BEYOND SUN, SAND, AND STITCHES: ASSIGNING RESPONSIBILITY FOR THE HARMS OF MEDICAL TOURISM

BEYOND SUN, SAND, AND STITCHES: ASSIGNING RESPONSIBILITY FORTHE HARMS OF MEDICAL TOURISMbioe_1942 1..10

JEREMY SNYDER, VALORIE CROOKS, RORY JOHNSTON AND PAUL KINGSBURY

KeywordsMedical Tourism,Health Tourism,liability,responsibility,Health Services trade

ABSTRACTMedical tourism (MT) can be conceptualized as the intentional pursuit ofnon-emergency surgical interventions by patients outside their nation ofresidence. Despite increasing popular interest in MT, the ethical issuesassociated with the practice have thus far been under-examined. MT hasbeen associated with a range of both positive and negative effects formedical tourists’ home and host countries, and for the medical touriststhemselves. Absent from previous explorations of MT is a clear argument ofhow responsibility for the harms of this practice should be assigned. Thispaper addresses this gap by describing both backward looking liabilityand forward looking political responsibility for stakeholders in MT. We usea political responsibility model to develop a decision-making process forindividual medical tourists and conclude that more information on theeffects of MT must be developed to help patients engage in ethical MT.

Despite having been a regular source of inspiration forlegal reviews,1 journal articles,2 and news items3 alike overthe past decade, the phenomenon of ‘medical tourism’(MT) has remained a poorly defined and under-examinedtrade practice. Large estimates of international patienttravel via MT have regularly been cited by parties with aninterest in making a profit from the industry4 as well as

those concerned with its potential to have a negativeimpact on access to health care within MT host coun-tries.5 However, unclear delineations of what MT is, andwhat it is not, have resulted in wildly irregular (and prob-ably inflated) estimates of how large the practice is. Forthe purposes of this paper, MT is conceptualized as theintentional pursuit of non-emergency surgical interven-tions by patients outside their nation of residence thatare typically paid for out-of-pocket. This travel may bearranged by individual patients or facilitated throughdedicated MT facilitators who specialize in makingarrangements for international patients.6 In this paper,MT includes elective procedures such as orthopedic, cos-metic and dental surgeries, among others. We limit ourdiscussion of MT to travel with the intention of receivingmedical care, usually paid for out of pocket; therefore, wedo not discuss practices such as established cross-border

1 L. Burkett. Medical Tourism: Concerns, Benefits and the AmericanLegal Perspective. J Legal Med 2007; 28: 223–245; M. Klaus. Outsourc-ing Vital Operations: What if US Health Care Costs Drive PatientsOverseas for Surgery? Quinnipiac Health Law 2005; 9: 219–247.2 E.A. Jenner. Unsettled Borders of Care: Medical Tourism as aDimension in America’s Health Care Crisis. Research in the Sociology ofHealth 2008; 26: 235–249; M. Lautier. Export of Health Services FromDeveloping Countries: The Case of Tunisia. Soc Sci Med 2008; 67:101–110; A. Whittaker. Pleasure and Pain: Medical Travel in Asia. GlobPublic Health 2008; 3: 271–290.3 J. Alsever. 2006. Basking on the Beach, or Maybe on the OperatingTable. The New York Times 15 October: 5; Economist. 2004. Get wellaway; Medical tourism to India. Economist 9 October: 60; J. Wolff.2007. Passport to Cheaper Health Care. Good Housekeeping 1 October:190.4 T. Ehrbeck et al. Health Care and the Consumer. McKinsey Quarterly2008; 4: 80–91; P.H. Keckley & H.R. Underwood. 2008. MedicalTourism: Update and Implications. Washington, DC: Deloitte Centrefor Health Solutions. Available at: http://www.deloitte.com/view/

en_US/us/Industries/Health-Plans-Healthcare-Health-Care/Center-for-Health-Solutions-Health-Plans/article/55d9f278c9184210VgnVCM200000bb42f00aRCRD.htm. [Accessed 1 Sep 2010].5 A. Sen Gupta. Medical Tourism in India: Winners and Losers. IndianJ Med Ethics 2008; 5: 4–5.6 D.A. Forgione & P.C. Smith. Medical Tourism and Its Impact on theUS Health Care System. J Health Care Finance 2007: 34: 27–35.

Address for correspondence: Jeremy Snyder, Faculty of Health Sciences, Simon Fraser University, 8888 University Drive Blusson Hall 11300,Burnaby, British Columbia V5A 1S6, Canada. E-mail: [email protected] of interest statement: No conflicts declared

Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2011.01942.x

© 2012 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

care arrangements between countries, expatriates access-ing care in their nation or region of residence, receiv-ing unanticipated emergency care while on holiday, orindividuals seeking complementary and alternative treat-ments abroad. While reproductive and organ transplan-tation tourism raise important ethical considerations intheir own right, they are not considered here as they raisedistinct ethical issues regarding commodification of thehuman body and possible gender discrimination not typi-cally associated with international patient travel for othersurgical procedures.

