disease

ASMA Medical Guidelines for Air Travel, 2003, 9

Medical Guidelines for Post-Op Air TravelMedical Guidelines for Post-Op Air Travel

Arrange indicated in-flight medical support (oxygen, Arrange indicated in-flight medical support (oxygen, humidification, medical attendant, etc.)humidification, medical attendant, etc.)

2-3 weeks after uncomplicated thoracic surgery or 2-3 weeks after uncomplicated thoracic surgery or pneumothoraxpneumothorax

At least 14 days after drainage of pleural effusionAt least 14 days after drainage of pleural effusion 1-2 weeks after abdominal surgery1-2 weeks after abdominal surgery 24 hours after colonoscopy24 hours after colonoscopy Xray or CT documented resolution of intracranial airXray or CT documented resolution of intracranial air After intraocular gas injection - 2 wk for sulfur After intraocular gas injection - 2 wk for sulfur

hexafluoride and 6 wk for perfluoropropanehexafluoride and 6 wk for perfluoropropane At least 24 hours after hyperbaric treatmentAt least 24 hours after hyperbaric treatment

Extracted from AsMA Medical Guidelines for Air Travel, 2003

Other Medical Contraindications Other Medical Contraindications to Air Travelto Air Travel

Unresolved intraocular air, Unresolved intraocular air, pneumothorax, pneumoperitoneum pneumothorax, pneumoperitoneum or air trapped in skull or sinusesor air trapped in skull or sinuses

Uncorrected, severe acute anemiaUncorrected, severe acute anemia CSF leakCSF leak

ASMA Medical Guidelines for Air Travel, 2003

Ethical ConsiderationsEthical Considerations Pressures from insurersPressures from insurers Treatments not yet approved in Treatments not yet approved in

home countryhome country Adequacy of informed consentAdequacy of informed consent Options for redress for malpracticeOptions for redress for malpractice Impact on local medical accessImpact on local medical access

Potential for harm to vulnerable communities• Financial enticements• Promotion of organ

selling, surrogacy, etc.• Organ procurement from

prisoners

http://www.the-scientist.com/article/daily/24539/

Ethical Ethical ConsiderationsConsiderations

SummarySummary Rapidly increasing practiceRapidly increasing practice Increasing media coverage and Increasing media coverage and

advertising of servicesadvertising of services Cost savings, high levels of care, Cost savings, high levels of care,

and travel/personalized services and travel/personalized services likely to increase its attractionlikely to increase its attraction

Need to weigh Need to weigh • Risks and benefitsRisks and benefits• Medical and ethical considerationsMedical and ethical considerations

Need for ResearchNeed for Research

““Despite engagement with the issue Despite engagement with the issue of medical tourism in the published of medical tourism in the published literature, it is clear that literature, it is clear that there is there is profound paucity of theoretical and profound paucity of theoretical and empirical understandings of this empirical understandings of this practicepractice that can ultimately help us to that can ultimately help us to understand the patient’s experience.”understand the patient’s experience.”

Crooks et al BMC Health Services Research 2010, 10:266,11.

RecommendationsRecommendations Ensure an informed decisionEnsure an informed decision• Don’t rely purely on websites or Don’t rely purely on websites or

representatives of host facilityrepresentatives of host facility• Select destination accredited by Select destination accredited by

the International Society for the International Society for Quality in Health Care (ISQua) Quality in Health Care (ISQua) or Joint Commission or Joint Commission /International/International

• Balance risks and benefitsBalance risks and benefits

http://www.kobobooks.com/ebook/The-Complete-Guide-Medical-Tourism/book-CQ4BllY9cUuSbMHCcg_AKA/page1.html

RecommendationsRecommendations

Ensure an informed decision (cont)Ensure an informed decision (cont)• Ask questions to insure adequate Ask questions to insure adequate

informed consent (including staff informed consent (including staff qualifications certifications and qualifications certifications and destination facility knowledge of medical destination facility knowledge of medical guidelines for air travel)guidelines for air travel)

• Be sure you know how organs are Be sure you know how organs are procured, surrogates recruited and procured, surrogates recruited and reimbursed, etc.reimbursed, etc.

Recommendations Involve primary physician in home Involve primary physician in home

country in planning for air travel, country in planning for air travel, including medical inflight support including medical inflight support requirements and follow-up after returnrequirements and follow-up after return

Bring a family member or friend as an Bring a family member or friend as an advocateadvocate

Insure translation is available if neededInsure translation is available if needed Insure insurance covers complications, Insure insurance covers complications,

medical evacuation to home country and medical evacuation to home country and return of remains should death occurreturn of remains should death occur

QUESTIONS?QUESTIONS?