Chapter 31 Travel medicine, ethics and health tourismDeborah Bowman1 and Richard Dawood2

1 St George ’ s, University of London, UK 2 Fleet Street Clinic, London, UK

571

HEALTH TOURISM

Introduction

‘ Health tourism ’ may be loosely defi ned as travel for the purpose of obtaining healthcare. This may or may not involve crossing an international border. In its modern context, it typically involves a quest for non - critical, elective rather than emergency care, and the purpose is frequently for one - off treatment – such as a surgical procedure or an expert opinion – rather than for the ongoing management of chronic disease.

Travellers who fall victim to illness or injury in the course of their travels are clearly excluded from this defi nition: they are not health tourists, though many of the issues they face are undoubtedly the same.

Travellers may become unintentional health tourists when they buy local medicines, or try out local therapies and treat-ments, without this being the primary purpose of their trip.

Historical background

Health tourism is not new. From the earliest times, people have travelled great distances in search of cures, a notion that was commonplace to the ancient Greeks and Romans, and one that is a recurring theme in the Old and New Testaments.

Spas and places linked historically with healing can be found across Europe, attracting health seekers and therapists alike. In England, for example, the discovery of the rejuve-nating properties of the Chalybeate Spring in 1606 by a young nobleman, Lord North, led to the creation of the spa town of Royal Tunbridge Wells, which reached the height of

fashion, popularity and patronage in the eighteenth century [1] . Its reddish waters offered the prospect of a cure from ‘ obstructions, especially of the spleen and liver; dropsy, jaundice, scurvy, the green sickness, defect and excess of female courses, inward infl ammations and hot distempers, palsy, apoplexy, rheums, hypochondriacal melancholy, pox, pimples and other external infi rmities; the waters scoureth and cleanseth the urinary passages … and nothing is better against barrenness ’ . Contemporary medicine had little else to offer against such ailments, and any health benefi ts prob-ably arose from the water ’ s high iron content. At around the same time, the purgative effects of the waters of Epsom led to the creation of another popular spa, as high society fl ocked there to take the waters – rich in magnesium sulphate, a substance that is still often referred to as ‘ Epsom salts ’ .

Holy places have also offered the prospect of a cure, and even today attract pilgrims by the thousand, seeking hope and health where other avenues have failed. During the latter part of the twentieth century, the developed countries of Europe and North America saw a massive infl ux of ‘ health tourists ’ from the oil - rich countries of the Middle East, seeking high - quality care that was unobtainable in their own countries. Several Middle Eastern governments have established ‘ health offi ces ’ in cities such as London and Washington, DC, for the purpose of facilitating such care, often seen as an extension of the countries ’ own health service arrangements. Today, there is an established, bi - directional fl ow of health tourists between developed and developing countries.

Health tourism today

There has been recent, rapid growth in health tourism from developed to developing countries. This has been especially marked in regions such as Southeast Asia. More than 1.28

Principles and Practice of Travel Medicine, Second Edition. Edited by Jane N. Zuckerman.© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

572 Principles and practice of travel medicine

Benefi ts and pitfalls

The notion of low - cost healthcare, in an exotic and alluring environment, with the added prospect of being able to enjoy a leisurely recuperation far from the routine stresses of one ’ s home surroundings is an attractive prospect. Unfortunately, for many people, the reality proves to be different. Many prospective patients place insuffi cient value on such factors as the professional indemnity cover of the doctors looking after them, the importance of follow - up care in the long term, and of easy access to a doctor who can take full respon-sibility for any problems that may crop up. One commenta-tor describes continuing care as the Achilles heel of medical tourism. Procedures are seldom as simple as they may seem, and the economic advantages may quickly be destroyed by the need to travel long distances repeatedly, for management of complications.

In developed countries, medical, nursing and supporting staff, as well as hospitals themselves, operate within a strict regulatory and compliance framework, and have to meet exacting standards at every level. This carries clear benefi ts for patient protection that may be utterly invisible to the end user, but comes at a high cost. Language and cultural differ-ences are also important, for example in pain management, and end - of - life decision making. There is a strong argument for obtaining care in one ’ s own familiar environment, from a medical team with whom one can have a continuing, long - term relationship.

