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Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists… Snyder, Jeremy; Dharamsi, Shafik; Crooks, Valorie A Apr 6, 2011

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DEBATE Open AccessFly-By medical care: Conceptualizing the globaland local social responsibilities of medical touristsand physician voluntouristsJeremy Snyder1*, Shafik Dharamsi2 and Valorie A Crooks3AbstractBackground: Medical tourism is a global health practice where patients travel abroad to receive health care.Voluntourism is a practice where physicians travel abroad to deliver health care. Both of these practices often entailtravel from high income to low and middle income countries and both have been associated with possiblenegative impacts. In this paper, we explore the social responsibilities of medical tourists and voluntourists toidentify commonalities and distinctions that can be used to develop a wider understanding of social responsibilityin global health care practices.Discussion: Social responsibility is a responsibility to promote the welfare of the communities to which onebelongs or with which one interacts. Physicians stress their social responsibility to care for the welfare of theirpatients and their domestic communities. When physicians choose to travel to another county to provide medicalcare, this social responsibility is expanded to this new community. Patients too have a social responsibility to usetheir community’s health resources efficiently and to promote the health of their community. When these patientschoose to go abroad to receive medical care, this social responsibility applies to the new community as well. Whilevoluntourists and medical tourists both see the scope of their social responsibilities expand by engaging in theseglobal practices, the social responsibilities of physician voluntourists are much better defined than those of medicaltourists. Guidelines for engaging in ethical voluntourism and training for voluntourists still need betterdevelopment, but medical tourism as a practice should follow the lead of voluntourism by developing clearernorms for ethical medical tourism.Summary: Much can be learned by examining the social responsibilities of medical tourists and voluntouristswhen they engage in global health practices. While each group needs better guidance for engaging in responsibleforms of these practices, patients are at a disadvantage in understanding the effects of medical tourism andorganizing responses to these impacts. Members of the medical professions and the medical tourism industry musttake responsibility for providing better guidance for medical tourists.BackgroundThe concept of social responsibility has been influentialin guiding professionals’ conduct, including in business[1,2], law [3,4], and medicine [5,6]. We understandsocial responsibility to entail the claim that an individualor group of individuals has a moral responsibility topromote the welfare of the communities to which theybelong or with which they interact [6,7]. For businesses,for example, corporate social responsibility is the claimthat corporations have a responsibility to promote thewelfare of the communities with which they do business,including providing a living wage to their employees,operating in an environmentally sustainable manner,and ensuring that some of their profits benefit commu-nity stakeholders [8]. Similarly, lawyers have not only afiduciary responsibility to their clients, but also, as mem-bers of a profession, are obligated to engage in pro bonolegal work that aids community members who areunable to pay for their services [9]. And for members ofthe medical profession, there have long been calls for* Correspondence: jcs12@sfu.ca1Faculty of Health Sciences, Simon Fraser University, Blusson Hall 11300,8888 University Drive Burnaby BC, CanadaFull list of author information is available at the end of the articleSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6© 2011 Snyder et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.physicians to look beyond the good of their ownpatients and act also to promote health within theircommunities [10].Typically, calls for social responsibility focus on anobligation to promote domestic welfare. However, asindividuals participate in more globally-oriented prac-tices, the scope of the targets of their social responsibil-ity expands. This phenomenon is evident in thecorporate social responsibility literature focusing onmultinational corporations [8,11]. For multinational cor-porations, their social responsibility is not dischargedsimply by benefiting the communities in which theircorporate headquarters are located. Rather, they mustalso ensure that stakeholders in all of the communitiesin which they operate benefit from their operations andthat these benefits are sustainable over the long term. Inpractical terms, this might mean that multinationals thatoutsource manufacturing from their home countriesmust ensure that they pay a living wage to foreign-basedworkers, refrain from polluting foreign communities,and spread some of their profits both at home andabroad [12,13].In this article, we explore the social responsibility ofthe participants in two global health care practices:voluntourism (travel abroad by physicians to delivermedical care) and medical tourism (travel abroad bypatients to receive medical care). The terms ‘voluntour-ism’ and ‘medical tourism’ can both be seen as pejora-tive and normatively loaded given the connotation thateach involves a frivolous, touristic element. For this rea-son, for example, some members of the medical tourismindustry prefer labels such as ‘medical travel’ or ‘globalhealth care’. We use the terms ‘voluntourism’ and ‘medi-cal tourism’ here because they are widely recognized andused in the academic literature. We do not intend toimply by the use of these labels that either practice isinherently morally problematic or any other relatednegative value judgments. While both of these groupsshare many attributes [14], we understand them to bedistinct phenomena practised by different groups. Wespecifically aim to explore the nature of the socialresponsibilities of these two groups and to drawtogether parallels and distinctions that can be used toassist with articulating wider trends regarding socialresponsibility in global health care practices. In doingthis we extend the traditional professional-centric focusof the social responsibility literature to consider thetypes of responsibilities inherent in the practice of medi-cal tourism for international patients. While medicaltourists travel from both developed and developingcountries and represent a diverse range of income levels[15], we focus on the social responsibilities of relativelywealthy patients from high income countries in order todraw a parallel between the relative privilege of thesepatients and that of physician voluntourists travelingfrom high income countries. As we argue below, thebetter defined social responsibility of physicians enga-ging in voluntourism holds lessons for the rapidly devel-oping practice of medical tourism. To accomplish ouraim, we first provide an overview of the global practicesof voluntourism and medical tourism, and then move toarticulate the social responsibilities of voluntourists andmedical tourists separately, focusing on the basis fortheir social responsibility and the targets of this respon-sibility. We then offer a discussion that compares thesetwo groups, looking for overlaps and distinctive ele-ments in their social responsibilities.Global Health Care Mobilities: Introducing Voluntourismand Medical TourismRecent years have witnessed the emergence of newforms of global health care mobilities, and increasedpopularity of