Ethical Duties to Provide Health Care to Undocumented Aliens
Irregular migration is a global phenomenon. Millions of undocumented aliens live and work in dozens of countries across the globe. As of 2009, estimates of migrants who were staying illegally in the European Union (EU) ranged from 4.5 to 8 million people, although exact numbers are impossible to obtain (European Union, 2009). U.S. government officials have estimated that in 2000 there were approximately 7 million undocumented aliens in the United States (U.S. General Accounting Office, 2004, p. 5). In fact, many estimates of the undocumented alien population in the United States are much higher than that, with some researchers using estimates in the range of 11 to 12 million (Kaiser Commission on Medicaid and the Uninsured, 2008, p. 2). There are large numbers of undocumented aliens in other countries as well. In 2004, Solomon Benatar noted that many undocumented immigrants were seeking treatment for HIV/AIDS in postapartheid South Africa (Benatar, 2004, p. 88).
Undocumented aliens might be persons who entered a country illegally. Alternatively, they might have entered legally with visas for education, tourism, or temporary employment and then remained illegally after the expiration of their visas. In some cases they are persons who made requests for asylum but were refused (Hjern and Bouvier, 2004. p. 1538). Millions of undocumented aliens were young children when they taken to a new country by their parents. As Anders Hjern and Paul Bouvier (2004) have pointed out, a child in that situation “is obviously a suffering, unprotected, innocent third party in the conflict going on between his parents and the state” (p. 1538).
Barriers to Access, Cost Implications, and Provider Response
Because of their irregular status, undocumented aliens often lack health insurance coverage, and they often are excluded from participation in government health programs (Rosenthal, 2007, pp. 138–140). It is estimated that almost 60 percent of undocumented aliens in the United States have no health insurance (Kaiser Commission on Medicaid and the Uninsured, 2008, p. 5). Generally, these individuals are also not eligible for benefits under the Medicaid program or the State Children’s Health Insurance Program, although they may be eligible for Medicaid benefits in emergency situations such as labor and delivery (Kaiser Commission on Medicaid and the Uninsured, 2008, p. 6).
In Europe, citizens of EU countries have the right to cross national borders to obtain health care services in other EU countries, and their national health plans will pay for services rendered in other EU countries under certain conditions (Bowden, 2009). However, undocumented aliens from non-EU countries are treated differently from local citizens and from citizens of EU countries in general, and they might not have complete access to health care services in the EU (Pace, 2007, p. 21). Even where care is officially permitted, undocumented aliens can be deterred from seeking care by practical barriers, such as fees, administrative requirements, and fear of deportation (Pace, 2007, pp. 21–24; Rosenthal, 2007, p. 140). A report from the International Organization for Migration described the conflict between theory and practice in many EU countries with regard to undocumented aliens, whom the report refers to as irregular migrants.
In the EU, the European Commission has noted that “illegal immigrants are protected by universal human rights standards and should enjoy some basic rights i.e. emergency health care and school education for their children.”…
In practice, however, the irregular migrant is not granted a complete right to health care in EU Member States. For example, the Danish law on health care limits irregular migrants’ access to the national health care system to urgent treatment. In Germany, in principle, irregular migrants are granted the same right to health care as asylum seekers, being entitled to emergency care, care in pain situations, or indispensable care in order to preserve health (for example avoiding long-term aggravation or complications of diseases). The implementation of these provisions conflicts, however, with the Aufenthaltsgesetz, under which public servants have to report the details of any irregular migrant they encounter during their job, and anyone who helps an individual without a regular residence permit can be punished if assistance is provided for financial gain, or if it is done repeatedly or for the benefit of several foreigners.
In countries like Spain, Italy, Portugal, Belgium, the Netherlands and the UK, there are various obstacles to the implementation of national legislation guaranteeing irregular migrants’ right to health care [Pace, 2007, pp. 20–22].
International conventions include lofty promises of access to care for migrant workers and their families (Hjern and Bouvier, 2004, p. 1535; Rosenthal, 2007, pp. 138, 141). However, those international conventions have not been ratified by all countries, and even where ratified, they are subject to numerous exceptions and limitations. Some countries, such as the United States, provide emergency medical care without regard to citizenship or immigration status but are more restrictive about providing nonemergency care.
One important aspect of this issue is the cost of providing care for undocumented aliens and deciding who should bear that cost. For example, hospitals in the United States complain that they are forced to pay the high costs for treating undocumented aliens who lack health insurance (Fried and Harris, 2007, pp. 8–9). The actual costs have been subject to dispute, and this is a politically-charged issue in the United States, with some people and organizations holding very strong beliefs (Blackwood, 2006).