MT has been associated with a range of positive andnegative effects for medical tourists’ home and host coun-tries, and for the medical tourists themselves. Absentfrom previous explorations of MT is a clear argument ofhow responsibility for the harms of this practice shouldbe assigned. This paper seeks to address this gap by firstclearly detailing the harms likely to emerge from contin-ued unregulated trade in MT. Second, we outline ThomasPogge’s argument for liability for the harms caused byunjust global institutions. Third, Pogge’s liability modelof responsibility is juxtaposed with Iris Young’s politicalmodel of responsibility applied to individuals. These twocomplementary models of responsibility are then appliedto MT, where we argue that the political responsibilitymodel is the one best suited to describing the responsi-bilities of most of the individuals associated with MT.Finally, we use the political responsibility model todevelop a decision-making process for individual medicaltourists and conclude that more information on theeffects of MT must be developed to help patients engagein less ethically problematic MT. The primary goal ofthis paper, then, is to describe the responsibilities ofindividuals involved in MT and to sketch the stepsneeded for individuals engaged in MT to discharge theseresponsibilities.

HARMS OF MEDICAL TOURISM

While some medical tourists seek out care in countrieswith a level of economic development similar to theirown, new focus has been applied to the flow of patientsfrom developed countries to low-middle income coun-tries (LMICs).7 According to proponents of MT, thisdirectionality carries with it a wide range of economicopportunities for host LMICs, chiefly the influx of hardcurrency, foreign investment into domestic health careinfrastructure, and the creation of financial and profes-sional incentives that may help retain health human

resources.8 Defenders of the industry focus on theseopportunities, arguing that MT can create an importantavenue for economic development in LMICs. This devel-opment, if properly directed through cross-subsidization,can be of benefit to all citizens of these countries. More-over by creating, in the health sector, well-paid jobs thatuse the latest medical techniques and technologies, theout-migration of the best trained health professionalsfrom LMICs can be lessened. Finally, if properly regu-lated, MT can provide a means for wealthier countriesto meet the health needs of their citizens safely andefficiently.9

Harms for three categories of stakeholders are alsoassociated with the development of the MT industry inLMICs. First, the health of medical tourists may be putat risk by seeking medical treatment abroad. The inter-national dimension of MT makes it more difficult forpatients to judge the quality of care they may receiveabroad and there have been documented cases of medicaltourists dying as a result of surgical complications.10

Other patients have suffered or died as a result of thedifficulty of obtaining follow up care after surgeryabroad, especially for procedures not available at home.11

Medical tourists have also found it difficult to obtaindamages for malpractice abroad.12 More generally,medical tourists are at particular risk of developing bloodclots due to flying so soon after surgery.13 They may alsobe at risk of experiencing heightened mental and emo-tional strain due to being distanced from family, friends,and other personal support networks while recoveringabroad.14 Medical tourists may be encouraged to receiveunnecessary care, be poorly informed of risks, and receiveinferior care.15 Accessing medical care abroad can alsocreate an undue burden for those for whom traveling isdifficult. For example, persons with physical impairments

7 R. Johnston et al. What Is Known About The Effects of MedicalTourism in Destination and Departure Countries? A Scoping Review.Int J Equity Health 2010; 9: 24.

8 Lautier, op. cit. note 2, pp. 101–110; Whittaker, op. cit. note 2,pp. 271–290.9 J. Arunanondchai & C. Fink. Trade in Health Services in the

ASEAN Region. Health Promot Int 2007; 21: 59–66; M.Z. Bookman &K.R. Bookman. 2007. Medical Tourism in Developing Countries. NewYork, NY: Palgrave Macmillan: 76–77; D.M. Herrick. 2007. MedicalTourism: Global Competition in Health Care. Dallas, TX: NationalCenter for Policy Analysis.10 J. Snyder, V. Crooks. Medical Tourism and Bariatric Surgery: MoreMoral Challenges. Am J Bioeth 2010; 10: 28.11 A. Morrow. 2010. Man Dies After Controversial MS Treatment,Doctor Says. The Globe and Mail 18 November.12 N. Cortez. Patients Without Borders: The Emerging Global Marketfor Patients and the Evolution of Modern Health Care. Ind L J 2008; 83.13 L. Carabello. A Medical Tourism Primer for U.S. Physicians. J MedPract Manage 2008; 23: 291.14 J. Law. Sun, Sand and Stitches. Profit 2008; 27: 69–70.15 L. Turner. 2007. From Durham to Delhi: Medical Tourism and theGlobal Economy. In Comparative Program on Health and SocietyLupina Foundation Working Papers Series 2006–2007, J.C. Cohen-Kohler & M.B. Seaton, ed. Toronto, ON: University of Toronto Press:109–131; L. Burkett. Medical Tourism: Concerns, Benefits and theAmerican Legal Perspective. J Legal Med 2007; 28: 223–245.

2 Jeremy Snyder, Valorie Crooks, Rory Johnston and Paul Kingsbury

© 2012 Blackwell Publishing Ltd.

and those who have limited experience with foreigncultures and languages may find travelling abroad formedical care particularly onerous.16

Second, MT raises ethical issues for members of thepatient’s home country. Patients seeking care abroadhave been found to be vectors for infectious diseases,such as the NDM-1 ‘superbug’ that was carried fromIndia to Europe and North America by medical tour-ists.17 Given their infectious nature, these diseases impactboth the medical tourists and individuals at home withwhom they come into contact. MT can create new costsfor their home healthcare systems if patients requireexpensive follow-up care when upon return. For example,ten patients who had travelled abroad for bariatricsurgery created CDN$162,791 in costs to the Canadianhealth system when they sought care for complicationsfor their surgeries after returning home.18 In this way,patients who opt out of their local health systems and payout of pocket for their care may still create considerablecosts for their local health systems. Moreover, if compli-cations from surgery abroad require emergency interven-tions, they may get priority for care over other patients.Providing this follow-up care is particularly difficult,as medical tourists’ regular physicians often have inad-equate information about the procedure performedabroad.19 This situation also raises legal issues for doctorswho are concerned they may be held responsible for post-operative complications arising from these surgeries.Such concern is not out of line given that leading MT hostcountries typically have weak malpractice laws, which isone of the ways that prices are kept low for internationalpatients.20