existing forms due to processes such asthe development of a globalized economy, establishmentof international and bi-lateral trade agreements, andexpansion of the international travel industry [16-18].Patient mobilities (the movement of patients acrossinternational borders for service use) and providermobilities (the flow of health care providers across inter-national borders for service delivery) are two importantforms of international health care mobility. These mobi-lities take many forms and involve flows between analmost endless number of home countries and destina-tion nations. Provider mobilities can include permanenthealth worker migration and short-term relocation toenhance skills through training abroad [16,19], whilepatient mobilities can include accessing arranged cross-border care through referral and obtaining emergencycare while abroad [17,20]. In the remainder of this arti-cle we focus on two specific forms of patient and provi-der mobility. Physician voluntourism and patientmedical tourism are international health care mobilitiesthat are both characterized by temporally-limited timeabroad and engagement in a minimum of two healthcare systems, either as a user or provider.Global health disparities and inequitable access tohealth care in developing countries is an ongoing con-cern for many physicians. For instance, sub-SaharanAfrica has close to 25% of the global disease burdenbut has only 3% of the global healthcare workforce[21]. Globalized processes have enabled physiciansfrom around the world, and particularly from highincome countries, to participate in humanitarian “med-ical missions” to developing countries to administermedical care as physician volunteers [22]. Physicianparticipants in these missions see themselves as part ofa long-standing humanitarian tradition in medicine ofbringing desperately needed medical care to vulnerableSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 2 of 14communities in developing countries. The popularityof medical volunteering is on the rise, with over 500medical mission organizations in the United Statesalone that help to organize over 6000 short-term mis-sions to foreign countries [23]. Medical students arealso enrolling in increasing numbers to participate asvolunteers in global health initiatives during theirtraining. Current figures suggest that close to 30% ofgraduating North American medical students havetaken part in a global health project [23]. Yet, there isalso growing concern around the lack of ethical guide-lines supporting medical missions and volunteerismthat has resulted in the labelling of these terms as“physician voluntourism”, used pejoratively to describevolunteering as initiatives that can do more harm thangood [24-27]. Nevertheless, those who continue to par-ticipate in this practice see it as a social responsibilityand a form of global citizenship [28].Medical tourism, on the other hand, takes place whenpatients leave the country in which they live to pursuenon-emergency medical interventions abroad [20,29].The care accessed abroad is not part of an establishedcross-border care arrangement (e.g., does not involvephysician referral), and is typically paid for out-of-pocket [20]. Medical tourism is thought to be a popularoption for patients on wait-lists for care in their homesystems, who have no health insurance or are underin-sured, or who are looking to access experimental or ille-gal treatments [18,30,31]. A number of developingcountries, including India and Thailand, have becomeleaders in this international industry [32]. Unfortunatelyno reliable estimates exist regarding the number of peo-ple travelling abroad each year as medical tourists [29].Despite this, estimates regularly project growth in theindustry in the years to come [20]. With the growth ofthe industry have also come concerns regarding theimpacts it is having on destinations, particularly withindeveloping nations. An oft-repeated worry is that it willexacerbate health inequities in both the destination andhome country for medical tourists [20,29]. In the desti-nation country, if medical tourists drive demand forexpensive services, they may price out poorer citizens,or at least create a second tier of medical care in thosecountries [33,34]. Medical tourism may shift servicesfrom preventive public health measures to less effective,and more expensive, clinical interventions [35]. Thedevelopment of private clinics serving foreigners mayalso encourage the movement of trained physiciansfrom the public to private sphere [33,35]. On the otherhand, proponents of medical tourism note its potentialto cross-subsidize health care in the public sphere [36],though some of these agreements have been violated inpractice [37].FindingsPhysicians’ Social Responsibility in VoluntourismPhysicians have long embraced a fiduciary duty to man-age and protect the health of patients, over and abovetheir own self-interest. This fiduciary relationship playsa foundational role in medicine, and is founded on prin-ciples such as fidelity, integrity, compassion, courage,altruism, and justice [38]. The concept of social respon-sibility is informed by these principles, and is one thatenables physicians to develop a public trust, and a pro-fessional identity around what it means to be a Doctorin society. There is a sense that modern day medicine isfailing to recognize its societal role [39] and failing toeducate physicians to meet the health care needs of adiverse society [20,40]. This situation is problematic as aphysician’s social responsibility to protect public interestis not an option, but a fiduciary duty that is entrustedto each and every physician, individually and collectively.It is based on the understanding that illness affects anindividual’s capacity to function as a productive andcontributing citizen, member of a family unit, and partof the socio-economic system. Health and health care,therefore, are regarded by many countries as concernsof society as a whole and not simply those who are ill.In the remainder of this section we explore the variousdimensions of physicians’ social responsibility and con-sider how they relate to their involvement in the globalhealth care practice of voluntourism.Physicians’ Social ResponsibilityOne manifestation of physician’s social responsibility isthe obligation to respond to inequities in health andhow health services are organized in their domesticcommunities. It requires physicians to be mindful ofresponsibilities beyond individualism, profit, and privateinterests. The first Code of Ethics, issued by the Ameri-can Medical Association in 1847, defines the duties ofphysicians to their patients, to each other, and to thegeneral public:As good citizens, it is the duty of physicians to be evervigilant for the welfare of the community, and tobear their part in sustaining its institutions and bur-dens: they should also be ever ready to give counselto the public in relation to matters especially apper-taining to their profession [41].Physicians are called upon to safeguard health systemsso that services are effective, efficient, equitable, andsustainable [42]. Social responsibility is not simply amatter of charity, but a moral commitment to thepatient that has been developed over centuries withinsocieties that have advanced the conception of medicineas a profession. Professional status cannot be claimedSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 3 of 14without public sanction [43-45]. For this reason, physi-cians are required to maintain very high levels of exper-tise and skillfulness, as well as virtuousness andtrustworthiness.The provision of health care as a social security mea-sure within an organized social system dates back toearly Egyptian and Greek civilizations where physicianswere hired