In 2004, the U.S. General Accounting Office (GAO) was unable to determine the costs incurred by U.S. hospitals in providing uncompensated care for undocumented aliens (p. 3). Subsequently, a 2006 study by researchers at the RAND Corporation estimated that the cost in 2000 for providing care to adult undocumented aliens (aged eighteen to sixty-four) was $6.5 billion (Goldman and others, 2006). To put that in perspective, $6.5 billion represented only about 1.5 percent of U.S. health care costs at that time (Goldman and others, 2006). However, the cost of providing care to undocumented aliens is not spread evenly across the United States. In regions with large numbers of undocumented aliens, this cost has a serious financial impact on state governments and some hospitals (Fried and Harris, 2007, p. 8). For example, in Texas as of 2001, the Harris County Hospital District, which includes Houston, had spent an average of $110 million per year in caring for undocumented aliens, who represented about 23 percent of patient visits for that public hospital district (Texas House of Representatives, 2001, p. 3). In 2005, that same public hospital district spent about 14 percent of its total operating costs on providing care for undocumented aliens, primarily from Mexico (Preston, 2006).
Under these circumstances, health care professionals, facilities, and governmental agencies have struggled to develop policies that balance the need to control health care costs with the need to provide necessary services to undocumented aliens (Coyle, 2003). As a result of the severe economic recession in 2009, even community health clinics in some parts of the United States have reduced some of the nonemergency services that they previously provided to undocumented aliens (Kaiser Daily Health Report, 2009). According to one activist opposed to illegal immigration into the United States, restricting public services is appropriate because, as she put it, undocumented aliens “have absolutely no right, No. 1, to be here and, No. 2, to take the tax dollars of law-abiding American taxpayers for anything” (Gorman, 2009). However, government officials and health experts recognize that limiting primary care services could increase the much more costly visits to emergency departments (Gorman, 2009).
In the United States the general rule is that hospitals must provide services in an emergency, without regard to a patient’s immigration status or ability to pay. However, there is no similar mandate for nonemergency hospital services on a national level. Thus, some hospitals choose to treat undocumented aliens on an equal basis with all other patients, but other hospitals are more restrictive about providing nonemergency care (Preston, 2006).
In fact, some U.S. hospitals have gone so far as to forcibly “repatriate” undocumented alien patients whose condition has been stabilized by the hospital but who require long-term care (Sontag, 2008). Undocumented aliens are not eligible to receive Medicaid benefits for long-term care, and they might not have private health insurance or sufficient assets to pay for extended care. Therefore, in cases involving such conditions as stroke or traumatic brain injury, hospitals may be unable to find any nursing home or rehabilitation facility to accept the patient after stabilization. Some stabilized patients in that situation have essentially become permanent residents of an acute-care hospital, even though they no longer need acute hospital care and the hospital does not receive any payment for their continued stay. Frustrated by the expense and the inefficient use of their facilities, some hospital managers in the United States have chartered private airplanes and returned the patients to their countries of origin. Although the hospital is required to make arrangements for appropriate follow-up care, the arrangements in some of these cases have been criticized as being woefully inadequate (Sontag, 2008), as in the following example.
American immigration authorities play no role in these private repatriations, carried out by ambulance, air ambulance and commercial plane. Most hospitals say that they do not conduct cross-border transfers until patients are medically stable and that they arrange to deliver them into a physician’s care in their homeland. But the hospitals are operating in a void, without governmental assistance or oversight, leaving ample room for legal and ethical transgressions on both sides of the border.
Indeed, some advocates for immigrants see these repatriations as a kind of international patient dumping, with ambulances taking patients in the wrong direction, away from first-world hospitals to less-adequate care, if any
Hospital administrators view these cases as costly, burdensome patient transfers that force them to shoulder responsibility for the dysfunctional immigration and health-care systems. In many cases, they say, the only alternative to repatriations is keeping patients indefinitely in acute-care hospitals (Sontag, 2008).