More speculatively, MT has been charged with con-tributing to the privatization and commodification ofhealth care.21 By allowing privileged persons (i.e. thosewith financial capital) to seek medical care abroad, theindustry may serve to undermine pressure for structuralchanges in the patient’s home country. Whereas theseprivileged patients might have lobbied for reforms athome, MT allows them to opt out of some aspects of theirlocal healthcare infrastructure, thus undermining the

solidarity needed to maintain or create adequate fundingfor health care.22 In these ways, the option of goingabroad for medical care for the privileged members of acommunity may undermine the status of health care as afundamental human right for all citizens over the longterm if sufficient numbers of patients engage in MT.

Third, critics charge that MT undermines access tohealth care in host countries. MT can contribute to atwo-tier medical system, with foreigners and wealthycitizens receiving a higher standard of care than poormembers of the host country.23 It can also underminepublic health goals by encouraging ‘cream skimming’ forpatients and crowding out the local population.24 Thistwo tier effect has been documented in countries such asIsrael where foreigners get preferential access to care atthe expense of local citizens; this situation is particularlyproblematic if regulations that would ensure that profitsfrom MT would cross-subsidize the public system arelacking.25 While these inequalities do not directly harmmembers of the host community, unequal access to healthcare and the unequal distribution of resources generallyhave been identified as social determinants of ill healthamong less privileged cohorts.26

Expansion of the private medical sector in host coun-tries can limit treatment options to private hospitals,which has been documented as increasing costs for treat-ment in Singapore and Malaysia.27 Moreover, develop-ment of the industry may result in doctors being shiftedfrom highly effective preventive medicine aimed at thedomestic population in favor of less effective and morecostly secondary and tertiary care services.28 Whiledefenders of the industry have argued that it will help toslow the brain drain of health workers abroad, MT maystill promote the internal migration of providers fromrural to urban areas, or movement from public to private

16 G. Pennings. 2007. Ethics Without Boundaries: Medical Tourism. InPrinciples of Health Care Ethics, R. Ashcroft, A. Dawson, H. Draper &J. McMillan, eds. Hoboken, NJ: Wiley: 505–510.17 V.A. Crooks & J. Snyder. Regulating Medical Tourism. Lancet 2010;376: 1456–1466.18 D.W. Birch et al. Medical Tourism in Bariatric Surgery. Am J Surg2010; 199: 604–608.19 I.K. Cheung & A. Wilson. Arthroplasty Tourism. Med J Aust 2007;187: 666–667.20 D.A. Forgione & P.C. Smith. Medical Tourism and Its Impact on theUS Health Care System. J Health Care Finance 2007; 34: 27–35; P.Mirrer-Singer. Medical Malpractice Overseas: The Legal UncertaintySurrounding Medical Tourism. Law Contemp Probl 2007; 70: 211–232.21 Turner, op. cit. note 14, pp. 109–131; Burkett, op. cit. note 1, pp.223–245.

22 Pennings, op. cit. note 15, pp. 505–510.23 R. Chanda. 2002. Trade in Health Services. Bulletin of the WorldHealth Organization 2002; 80, no.2:158–163; D. Woodward, N. Drager,R. Beaglehole and D. Lipson. 2002. Globalization, Public Goods andHealth. In Trade in Health Services: Global, Regional and Country Per-spectives. N. Drager, ed. Washington DC: Pan-American Health Orga-nization; L. Turner. First World Health Care at Third World Prices:Globalization, Bioethics and Medical Tourism. Biosocieties 2007; 2:303–325.24 Ibid.25 D. Even & M. Zinshtein. 2010. Haaretz Probe: Israel Gives MedicalTourists Perks Denied to Citizens. Haaretz.com 18 November. Avail-able at http://www.haaretz.com/print-edition/news/haaretz-probe-israel-gives-medical-tourists-perks-denied-to-citizens-1.325275?localLinksEnabled=false [Accessed 1 Sep 2010].26 R. Wilkinson & K. Pickett. 2009. The Spirit Level: Why More EqualSocieties Almost Always Do Better. 2nd edn. London, UK: Allen Lane;M. Marmot. Social Determinants of Health Inequalities. Lancet 2005;365: 1099–1104.27 C.H. Leng. Medical Tourism and the State in Malaysia andSingapore. Global Social Policy 2010; 10: 336.28 A. Ramirez de Arellano. Patients Without Borders: The Emergenceof Medical Tourism. Int J Health Serv 2007; 37: 193–198.

