Introduction

On June 24–25, 2010 a conference was convened in Vancouver, Canada to discuss ethical issues in the growing field of medical tourism (MT).Footnote 1 The International Conference on Ethical Issues in Medical Tourism (ICEMT) included participants from six countries and representatives from academia, government, industry, and non-governmental organizations. MT involves travel across international borders with the intention of receiving medical care that is typically paid for out-of-pocket, though exact definitions vary. MT raises a range of ethical concerns, including its effects on destination countries (e.g., exacerbating health inequities); on source countries (e.g., creation or entrenchment of two-tier medical systems); and on patients (e.g. discontinuity of care) (Turner 2007; Pennings 2007; De Arellano 2007).

We co-organized (Snyder and Crooks) and gave a keynote presentation at (Turner) ICEMT. In this report, we draw three lessons for research on MT through synthesizing presentations and reflecting upon central themes explored during ICEMT. While MT raises distinct ethical issues, it has much in common with other topics in medical ethics where new practices and technologies—especially in the absence of regulatory protections—are rapidly being embraced. Because of this, the lessons observed here arguably are applicable beyond MT research specifically.

The Potential for Cross- or Inter-disciplinarity

Calls for cross-disciplinary (disciplinary perspectives remain distinct) and inter-disciplinary (disciplinary perspectives are fused) approaches to scholarship are increasingly being made within health research (Nair et al. 2008). For example, the Ethics Director at the Canadian Institutes of Health Research—the main ICEMT funder—recommends broadening the scope of ethics research through the involvement of investigators from multiple disciplines (Trevor-Deutsch 2006). While researchers from “traditional” ethics disciplines (e.g., law, philosophy, bioethics) attended ICEMT, so too did scholars from a variety of other disciplines (e.g., sociology, anthropology, business) and sectors (e.g., industry, health policy, health services). A contributing factor to this diversity was likely our circulation of conference information beyond traditional ethics channels. In effect, the conference fostered a dialogue across disciplines. That this happened serves as a promising sign that ethics research in MT has the potential to develop a cross- or inter-disciplinary dimension.

It was evident from the conference, however, that challenges remain in instilling a cross- or inter-disciplinary paradigm in scholarship on ethical issues in MT. A significant challenge pertains to the integration of ethical frameworks and arguments in research on this issue. Presenters who seemed to lack familiarity with current bioethics scholarship, while offering valuable insights from their base disciplines, had a tendency to use simplistic ethical concepts and often lacked persuasive moral reasoning. On the other hand, those trained in normative modes of enquiry sometimes used dense frameworks to make points that could not be effectively followed by those without specialized training. The tension here is between producing ethics-focused knowledge on MT that is broadly accessible versus producing knowledge that is theoretically robust. For those engaged in research on the ethics of MT, this tension must be recognized and addressed if scholars are to produce work that is truly cross- or inter-disciplinary.

Interestingly, the tension between robustness and approachability at ICEMT seemed to be best overcome during question periods following presentations, when attendees engaged in dialogue to further understand the scope of ethical issues in MT in both an approachable and meaningful way. This suggests that a “way ahead” in this and other related areas of scholarship might be to engage scholars in dialogues across disciplines at the outset of new studies and analyses in order to work towards effectuating cross- or inter-disciplinarity.

The Role of Empirical Research in Advancing Normative Analysis of MT

One important reason to promote cross- or inter-disciplinary approaches to MT is that normative analysis benefits from incorporating empirical research when developing arguments about the ethical significance of particular issues. At present, though it is possible to identify numerous ethical concerns related to MT, it is difficult to offer firm normative conclusions or policy recommendations because few studies explore its local, national, and transnational consequences.