by the state to treat its citizens withoutcharge [46]. In 1601, Britain passed the ElizabethanPoor Law, allowing for a general taxation system toensure medical care for the poor and infirm; and duringthe latter part of the Industrial Revolution several social,professional and religious associations or guilds alsocontributed a set sum of money voluntarily toward aform of protection that could provide assistance to itsmembers who became incapacitated due to illness [47].These early initiatives established a precedent regardingphysicians’ involvement in maintaining the social, orcommon, good beyond simply caring for their patients.The notion of health care as a common good, rootedin social and religious ideas of charity, beneficence andcompassion, is now recognized within the broader con-text of distributive justice, and the growing sensitivity tothe equitable distribution of health care [48]. Hence, inmedicine there is a growing reaffirmation that physi-cians have an obligation to the individual patient as wellas an enduring responsibility to the broader society [49],particularly when dealing with issues around resourceallocation, the social determinants of health, and relatedinequities. To this effect, the World Health Organizationsuggests that physicians need to be mindful of medi-cine’s social responsibility [50]. Hence, medical organiza-tions are called to direct their education, research andservice activities toward addressing the priority healthconcerns of each community, region and/or nation thatthey have a mandate to serve, and particularly the morevulnerable and marginalized segments of their popula-tions [51].Medical Voluntourism and Physician Social ResponsibilityThough discussions of physicians’ social responsibilitytend to focus on their responsibility to domestic com-munities, many medical students and physicians choosealso to participate in medical voluntourism abroad outof a sense of social responsibility [21,28,52,53]. Throughthe act of voluntourism, these physicians invest personaltime and resources toward reducing global healthinequities. However, the growth of medical voluntour-ism is also outpacing the development of physicians’social responsibilities toward communities abroad andethical guidelines to ensure that vulnerable communitiesare not subjected to more harm than good. Concernsabout the lack of guidance for voluntourists derive inpart from ethical tensions that emerge when researchprojects are conducted by researchers from high incomecountries in developing countries [24]. While host coun-try members appreciate some aspects of these volun-teers’ work, responses to voluntourism are mixed [54].A short-term clinical stint in a developing country canbe seen as nothing more than a glorified form of tour-ism wrapped in a veneer of altruism, with no sustainablebenefits for receiving communities [55-57]. Medical stu-dent voluntourists have also been criticized for usingvulnerable people in developing countries to practiceclinical skills, enhance résumés, and provide opportu-nities for travel to far-away and exotic places. Shah andWu [58] provide a compelling example of the possiblenegative outcomes of medical student voluntourismthrough sharing a student’s reflection:After finishing my first year of medical school, I par-ticipated in a mission trip to Mexico. Before flying toMexico, I was not given any cultural, medical, orother training, nor could I speak Spanish. Uponarriving, I was assigned to a clinic where there werehundreds of patients but only one physician. Iremember vividly seeing a frail 11-year-old boy withpolyuria, polydipsia and nocturia. My lack of medi-cal training limited my differential. With only a scat-tered history and no other tests, I told him to limitcaffeine intake and see if that helps. Thinking back,he could have had a urinary tract infection, anynumber of renal abnormalities, or worse, I sent himout without ruling out diabetic ketoacidosis. Andwhile I was seeing patients by myself, other first yearmedical students were performing surgeries in theother clinics and later bragging about it.The bragging by these students highlights the danger ofvoluntourism serving the needs of the voluntourist ratherthan the community abroad. Providing health care ininternational settings without carefully thinking aboutpatient safety, sustainability, cultural appropriateness,quality of care, and consultation with local healthcareproviders, among other similar issues, threatens to runcounter to rather than discharge physicians’ socialresponsibility abroad. Although participation in globalhealth initiatives has great potential to offer medical trai-nees and physicians the opportunity to discharge theirsocial responsibility [24], the risk of undesirable impactsfrom voluntourism can outweigh these benefits [59]. Vul-nerable communities can easily become a means to thevolunteers’ ends instead of serving first the community’sidentified needs and empowerment interests.Voluntourism is also often criticized for taking anexclusively charity-based approach to the provision ofmedical care, rather than enabling an equal and colla-borative partnership with communities for developingcapacity to address the root causes of systemic socialSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 4 of 14inequity and disparity [60]. Charity based activities arebased on the “good Samaritan” concept - providingresources, time, knowledge, and clinical service to vul-nerable people. This approach is not only difficult tosustain, it can also create a dependency relationshipthrough ‘band-aid’ solutions that do not address theroot problem of health disparities. This line of criticismof voluntourism parallels critiques centred on the com-mon establishment of temporally-limited selective pri-mary health care initiatives in developing nationsthrough aid programs, where a more community-centred intervention is thought to be the creation oflong-term comprehensive primary health care plans[61,62]. In relation to voluntourism, a sustainable andcommunity-centred approach requires physicians tofocus their efforts on understanding and working tochange the structural or institutional factors that contri-bute to inequitable conditions.The Association of American Medical Colleges’(AAMC’s) offers four foundational ethical considerationsprior to embarking on global health voluntourism: (1)ensuring high ethical and moral standards, (2) developinga social contract with the communities served, (3) subor-dinating self-interest to the interest of the communitiesserved, and (4) ensure that core humanistic values (hon-esty and integrity, caring and compassion, altruism andempathy, respect for self and others) are at the forefrontof all activities [23]. These ethical considerations point toa number of specific social responsibilities that physiciansinvolved in voluntourism hold, such as ensuring thatcompassionate and respectful care is provided that meetsthe highest ethical and moral standards that the contextallows for. What these guidelines lack are specific, con-crete strategies for enacting ethical, socially responsiblecare. The 4Rs that were developed by Aboriginal leadersin Canada to guide researchers in working with theircommunities, which are summarized in Table 1, offersome suggestions for specific strategies [63].Generally, socially responsible medical voluntourism isa collaborative process that considers the full participa-tion of local communities, local healthcare workers, andlocal health authorities [54]. It complements principles ofinternational solidarity and social capital within thecontext of civil society, where voluntourists act volunta-rily and without seeking personal profit to share benefits.Patients’ Social Responsibility in Medical TourismWhile patients