Beyond Sun, Sand, and Stitches 3


practice health care.29 Another issue of concern is thatproviders trained in publicly-funded education systemsmay redirect the focus of their practice to internationalpatients, thus no longer treating those same citizens whofinancially supported their training through taxation.30

Finally, local taxpayers may also have to bear the bruntof tax incentives aimed at luring private hospital devel-opment. Whereas these incentives are often coupled withpromises of access to care for the local population, inIndia, at least, these promises have not always beenkept.31

The harms described above are the result of the actionsof large groups of individuals against a backdrop ofdomestic and global institutions that shape these actions.These harms result from many systems-level processes,including the migration of large numbers of healthworkers, health systems and policy choices of host anddestination countries alike, and the effects of thousandsof patients traveling abroad for care. Nonetheless, forindividual government officials, health sector workers,and individuals in need of medical care, among others, wecan ask whether it would be morally permissible to par-ticipate in MT if, in a given context, these harms out-weigh the potential benefits of MT.32 In order to addressthis question, we will now examine two alternative con-ceptions of individual responsibility for harms broughtabout by global practices like MT.

LIABILITY AND GLOBAL INJUSTICE

Given the harms that can be caused by MT, who shouldbe held responsible for having caused these harms?Moreover, who should take responsibility for preventingharms from continuing? A standard conception ofresponsibility maintains that we are morally responsiblefor the harms that we cause others, particularly when theeffects are intentional. In cases of intentional wrongdo-ing, the claim of liability for harms supports, amongother things, a remedial duty by the responsible agent tocompensate the victim for the harms caused. While theperpetrator may owe the victim much more than thisminimal duty of reparation, at the very least, all thingsbeing equal, the victim should be restored to the level ofwelfare he or she had prior to the action that caused theharm.

The liability model of moral responsibility is commonin cases where the causal action that brings about the

harm is proximate to the harm. But the basic logic thatone is liable for the harms to which one is causally linkedcan be applied to distant harms as well. Thomas Poggefollows this logic by extending the liability model ofresponsibility for harm to cases whose chains of causa-tion span the globe.33 In these cases, multiple agents arecausally responsible for harms to numerous others. Themechanisms by which these harms take place are typicallynon-proximate, spanning global institutions and realizedthrough multiple chains of causation. In many cases,these harms are actually the aggregation of multiple,smaller harms, some of which may be the result of actionstaken in the distant past.

In order to see how Pogge applies the causal modelof harm to global cases, we can examine one of hisexamples. He argues that the World Trade Organization(WTO) was designed in such a way that tariffs on manu-factured goods from LMICs are four times greater thanthose from rich countries.34 This disparity was created bythe superior technical knowledge and bargaining strengthof rich countries during the Uruguay Round of WTOnegotiations. This superior bargaining power extends toother international agreements, and allows for inequalityto emerge in the distribution of the benefits created bythese agreements. As a result, LMICs are systematicallydisadvantaged relative to rich countries, which in turndeepens international economic inequality and slows therate of development in LMICs.

Critics of Pogge observe that, even if internationalinstitutions are not entirely fair, LMICs still benefit fromtheir existence. Given the enormous increase in techno-logical and economic development in the past century, itis difficult to argue that LMICs would have been betteroff on their own, completely disconnected from thevenues for trade and assistance made possible by global-ization and increased development of international insti-tutions.35 Pogge, however, is clear that his argument isnot based on a comparison of the welfare of the globalpoor under the current global order to their welfare in aworld lacking international institutions. This comparisonrests on a false dichotomy, where the global order mustexist as it now stands or be cast aside completely. Pogge’spoint, rather, is that the present global order harms theglobal poor when we compare their present welfare tothat under a more just international order. Pogge is vagueon what a more just global order against which harmwould be measured looks like. This vagueness is in partstrategic as he seeks to set a minimal baseline for justicewith which as many people as possible can agree. Thisbaseline ‘merely requires that any institutional order

29 Chanda, op. cit. note 22.30 Pennings, op. cit. note 15, pp. 505–510.31 A.S. Gupta. Medical Tourism in India: Winners and Losers. Indian JMed Ethics 2008; 5: 4–5.32 Similarly, we can ask whether individual actors may or even have anobligation to participate in MT if the benefits of this practice outweighthe costs in a specific context. Our focus in this paper is on responsibilityfor the harms of MT, however.

33 T. Pogge. 2008. World Poverty and Human Rights. 2nd edn. Malden,MA: Polity Press.34 Ibid.35 M. Risse. Do We Owe the Global Poor Assistance or Rectification?Ethics Int Aff 2005; 19: 9–18.



imposed on human beings must be designed so thathuman rights are fulfilled under it insofar as this is rea-sonably possible.’36 The current institutional order,Pogge argues, does not meet this minimal condition andis, therefore, unjust by any reasonable measure. As thisunjust order was created and is maintained by rich coun-tries, their leaders are causally responsible for harmingthe average citizens of LMICs compared to a baseline oftheir welfare under a minimally just global order.

Pogge’s liability model of responsibility for globalinjustice has the virtue of clearly identifying agentsresponsible for the harms caused by global institutions.However, Pogge’s approach faces significant limitationswhen identifying responsibilities for global injustice.First, it is limited to those agents that have strong andclear causal roles in establishing the terms on which inter-national institutions are established. As we have seen, thiscausal focus in not problematic when placing responsibil-ity in the hands of entire Western governments and, spe-cifically, very powerful agents within them. However, it isnot clear what should be said of the causal responsibilityof the leaders and citizens of LMICs and less influentialcitizens in powerful countries. Second, Pogge’s approachfocuses on identifying blame for the effects of individualchoices rather than on steps that can reduce injustice. Inthis way, the liability model of responsibility is primarilybackward looking, focusing on the harms caused by dis-crete, past actions.37 The concern with this focus is that itfails to capture the ways by which structural injusticecreates systematic and ongoing disadvantages for somegroups. In the case of disadvantage caused by the struc-ture of the WTO, concern should not only be with theharms that have been caused by the negotiators for richnations. We should also be concerned, in a forwardlooking manner, with what actions should be takento reform the WTO and other unjust internationalinstitutions.