Role of the travel medicine specialist

Prospective health tourists may seek health advice from spe-cialists in travel medicine, typically before travelling, though possibly while still away, or on return home. Specifi c health needs to consider include the following: • risk assessment for travel - related health risks • pre - travel immunisation • malaria protection • assuring a supply of routine medication if this has not been provided elsewhere • where surgery is contemplated, it should certainly include protection against hepatitis B. Advice may also need to be offered in relation to preventing deep vein thrombosis during the journey home. • the opportunity to counsel the traveller about the wisdom or otherwise of undertaking the intended treatment, and alerting them to any risks that have not been adequately considered. A fuller analysis of pre - travel risk assessment can be found in Chapter 4 .

million foreigners underwent treatment in Thai hospitals in 2005. In Malaysia, 300,000 foreign patients were treated in 2006, a fi gure that is growing at an annual rate of 30%. In 2006, 410,000 foreigners visited Singapore to obtain health-care. India is also a popular destination, accounting for half the value of an industry that now has a turnover in Asia alone that will be worth $4 billion by 2012. Half a million US citizens travelled abroad to receive medical care in 2007, and 1.29 million UK citizens travelled abroad for dental treatment.

Drivers

Economics is by far the most powerful driver for this recent trend (Table 31.1 ). The combination of long waiting times for access to publicly funded care (where available at all), and the high cost of medical insurance, or of uninsured care in the private sector, leads many people suffering from non - acute medical conditions to examine the options for treat-ment elsewhere.

Economic drivers apply equally to non - surgical, ‘ one - off ’ treatments that include residential addiction rehabilitation programmes, with savings of up to 75%. Resource availabil-ity may be another key factor: ready access to good facilities may simply be unavailable locally, at any price. Another key driver may be legal or social issues, for example in the case of women seeking termination of pregnancy or fertility treatment outside locally acceptable social criteria (such as maternal age), or in people seeking assisted suicide. Such drivers may act in combination: besides being legal and accessible, gender reassignment surgery in Thailand may be ten times cheaper than in the west, or the Middle East, with ‘ good results ’ [3] .

Table 31.1 Surgery in USA and Asia (costs in USD)

US India Thailand Singapore

Cardiac bypass

80–130K 6.7–9.3K 11K 16.5K

Cardiac valve replacement

160K 9K 10K 12.5K

Angioplasty 57K 5–7K 13K 11.2KHip

replacement 43K 5.8–7.1K 12K 9.2K

Hysterectomy 20K 2.3–6K 4.5K 6KKnee

replacement 40K 6.2–8.5K 10K 11.1K

Source: Muddle GR (2008) Medical Tourism [2].

Travel medicine, ethics and health tourism 573

quest for elective cosmetic surgery co - exist. Such diversity makes the ethical terrain unpredictable, vast and constantly changing. The moral questions relevant to aid work in a war zone appear utterly removed from those relevant to the pro-vision of privately funded dental treatment. How can ethical analysis acknowledge such plurality yet remain useful to the millions of patients and clinicians participating in the rich realities of travel medicine on a daily basis? The answer might be to shift the focus from specifi c ethical problems and to seek common virtues or best practice to which all those working in travel medicine would aspire. Identifying considerations that, if not universal, warrant attention and thought whatever the context and provide a framework within which plurality of practice and contrasting experi-ence can be effectively scrutinised. By exploring the funda-mentals that both the poorest and the most advantaged value in clinicians, a model emerges that fosters an ethical frame-work that travels across borders and serves the widest range of patients.

The good doctor: virtues, healthtourism and travel medicine

Travel medicine and health tourism raise questions about fundamental ethical concepts such as notions of justice, equity and fairness irrespective of the specifi c context in which care is sought and provided. However, due to the widely varying locations in which health tourism and travel medicine takes place, notions such as fairness can seem alarmingly elusive and vague as each subjective reinterpreta-tion is adapted to differing cultural contexts and pragmatic constraints. Among those who study tourism (in its general rather than health - specifi c form), virtue ethics is of increas-ing interest [4] . It is suggested that it is also a valuable approach for those working within health tourism and prac-tising travel medicine. Once the emphasis shifts to the indi-vidual and the motivations of those both seeking and providing care, what begins to emerge is a framework for ethical practice whatever the clinical scenario. So, what might a good practitioner in travel medicine look like? What are the characteristics that should inform best practice, whatever the setting? Writers disagree about what might appear on any list of virtues [5] , but most accept that there is a core of virtues that are essential to ethical character and therefore practice. Table 31.2 suggests what a list of virtues for a professional working in travel medicine might incor-porate and how practical wisdom may ensure the ethical enactment of these in clinical practice. It is not intended to be an exhaustive or defi nitive list but a starting point, and readers are encouraged to consider what they would include

Future trends

Future trends in health tourism are hard to predict – espe-cially with the altered economic environment that has fol-lowed the economic downturn affecting many countries.