do not form a professional group, withtheir own institutions, leadership, and codes of ethicslike physicians, there have been claims that individualpatients do have social responsibilities to their domesticcommunities. Much of the literature on patient respon-sibility has focused on the degree to which patients areresponsible for their own health [64]. This literatureseeks to determine the balance between personalresponsibility for health and the responsibility of com-munities for the health of their individual members.There is, however, some discussion of the responsibil-ities of patients to their domestic communities and totheir health care systems [65,66]. In the remainder ofthis section we articulate the hallmarks of patients’social responsibility and consider the specific types ofresponsibilities international patients hold when theyengage in medical tourism.Patients’ Social ResponsibilityPatients may have a sense of social responsibility due tohaving a sense of solidarity among the members of acommunity (e.g., other clinic users). Solidarity canrepresent a sense of togetherness and independencebetween individuals. Community members need not feelpersonally close or attached, but rather are part of a sys-tem that is valuable. These systems are made up ofshared institutions, an example of which is a health caresystem. For individuals, this sense of solidarity impliesnot simply that the individual receives benefits fromthese institutions, but that she also contributes back inkeeping with a value of reciprocity. In the context ofsolidarity around institutions that provide for the healthof a community, “people should not be only passiverecipients of services but should actively contribute toand try to avoid harming the system. This means thatthey should act responsibly when it comes to theirhealth and that it is justified to expect this to a certainreasonable degree” [66]. Without reciprocity, sharedinstitutions are unlikely to survive and the shared goodwill be lost. On this reading of personal responsibility,Table 1 The 4Rs of Ethically Sound ResearchEthicalPrincipleStrategyRespect Valuing cultures’ and communities’ diverse knowledges regarding health matters and developing knowledge that contributes tocommunities’ and cultures’ health and wellbeingRelevance Ensuring that research (or practice) is relevant to the culture and communityReciprocity Incorporating a two-way process of knowledge exchange and learning, where all parties benefit from these opportunities and thedevelopment of relationshipsResponsibility Fostering empowerment through allowing for active participation and rigorous engagement by all partiesSource: Kirkness & Barnhardt 2001 [63].Snyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 5 of 14looking after one’s own health and the efficient use ofpublic health care resources can be understood as anexpression of solidarity with community members. Inaddition to responsibilities for one’s own health, thepatient may also be said to have responsibilities to: (1)others, in the form of not harming others and meetingthe health needs of those under one’s guardianship; (2)the health care system, so that it may function fairly andefficiently and serve as many people as fairly as possible;and (3) the judicial authority, where patient responsibil-ities have been codified explicitly [65,67].Under public health care schemes, patients have aresponsibility to look after their own health for theirown sake, but also as a social responsibility to the othercontributors to the health system and to the health sys-tem itself. For example, the Romanow Report in Canadaincludes a proposed health covenant that lists a series ofresponsibilities for Canadians, including to “observegood health practices, and to promote and support thewell-being of their families and communities” and “touse the system prudently, and to support the systemthrough their actions and tax dollars” [68] (p.50). Simi-larly, the National Health Service (NHS) in Scotland dis-tributed a pamphlet called The NHS and You [69] thatdetails both the responsibilities of the NHS to itspatients and the responsibilities of patients to the NHS.These responsibilities are clearly directed toward thewider community and the system itself, as they are waysthat the patient can help “yourself, other patients, andNHS staff” [69] (p. 15). These responsibilities include:treating NHS staff considerately, keeping appointmentsand informing staff if an appointment must be can-celled, keeping contact information up to date, followingmedical advice, using emergency services appropriately,finishing any course of medications, and helping to stopthe spread of infection. The pamphlet also discussesother ways to help promote health, including by donat-ing blood, organs, and tissues and by volunteering withthe NHS. These responsibilities are intended to allowthe public system to operate more efficiently and betterserve the whole community.While the Canadian and Scottish examples above arenon-binding, a Medicaid member agreement in the USstate of West Virginia is binding on its members. Someof the responsibilities listed in this document areresponsibilities to look after the patient’s own health,though these responsibilities too can be construed as asocial responsibility to use public resources efficiently.Other listed responsibilities are more clearly injunctionsagainst inefficient use of public resources. These respon-sibilities include requirements to show up on time forappointments ("I will show up on time when I have myappointments” and “I will bring my children to theirappointments on time”), the responsibility to facilitatecontact with the Medicaid system ("I will let my medicalhome know when there has been a change in myaddress or phone number for myself or my children”),and the responsibility not to misuse emergency services("I will use the hospital emergency room only for emer-gencies”) [70]. Similarly, the state Medicare program inKentucky includes the interlinked goals to “1) Stretchresources to most appropriately meet the needs of mem-bers; and 2) Encourage Medicaid members to be person-ally responsible for their own health care” [71] (p.3). Aswith West Virginia, the Kentucky plan targets additional‘get healthy’ benefits to persons who document partici-pation in identified healthy practices.The guidelines shared above have been rightfully criti-cized as potentially shifting burdens onto the most vul-nerable members of society as Medicaid users in the USfall into the lowest income brackets [72,73]. These con-cerns can be addressed by noting that the patient’ssocial responsibility is coupled with society’s responsibil-ity to provide for community health and limited by thepatient’s capacity for choice. That is, we can describethe responsibilities of society to patients, particularly forthe social determinants of health, while at the sametime acknowledging the role of personal conduct notonly in personal health, but also in the functioning ofone’s health care system. This mutual responsibility forhealth admits of degrees just as an individual’s ability tocontrol her health varies depending on contextual fac-tors, including her position in her social hierarchy [65].Medical Tourism and Patient Social ResponsibilityIf medical tourists have a social responsibility to look tothe efficient functioning of their own domestic healthsystems, then participation in medical tourism willextend this responsibility to the health systems of thedestination countries to which they travel and developnew connections. Medical tourism for procedures thatwill serve to undermine health equity and the sustain-ability of the health system in destination countries istherefore a potential violation of the patient’s socialresponsibility. Crucially, however, many