POLITICAL RESPONSIBILITY ANDGLOBAL INJUSTICE

Due to the limitations of the liability model of responsi-bility, Iris Young has developed what she calls a politicalresponsibility (PR) model. Young argues that, in additionto the responsibilities that can accrue from the causaleffects of one’s actions, we also take on responsibilities toothers by virtue of our social roles and relationships. ThisPR is generated by participation in a global social struc-ture that systematically disadvantages certain groups. As

Young puts it, ‘Our responsibility derives from belongingtogether with others in a system of interdependent pro-cesses of cooperation and competition through which weseek benefits and aim to realize projects. Even though wecannot trace the outcome we may regret to our ownparticular actions in a direct causal chain, we bearresponsibility because we are part of the process’.38 ThisPR model does not replace the liability model but, rather,augments it. In large-scale social interactions, wheredirect lines of causation are unclear and individualsimpact one another’s welfare in minute but systematicways, the PR model describes how one’s place in a politi-cal system generates responsibility that is distinct fromliability and generated by participation in a shared globalsocioeconomic order.

The PR model is predominantly forward-looking inthe way it directs individuals to discharge their responsi-bility. Rather than make up for the harms of past actions,politically responsible agents should join with others tocollectively reform unjust institutions. How this PR is tobe discharged depends on two sets of factors. First, giventhat PR is a collective responsibility, the actions ofindividuals will be constrained by the range of collectiveactions available to them. An individual wishing toreform the unjust working conditions in cocoa planta-tions, for example, may need to form a group to protestthese conditions or raise public awareness. depending onwhat actions have already been taken by others and whatinstitutions for channeling PR already exist.

Second, the shape of an individual’s PR will depend onher place within the unjust global order. Young arguesthat, given the many different unjust institutions to whichwe are connected and the many consequent responsibili-ties we face, each person has some discretion as to how todischarge the responsibility to reform the global institu-tional order. This does not entail that each individualhas complete freedom to determine when her PR is dis-charged, however. Rather, given the communal nature ofPR, one must be able to give a public accounting of heractions in discharging the shared PR. Young argues thatan agent’s position within unjust institutions is crucial todetermining PR. Specifically, Young cites one’s power orcapacity to initiate change within structural processes, thedegree to which one is privileged by or benefits from anunjust institution, one’s interest in reforming the institu-tion based on one’s own good or life projects, and thecollective ability of individuals to initiate reform as con-straints or enablers to contributing to structural change.

Young notes that an individual’s PR augments, ratherthan replaces, her liability responsibility. Even withinglobal trade frameworks that restrict individuals’ choicesand tie disparate people to one another across long causalchains, individuals can and will engage in harmful actions

36 T. Pogge. Severe Poverty as a Violation of Negative Duties. Ethics IntAff 2005; 19: 55–83: 56.37 I. Young. Responsibility and Global Justice: A Social ConnectionModel. Soc Philos Policy 2006; 23: 102–130. 38 Ibid.



that are best captured by the liability model. In a global-ized context, these forms of wrongdoing will most typi-cally take place directly between individuals rather thanbe mediated by global socioeconomic structures andlonger causal chains. That is, as the liability model is mostuseful for assigning responsibility when there is a clear,causal connection between a person’s action and a nega-tive consequence stemming from that action, this form ofresponsibility will tend to be restricted to more proximatecausal relationships that allow for the assignment ofliability.

LIABILITY AND MEDICAL TOURISM

When we turn to the task of assigning responsibility forthe potential harms of MT, the liability model of respon-sibility, though essential, describes only a limited aspectof this responsibility. The most plausible candidates forliability are those government officials who shaped, pro-moted, and passed into law the regulations that form thelegal backdrop for international trade in health services.This includes the WTO representatives that promotedliberalization of health services trade, host country offi-cials that promoted their own countries as destinationsfor medical tourists and failed to regulate the industryappropriately, and home country officials whose deci-sions (often inadvertently) helped bring about the condi-tions that have pushed patients into traveling abroadfor medical care. In each of these cases, distinct policychoices attributable to specific individuals have helped todevelop the background institutions that enable harmsthat, we have argued, can be associated with MT. Insofaras MT can be promoted in a manner that develops asustainable model of health care for both host and homecountries, these officials are liable for not doing so. Whenand if MT is empirically demonstrated to be inferior tomodels of health care that do not rely on internationaltravel for care, these officials are liable for promoting MTat the expense of models that promote better access tocare.

Although it may be satisfying to pin the blame for theharms of MT on specific government officials, even at thislevel the liability model shows its limits. The PR model ofresponsibility stresses that socioeconomic structures limitindividuals’ options. For government officials in LMICs,their choice to participate in international health servicestrade may be predetermined by a global economic systemthat impoverishes countries that do not participate in freetrade arrangements such as the WTO. These countriesmay also face heavy pressure to build their hard currencyreserves and reduce deficits based on International Mon-etary Fund structural adjustment programs. For theseofficials, engaging in MT may be the best of a range ofbad options constrained by the global economic system.

