GUEST EDITORIAL

NEW ETHICAL PERSPECTIVES ONMEDICAL TOURISM IN THEDEVELOPING WORLD

International travel for private medical services, com-monly known as medical tourism, is perceived as agrowing international trade practice in terms of patientnumbers, expenditures, and geographic scope. A range ofmedical services are purchased by patients who travelabroad for care, including orthopaedic surgery, experi-mental treatments not available in the patient’s homecountry, organ transplantation, and reproductive treat-ments.1 Medical tourists typically pay for these servicesout-of-pocket, and in this way this practice can be distin-guished from cross-border health care that is planned andadministered by national and regional health care sys-tems.2 As medical tourism is understood as travel with theintention of receiving medical care, it is also separablefrom cases where travelers become sick while abroad andare forced to access medical care.

Medical tourism is not a new phenomenon and hasbeen practiced for thousands of years.3 Until recently,medical tourism was typically understood to involve twoforms of travel. First, wealthy patients from high incomecountries and the Developing World would travel to highincome countries with technologically advanced healthcare systems in order to access treatments and expertisenot available in their home countries.4 Second, patientsfrom the Developing World would travel regionally toother Developing World countries to access care andexpertise not available in their home countries.5 Morerecently, attention has focused on a relatively new formof medical tourism: travel by patients from high incomecountries to private facilities targeting internationalpatients in the Developed World. Prominent destinationsfor these patients include India, Thailand, Singapore,Costa Rica, and Mexico, but the number of DevelopingWorld countries and clinics participating in this practice

is perceived to be growing quickly, even in the face of therecent global economic downturn.

This special issue of Developing World Bioethics pre-sents five articles highlighting some of the ethical con-cerns that have arisen in response to a medical tourismindustry that actively seeks to recruit patients from highincome nations to hospitals and clinics in the Develop-ing World. Over the past several years, as awareness ofthis global health services practice has increased, schol-ars have noted a wide range of concerns with medicaltourism, focusing on the potential impacts it holds forthe populations of Developing World destinations forinternational patients, as well as health and safety con-cerns for the patients themselves.6 Ethical concerns fordestination countries focus on the prospect of medicaltourism worsening inequities in access to health carewithin the populations of these countries. As the facili-ties serving international patients are typically privateand often charge prices for their services that are unaf-fordable to most members of the local population, theworry is that these clinics will be limited to serving rela-tively wealthy international patients and elites amongthe local population. These inequities may also result inworsening access to care in absolute terms if public sub-sidies are used to support these clinics, if they shift focusfrom preventive care for the local population to acutecare for international patients, and if health humanresources are drawn from the public sector to staff theseprivate facilities.7 Meanwhile, proponents of medicaltourism typically note the potential of this sector tocross-subsidize public health systems by bringing in newtaxable revenue to the country and helping to retainworkers who might have emigrated otherwise.8 Theprospects of these potential positive effects outweighingthe potential negative effects of medical tourism isuncertain and will likely depend on contextual differ-ences, including regulatory measures and oversight thatwill vary highly between destination countries.

The phenomenon of patients from high income coun-tries traveling to the Developing World for care hasbeen made possible by the widening availability of hightechnology equipment, Western-trained doctors, new

1 V. Crooks, P. Kingsbury, J. Snyder, & R. Johnston. What is Knownabout the Patient’s Experience of Medical Tourism? A Scoping Review.BMC Health Services Research, 2010; 10(1): 266.2 V. Crooks, P. Kingsbury, J. Snyder, & R. Johnston. What is Knownabout the Patient’s Experience of Medical Tourism? A Scoping Review.BMC Health Services Research, 2010; 10(1): 266.3 M.Z. Bookman & K.R. Bookman. 2007. Medical Tourism in Devel-oping Countries. New York, NY: Palgrave Macmillan.4 R. Johnston, V.A. Crooks, J. Snyder, & P. Kingsbury. What isKnown about the Effects of Medical Tourism in Destination andDeparture Countries? A Scoping Review. International Journal forEquity in Health 2010; 9(1): 24.5 B. Kangas, B. (2010). Traveling for Medical Care in a Global World.Medical Anthropology 2010; 29(4): 344–362.

6 L. Turner. First World Health Care at Third World Prices: Global-ization, Bioethics and Medical Tourism. BioSocieties 2007; 2(3): 303–325.7 R. Johnston, V.A. Crooks, J. Snyder, & P. Kingsbury. What isKnown about the Effects of Medical Tourism in Destination andDeparture Countries? A Scoping Review. International Journal forEquity in Health 2010; 9(1): 24.8 M.Z. Bookman & K.R. Bookman. 2007. Medical Tourism in Devel-oping Countries. New York, NY: Palgrave Macmillan.

