Is Medical Tourism Ethical?
Scholar: I Glenn Cohen, JD
In brief: When is it ethical to travel abroad for health care? What are the risks and legal implications for patients, doctors, and everyone else? Glenn Cohen studies these and other ethical questions raised by medical tourism.
Imagine you need a hip replacement. Can your employer require you to travel to India as a condition of insurance coverage, because the surgery is cheaper there? If you’re injured, can you sue the doctor, hospital, or insurer for medical malpractice in the country where you live? Can a country prohibit its citizens from helping a relative travel to Switzerland for assisted suicide, or traveling to Bangladesh to buy a kidney on the black market? What about travel for abortion? Greenwall Faculty Scholar I. Glenn Cohen’s research tackles these important questions relating to medical tourism, also known as medical travel or cross-border health care. Medical tourism is the travel by a patient from their country of residence (the “home country”) to a foreign country (the “destination country”) for the primary purpose of securing care. Cohen has written the first comprehensive legal and ethical analysis of medical tourism, culminating in a series of articles and the book Patients With Passports: Medical Tourism, Ethics, and Law (Oxford University Press 2014).
Medical tourism represents a growing multi-billion-dollar industry in which millions of patients travel abroad each year to get health care. Some seek services like hip replacements that are legal in their home countries and travel to avoid lines, save money, or because their insurer has given them an incentive to do so. Others travel in search of services that are illegal at home, such as abortions, assisted suicide, reproductive surrogacy, or experimental stem cell treatments. Both types of medical tourism raise a host of thorny ethical and legal questions.
Professor Cohen’s work examines why people travel for medical tourism, the dangers they face, and the ethical and legal issues their travel raises for other patients in their home country and in the destination country.
Medical tourism for legal services
The first half of Cohen’s Greenwall Faculty Scholar project focuses on people who travel for health care services legal in their home country, such as hip replacements, cardiac bypass, or cosmetic surgery. For U.S. patients paying out of pocket, the savings can be enormous (upwards of 70% in some cases), but even insurers can achieve dramatic savings if they can induce patients to travel abroad for health care.
Cohen’s work charts the ecosystem of medical tourism and its many players: destination country governments eager to develop their health care sectors, destination country hospitals and physicians, accreditors seeking to assure quality for patients, facilitators (the middlemen and women who connect patients to foreign facilities), health insurers, home country academic medical centers who partner with foreign facilities, and industry associations that try to market the industry and improve its quality.
Cohen also examines and makes recommendations as to a series of legal and ethical challenges:
- How can we manage the risk of disease transmission in the course of medical tourism, especially antibiotic-resistant bacteria?
- How can patients make informed choices when considering a foreign facility for treatment?
- What can we do to ensure better continuity of care and document availability and intelligibility when patients return to their home country physician?
- If medical error occurs, medical tourists who sue for malpractice are less likely to win, and even if they do, they’re likely to recover less financially than those who stay in country for medical care. How should we think about this? Can arbitration or insurance products help patients get fully reimbursed?
- Do home country physicians face difficulties with incomplete medical records or records in other languages when their patients travel abroad and return to their care?
- How should state or federal governments regulate whether insurers can offer, incentivize, or require their patients to travel abroad for health care? How would any new rules intersect with the Affordable Care Act?
- What effect does medical tourism have on access to health care by the poor and middle class in destination countries such as India, Thailand, and Mexico? What can theories of global justice tell us about our obligations if medical tourism makes health care worse or less available for citizens of destination countries? How does the answer change at the level of patients, home country governments, destination country governments, insurers, and hospitals?
- What can we learn from the robust regulation of cross-border health care in the EU, especially as we consider whether medical tourism might be helpful as an option for the health care needs of retirees?
Crossing borders for illegal services
The second half of Cohen's project focuses on medical tourism for services illegal in the patient’s destination country, and either legal where the patient is traveling (abortion, assisted suicide, reproductive technologies, stem cell therapies) or illegal in both places but with a flourishing black market in the destination country (primarily transplant tourism–crossing national boundaries to buy kidneys and other organs). Among the many difficult issues Cohen tackles:
- What information is available on the effectiveness of stem cell therapies offered in countries like China and Russia? Are they offering real help or exploiting hope? What should the state or medical profession do when parents want to take their children abroad for potentially harmful treatments?
- What does the data tell us about people who sell their kidneys on the black market in places like India, Bangladesh, Pakistan, and the Philippines? How healthy are patients who return to Canada and the U.S. after buying and transplanting a kidney? Does transplant tourism exploit or coerce kidney sellers into parting with their organs? Does the market for kidneys corrupt the way we think the human body should be valued? What forms of regulation are or would be effective for deterring or regulating transplant tourism?
- How should countries that criminalize abortion handle travel abroad for abortions? Does international law permit home countries to say it’s a crime for their citizens to travel abroad for abortion? If so, should home countries extend their law in that way? How does the answer change if, instead of abortion, the issue is assisted suicide?
- Is it ethical for people to travel abroad to find commercial surrogate mothers or to buy eggs for in vitro fertilization? Does it matter whether they are trying to save money or avoid a criminal prohibition at home? Should their home countries be required to recognize the citizenship of children born through reproductive technologies abroad in all situations? If not, how can we avoid creating a category of stateless children?
Currently, Cohen is working on cutting-edge issues including mitochondrial replacement therapy, the use of predictive analytics and big data in health care, the wisdom and constitutionality of FDA’s lifetime ban on gay men donating blood, mobile health, and the role of physicians in assisting with executions. Cohen has published on these topics in journals such as Health Affairs, JAMA, the New England Journal of Medicine, Cell, and Science, as well as several law reviews. His work has been featured by media outlets including PBS, NPR, ABC, CNN, MSNBC, Mother Jones, the New York Times, the New Republic, and the Boston Globe.