If so, the liability model will do a poor job of assigningresponsibility for the effects of these officials’ choices,even when they are the most powerful members of theircommunities.

When we turn to less powerful individuals, like thehealth workers engaged in MT, the liability model dem-onstrates its limitations even more clearly. One mightdraw a causal chain linking the decision of health workersto enter into private practice serving medical tourists to: alack of care in rural areas in host countries, labor short-ages in the public sector, and growing inequality betweenthe public system serving the domestic population andthe private system addressing the needs of wealthy for-eigners and local elites. While this causal connectionmight reasonably support some liability on the part ofhealth workers, it is problematic for two reasons. First,the causal chains between the decision of individualhealth workers to enter private practice and harms tocertain patients will be difficult to substantiate. Whilespecific government officials might be held accountablefor particular policy choices and their effects, the harmsof a two-tier medical system brought on, or exacerbated,by MT will have diffuse causes and effects. Second, theoptions available to individual health workers may beseverely constrained by poor working conditions, inad-equate compensation, discrimination, and a variety ofother factors pushing them out of the public sector.39

Even if a clear causal connection could be found betweenthe actions of individual health workers and harms toparticular patients, the unjust working conditions theyface cast doubts on whether these workers should be heldliable for their incremental contributions.

Medical tourists as a group can be found to be liablefor some of the harms associated with MT. By creating amarket for MT, they encourage health workers and gov-ernment officials in host countries to develop infrastruc-ture for the industry, potentially at a cost to domesticaccess to health care. Moreover, medical tourists help torelieve some pressure for health reform in their own coun-tries by seeking care abroad. While MT serves as a solu-tion to wait-time problems and inadequate care for thosepersons with the means to engage in it, the underlyingshortcomings in their home healthcare systems willremain for those unable to afford to go abroad. It is moredifficult, however, to assign liability for harms to indi-viduals in host countries to specific medical tourists. Aswith health workers in host countries, the lines of causa-tion are unclear and attributions of liability feel unnatu-ral. Just as health workers face unjust constraints on theirdecisions, patients who decline to participate in MT maybe left with lengthy waiting times or unaffordable costs

39 A. Astor et al. Physician Migration: Views From Professionals inColombia, Nigeria, India, Pakistan and the Philippines. Soc Sci Med2005; 61: 2492–2500.



for essential medical treatment, thus unjustly constrain-ing the range of options available to them.

The PR model of responsibility is able to acknowledgestructural limitations placed on the choices of the partiesinvolved in MT while still assigning responsibility foraltering the potentially unjust institutional structure gov-erning the industry. As we have noted, the PR modelholds that each individual’s context helps to determineher PR, and therefore it is not possible to give detailedguidelines for each person’s PR independent of thiscontext. However, we will discuss the PR of governmentofficials and health workers in general terms beforeproposing a decision-making structure for individualpatients considering engaging in MT in LMICs.

POLITICAL RESPONSIBILITY ANDMEDICAL TOURISM

As we have noted, policy makers, both in source and hostcountries, are the most reasonable targets for liabilityresponsibility for the harms of MT. But the PR modelwill also assign responsibilities for reform of the presentsystem of health services trade to these officials on top oftheir liabilities. Going forward, policy makers in bothsource and host countries should develop bilateraltrade agreements to ensure that the health needs of themembers of both communities are served by MT. Theseagreements could mimic bilateral agreements regardinghealth worker recruitment, where the movement of healthworkers from LMICs to high income countries has insome cases been regulated to reduce the harms from theloss of these workers.40 In the realm of MT involvingpatients traveling to LMICs, intermediaries like MTfacilitators or private insurance companies, and/orhost country governments and health systems could berequired to pay a public infrastructure development taxthat must remain in the host country and be used todevelop and maintain its public health care system. Thistax could help cross-subsidize the public health sectors ofdestination countries and counter the concern that theprofits of MT will simply go abroad to internationalinvestors or remain with wealthy elites, thereby exacer-bating inequality.

Certain ethical issues linked to MT could be mitigatedby requiring that health workers moving to the privatesector also spend time within the public health system,either by splitting time between the two sectors or bytraining public sector workers. These policies would

mirror proposals to make international health workermigration more sustainable.41 This strategy acknowledgesthat individual health workers have a PR to mitigate theharms of moving into a private health sector that con-tributes to two-tier care within their home communities.As the large-scale shift of highly trained health workersfrom the public to the private sector can create an internalbrain drain, these workers should also seek means oftraining workers who can serve within the public sector.These steps may mitigate some of the harms of MT, buthealth workers need also to advocate for policy changesthat will enable less ethically problematic MT. Whilehealth workers may lack the power of policy makers inregulating the industry, their voices may carry a specialweight in policy debates, given their familiarity with andprofessional responsibility to the healthcare system. Forexample, professional groups representing specific healthprofessions, such as the American Medical Association,have been influential in past public policy debates. There-fore, these workers must ensure that, singly and as agroup, they encourage industry regulations that willdirect the resources gained through MT toward theprivate and public sectors of their communities. Policychoices, such as creating a public infrastructure develop-ment tax or requiring health workers to contribute to thepublic system, acknowledge that MT is not inherentlyharmful to LMICs and might actually contribute to theirhealth systems, but only if the industry is regulated toencourage sustainable and ethical practices.