It is possible that private healthcare costs in wealthier countries may be driven downwards, reducing the cost dif-ferential between care at home and abroad. Reduced dispos-able income might reduce the ability of individual health tourists to travel at all, or conversely, might increase pressure to seek care abroad if care at home becomes further out of reach.

ETHICAL PERSPECTIVES

The most virtuous are those who content themselves with being virtuous without seeking to appear so.

Plato

Introduction

Travel solely or partly for the purpose of healthcare is increas-ingly common with both patients and healthcare profession-als crossing geographical borders with increasing frequency. What implications does such travel have on ethical practice? Do morality and notions of ‘ ethical practice ’ remain constant irrespective of location? What particular ethical challenges arise for those working in the fi eld of travel medicine? This chapter explores the ethical landscape of travel medicine and discusses the dilemmas that professionals working in the specialty may encounter. The aim is to discuss what the ‘ good specialist in travel medicine ’ would be like and to demon-strate how focusing on being ‘ a good practitioner ’ enables moral constancy no matter what specifi c ethical challenges arise for individuals.

Why might health tourism be perceived as a moral problem? After all, it has a long history. For example, in the UK, royalty regularly travelled to take the spa waters. Its signifi cance perhaps lies in its purpose, namely that people are travelling not just to improve health by doing specifi c activities or going to a restorative destination, but specifi cally to seek medical treatment. The breadth of what is covered by the overarching terms ‘ travel medicine ’ and ‘ health tourism ’ is enormous. It is a fi eld characterised by economic, social, political and cultural differences: the professional pro-viding basic care to the most disadvantaged in the world and the affl uent individual fl exing the muscle of privilege on a

574 Principles and practice of travel medicine

At the most basic level, LH needs accurate, informed, reliable and appropriate advice that is communicated effectively. The virtues of competence, conscientiousness and commitment to service cover the range of behaviours from providing accurate information that is specifi c to the situation and meets the required standards of care. So far, so uncontrover-sial: it is the sort of encounter that occurs in clinics daily.

in their own list of aspirations for best clinical practice in travel medicine.

Moral journeys: ethics in practice

Having suggested that virtues may be a useful way to con-ceptualise what it means to act ‘ ethically ’ as best clinical practice irrespective of context, the following section of this chapter demonstrates, via vignettes, how such an approach enhances ethical analysis of situations that occur at each stage of travel and health tourism.

Travel planning

Ethical practice in travel medicine begins before anyone has, in fact, travelled anywhere. A commitment to fostering a partnership in which information is shared honestly and individual needs are served while not losing sight of other interests requires clinicians to consider the ethico - legal responsibilities that arise prior to travel. In recognising what Crozier and Bayliss [6] term ‘ decision spaces ’ , i.e. the context

Table 31.2 Virtues for a professional working in travel medicine

Characteristic or trait: the virtues in health tourism and travel medicine Behaviour: the ethical enactment of virtue in travel medicine and health tourism

Trustworthiness Those seeking care can rely on those providing it to be authentic, open and truthful even when there is diffi cult news to impart, e.g. about limited or absent resources and the systems for allocating those resources

Conscientiousness A professional is competent and remains so throughout their career. In addition to competence, the clinician is reliable and accountable. They meet commitments and are alert to sustainability, e.g. where teams travel to regions of the world to provide immediate care that may not endure once the team leaves

Compassion Even if there is no cure, there will be care and individuals are valued irrespective of perceived status, e.g. in situations where effective biomedical therapies are unavailable, there remains a case for providing care, advice and support

Sensitivity Professionals are aware of the practice environment, competing agendas, power differentials, diverse interests and the importance of emotion. There is recognition that practice may be adapted according to circumstance. For example, in non -Western cultures, the dyadic model of patient –doctor confi dentiality may be inappropriate when patients present as part of a family unit