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Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) doi:10.1111/j.1471-8847.2012.00321.xVolume 12 Number 1 2012 pp iii–vi

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facilities targeting these patients, and the spread of inter-national accreditation standards. The Bumrungrad Hos-pital in Thailand, for example, has been described asbeing more like a hotel or mall than a hospital, withamenities designed to appeal to relatively wealthypatients from around the world. While many of thesefacilities are perceived and advertised as offering highquality care that is as good as or better than that availablein the West, the quality of facilities is likely to be highlyvariable. Patients may have a difficult time decidingamong facilities given a dearth of reliable information onpatient outcomes internationally. Linguistic and regula-tory differences further complicate this decision-makingprocess, as does the prominence of industry-affiliatedwebsites on the internet. While informed decision-makingabout care is always complicated for patients, the inter-national dimension of medical tourism heightens thisproblem, underscoring the need for reliable informationfor these patients. Due to a lack of systematic data gath-ering, we cannot be certain whether patient outcomes formedical tourists are worse or better than those forpatients seeking care domestically. Certainly, any answerto this question will vary by source and destination coun-tries for medical tourists. Developing better informationon patient outcomes is essential, however, not only forthe sake of patient safety, but because these patients mayface medical complications or exposure to infectiousdisease that will create new, and possibly inequitable andunethical, burdens for their home health systems.9

The five articles showcased in this special issue ofDeveloping World Bioethics help to enhance our under-standing of the ethical dimensions of medical tourism, agrowing form of globalization that impacts populationsin both the Developed World that are destinations formedical tourists and patients in high income countriestraveling to the Developed World in search of care. Thefirst two of these articles, by Kristin Smith and GlennCohen focus on the economic and regulatory systems thathave enabled the expansion of medical tourism and thatmust be modified if the ethical problems associated withthe industry are to be addressed.

In her article, Kristen Smith highlights and critiquesthe neoliberal rationale for medical tourism. She arguesthat a neoliberal discourse encourages hard currencyflows into Developing World economies, increasing thegross domestic product of these countries and thereforetheir wealth. Focusing on the case of India as a leadingmedical tourism destination, Smith contends that theneoliberal discourse fails to take account of the negativeimpacts of the expansion of the private medical tourismsector on equity in Developing World countries. By

focusing on the aggregate economic gains made possibleby this practice and the increased options for ‘medicalrefugees’ from high income countries, an importantaspect of the debate around the impacts of medicaltourism is ignored. Smith argues that future researchinto medical tourism should emphasize the equityimpacts of this practice and work toward identifyingthose populations that will be made worse off in abso-lute and/or relative terms to the potential beneficiaries ofthis practice.

Glenn Cohen explores regulatory options to controlmedical tourism both in patients’ home countries and indestination nations in the Developed and DevelopingWorlds. Cohen notes that regulatory responses bypatients’ home countries are more readily available forgovernment-prompted forms of cross-border care than incases where patients initiate travel and pay for it out-of-pocket as medical tourists. As Cohen argues, however, awide range of potential responses by patients’ homecountries are available to regulate different stakeholdersin medical tourism and for different procedures, such aspaid surrogacy and organ transplantation. In destinationcountries, the regulatory question is seemingly morestraightforward as these countries can simply choose tolimit certain forms of medical tourism or outlaw the prac-tice altogether. However, the allure of potential financialgains from this industry will make it difficult for countriesto ban some forms of medical tourism altogether. More-over, regulatory reforms aimed at mitigating the poten-tial negative effects of this practice may also be difficult toimplement given that patients can simply choose topatronize facilities in countries with ‘loose’ regulatoryenvironments. Multilateral agreements can circumventthis problem, but Cohen argues that the political will todevelop these agreements is likely lacking. The creationof professional norms within the industry is desirable andmay be more likely to develop in order to protect thereputation of the industry, but Cohen notes that thesenorms are not likely to be effective in controlling badactors in the industry. Cohen’s discussion is helpful forassessing the range of regulatory options available tohome and destination nations participating in medicaltourism. It importantly helps to ground discussion of theethical problems associated with medical tourism in ameaningful understanding of the options for effectivepolicy responses to these problems.

The remaining three articles, by Leigh Turner, EdnaEinsiedel and Hannah Adamson, and Gillian Crozier andDominique Martin each discuss specific forms of medicaltourism. Focused discussions of this kind are importantas international travel for necessary care, elective care,experimental treatments, reproductive services, andorgan transplantation all raise distinct ethical issues.These studies help to avoid generalization about theethical terrain of medical tourism and also, in the case of

9 V. Crooks, P. Kingsbury, J. Snyder, & R. Johnston. What is Knownabout the Patient’s Experience of Medical Tourism? A Scoping Review.BMC Health Services Research, 2010; 10(1): 266.

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Turner and Einsiedel and Adamson, present empiricaldata to help further explore these insights.

Leigh Turner describes a series of 26 cases of morbidityamong patients seeking cosmetic or bariatric surgeryabroad spanning from 1993-2011. While Turner does notuse these cases to argue that medical tourism results ingreater levels of complications and morbidity for patientsor lower quality of care than can be found in their homecountries, these cases do reinforce the need for reflectionon means of protecting the safety and welfare of patientsengaging in medical tourism. These cases, Turner argues,demonstrate the need for better tracking of clinical out-comes of patients traveling overseas for cosmetic andbariatric surgeries in order to understand the effects ofmedical tourism on patient safety and to design interven-tions to improve outcomes. As Turner notes, a largenumber of these case reports resulted from surgeries thattook place in Mexico and the Dominican Republic. Whilethis result may simply reflect reporting biases from thesources Turner used, it also demonstrates that certaindestination countries and procedures are likely to developgood and bad reputations for safety. Successful invest-ment in medical tourism, then, is dependent on reputa-tional factors outside of the control of any single clinic oreven country, a point that should give pause to countriesseeking to invest public resources into this sector.