of the worriesabout the negative impacts of medical tourism on desti-nation countries are matters of conjecture rather thanwell-established fact [29]. Moreover, while manyinstances of medical tourism may exacerbate healthinequities, it is not clear that all forms of medical tour-ism are fated to do so. Medical tourists who wish toengage in forms of medical tourism that do not causethese negative effects for destination countries, then,will be faced with severe difficulty in assessing theeffects of their travel.Medical tourism has also been associated with nega-tive effects for the patient’s home country in terms oflessening equitable access to care. As medical tourismallows relatively wealthy patients to opt out of treatmentSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 6 of 14in their home health care systems, it may underminepolitical pressure for change as privileged patients areable to have their health care needs met abroad [74]. Ifso, less privileged patients who are less mobile will beleft in a lower tier of care at home. For publicallyfunded health care systems, the practice of paying out ofpocket for necessary medical services can also help toencourage the privatization of health services at home,which may also undermine health equity [75,76]. Aswith the negative effects of medical tourism on destina-tion countries, however, these concerns are mostly mat-ters of conjecture. While the patient may have a socialresponsibility not to travel abroad for care if doing sowill undermine efficiency and equity in her home sys-tem, she may not have the information necessary tojudge whether becoming a medical tourist will encou-rage these effects.Medical tourism can serve as a means for patients tosecure care more cheaply and quickly than if theyremain within their local health care systems. However,travelling abroad for care creates a series of risks for thepatient and long-term costs for the patient’s homehealth system [20]. Travel itself creates risks by hasten-ing the pace of care and surgeries and by increasing therisk of deep vein thrombosis or other complicationsfrom long plane flights [77]. Travel for care abroad canresult in negative health consequences if an experimen-tal treatment results in complications for the patient orother side effects [78]. While care abroad, even in lowand middle income countries, is often of very high qual-ity, poor oversight of facilities in some countries canresult in sub-standard care and therefore complicationsand the need for follow-up care for the patient [79].Patients receiving care abroad may also bring infectionsback home with them, including the NDM1 ‘superbug’that has been linked to medical tourists [80]. Finally,many forms of treatment require extensive follow-upcare even if the principle intervention is successful orcompleted without complications. If arrangements forfollow-up care in the patient’s home country have notbeen made, then recovery can be delayed, resulting incomplications [79]. Similarly, difficulties in transferringmedical records between home and destination coun-tries can complicate follow-up care [81].As a result of these risks for medical tourists, theymay incur more extensive expenses for follow-up carethan persons remaining within their home countries.Insofar as these patients have a social responsibility tolook to the efficient functioning of their home healthcare systems, engaging in medical tourism can poten-tially constitute a failure to discharge this social respon-sibility. Such an efficiency-based responsibility has beencodified in Germany, for example. There, patients areasked to respect “the clinical and cost effectiveness ofservices, which are only to be used insofar as necessary”[67]. These responsibilities will exist for both membersof public systems like those in the UK, Canada, andGermany, public portions of highly privatized systemslike Medicaid in the US, and even insurance holders inprivatized systems who have a duty of solidarity to theirfellow insurance pool members.As with other patient social responsibilities, theresponsibility to use health resources efficiently shouldnot undermine fair access to care, should not fall dis-proportionately on disadvantaged populations, and mustadmit of degrees in reflection of the extent of individualchoice over health care decisions [67]. As some patientsengage in medical tourism for necessary care that theywould not otherwise be able to afford or access, theirdecision to go abroad for care may not be a matter ofchoice. Moreover, patients may not be aware of the dan-gers associated with medical tourism or the require-ments for follow-up care for their specific procedures[75,82]. More generally, discerning the effects of enga-ging in medical tourism is difficult even for highlyinformed patients given a lack of data on the effects ofmedical tourism [29] and most patients would likely nothave access to this information even if it were available.Therefore, it is inappropriate to hold medical touristssocially responsible for specific negative effects of medi-cal tourism under these conditions. This is because dis-charging one’s social responsibility by using healthresources efficiently and mitigating third party harmsrequires knowledge of the effects of personal and healthcare choices [66]. Therefore, a first step toward a call togreater social responsibility among medical tourists isnot to blame them for the effects of engaging in thisglobal health care practice but rather to educate themon the effects of medical tourism.In terms of assigning social responsibility for medicaltourism, it is useful to differentiate between travel formedically-necessary and elective treatments. Whilemany medical tourists travel abroad for much neededhip replacements, cardiac surgeries, or eye surgeries,other treatments such as elective cosmetic surgerywould not be considered medically necessary. While wecan grant that there will be considerable grey areabetween the categories of medically necessary andpurely elective treatments, the differences between thesetwo kinds of treatment have implications for whetherpatients are discharging their social responsibilities. If atreatment is not medically necessary but does createharms for others, including contributions toward healthinequities in the destination country and publicexpenses for follow-up care in the patient’s home coun-try, then she can reasonably be held responsible forthese negative effects. Such steps have been taken else-where. In Germany, for example, co-payments areSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 7 of 14required of patients needing treatment as a result of a“non-medically indicated measure such as cosmetic sur-gery, a tattoo, or a piercing” [67](p.1188). Even formedically-necessary treatments, however, any determina-tion of whether the medical tourist has failed in hersocial responsibility will depend on that patient’s abilityto assess potential harms to the destination country andthe degree of the patient’s control over the decision toengage in the elective surgery.If patients engaging in medical tourism do have asocial responsibility to restrict their participation in thispractice, we must be sure that this responsibility doesnot fall disproportionately on the poor, uninsured, andother vulnerable groups who may be driven into travelabroad for medical care due to a lack of options athome. The danger is that talk of patient responsibilitycan be used to further burden the most disadvantagedmembers of a community [83]. Any determination ofwhether a proposed social responsibility for medicaltourists would unfairly burden certain patients willrequire reference to the particular context in which thepatient acts, including whether her home health caresystem