A patient decision-making process for ethicalmedical tourism

International patients have a responsibility to engage informs of MT that, if possible, benefit rather than harmLMICs and to advocate for the regulation of the industryby their government representatives. Along these lines,we would like to propose a decision-making process forpotential medical tourists and, in light of this process,suggest future areas for research. This process is visual-ized in Figure 1. First, the patient should determine if thetreatment entails participation in a structure for trade inhealth services that is on balance harmful to the membersof the host community, her own community, or to anyother relevant groups. If not, the patient should feel freeto proceed with the treatment. That is, if the person is notparticipating in a harmful form of MT, then there is norelevant PR created through her actions. As we notebelow, this step is very demanding in the largely unregu-lated MT industry and points to the need for ethical40 United Kingdom Department of Health. 2004. Code of Practice for

the International Recruitment of Healthcare Professionals. UnitedKingdom: United Kingdom Department of Health; L.O. Gostin.Meeting Basic Survival Needs of the World’s Least Healthy People:Toward a Framework Convention on Global Health. Georgetown LawJ 2008; 96: 331–392.

41 B. Séguin, P.A. Singer & A.S. Daar. Science Community: ScientificDiasporas. Science 2006; 312: 1602–1603; J. Connell et al. Sub-SaharanAfrica: Beyond the Health Worker Migration Crisis? Soc Sci Med 2007;64: 1876–1891.



Figure 1. Proposed Patient Decision Making Model for Involvement in Medical Tourism.



labeling of MT destinations and facilitators who arrangefor travel for these patients.42 Such labeling, akin to thatoffered for apparel and certain food items, is currentlylacking and would require the development of indepen-dent labeling agencies, whether through governmentagencies or non-governmental agencies.43

Second, the patient should determine if the treatment isessential to her physical and/or mental health. We do nothere attempt to define essential health and we understandthat non-essential and essential health care rest on a con-tinuum, with many treatments resting in an indeterminategray area. Nonetheless, some treatments will clearly benon-essential to the health of the patient. In these cases,participation in a harmful MT structure is not necessaryto meet the patient’s basic needs and should be avoided.Demand for non-essential procedures, such as someforms of cosmetic surgery, can undermine access to essen-tial services by encouraging physicians to train in non-essential areas, drawing trained health workers fromprimary care to non-essential areas, and by encouragingbrain drain from public to private health systems; theseproblems are particularly acute if human health resourcesare already inadequate in the community.44 If the patientwishes to pursue a non-essential procedure, then thatindividual must do so in a way that will not contribute toharms to others, even if seeking care domestically resultsin greater expense. This can be compared to a responsi-bility to purchase luxury goods such as coffee or runningshoes from suppliers who treat their employees ethically.

Third, if the patient is seeking essential care and doingso will require participation in a harmful MT system, thepatient must discharge her PR by first seeking to mitigatethe harm to others. This step may be completed byseeking the least harmful forms of MT available orchoosing to use the services of providers who do the leastharm to their home communities. Patients whose post-operative care will fall to their local healthcare systemshould also take steps to arrange for this care with theirhome country doctor and to facilitate continuity of carefollowing travel abroad by ensuring the transfer of healthrecords between countries. Even if less harmful MTplaces burdens on the patient in terms of higher costs orless convenient travel, these burdens must be balancedagainst mitigating the harms that more convenient MTcauses other parties connected to a global trade in healthservices.

Fourth, having participated in and benefited from aharmful system of MT, the patient has a PR to worktoward structural change. The shape of this PR willdepend on the patient’s context, and so we must speak ingeneral terms. Any patient traveling from a democratichigh-income country will have a responsibility to lobbyfor changes in how that government participates in MT,including lobbying for the development of ethical bilat-eral health services trade agreements and reforming thedomestic health care system to lessen the need for travelfor care. The power of the average citizen to influencegovernment policy is limited, and so individual medicaltourists should look to their collective ability to initiatechange. Where lobbying groups already exist, all thingsequal, the medical tourist should join these efforts. Wherethese groups do not exist, the medical tourist has aresponsibility to help organize the efforts of others. AsMT for essential health care confers an enormous benefiton patients and their interest in receiving timely andaffordable essential medical care is great as well, the PRto organize for policy changes may be sizable. Thestrength of the PR will be mitigated by the degree towhich the patient was able to seek medical care that wasminimally harmful to other persons and the degree towhich the patient is otherwise connected to the commu-nities she has affected.

The above sketch of the PR of medical tourists shouldmake clear that MT should not be engaged in lightly andthat these individuals have a responsibility to limit thenegative impact of their actions on others through unjustsystems of trade in health services. While we do notbelieve it is unreasonable to ask patients to consider theimpact of their health care choices on others, a dearth ofinformation on the impact of MT will severely limit theability of patients to discharge their PR as it has beendescribed. As we have observed, many accusations havebeen made as to whether MT is a harmful or beneficialpractice. These arguments are poorly backed by empiricalresearch or other forms of evidence and there is a greatdeal of confusion as to both the short- and long-termeffects of MT on participating communities. The mostlikely scenario is that MT can and will develop in waysthat will benefit host and source communities of medicaltourists alike, both absolutely and in terms of its impactson access to care. At the same time, MT will also developin ways that exacerbate inequalities both at home andabroad and we cannot know in advance which pathspecific host countries and their health care facilities willtake.

