In July, the Harvard Pilgrim Health Care Ethics Advisory Group (which I chair) discussed the ethics of health plan involvement with medical tourism. (A summary of the discussion is available in the “Medical Travel Today” newsletter.) Although out-of-U.S. treatment is not yet a large issue for U.S. health insurers, Harvard Pilgrim had received a few appeals for medical travel, and wanted to scope out potential ethical concerns in advance.
Ripples of change are emerging, like the self-insured construction company in Albuquerque that charges its employees 50% of the cost of procedures done in the U.S. but only 25% of the overseas cost. And last night National Public Radio began a series on the internationalization of medicine.
Out-of-the-U.S. travel for treatment will grow. The phenomenon raises some significant ethical issues. We should try to anticipate these issues and plan for them before too many problems hit the fan.
There are five main reasons why Americans travel abroad for treatment. Most commonly the target is cosmetic treatment or other services, such as surrogacy, not covered by health insurance. Second, individuals who are uninsured or whose insurance has substantial deductions or coinsurance may seek treatment in Thailand, India or elsewhere to save money – the treatment may cost 10 – 20 % of what they would pay in the US. Third, individuals may seek treatments that are unavailable in the US, such as cancer treatments or surgical devices that have not received FDA approval. Fourth, as good as medical care can be in the US, individuals may believe that a higher quality of care is available elsewhere, as for surgical procedures where surgeons in other countries may have significantly more experience. Finally, individuals on transplant waiting lists may seek transplantation in countries where the wait may be shorter.
The primary challenges are assuring the quality of the out-of-U.S. treatment, planning for continuity of care on returning, and creating mechanisms to address the liability concerns of all parties. Quality, continuity, and accountability, are core ethical commitments in health care. In these areas we know what we are aiming for. The challenge is making our ideals real.
The most perplexing ethical concerns for medical tourism are the impacts on the host country. In economically less developed societies health professionals are already being lost to the home country through “brain drain.” Nurses and physicians could easily be further diverted away from the home population by catering to better paying foreign patients. And in the area of transplantation there is reason to believe that organs are being sold (and sometimes taken by force, as from prisoners). Stuart Rennie has a passionate posting on this topic in his excellent “Global Bioethics Blog.”
Medical tourism will expand. Done right it could provide benefits for all parties – patients receiving treatment, the “exporting” country, and the medical “host.” But if we allow an unbridled free market to govern the expansion we will also see ethically unacceptable developments as well.
It wasn’t the free market that ended the slave trade.