Commitment to service The role of the professional is to serve needs and to act in the patient ’s best interests. For some, this may extend to formal advocacy or activism, e.g. clinicians might use their experiences to highlight neglected issues in global health

Kindness In all encounters, there is consideration and regard for others, e.g. irrespective of outcome, it is right to be generous, patient and responsive in clinical encounters

Humility Practitioners are open to feedback, do not presume authority and acknowledge mistakes or misjudgements, e.g. partnership arrangements with local communities are meaningful and do not impose a particular or ethnocentric approach

LH is a fi nal year medical student who attends her uni-versity ’ s occupational health department and asks to be immunised for her forthcoming elective in Uganda where she will be working in a remote hospital for 6 weeks.

How might the practitioner who sees L make the most use of the ethical ‘ decision space ’ in which the consulta-tion occurs?

in which choices are made and the extent of those choices, the good practitioner is alert to the fundamentally moral opportunities available. Consider the vignette below.

Travel medicine, ethics and health tourism 575

For many clinicians the fundamental question is whether there is a duty to act in emergency situations such as that described in the scenario above. It is a question that has both a legal and ethical dimension. Legally, the duty to inter-vene or ‘ rescue ’ varies depending on the jurisdiction in ques-tion and the relationship between the parties. For example, in the UK, there is no legal duty to intervene unless a fi duci-ary relationship exists, e.g. where a doctor has assumed responsibility for a patient. However, that is not the whole story because professional bodies commonly impose a nor-mative requirement that a professional will act as a ‘ good Samaritan ’ and intervene to the extent that it is reasonable to expect given the circumstances and taking account of safety, competence and the availability of other options for care [11] . Such advice implies that there is, if not an obliga-tion to act, a duty to weigh up the possibility of acting and assess the situation, and most defence organisations now cover (within certain parameters) clinicians who act in emergencies.

What might a virtue ethics approach add to Dr AM ’ s dilemma? Trustworthiness and conscientiousness require Dr AM to explain the extent of her competence: she is an oph-thalmologist and she has had a few glasses of wine. However, merely declaring a situation to be beyond her specialist knowledge is, taking a virtue ethics approach, not the optimal way to respond. Even if Dr AM feels that she can offer only limited assistance, the virtues of sensitivity, compassion, humility and kindness may require more from her. Dr AM can provide support to the crew and the sick man himself, which may take the form of keeping an eye on him, devising

What else might a virtue approach to ethics prompt? The virtues of sensitivity, compassion and humility demand that the relationship, however fl eeting, between LH and the clini-cian is not compromised by assumptions about what she knows, hopes and fears. Seeing the encounter through the lens of virtue ethics enhances the consultation. The acknowl-edgement that character and motive matter in ethical deci-sion making results in a richer and more nuanced approach to even the most routine consultation. While there will be practical constraints such as time and workload, this poten-tial ‘ decision space ’ is redolent with opportunity. What are the potential differences of which LH should be aware when living and working in Uganda? Is she particularly concerned about anything? Some readers may believe those questions to be the preserve of others, but a best clinical practice approach demands that a good practitioner identifi es and responds not only to LH ’ s explicit concerns and priorities, but also explores health in its widest sense to reach that which is implicit.

Beyond the walls of the occupational health clinic and the specifi c encounter with LH, there are wider moral questions to be asked about the role of medical students and global health. Students may provide additional manpower in chal-lenging situations across the world, but they may also cause harm [7] . Students may choose a destination because of the experience that they anticipate having in a particular country where resources are scarce. Indeed, some students will exceed both their competence and role while on elective, creating signifi cant ethical dilemmas for their peers [8] . Students, too, must be encouraged to refl ect on the core virtues of best clinical practice that should not change however many geo-graphical borders are crossed. Drawing once more on this approach, to prioritise ‘ experience ’ over human dignity and for the powerful to compromise the powerless is to act unethically: it is a failure of trust, compassion, sensitivity and kindness. Awareness of the standards expected of students, wherever they may be in the world, is as vital to clinical preparation for travel as vaccinating and providing sterile equipment [9] . Those already working in the fi eld of travel medicine have an obligation to provide leadership and be role models to those who seek to follow in their professional footsteps.

In transit

The act of travel itself has potential for multiple ethico - legal dilemmas: medical repatriation, choices about when and why to cross geographical borders, coping with unfamiliar or absent equipment, and working with new colleagues are but some of the moral challenges that can arise. One particu-larly common (and dreaded) experience [10] is that of the mid - fl ight medical emergency described below.