We have argued that potential medical tourists, if theyare to behave responsibly, must educate themselves as tothe impact of their actions on a variety of stakeholders.But this task will be impossible if more information is notmade available with which patients can make these judg-ments. What is needed is a way to guide more ethical

42 Calls for better regulation and accreditation of MT facilitators areincreasing. See 1. Turner LG. Quality in Health Care and Globalizationof Health Services: Accreditation and Regulatory Oversight of MedicalTourism Companies. Int J Qual Health C. 2011; 23:1–7.43 See for example N. Eval. Global Health Impact Labels. In GlobalJustice in Bioethics. E. Emanuel & J. Millum, eds. New York, NY:Oxford University Press.44 F. Pasquale. Access to Medicine in an Era of Fractal Inequality. AnnHealth Law 2010; 19: 269–441.



participation in MT by rating communities and hospitalson their impact on access to health care and the distribu-tion of health care resources. Just as the ethical rating ofproducts such as coffee and shoes has been developed intheir global trade, ratings of the health equity impact ofMT providers must be developed.45 It is important tonote, however, that health equity impact ratings are enor-mously complex, though more sophisticated guidelinesfor these measures are being developed.46 Nuanced andcontext specific ratings will be necessary in order toprovide accurate and useful information. While MT com-panies and other groups with vested interests in the indus-try have used websites to make information about MTavailable to potential customers, this information mustbe augmented by less clearly biased sources such asgovernment health agencies and non-governmental orga-nizations if it is to be of reliable use in patient decision-making.47 Doing this also requires educating potentialmedical tourists about the limits to access to health carein host countries and the types of actions and activitiesthat exacerbate them. The first priority for medical tour-ists to discharge their PR, in the face of uncertainty aboutthe effects of engaging in MT, should be to pressurize MTfacilitators, providers, and interested non-governmentalorganizations to develop these ratings. Until they aredeveloped, potential medical tourists will be unable toassess the effects of engaging in MT or mitigate theirparticipation in harmful forms of MT and in this sensewill be traveling blind.

While creating and maintaining ratings of MT pro-viders and facilitators will not be a simple task, it is anessential one and a vital information source that highincome countries wishing to use MT as a solution to theirown health care problems should embrace. Some MTproviders have already pushed for accreditation of theirhospitals from respected international bodies in order toassure patients of the quality of their services.48 This pushfor accreditation is a business and marketing tool, meantto increase the supply of potential patients. If patientsmake clear that they will no more participate in unsafeMT than they will in unethical MT, then the developmentof health equity impact ratings will also become a busi-ness and marketing tool, smoothing the way to a more

responsible MT system that can potentially lessenunequal access to health care in both LMICs and highincome countries alike.

CONCLUSION

We have observed that the practice of MT has createddocumented harms for a range of stakeholders. Other,potential harms have been speculated. These negativeeffects, especially if outweighed by the potential positiveeffects of MT raise questions about how responsibilityfor these harms should be assigned, a common problemin global trade practices. This paper represents a firstattempt to answer this question in the literature on MT.We argued that a liability model of responsibility, whileapplicable to some actors, should be augmented by aPR model. After discussing the liability and PR of gov-ernment officials and health workers in general terms,we developed a decision making model for individualpatients. As this model relies on the ability of individualsto make judgments as to whether their engagement in MTwould harm others, it creates a strong case for continuedresearch on the effects of MT in specific contexts and thedevelopment of rating and accreditation systems for spe-cific MT destinations, providers, and facilitators. Thispush for greater transparency on the effects of MT shouldcome from all MT stakeholders including, as this paperargues, potential medical tourists themselves.

Acknowledgements

This work was supported through a Catalyst Grant from the CanadianInstitutes of Health Research.

Jeremy Snyder is an Assistant Professor in the Faculty of Health Sci-ences at Simon Fraser University in Burnaby, British Columbia. Hisresearch interests encompass ethical issues related to public and popu-lation health, including medical tourism, health worker migration, lowwage labour, ethical issues in human subject trials, and the concept ofexploitation.

Valorie Crooks is Associate Professor in the Department of Geographyat Simon Fraser University (Canada). She specializes in health geogra-phy. Her main research focus is on health care and services.

Paul Kingsbury is an Associate Professor in the Department of Geog-raphy at Simon Fraser University. Specializing in social and culturalgeography, his research draws on the theories of Jacques Lacan andFriedrich Nietzsche to examine multiculturalism, consumption, power,and aesthetics.

Rory Johnston is a graduate student in the Department of Geography atSimon Fraser University in Burnaby, British Columbia. He is studyinghealth geography, with his graduate research focusing on medicaltourism in the Canadian context.

45 Eyal, op. cit. note 42.46 S. Simpson et al. Equity-focused Health Impact Assessment: A Toolto Assist Policy Makers in Addressing Health Inequalities. EnvironImpact Assess 2005; 25: 772–782.47 N. Lunt, M. Hardey & R. Mannion. Nip, Tuck and Click: MedicalTourism and the Emergence of Web-Based Health Information. OpenMed Inform J 2010; 4: 1–11.48 Herrick, op. cit. note 9.



BEYOND SUN, SAND, AND STITCHES: ASSIGNING RESPONSIBILITY FOR THE HARMS OF MEDICAL TOURISM

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