Edna Einsiedel and Hannah Adamson discuss theethical issues surrounding stem cell tourism; that is, inter-national travel for stem cell treatments that are typicallynot available in the patient’s country of origin. While thislack of local access sometimes results from insufficienttechnology and expertise to offer these treatments or theirhigh price, in many cases regulations against offeringexperimental treatments are the source of this inaccessi-bility. The authors estimate that over 700 clinics world-wide, most of which are in the Developing World, offerexperimental stem cell treatments, taking advantage ofease of travel and globalization to allow patients to cir-cumvent local restrictions. Einsidel and Adamson reporton five focus groups they led with Canadians in order tobetter understand these citizens’ willingness to engage instem cell tourism. Hope and desperation have been citedas key factors that were thought to potentially motivatepatients to travel internationally to access experimentaltreatments, and the citizens they spoke with reported thatthey would consider accessing these treatments them-selves under similar circumstances despite awareness ofhealth and safety risks associated with going abroad forexperimental medical care. While improved regulationand governance would help to address the safety issuesraised by stem cell tourism as it is currently practiced, theauthors note that this practice is likely to continue togrow. As with Turner’s discussion of morbidity in cos-metic and bariatric surgery, the sensational health andsafety concerns associated with experimental stem cell

treatments may influence perceptions of medical tourismmore widely, with impacts on its viability even in coun-tries with relatively strong regulations of this industry.

Finally, Gillian Crozier and Dominique Martin con-sider travel for reproductive services that include the useof paid surrogacy or purchase of human ova. Paymentsfor these services raise a number of ethical concerns.These worries are particularly heightened in cases wherethere are large socioeconomic gaps between those par-ticipating, as is typical when patients from high incomecountries travel to the Developing World for theseexchanges. In response to these concerns, the authorsconsider two policy alternatives. First, the national self-sufficiency model aims to make countries self-sufficientin terms of the reproductive needs of their members,thus reducing the push factors toward internationaltravel for these services without banning the practice.Second, the regulated market model focuses on provid-ing additional benefits to women in the DevelopingWorld participating in these exchanges in order toreduce the negative and enhance the positive effects ofthis practice. As the authors note, these models haveconflicting objectives but do overlap in many ways thatoffer a path forward toward policy action that couldhelp reduce some of the ethical concerns associated withthese forms of reproductive travel. In this way, thisarticle complements Cohen’s work by offering a case-specific and pragmatic regulatory response to theexpanding practice of medical tourism.

The articles included in this collection offer many newand important ethical insights into the growing practiceof medical tourism in the Developing World. While eachconsidered different aspects of medical tourism, therewere indeed some commonalities. One was the simulta-neous consideration of both individual actors, and mostparticularly the medical tourists themselves, and thewider structures of medical tourism. For example, whileTurner’s article presented the cases of individual medicaltourists, his discussion engages with larger regulatoryissues and other industry dimensions. While Smith’sarticle is focused on the large-scale issue of the neoliberaldiscourse that surrounds medical tourism, she gives con-sideration to the needs of individual citizens in destina-tion countries. This common thread in the collectionpoints to the importance of research on the ethical issuesassociated with medical tourism in the Developing Worldto consider the local and global along with the perspec-tives of individual actors and the global structures againstwhich their actions are framed. The consideration ofthese multiple perspectives, as contained in the currentfive articles, is essential to develop insights that contrib-ute to our current understanding of the ethical issuesraised by medical tourism. Another commonality acrossmany of the articles was a concern for the safety ofmedical tourists. While the articles did not focus on new

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threats to patient safety, they typically linked their find-ings to implications for patients’ health and safety. Thiscommon theme is important in light of consideringemerging research directions, as it highlights the potentialfor ethics research to offer new insights into health andsafety issues and how these issues might be shaped byeither the actions of individual actors or the structuresthat shape this global health services industry.

The findings and discussions shared in this DevelopingWorld Bioethics special collection point to the fact thatmuch remains to be learned about medical tourism. Newempirical insights need to be brought forth in order toassist with assessing the practicality of the types of con-ceptual arguments put forth by Cohen and Crozier and

Martin about mitigating the potential harms of medicaltourism or instilling regulatory frameworks. Such empiri-cal insights need to be coupled with the development ofnew ethical argumentation around the harms and benefitsof both the industry and the practice of patients travelingto Developing World countries for private medical care.This argumentation will benefit from acknowledging thediversity of practices, places, and actors that make up thisindustry, as was so well done by the contributors to thiscollection, which may result in ‘one size fits all’ solutionsbeing rendered ineffective.

JEREMY SNYDERVALORIE A. CROOKS

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