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Monday, November 07, 2011

Global Justice and Medical Tourism

Over the last few years, when I have not been working on bioethical issues relating to reproduction and reproductive technologies, I have been working on a different project relating to medical tourism – the travel of patients from one country (the “home country”) to a foreign country (the “destination country”) for the primary purpose of getting health care.  I have done three major law review articles on the subject (and a few other bioethics and medical journal articles). The first law review article focued on quality of care and medical malpractice recovery.  The third, which is forthcoming in the Cornell L. Rev, focuses on circumvention tourism -- patients who travel abroad for the purpose of circumventing a home country restriction on access, such as in the case of abortion, assisted suicide, female genital cutting, and reproductive technology use in some contexts.  The second law review article is coming out this week in print, but I have already posted it online here. This piece of the project, I hope, will be useful beyond medical tourism to those interested in globalization and global justice theory more generally.

A good way to frame my subject of inquiry is by way of a recent New York Times article  by Somini Sengupta, entitled “Royal Care for Some of India’s Patients, Neglect for Others,” which captures a particular global justice critique well: She begins by describing the care given at Wockhardt Hospital in India to “Mr. Steeles, 60, a car dealer from Daphne, Ala., [who] had flown halfway around the world last month to save his heart [through a mitral valve repair] at a price he could pay.” The article describes in great detail the dietician who selects Mr. Steele’s meals, the dermatologist who comes as soon as he mentions an itch, and Mr. Steeles’s “Royal Suite” with “cable TV, a computer, [and] a mini-refrigerator, where an attendant that afternoon stashed some ice cream, for when he felt hungry later.” This treatment contrasts with the care given to a group of “day laborers who laid bricks and mixed cement for Bangalore’s construction boom,” many of whom “fell ill after drinking illegally brewed whisky; 150 died that day.” “Not for them [was] the care of India’s best private hospitals,” writes the article’s author; “[t]hey had been wheeled in by wives and brothers to the overstretched government-run Bowring Hospital, on the other side of town,” a hospital with “no intensive care unit, no ventilators, no dialysis machine,” where “[d]inner was a stack of white bread, on which a healthy cockroach crawled.”

There is also a more academic or policy strain of critiques among those who write about global health and/or globalization.

The goal of this paper is to examine this kind of critique.  Here is my take...

As I argue in the paper these kinds of critiques should be understood as raising there kinds of questions: (1) An empirical question: Does medical tourism have negative effects on health care access for the poor in the destination country? (2)  The normative question: If so, do home countries or international bodies face obligations to prevent or correct those negative effects, and under what circumstances? (3) The regulatory question: If so, how might they do so?

I discuss some of the development economics and health system design pertaining to the first question and regulatory options as to the third question, but most of the paper is focused on the second normative question. This gives me an opportunity to engage ongoing debates in normative and applied ethics between theories of global justice, cosmopolitan, statist, and intermediate. I discuss the ways in which these theories suggest we may owe different things to those inside versus outside the nation state, or the ways in which the obligations may be activated under different circumstances depending whether those who suffer are our fellow nationals or foreign.  While my focus is on medical tourism, I also show how some of the ideas I develop are applicable to other instances of the globalization of health care such as medical migration (the brain drain).  The goal (you, dear reader, can judge if it is successful) is to have a dialogue between these theories and the concrete medical tourism cases, to see ways in which the theories speak to the cases but also the ways in which the cases identify gaps, ambiguities, and possible divergeny ways of filling the blanks.

 I am currently editing a book for Oxford on legal and ethical issues in health care globalization and starting a new book project on medical tourism specifically. While I have found the global justice literature useful as to these project, I actually think it has many more applications to the work done by law prawfs – for example in immigration law and labor and employment law, among other areas.  Since this law review article represents a part of an ongoing project, I am definitely eager for your thoughts.

Posted by Glenn Cohen on November 7, 2011 at 11:17 PM in Article Spotlight, Books, Immigration, International Law, Legal Theory | Permalink

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Glenn,

In case your university spam filter doesn't let my mail go through (it's not an '.edu' address), I've sent four bibliographies along related to your research: on bioethics, health law, health & social justice, and global distributive justice. Perhaps you and/or your students will find them useful.

Posted by: Patrick S. O'Donnell | Nov 8, 2011 7:57:07 AM

Thanks so much Patrick. I always learn from your work and what you post on here.

Posted by: I. Glenn Cohen | Nov 8, 2011 11:40:11 AM

But what is your conclusion regarding question (1)?