Three areas of research at ICEMT demonstrated the value of integrating empirical research into ethical discussions of the effects of MT. First, numerous scholars at ICEMT expressed concerns about the quality of care medical tourists receive while abroad. Case reports reveal that some patients require treatment after receiving substandard care or acquiring infections at destination facilities (Birch et al. 2007; Cheung and Wilson 2007; Newman et al. 2005). However, these reports are of limited value because patients can experience negligent care both at home and abroad. Quantitative data comparing patient outcomes at home and abroad are needed to assess quality of care for medical tourists. Second, scholars from many disciplines are concerned that MT undermines health equity (Meghani forthcoming; Mudur 2004; Sen Gupta and Nundy 2005). To date, however, few studies analyse consequences of MT for health equity, public health, and health care systems in destination nations. Presentations by social scientists at ICEMT suggested that, as their research programs advance, it will be possible to develop more empirically-informed accounts of the public health effects of MT. Third, several presentations at ICEMT examined how MT is marketed by destination hospitals, companies, and government agencies. Studies examining images and messages found in promotional literature and on websites will illuminate how businesses promote MT to specific clienteles. Given the value bioethicists place upon informed consent and disclosure of risks and benefits of treatment, researchers addressing the ethics of MT will benefit from studies examining how MT “packages” are promoted to international patients.

Careful normative analysis will benefit from empirical research into individual, social, economic, health system, and public health effects of MT. Conference presentations demonstrated the importance of investigating social and economic contexts when engaging in ethical deliberation and considering how moral norms should be interpreted, weighed, and specified in particular settings. Insofar as ICEMT demonstrated the possibility of cross- or inter-disciplinary collaboration in MT research, these partnerships can help to integrate the findings of more theoretically and empirically oriented researchers.

The Need for Integration Between Population- and Individual-level Ethical Analyses

Ethical analyses of medical practice have traditionally emphasized the physician or researcher’s role in protecting the rights of individual patients and research participants (Bayer et al. 2007). In practice, traditional bioethics has emphasized the value of autonomy above other ethical values (Upshur 2002). Over the last decade, there has been a movement to expand the scope of medical ethics to more explicitly consider ethical issues affecting populations. Current work on public or population health ethics acknowledges the significance of respect for autonomy while also giving considerable emphasis to consequentialist frameworks and social justice (Beauchamp and Steinbock 1999; Kass 2001).

The rise of “public health ethics” to counter the alleged biases of individual-level “bioethics” has produced a clash of ethical models. This divide was witnessed at ICEMT. Numerous presentations focused squarely on the ethical perspective of individual patients, including talks on reproductive, organ, and stem cell tourism, and presentations by MT brokers who specialize in making arrangements for international patients. Others examined the effects of MT on health equity and entire health care systems, including presentations using a social justice lens and a pair of presentations by medical anthropologists that traced the changes in health care practice encouraged by MT. While not all of the presentations fell neatly into one or the other of these camps, the divide between population and individual-level concerns reflected a broader discussion concerning how to resolve the needs of individual medical tourists (including wait times for care, high costs of health care, and limited access to interventions) with population-level effects (including, possibly, undermining health equity in source and destination countries alike).

While the development of public health ethics has frequently resulted in language that sets its concerns in opposition to those of traditional bioethics, an adversarial approach is not necessary. Rather, the concerns of public health ethics, including a focus on social justice and population-level perspectives can serve as a complement to an interest in patient perspectives and the value of autonomy (Coggon 2010). In the context of MT, ICEMT presentations revealed that we face a range of difficult ethical dilemmas that require individual patients to seek health care in a context where doing so may require them to take part in unjust institutions and practices. Resolving these conflicts does not require a blinkered focus on populations or individuals but an encompassing ethical framework that takes both perspectives into account.

Conclusion

The three lessons we draw from ICEMT are not only applicable to MT. The practice of medicine is increasingly globalized, with infectious disease, human subject research, and health worker migration among many other cases, each raising distinct ethical questions in a global context (Green et al. 2009; O’Neill 2002; Petryna 2009; Selgelid et al. 2006). We believe that, as is the case with MT, these areas of ethical concern all require interdisciplinary co-operation, and must engage with empirically driven approaches and also be responsive to both population and individual-level ethical concerns. As we observed from the conference, research of this kind is challenging, but these challenges are surmountable.