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Ethical Issues in Travel Medicine

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Ethical Issues in Travel Medicine Ethical issues in travel medicine Adriano G Duse - Department of Clinical Microbiology and Infectious Diseases School of Pathology of the NHLS & University of the Witwatersrand, Johannesburg, South Africa George Edward Moore [Principia Ethica, 1903] “It appears to me that in Ethics, as in all other philosophical studies, the difficulties and disagreements, of which history is full, are mainly due to a very simple cause: namely to the attempt to answer questions, without first discovering precisely what question it is which you desire to answer” Travel medicine is a BROAD topic; my focus is on medical tourism Scope of travel . To seek healthcare – patients / ‘clients’ . To deliver healthcare for gain, or altruism (voluntourism) – health-care workers Both . Affected by ease and speed of international travel and communication associated with globalization . Raise questions about continuity of care & issues related to cultural, language & legal differences . Raise concerns about ethics Medical tourism . Relatively recent phenomenon of travelers leaving family and friends to seek healthcare abroad, frequently in less developed countries, and the organizations that support or offer incentives for such travel Historical context: Ancient Egypt / Greece Ancient Egypt: highly sought sophisticated medical expertise Ancient Greece: worshippers of Aesclepius (God of medicine) made pilgrimages to his temple in Epidaurus where they underwent healing 17th C emergence of spa towns in appealing places like the Pyrenees attracted the wealthy from all over Europe Etc, etc, etc … Globalization of travel Projected international tourist arrivals worldwide from 1995 to 2030 by region (in millions) Globalization of travel ‘Categories’ of medical tourism include those services that: [I. Glenn Cohen ‘Patients with Passports: Medical tourism, Law, and Ethics’] • Are legal in both home and destination countries (e.g. hip replacements, cardiac bypass, plastic surgery, tooth implants, cosmetic dentistry) • Are illegal in the home country but legal in the destination country (e.g. abortion, assisted suicide, stem cell treatments) – ‘circumvention medical tourism’ • Are illegal in both home and destination countries (e.g. organ trafficking) Popular destinations for medical tourism • Brazil • Costa Rica • India • Mexico • Panama • Singapore • South Africa • Thailand Medical ethics: Principlism (Beauchamp & Childress: Principles of Medical Bioethics, 1979) • Four principles: – Autonomy – respect the right of patients to make informed decisions about their bodies – Beneficence – obligation to act in patient’s best interest – Non-maleficence – requirement to minimize harm (based on Hippocratic Oath) – Justice – requirement of fairness in the treatment of patients, colleagues and the community 2015/12/03 9 Examples of categories of medical tourism • Reproductive tourism • Non-cosmetic dentistry • Non-cosmetic surgery • Transplantation • Stem cell therapy • Cosmetic dentistry • Cosmetic surgery Etc. Reproductive tourism • Termination of pregnancy • Infertility treatments • Sex selection • IVF versus adoption • Surrogacy Reproductive tourism Ethical issues: organ transplantation 1; philosophy of organ donation • Transplantation ethics: philosophy that systematizes, defends & recommends concepts of right and wrong conduct related to organ donation • Increasing demands for organs calls for bio-ethically acceptable new & innovative laws, policies and strategies of increasing organ supply • In organ transplantation , role of altruism & medical ethics values are significant to societal welfare . Altruism (French ‘autrui’ – other people): living for others; neural bases for altruism . Two types: (i) obligatory: moral duty to help others, (ii) supererogatory: morally good, but not mortally required going ‘above and beyond’ one’s duty [Act that maximizes good consequences for the majority of society is ‘utilitarianism’] Ethical issues: organ transplantation 2 Need for transplantable organs far exceeds supply worldwide . E.g. in US, Jan-April 2008: 9029 transplants from 4578 donors with 99,393 candidates on nationally coordinated transplant list [http://www.optn.org] Less rigorous methods of organ distribution in some countries termed ‘transplant tourism’ . Transplant recipients (majority: kidney) more likely to be male, college educated, nonresident/foreign resident, self-funded) . US: analysis of kidney & liver transplants to non-resident showed liver candidates to have shorter times to transplant & self-paying, the shortest time [Transplantation2 007;84:1548-14556] . Notion that deceased donor organs are a ‘national resource’ Ethical issues: organ transplantation 3; illegal trafficking • Adverse