In contrast to these examples of restricting services, some health care providers in the United States and other countries have decided to provide care for undocumented aliens, even when that has required standing up against their own government authorities. For example, in the State of Texas, a state official determined that public hospital districts were not permitted to provide nonemergency care to undocumented aliens for free or at a discount. Nevertheless, some of those public hospital districts continued to provide nonemergency services for undocumented aliens for free or at a discount, despite the risk of criminal penalties for the hospital district or its officials (Fried and Harris, 2007, p. 9). In Sweden, pediatricians “openly defied a state policy to exclude asylum-seeking children from medical care if their asylum request was denied.” The Swedish pediatricians had the support of their professional association, and their actions caused the government to provide state-funded care for undocumented children in Sweden (Hjern and Bouvier, 2004, p. 1538). Similarly, the unwillingness of health professionals in Italy to enforce a restrictive law regarding treatment of undocumented aliens caused the Italian government to change its legislation (Pace, 2007, pp. 23–24). In the United Kingdom, regulations passed in 1989 required hospitals to play a role in immigration checks, but trade unions encouraged their members to refuse to participate in such checks. This enabled many undocumented aliens to receive government health services, although subsequent actions by the government have continued to try to prevent these services (Pace, 2007, p. 24, n. 94).
Ethical Analysis of Providing Care for Undocumented Aliens
Is there an ethical obligation to provide care to individuals in need, regardless of their immigration status? Do health care providers have an ethical obligation to provide health care services to undocumented aliens? Does society as a whole have this obligation? Ethical theories and approaches can be used both to support and to oppose this proposed obligation.
The proposed obligation to provide care for undocumented aliens can be supported by ethical theories or approaches of principlism, Kantian ethics, and utilitarianism and also by the professional ethics of health care providers and health care managers. Under principlism, there is a moral duty of beneficence to provide care to people in need, regardless of their legal status. In addition, there is a moral duty of justice to provide care to undocumented aliens, because those aliens are living and working as members of society in the host country. Even assuming that resources are limited and must be rationed in some way, the moral duty of justice requires that rationing decisions be made on the basis of need and not on the basis of a person’s immigration status.
The moral duty of justice also applies to the related issue of whether undocumented aliens should be allowed to receive organ transplants in the host country. This issue has arisen on a number of occasions in the United States, including the tragic case of Jesica Santillan. Jesica was an undocumented immigrant from Mexico who needed a heart-lung transplant (Williams, n.d.). At an academic medical center in the United States, Jesica was given an organ transplant. Unfortunately, the organs were not properly matched to Jesica by blood type, and her condition became critical. Subsequently, the medical center performed another transplant, despite her weakened condition, but she lost all brain function and life support was terminated. Many people have expressed ethical concerns about the medical center’s decision to perform the second transplant, both because of Jesica’s weakened condition at that time and because the second transplant for Jesica necessarily resulted in denying a transplant for a different potential recipient (Williams, n.d.) However, there has been less consensus about whether Jesica’s status as an undocumented alien should have precluded her from receiving the first transplant. The rules of the transplant system in the United States generally allow nonresidents to receive up to 5 percent of the organ transplants at each transplant center (Vedantam, 2003). Some people argue that noncitizens, and particularly undocumented aliens, should not receive any organ transplants in the United States (Darr, 2005). However, others point out that noncitizens contribute more organs to U.S. citizens than noncitizens receive from U.S. citizens (Vedantam, 2003). Under these circumstances the ethical principle of justice supports allowing undocumented aliens to receive organ transplants in the United States or another host country, regardless of their irregular immigration status.
Kantian ethics also supports the proposed obligation to provide care for undocumented aliens. Providing care would be consistent with Kantian ethics because every person—including an undocumented alien—must be treated as an end in himself or herself. In addition, providing care to undocumented aliens in need is consistent with the categorical imperative, because we can consistently will or wish that to be a rule for all similar situations. Similarly, there is a utilitarian justification for providing medical care that would maintain the health of undocumented members of society, including those people who do the most difficult physical work in society.
Finally, the professional ethics of health care providers and health care managers support the existence of a duty to provide care to undocumented aliens. The most basic principle of professional ethics is the duty to provide care to people in need, regardless of their legal or financial circumstances. Similarly, providing care to people in need is the fundamental reason for the existence of health care facilities. Therefore, denying medical care on the basis of a person’s immigration status would violate professional ethics. Some people would argue that health care professionals and managers must refuse to comply with unethical laws that limit care for undocumented aliens, as in the examples from several countries discussed previously. The American Medical Association (1994) has recognized that in “exceptional circumstances of unjust laws, ethical responsibilities should supersede legal obligations.” Under some circumstances, ethical duties might even require health care professionals and managers to use—or cooperate in the use of—patient names that they know to be false, such as when an undocumented alien is entitled to employee health insurance benefits under the false name that the alien uses for purposes of employment.
