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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?