Dr AM, an ophthalmologist, is on a transatlantic fl ight. She has enjoyed lunch and three glasses of wine. Approxi-mately 4 hours into the fl ight a call goes out asking for ‘ anyone who is a physician or nurse to make himself or herself known to a fl ight attendant ’ . Dr AM looks around and does not see anyone responding to the call. A second call is made asking for ‘ anyone medically qualifi ed to make contact with a member of the cabin crew ’ . Some-what hesitantly, Dr AM tells a fl ight attendant that she is a doctor, albeit ‘ a specialist in eyes ’ . The fl ight attendant leads Dr AM to the back of the plane where she fi nds a man in his late fi fties. Dr AM observes that he is obese, sweating and has vomited. He is pale and clammy to the touch. One of the cabin crew has measured the man ’ s blood pressure as 110/70. Dr AM begins to talk to the man, but the steward intervenes and says that the pas-senger does not speak any English. How should Dr AM proceed?

576 Principles and practice of travel medicine

In purely economic terms it is relatively easy to assess the (considerable) cost of JH ’ s proposed trip abroad for stem cell treatment. Yet, there are many other potential ‘ costs ’ to be considered in the ethical analysis of this scenario, some of which are shown in Table 31.3 .

By taking an ethically based approach to the consultation, the broader and more nuanced aspects of ‘ cost ’ are revealed. The clinician who is open, trustworthy, conscientious and kind is the clinician to whom JH is most likely to reveal herself. A principle - based approach may prompt the profes-sional to think about what autonomy, benefi cence, non - malefi cence and justice mean in JH ’ s case, but it would be possible to do so without reaching the essence of the problem.

non - verbal ways of communicating, suggesting that a call is put out for anyone who might be able to interpret or simply holding the man ’ s hand and providing some comfort. These suggestions about the ways in which Dr AM might still support the passenger despite her specialism and enjoyment of a good lunch may seem unduly saintly or even mundane to some readers. However, ambivalence about, or antipathy towards, providing such basic care outwith the familiar structures of clinical work are themselves revealing. A virtue ethics analysis often throws the essence of healthcare and what it means to be a clinician into sharp relief. And, in so doing, other, less appealing human traits such as pride, ambition and selfi shness are revealed as the ‘ shadow side ’ of clinical work. Dr AM ’ s dilemma is not just a question of how one responds to emergencies in travel. Rather, that short vignette about Dr AM asks that most fundamental of moral questions: what does it mean to be a ‘ good ’ clinician and to ‘ care ’ for another person? The reader ’ s response to this sce-nario is a barometer of moral values that extends well beyond the realms of ‘ Good Samaritan ’ acts.

In a strange land

Many ethical dilemmas in travel medicine arise as a result of the location in which care is sought or provided. It is common to view moral problems in travel medicine at a systemic level: big issues such as resources, confl ict and political power are invoked to explain why a particular situation is or is not ethi-cally acceptable. While the macro - level variables that shape global health are essential to ethical reasoning, there is a risk that these ‘ big ’ concepts become meaninglessly overarching and exclude the human factor in travel medicine and health tourism. Even the most bureaucratic and centrally adminis-tered system of providing, limiting or withholding healthcare is ultimately operated by people: clinicians, patients and rep-resentatives of other agencies are the heart of travel medicine. And people are individuals not commodities [12] . A virtue ethics approach demands that the individual refl ect on how they work within a system. It is a moral framework that requires more than a resigned shrug or an exasperated rant about the latest obstacle in delivering healthcare.

As an example, let ’ s consider the notion of ‘ cost ’ , which is frequently cited as a reason for healthcare being sought or provided in a particular way or specifi c geographical loca-tion. For such analysis to be meaningful, ‘ cost ’ must be broadly interpreted and extend well beyond the merely eco-nomic. Individual clinicians who adopt even some of the virtues discussed in this chapter will quickly learn that there are multiple ways in which ‘ cost ’ both does and should inform healthcare, many of which are not objectively meas-urable, systemically controlled or universally experienced. Consider the scenario below.