is public or private, the environmental healthburdens faced by the patient, her socio-economic posi-tion within her community, and individual factors thatmight undermine her ability to access healthcare. Whileit is difficult to say in general and without reference tothe particular circumstances of a patient what the extentof a medical tourist’s social responsibility is, the claimthat we have defended here is that individuals face asocial responsibility to their health systems to use thesesystems efficiently and to protect fair access to others.By choosing to access the health systems of other coun-tries, medical tourists expand the scope of this socialresponsibility, entailing new responsibilities to notunduly burden their home health systems and also touse the health systems of other countries both fairly andefficiently.DiscussionVoluntourism and medical tourism are both globalhealth care practices that have dominant flows wherebycitizens of the global north travel to the global south.As our discussion of both of these practices has shown,they each entail social responsibilities for their partici-pants. By analyzing the similarities and points of diver-gence in the social responsibilities generated byvoluntourism and medical tourism, we identify how ourunderstanding of the social responsibilities of voluntour-ists can be illuminated by a discussion of the socialresponsibilities of medical tourists and vice versa. InFigure 1 we present a conceptual model that visualizes Figure 1 Overlaps and Dissimilarities in Medical Tourists’ and Voluntourists’ Social Responsibilities.Snyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 8 of 14the similarities and points of divergence discussed inthis section.OverlapsPhysicians and patients both have social responsibilitiestoward their domestic communities and health care sys-tems. Physicians have an obligation to ensure that localmedical systems are equitable and accessible and do notcreate conditions that encourage medical travel. As wehave noted, physicians are bound by professional codesof ethics that require them to serve the interests ofthose in need. Physicians are in a unique position tomeet the medical needs of their communities, and torefuse to do so can serve to show a callous disregard forthese needs. Patients, we have argued, have a socialresponsibility to use medical resources responsibly andto take steps to avoid worsening the health of thosearound them, including through the spread of infectiousdiseases. A patient who took no steps to protect thehealth of fellow community members would, throughher actions, not demonstrate respect for their claim tohaving their basic health needs met.While voluntourists and medical tourists have socialresponsibilities to the communities with which theychoose to engage, they are also put into positions of vul-nerability by engaging in these practices of global healthcare that are undertaken across vast distances. Bothvoluntourism and medical tourism may entail travel farfrom one’s home community. This travel may createstresses, including separation from one’s friends andfamily, cultural and linguistic differences, and anxietyduring the time abroad [20,22]. Voluntourists may facerisks to their health and safety, particularly if they aretraveling to a community that has poorly developedinfrastructure, as will commonly be the case. Medicaltourists are in a position of vulnerability as, like otherpatients, they face risks to their health from complica-tions stemming from their medical procedures. Butunlike most other patients, they often face these risksfar from their support networks.Persons engaging in voluntourism and medical tour-ism both can face exposure to political, social, and cul-tural instability. Voluntourists are called to administercare in communities abroad that are often impoverished,have poorly developed infrastructure, face politicalinstability, and are exposed to endemic disease. Whilemedical tourism is often advertised as providing patientswith a safe and relaxing environment for care andrecovery, they too can be exposed to unstable environ-ments abroad. Many medical tourists were in Thailandduring a recent outbreak of political instability, forexample, and medical tourists may not be well informedabout the local political conditions in the countries towhich they are considering traveling [84]. Thus, bothvoluntourists and medical tourists, by choosing to travelabroad and engage in global health practices, areexposed to new vulnerabilities.For both physicians and patients, the decision to travelto another country to receive or deliver health care servesto expand the range of the individual’s social responsibil-ity. The logic for this expansion of a pre-existing respon-sibility follows the rationale for the original socialresponsibility. Just as choosing to ignore the health needsof one’s own community members when one could easilytake steps to address these needs shows a disregard forothers, engaging in voluntourism and medical tourismbrings people into contact with new communities withtheir own distinctive needs. This contact creates newopportunities to take actions to meet local needs, or toignore them altogether. Just as disregard for others’needs in one’s original community would call into doubtone’s commitment to others as having a right to adequatehealth, contact with a new community raises the possibi-lity of similar, morally problematic inaction.In order to ensure that they demonstrate concern forthe needs of others and thereby discharge their socialresponsibilities, both voluntourists and medical touristsmust take steps, before they travel abroad, to ensurethat their choice to engage in these practices will notharm those with whom they come into contact. As wehave observed, voluntourism raises the possibility ofsuch harm if physicians fail to take into account the dis-tinct needs of the local population, develop culturaland/or linguistic competency, or fail to ensure that thecare they offer is sustainable. Medical tourists canencourage inequitable access to care in the countries towhich they travel and may carry new infections to orcreate new costs for their home community. By takingsteps to mitigate the potential for these harms prior todeparture, voluntourists and medical tourists both helpto discharge their social responsibilities.DissimilaritiesWhile both voluntourists and medical tourists face newvulnerabilities in virtue of their decision to travel abroad,the types and degrees of vulnerabilities faced by eachgroup will likely be different. The key difference in thesevulnerabilities is linked to the roles that each group takeswhen travelling abroad. The medical tourist often entersinto travel in a very vulnerable position as she is seekingcare to address her health needs. While some forms ofmedical tourism for purely elective procedures likecosmetic surgery may not place the medical tourist in aposition of great need, any medical procedure carriesrisks of adverse side effects and post-operative infections.Some procedures, like cardiac surgery, will place themedical tourist in a position of great vulnerability due tohigh risk of negative outcomes [85,86].Snyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 9 of 14While we should not discount the vulnerabilities facedby voluntourists, relative to medical tourists they willoften be in a position of power due to the hierarchiesimplicit and explicit in the provision of medical care.The medical tourist may feel forced to travel abroad forcare because of wait times for services or the high costof medical care at home, particularly if the patient isuninsured [20]. The voluntourist, on the other hand,engages in this practice much more freely, though he orshe may feel that doing so is part of an