events – insufficient information regarding outcomes of medical care abroad; infectious and non-infectious complications – Whose responsibility? Whose cost (both individual and country levels)? What is the legal recourse? • Shortages of organs are a universal problem (e.g. Spain that has a well- developed program can meet only 50% of demand); other models involving living donors must be explored – regulated, prevent organ vending, protect the donor and be transparent • Where do the organs come from? Possibility that organs from deceased ‘donors’ are from executed prisoners (notably China) or from criminal rackets • Duty of travel medicine practitioner to inform patient of risks and where possible mitigate risks (e.g. offer relevant immunizations) Organ transportation / trafficking Ethical issues: stem cell tourism • Patient travel to receive stem cell treatments typically not available in home country • Therefore sought in countries with more permissive regulatory environments (e.g. China, Thailand, South Korea, Panama, Costa Rica) • Mainly autologous stem cell injections (marrow, adipose tissue etc. cells, cultured, ‘treated’, & administered): • Touted as effective in broad array of diseases, from CVS to neurodegenerative e.g. MS, Parkinson’s, Alzheimer’s; despite lack of science patient testimonials bolster success claims • Generally expensive • For some patients, unproven treatments are the ‘last option’; Physician’s duty for informed decision-making is • Provide patients opportunity to choose among all available options & referring patient to reliable online resources • Assist patients with asking the right questions to assess veracity of advertising claims, what clinics are offering, whether facilities are accredited/approved, risks of procedure & possible side effects especially if these occur when patient gets treatment in another country (the traveler) Aesthetic (cosmetic) medicine; historical context: ‘Beauty Doctors’ Aesthetic/cosmetic surgery Ethical issues: aesthetic surgery 1 • Chung et al in a systematic review of plastic surgery found only 110 articles in a pool of > 100 000 that deal with ethics. Plast Reconstr Surg, 2009;124(5):1711-1718 • Aesthetic (cosmetic) surgery is requested to (i) satisfy patient’s desire, and (ii) address patient’s psychological & psychosocial needs, perceptions and expectations • Interventions enhance patient’s life, not ‘save’ it i.e. aesthetic procedures perceived as a tool to fulfil wishes instead of relieving suffering or treating illness • Aesthetic surgery is primarily a business, guided by a market ethic aimed at material gain and profit and not necessarily part of the healthcare system Ethical issues: aesthetic surgery 2 • Restriction of aesthetic surgery to the ‘rich’ counteract notions of distributive justice • Inherent conflicts of interest may interfere with balanced information, detailing pros and cons, required for informed consent • Patients seek out surgeon for interventions so, if fully informed by surgeon, autonomy is assumed but a competent patient may have unrealistic expectations, ignore risks, or seek services on basis of misconceptions about their body image • If patient is a traveler who has the obligation to correct these beliefs? Ethical issues: cosmetic surgery e.g. rhinoplasty She who knows not, nose not … Dental tourism 1 • Driven by multiple socioeconomic factors: lack of access & cost • Is another example of globalization although, for convenience purposes, occurs along regional pathways vs. global networks (e.g. UK => C Europe) • Un-affordability of private dental care in many countries • Need for timely dental treatment • Patient realization that lower prices don’t necessarily equate to low quality care • ‘Word of mouth/ []; internet; dental tourism companies offering ‘all-inclusive deals’ • ‘Packages’: pre-established dental fees, air fare, ground transportation, accommodation, ‘VIP treatment’, restaurant reservations & side trips to tourist attractions Dental tourism 2 • Quality of care ranges from excellent to substandard • Variability in standards of training, accreditation & licensing of dentists • Patients must • Be wary of substandard procedures • Understand that episodic nature of treatment undermines continuum of care especially as multiple procedures are compressed into abbreviated period • Understand difficulties in returning to international clinics for further treatment; local practitioners may not be willing to treat problems associated with care by dentist in another country (medico-legal liability) • Understand that often they must sign waiver of liability forms • Know that to initiate medico-legal action patient must turn to courts of country wherein clinic is located • Mechanisms are required to protect vulnerable clients from possible adverse consequences of dental tourism Dental
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