Table 31.3 Potential ‘costs’ to be considered

Individualcost to JH

Therapeutic cost to JH and the clinical team

Societal and political cost

Response to the trip and thetreatment

Responsibility to inform JH

Division between those who can afford cutting-edgetreatment and those who cannot [13]

Risks of the treatment andpotentialharm

Possible duty to prevent JH from travelling

Effect on local healthcare provision

Availability of ongoingcare

Impact of proposed treatment and expertise to meet JH’s needs following treatment

Impact on the reputation of the relatively ‘young’science of stem cell research and its clinical application

Compromised trust in healthcare professionals

Effect of disagreement on therapeutic relationship and alliance

Commodifi cation of human life and stem cells

JH is a 40 - year - old woman who has multiple sclerosis. She has become increasingly unwell in the last year and she uses a wheelchair. JH has decided to travel from her home in Scotland to Singapore, where she is intending to pay for private stem cell treatment. JH tells her neurolo-gist about her plans. The neurologist is concerned and explains to JH that the treatment remains experimental and unlicensed in the UK. JH replies that she ‘ has done her homework ’ .

Travel medicine, ethics and health tourism 577

How should the good practitioner respond? There may be, indeed there probably are, multiple ways in which to respond and those different responses refl ect the range of ways in which the ethical question or dilemma is perceived. What ’ s more, different ethical problems and the concomitant range of responses can co - exist. PH needs care. The clinicians to whom she has presented have a duty to provide that care without judgement. The good healthcare professional will respond to PH with sensitivity, compassion and kindness. However, what of the wider implications? If PH is found, as seems likely, to have suffered the ill effects of a procedure that has been performed elsewhere and perhaps in a sub - standard way, what else should be considered? Again, clini-cians will hold contrasting views about the extent to which they should engage with the wider ethical considerations arising from PH ’ s example. For some, the primary and perhaps even sole responsibility is to provide care to PH. However, others will suggest that those with a voice and in a relatively privileged position in society should expose unacceptable practice and protect others from its effects. Activities such as lobbying, contributing to public health campaigns, contributing to debates, writing opinion pieces

For example, it might be argued that JH has made an auton-omous decision and her neurologist has a responsibility to explain the risks of her choice, those risks in relation to her best interests and the wider issues of accessing care across borders. Yet such an analysis risks setting JH ’ s preferences against those of the healthcare professional, thereby frustrat-ing each party and creating an ethical stand - off. An ethical approach that prioritises trust, humility, conscientiousness and kindness provides a potential ethical bridge across the biomedical divide. The aim is not to ‘ be right ’ but to value characteristics and behaviours that have intrinsic value in all clinical encounters. JH and her neurologist may never agree about the wisdom of seeking stem cell treatment abroad, but they can prioritise their relationship and create a collabora-tive clinical environment in which the notion of ‘ cost ’ is understood to be multilayered, complex and differently experienced. Such an approach facilitates understanding and allows for change: a virtuous present creates the opportunity of a functioning future.

The example of JH and her neurologist describes a spe-cifi c, micro - level situation, but what of the broader, macro - level dilemmas inherent in people travelling across the globe for healthcare? What is an appropriate ethical response to the inequities refl ected and created by a system in which the wealthy travel [14] and the marginalised accept whatever is available, however questionable the quality? [12] Unfortu-nately, it is easier to identify the moral questions than it is to come up with effective solutions. Perhaps the best that can be offered is a multifactorial response encompassing a range of responses. Some of the possible approaches to the big questions in travel medicine and health tourism are shown in Table 31.4 .

The extent to which individuals feel inclined, or able, to address the sometimes overwhelming moral complexity of health tourism and travel medicine will vary, but every single practitioner makes a difference to the experience of their patients on a daily basis. Reviewing those individual experi-ences, refl ecting on the emergent themes and sharing exper-tise will inevitably contribute to, and enhance, the ethical identity of the specialty and its collective response to the moral dilemmas that feel so daunting when faced alone.

There ’s no place like home

The fi nal stage of the moral journey is when the patient returns home after receiving care abroad. Of course, for some patients there are no sequelae of the care they obtained abroad and there will be a need for no, or negligible, follow - up when they return home. However, what is the situation when patients require signifi cant follow - up as a result of care they obtained overseas? [15] A typical scenario is described below.