Posted by: Former AE | Nov 8, 2011 1:16:02 PM

Thanks AE-- as you will see from the paper, while there are several academic and on the ground anecdotal accounts of this effect, I think the existing empirical evidence is not clear enough to reach a firm conclusion, and that the likelihood of the claim being true varies country-by-country and facility-by-facility and procedure-by-procedure. I do set out the following six (non-exhaustive) vectors likely to make the claim true (with long discussions specifying what I mean in the paper after each, but here I just list them):
(1) The health care services consumed by medical tourists come from those that would otherwise have been available to the destination country poor.
(2) Health care providers are “captured” by the medical tourist patient population, rather than serving some tourist clientele and some of the existing population.
(3) The supply of health care professionals, facilities, and technologies in the destination country is inelastic.
(4) The positive effects of medical tourism in counteracting the “brain drain” of health care practitioners to foreign countries are outweighed by the negative effects of medical tourism on the availability of health care resources.
(5) Medical tourism prompts destination country governments to redirect resources away from basic health care services in a way that outweighs positive health care spillovers.
(6) Profits from the medical tourism industry are unlikely to “trickle down.”
As I put it in the paper
"In countries where the triggering conditions all obtain, one would expect medical tourism to cause some diminution in access to health care for the destination country’s poorest due to medical tourism; as fewer factors obtain, this becomes less likely. This list of factors is certainly not exhaustive, and there may be additional factors in particular countries that push in the other direction. While I cannot prove that this result obtains in any country, and some readers will no doubt be skeptical, the claim seems at least plausible enough to merit a normative analysis."
I am hopeful that this paper prompts those whose forte is in development economics to do more to gather the relevant info...

Posted by: I. Glenn Cohen | Nov 8, 2011 1:24:46 PM

It seems to me that there is another factor at play. When medical tourists consume health care abroad, they are essentially investing in that country's health care infrastructure. This gives foreign hospitals an incentive to invest in the relevant medicines and technologies. At some point of saturation, these medical goods spillover into the general population and will become accessible to all. It seems like the idea of FDI is an important consideration. Do you address this? (Sorry, I don't have time to read your paper -- hope you understand).

Also note that this is different from the "trickle down" argument.

Posted by: Former AE | Nov 9, 2011 8:23:14 AM

Thanks "Former AE." This is discussed as part of factor (5) mentioned above "Medical tourism prompts destination country governments to redirect resources away from basic health care services in a way that outweighs positive health care spillovers."
Here is an excerpt from the relevant part of the paper (minus the citations)
"In order to compete for patients on quality and price against both the patient’s home country and other medical tourism hubs, destination countries will need to invest in their nascent medical tourism industry through, for example, direct funding, tax subsidies, and land grants. Unfortunately, such funding often comes from money devoted to other health programs, including basic health care and social services, and those effects are likely to be felt most strongly by the destination country poor. In other words, we need some sense of whether governments actually invest in health care services accessible by the poor (or at least do not take them away) in a counterfactual world where medical tourism is restricted. We also need to examine this dynamic as against a potential countervailing dynamic wherein medical tourism leads to a diffusion of Western medical technology or standards of practice or other health care spillovers that are beneficial to the entire patient population. Which dynamic wins out can only be answered on a country-by-country basis, but in India, for example, some commentators have suggested that the product of these countervailing forces has ultimately been a net negative for the destination country poor."
I think the complexity here is two-fold. One is empirical/mechanical, the way in which this factor interacts with the other factors, especially regarding whether the spillover is service-specific, and whether it is the kind of service that benefits all patients. The second complexity is normative, pertaining to (a) Time Frame: Over the very long term diffusion may take place, but in the short and middle term patients are not getting care, and given mortality and morbidity predictions those patients will never "recoup" later on. And (b) Target: Whose welfare matters and why? The spillover effect may dominate for middle and upper income Indians (to use a recurring example) in the middle term, but not poor Indians who are overally hurt. The question then becomes whether on a series of welfarist theories (utilitarian, prioritarian, sufficientarian) or non-welfarist ones (e.g., the Capabilities approach) we ought to care particularly about the poor in India in this regard. All of this is separate from the question about whether we ought to be statists, cosmopolitans, or intermediate types about global justice in the first instance.
I am glad you find the issues so interesting...

Posted by: I. Glenn Cohen | Nov 9, 2011 9:04:46 AM

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