Despite the foregoing analysis, some of the same ethical theories and approaches can be used to argue against the proposed obligation to provide care for undocumented aliens. Under principlism, one could argue that the duty of beneficence to undocumented aliens is outweighed by the duty of nonmaleficence, because providing care to undocumented aliens would take limited resources away from citizens and lawful residents. In every country, resources are limited and must be rationed in some way. Under this argument, health care facilities in each country should first meet the needs of people who are there lawfully, before providing services to people who are there unlawfully.
The ethical duties of nonmaleficence and justice could also be used to argue against providing scarce organ transplants to undocumented aliens. According to this argument, it would be harmful and unjust for a government to allow citizens and lawful residents to die while waiting for organ transplants, and to simultaneously allow illegal aliens to receive the scarce human organs. From a utilitarian perspective, one could argue that the greatest good for the greatest number of people would be achieved by using limited health care resources for the majority group of people in each country, those who are the citizens or lawful residents, rather than by diverting limited resources for the benefit of a minority group of people, those who are undocumented aliens.
Under Kantian ethics, the ends do not justify the means. Therefore, health care professionals and managers should not lie to health insurance companies or government health programs by signing or submitting a document that contains a patient name that they know, or have reason to know, is not the patient’s legal name. Health care professionals and managers should not cooperate in misleading or defrauding insurance companies or government programs, because that is not a type of conduct that we can consistently will or wish to be a rule for all similar situations.
As discussed previously, some people argue that society in the host country has an ethical duty of justice to provide care to undocumented aliens. However, if we were to recognize or impose an ethical obligation to provide care for undocumented aliens, that could raise other potential obligations under the ethical duty of justice. It seems clear that the host country’s society does not have an ethical obligation to provide medical care to every person living in every other country on the planet. Even though it would be good to help every person in every other country, the society of the host country really does not have an ethical obligation to do so, and that society would not be acting unethically by failing to do so. Therefore, this argument goes, it would not be fair or just to impose an obligation to provide care for people who have come from those other countries and are now in the host country. As a practical matter, that proposed ethical obligation would impose a duty to help only those people who had managed to “jump the fence” and get into the host country illegally. It would not impose any obligation to people who remained in their own countries, including those people too sick or disabled to travel. In addition the proposed obligation would impose a duty to help only those people who broke the law, while imposing no duty to help people who were willing to obey the law. Finally, the proposed obligation would impose a duty to help people only during those periods of time that they are physically present in the host country, but not while they are visiting their friends or relatives in their countries of origin. For all of these reasons, it could be argued that imposing the proposed ethical duty to provide care for undocumented aliens would be irrational and would raise other problems of justice and fairness. The counterargument, of course, is that society in the host country owes a greater duty to undocumented aliens in the host country than it owes to people outside the host country, because those undocumented aliens are living and working as contributing members of society in the host country.
Finally, the issue of an ethical obligation to provide care for undocumented aliens raises the related issue of whether health care providers have an ethical obligation to provide translation services for patients who are unable to communicate effectively in the language of the host country. These issues are not totally congruent, because some undocumented aliens can indeed communicate effectively in the language of the host country, whereas some aliens with proper visas have limited proficiency in the host country’s language. Nevertheless, language can present an additional barrier to access for many undocumented aliens, and the need to provide translation services can impose an additional cost on the health care system of the host country.
For example, in the United States in the year 2000, more than 21 million people (more than 8 percent of the U.S. population) had limited English proficiency (Flores, 2006). According to a survey of U.S. hospitals conducted in 2005 and 2006, 88 percent of hospitals provided language services at all times, but only 3 percent were directly reimbursed for those services (Health Research and Educational Trust, p. 9).
Health care professionals and health care organizations have an ethical obligation to provide high-quality care. In order to provide care of high quality, health care personnel must be able to communicate with their patients. However, translation and other language services can be expensive, and health care resources are limited. Do host-country health care providers, such as hospitals and other health care facilities, have an ethical obligation to provide translation services or multilingual staff at the provider’s expense? Put another way, do all patients have an ethical right to be seen by a health care professional who speaks their language or, alternatively, to have a translator provided to them by the hospital at the hospital’s expense?
If you were sick or injured in a foreign country and you needed to go to a hospital, you would be very happy if someone at that hospital could speak your language. It would be a great relief to be able to explain your symptoms and your medical history in your own language, to be able to find out what is wrong with you, and to understand what you are supposed to do for your treatment. That would be a great relief, but do you really have a right to it as an ethical matter?