Table 31.4 Approaches to the big questions in travel medicine and health tourism

• Make visible the invisible: the fi rst step in addressing a moral problem is to name it. All those who work in the fi eld should be aware of, and highlight, inequity • Identify the agents of change: who are the organisations and people who have the power to address injustice in healthcare provision? • Map the moral landscape: what are the criteria that distinguish ‘ethical’ from ‘unethical’ practice in travel medicine and health tourism?• Foster awareness of, and debate about, the sociopolitical effects on ethical practice and standards: what are the implications of a market -driven approach to the quality of care? • Develop good practitioners who value, expect and demonstrate desirable traits and behaviours: systems are established and implemented by individuals • Consider the role of the law and regulation in protecting and promoting cross -border standards of care irrespective of the healthcare system

PH has recently returned from Bulgaria, where she had liposuction. She presents at her local hospital ’ s Accident & Emergency department with a fever complaining of feeling ‘ dreadful ’ . She has pain in her chest, feels breath-less and is very frightened.

578 Principles and practice of travel medicine

2. Yap J et al. ( 2008 ) Medical Tourism: The Asian Chapter . Deloitte Consulting SEA.

3. Woodman J ( 2008 ) Patients Beyond Borders: Everybody ’ s Guide to Affordable, World - Class Medical Care Abroad . Joseph Woodman. Ig Publishing , Chapel Hill .

4. Jamal TB ( 2004 ) Virtue ethics and sustainable tourism pedagogy: phronesis, principles and practice . J Sust Tourism 12 ( 6 ): 530 – 545 .

5. Gardiner P ( 2003 ) A virtue ethics approach to moral dilemmas in medicine . J Med Ethics 29 : 297 – 302 .

6. Crozier GKD and Bayliss F ( 2010 ) The ethical physician encounters international medical travel . J Med Ethics 36 (5): 297 – 301 .

7. Shah S and Wu T ( 2008 ) The medical students global health experi-ence: professionalism and ethical implications . J Med Ethics 34 : 375 – 378 .

8. Bowman D ( 2009 ) Students whose behaviour causes concern: ethical perspective . Br Med J 338 : a2882 .

9. Banatvala N and Knowing DL ( 1998 ) When to say ‘ no ’ on the student elective. Students going on electives abroad need clinical guidelines . Br Med J 316 : 1404 – 1405 .

10. Gendreau MA and DeJohn C (2002) Responding to medical events during commercial airline fl ights . N Engl J Med 346 : 1067 – 1073 .

11. General Medical Council Good Medical Practice . GMC , London . 12. Gray HH and Poland SC ( 2008 ) Medical tourism: crossing borders

to access health care . Kennedy Inst Ethics J 18 ( 2 ): 193 – 201 . 13. Pennings G ( 2002 ) Reproductive tourism as moral pluralism in

motion . J Med Ethics 26 : 337 – 341 . 14. Connell J ( 2006 ) Medical tourism: sun, sea, sand and . . . surgery .

Tourism Manag 27 : 1093 – 1100 . 15. Jones JW and McCullough LB ( 2007 ) What to do when a patient ’ s

international medical care goes south . J Vasc Surg 46 : 1077 – 1079 .

and participating in information initiatives all have their moral antecedents in the notion of caring about inequities that exist beyond one ’ s immediate remit. Indeed, it seems likely that the good clinician, who values commitment to service, does consider the wider context in which they work and is able to operate on multiple levels both to care for the patient in the room and infl uence the evolution of global healthcare.

Conclusion

Travel medicine and health tourism are fertile ground for ethical analysis. For ethicists, that may be welcome news, but for those working in the fi eld as practitioners it can be over-whelming, frustrating and burdensome. The premise of this chapter is that despite the range of experience and plurality of perspective within the specialty, there are moral roots that ground the discipline and its practice. One way of under-standing those roots is to refl ect on the virtues and their practical enactment to discover what it means to be a ‘ good ’ clinician practising travel medicine. By refl ecting on what it means to be a healthcare professional serving others, ethical practice becomes clearer and more authentic. Individual judgement, personal discretion and variety are to be embraced and not feared. Difference of approach can and will follow, but the core virtues are common. Social, political, economic and clinical challenges in travel medicine will remain a feature of the specialty, but every reader who strives to be a ‘ good ’ clinician can contribute to meeting those challenges.

References

1. Ford JMT ( 1986 ) Taking the waters at Tunbridge Wells . Stress Med2 ( 2 ): 169 – 174 .