ethical obliga-tion [7,44]. The knowledge and position of voluntouristsallows them actively to provide medical services andintervene in addressing the needs of others. By contrast,medical tourists seek medical care and may be bound bya range of geographical and cost constraints.The role of physician is much better defined than thatof patient. While we have argued that patients are agroup to whom distinct social responsibilities areattached, they are a more loosely defined group withfewer clear norms of behaviour and less of a governinginstitutional structure. While we all are patients at somepoints in our lives, physicians make up distinct profes-sions, the membership of which is shaped by profes-sional bodies. These bodies can in part dictate whichindividuals can be counted as members and help setgoverning norms for their behaviour. Thus, the socialresponsibilities of physicians, including those whochoose to act as voluntourists, are much better definedthan those of patients, who lack professional bodies todevelop codes of conduct. Those codes of patientresponsibility that we have identified and discussedabove are typically the result of public health care insti-tutions choosing to set norms for their members. Manypatients, particularly in privatized systems, will not fallunder the umbrellas of these public bodies, however,and will not be as clearly governed by these norms.Moreover, by choosing to travel abroad for care and, asis typical, pay out-of-pocket for this care, medical tour-ists frequently opt out of public health care systems andthereby the norms that dictate their responsibilities. Forthese reasons, codes of social responsibility for medicaltourists have been slower to develop than those forvoluntourists.Finally, we have suggested that both voluntourists andmedical tourists have a social responsibility to eliminateor mitigate any risks of harm to others that may be aconsequence of their decision to engage in these globalhealth practices. As we have already observed, medicaltourists’ choices may be much more circumscribed thanthat of voluntourists. Moreover, the information avail-able to the medical tourists, with which they mayattempt to mitigate the risk of harms stemming fromtheir actions, is much more limited. As medical touristsare often very sick and in pain, they may not have theenergy or focus to try to bridge these informationalgaps. This informational asymmetry is due, in part, tothe training of physicians compared to that of the typi-cal medical tourist. Most of these international patientswill not have access to specialized medical knowledgeand may not be aware of the potential for medical tour-ism to exacerbate health inequities in destination coun-tries or contribute to the spread of infectious disease.While physicians engaging in voluntourism willfrequently receive specialized training specific to thecontext of the community to which they will be travel-ing, medical tourists typically travel at their own volitionand without any formal guidance. Medical tourists maytravel with the assistance of medical tourism facilitators[29], but we have no evidence that these facilitatorsprovide information to medical tourists that would berelevant to discharging their social responsibilities. Thus,relative to voluntourists, medical tourists will often findit very difficult to determine how to mitigate any nega-tive consequences of their travel, if they are even awarethat such risks exist.Moving ForwardAs we have discussed, physician voluntourism is seen apotentially ethically problematic approach to the provi-sion of medical services in international settings, espe-cially by students [87]. Hence, agencies that supportmedical student volunteers are beginning to insist onadequate pre-departure training to prepare them for therange of ethical issues they may encounter abroad [88].Equipping volunteers for ethically responsible practiceswill require a transformative pedagogy [89], and thedevelopment of critical consciousness about the rootcauses of disparities in healthcare [90]. Pre-service medi-cal training using international service-learning (ISL)opportunities appears to provide a promising experien-tial pedagogy for nurturing a sense of social responsibil-ity and global citizenship among volunteers [24]. Unliketraditional voluntourism, ISL provides a platform forreciprocal, collaborative and mutual learning between acommunity and the volunteer. Volunteers are expectedto develop a sense of critical awareness about the pro-blems vulnerable communities face, and demonstrateethical conduct and problem-solving skills as theirexperience in a given community unfolds. The focus ofISL is less on clinical skills development and more ondeveloping an understanding of the social determinantsof health that affect vulnerable communities. Interven-tions are designed in collaboration with communities inways that are locally sustainable, enabling volunteers tolearn how social determinants impact health and illnessand health inequities [91].Some training programs have successfully utilized thecritical incident technique [92] to help physicianSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 10 of 14volunteers explore how best to engage communities inways that strive for social justice by understanding andacting to change the social structures that stifle indivi-duals and communities due to unequal power relations,poverty and vulnerability. Physician volunteers areencouraged to develop a sense of professional and per-sonal growth, and to examine critically what it means tobe a socially responsible practitioner [93]. For example,many voluntourists seem to believe that being sociallyresponsible means charity [60]. But charity can createdependency relationships whereas social responsibilityaims at social justice, understood as developing sustain-able relationships based on mutual respect. It involvesworking with and for communities to enable what theyfeel is best for them rather than using a paternalisticapproach. Dickson and Dickson [60], identify a list ofpersonal attributes that physicians need to develop aspart of their professionalization and to act responsiblythat include: a concern with global equity; a commitmentto redressing injustices in healthcare; respect for diver-sity; openness to mutual learning; and embracing ethicalvalues like human rights and social justice. The professio-nalization of physicians gives them norms by which theirsocial responsibilities as voluntourists are increasinglyclearly stated. It also gives physicians the information andexpertise with which they may act on these norms.By comparison, medical tourists are given little gui-dance on their social responsibilities and little capacityto act on these norms. In order to address this gap,there is great need for the development of guidelines formedical tourists on how they can prepare for their tra-vel, engage in this practice with a minimum of personalrisk, and take steps to maintain their own health andarrange follow-up care after travel. Because of the frag-mented nature of the many community and nationalsystems for distributing health care, these guidelines willlikely take time to achieve widespread uptake. A startingpoint would be to have specific countries develop modelpatient guidelines that can be adapted and then adoptedby other countries, thus encouraging better patient pro-tections through their examples. These guidelines couldbe distributed by medical tourism facilitators or travelhealth providers. The latter group could be trained togive other advice on ethical medical tourism to theirpatients (Eyal: Global Health Impact Labels, submitted).International patients need transparency so that theycan make informed and responsible health choices.Given the lack of regulation in the medical tourismindustry - due in part to its newness and global nature -patients may have difficulty getting information on thepractices of the medical facilities they wish to travel toand may have no way of judging the accuracy of theinformation that they do receive [29]. One way ofaddressing this problem would be to develop ethicalbuying guidelines for patients engaging in medical tour-ism akin to those for consumers of other products likeapparel, coffee, and chocolate. Patients will face difficul-ties in developing these guidelines on their own giventhe informational gaps discussed above and the fact thatthese patients may be in pain or short of time giventheir ill health. Moreover, the medical tourism industrymay be reluctant or unable to develop these guides andto self-regulate both because of a reluctance to placerestrictions on their business and because of the frag-mentary nature of this industry at this early stage in itsdevelopment. Non-governmental groups can take on therole of regulators, developing information from medicaltourism facilities, assessing the accuracy of this informa-tion, and rating facilities for their tendency to promotethe positive and mitigate the negative effects of medicaltourism. While a non-governmental agency will not beable to compel medical tourism facilities to participatein a rating scheme, patients who see engaging in medi-cal tourism responsibly as a moral obligation could cre-ate market pressure for participation (Eyal: GlobalHealth Impact Labels, submitted). Alternately, patients’home country governments may need to take a moreactive role in regulating the medical tourism industryand providing patients with more information and trans-parency [94]. As medical tourism facilitators and otherindustry members can escape restrictions on their prac-tices if they are developed piecemeal, there is a strongargument for finding ways to increase the informationavailable to medical tourists and raising awareness ofthe potential negative effects of this practice. Doing sowill allow medical tourists to apply pressure within themarket for medical tourism services to counter proble-matic elements within this industry (Eyal: Global HealthImpact Labels, submitted).Medical professionals can and should help to developthe norms and infrastructure needed for medical touriststo discharge their social responsibilities. Doing so can beconnected to these physicians’ own responsibilities, asmedical tourism will increasingly affect patients’ homecountries through the need for expensive follow-up careand the need to create systems to monitor and minimizethe spread of infectious disease. Moreover, physicianscan be implicated in the push factors encouraging medi-cal tourism [20]. If patients are traveling abroad due toa lack of insurance, perceived lengthy wait times forcare, or the unavailability of certain procedures, thenhealth professionals must ask what their role is in redu-cing these factors and caring for the patients whochoose to seek care abroad. While medical tourism andvoluntourism are distinct global health practices, thoseengaging in them are closely connected through theincreasingly global nature of health care, travel, and thebusiness of medicine.Snyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 11 of 14SummaryVoluntourism and medical tourism share many qualities,including being tied to an expansion of social responsi-bilities due to an individual’s choice to engage in a glo-bal health practice. Both voluntourists and medicaltourists have a social responsibility to limit the risk ofharms to members of their home and destination coun-tries and to take steps to ensure that the global healthpractices in which they engage allow for sustainabledevelopment in their destinations. The complicationsassociated with health care in low and middle incomecountries mean that voluntourists and medical touristsmust prepare for their travel in order to avoid inadver-tent harms to others. Yet, as we have seen, physicianvolunteers are much better prepared to do so than med-ical tourists in virtue of their membership in a well-organized professional group with a strong historicalsense of social responsibility.While physicians must continue developing and enfor-cing guidelines for discharging their social responsibilitywhile practicing abroad, the field of medical tourism is lesswell prepared to develop the tools and guidelines neededfor socially responsible medical tourism. As medical tour-ists themselves are not a well-organized group and maynot be aware of the implications of their choice to engagein medical tourism, it is important that better organizedand informed groups help to fill this vacuum. Physiciansand other health professionals are members of groups thatcan draw on their knowledge, skills, and sense of socialresponsibility to help develop guidelines for responsiblemedical tourism. But it will also be important for medicaltourism industry groups to engage in this process, includ-ing professional organizations like the Medical TourismAssociation and medical tourism facilitators [95]. Fortu-nately, there is a long history of professional and businessgroups developing guidelines for socially responsible prac-tice, from which medical tourism industry groups canlearn [96]. It will be up for the rest of society, however, tohelp guide these groups and to ensure that they areencouraged or even required to develop these guidelines.Acknowledgements and FundingFunding was provided by a Catalyst Grant from the Canadian Institutes ofHealth Research. Thanks also go to Krystyna Adams for research andreferencing help.Author details1Faculty of Health Sciences, Simon Fraser University, Blusson Hall 11300,8888 University Drive Burnaby BC, Canada. 2Department of Family Practice,University of British Columbia, David Strangway Building, 3rd Floor 5950University Boulevard, Vancouver, BC, Canada. 3Department of Geography,RCB 6141, Simon Fraser University 8888 University Drive Burnaby, B C,Canada.Authors’ contributionsJS wrote the introduction and summary, parts of the background, and themedical tourism sections of the discussion and edited throughout. SD wrotethe social responsibility and voluntourism sections of the background anddiscussion. VC contributed to the background section, and contributedgreatly to conceptualization and editing of this manuscript. All authorsprovided feedback on drafting this paper and approved the final version ofthe manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 2 December 2010 Accepted: 6 April 2011Published: 6 April 2011References1. Bowen HR: Social responsibilities of the businessman Harper; 1953.2. Freeman I, Hasnaoui A: The Meaning of Corporate Social Responsibility:The Vision of Four Nations. Journal of Business Ethics 2010.3. Ginsburg RB: Access to Justice: The Social Responsibility of Lawyers.Journal of Law & Policy 2001, 7: 1.4. Medcalf M: Advancing Social Justice Through an InterdisciplinaryApproach to Clinical Legal Education: The Case of Legal Assistance ofWindsor Rose Voyvodic. Journal of Law & Policy 2004, 14: 101.5. Foreman S: Social responsibility and the academic medical center:building community-based systems for the nation’s health. AcademicMedicine 1994, 69: 97.6. 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Bus & Society 1999, 38: 268-295.doi:10.1186/1744-8603-7-6Cite this article as: Snyder et al.: Fly-By medical care: Conceptualizingthe global and local social responsibilities of medical tourists andphysician voluntourists. Globalization and Health 2011 7:6.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSnyder et al. Globalization and Health 2011, 7:6http://www.globalizationandhealth.com/content/7/1/6Page 14 of 14


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