Using a family member or friend as translator for medical problems could be ineffective, inappropriate, and potentially dangerous. Family members and friends are probably not trained as translators, and they probably do not understand medical terminology. Moreover, using a family member or friend as translator could violate the patient’s privacy or could limit the extent of communication by the patient, as he or she tries to preserve some degree of privacy. Former U.S. surgeon general Richard Carmona (2007) has written about his childhood experiences in having to translate for his grandmother, his Abuelita, during her visits to the doctor. “I felt honored to do so, but I knew it was too much responsibility to interpret words and symptoms that I did not understand. What I know now that I could not have understood then is that Abuelita’s own dignity would prevent her from speaking openly about her symptoms in front of me—her young grandson. I know that my experience as a child interpreter was not unique then and is not unique now” (p. 277). Under these circumstances, some people argue that patients who have limited proficiency in the local language have an ethical right to a health care professional who speaks their language or a qualified translator at the hospital’s expense. However, the ethical basis for that right needs to be considered and articulated more fully. You will have an opportunity to consider this ethical issue, together with the related ethical issue of providing care for undocumented aliens, in the activity at the end of this chapter.
Ethical Issues in Medical Tourism
Wealthy patients have traveled to world-famous hospitals in other countries for many years in an effort to obtain the best quality of care. More recently, many patients from industrialized countries have traveled to developing countries in an effort to obtain services that are less expensive or more available than in their country of residence (Fried and Harris, 2007, p. 6). Although the term medical tourism has been defined in several different ways (Bookman and Bookman, 2007, p. 1; Cortez, 2008, p. 76), it is useful to distinguish the modern concept of medical tourism from more traditional forms of travel to obtain medical care. As Michael Horowitz and colleagues have explained:
In medical tourism, citizens of highly developed nations bypass services offered in their own communities and travel to less developed areas of the world for medical care. Medical tourism is fundamentally different from the traditional model of international medical travel where patients generally journey from less developed nations to major medical centers in highly developed countries for medical treatment that is unavailable in their own communities. The term medical tourism does not accurately reflect the reality of the patient’s situation or the advanced medical care provided in these destinations. Nevertheless, this phrase has come into general usage and it provides an unambiguous way of differentiating the recent phenomenon of medical tourism from the traditional model of international medical travel [Horowitz and others, 2007].
Under the four-part framework for trade in services discussed earlier in this chapter, medical tourism fits within Mode 2, because the recipient of health care services is traveling to the country of the provider.
An estimated 50,000 people traveled from Great Britain to other countries for medical care in 2003 (Mattoo and Rathindran, 2006, p. 358). In 2005, an estimated 150,000 people traveled from various countries to India for medical care (Chinai and Goswami, 2007, p. 164). The estimated number of medical tourists traveling to Thailand ranges from 400,000 to over 1 million per year, although it is unclear whether these estimates include expatriates who were living and working in Thailand at the time they sought medical treatment (Saniotis, 2008, p. 150).
Why do people from industrialized countries travel to developing countries for medical care? The lower cost of treatment is not the only reason, but cost is certainly an important factor (Fried and Harris, 2007, p. 6). For example, knee surgery on an inpatient basis costs over $10,000 in the United States, but costs less than $2,000 at top hospitals in India or Hungary, including the cost of travel (Mattoo and Rathindran, 2006, p. 358). In the expensive U.S. health system millions of U.S. citizens are uninsured or underinsured, and this has led some U.S. citizens to seek less expensive care in other countries. In the opinion of Arnold Milstein and Mark Smith (2006), these “patients are not ‘medical tourists’ seeking low-cost aesthetic enhancement. They are middle-income Americans evading impoverishment by expensive, medically necessary operations, as health care services are increasingly included in international economic trade” (p. 1637).
Meanwhile, some people travel to other countries in order to obtain drugs or treatments not available in their home countries. The regulatory authorities in some countries approve new drugs more quickly than other countries’ regulators do, and patients may be able to obtain those drugs only by travelling to a different country (Cortez, 2008, pp. 77–78). In addition, people might travel to a country that allows more choice in reproductive decisions, such as abortion or new reproductive technologies (Cortez, p. 77). Because of the severe shortage of transplantable organs in their home countries, thousands of patients have obtained transplants in other countries, such as China and the Philippines; this is referred to as transplant tourism (Biggins and others, 2009, p. 831). Like other types of medical tourism, transplant tourism raises significant ethical issues, which are discussed in detail in the remainder of this section.
In analyzing the ethical issues of medical tourism, it is important to consider its effects on the host country that provides the medical services, the patient’s home country, the individual patient, and those individuals in the host country who would be personally affected by the provision of services to the patient. For the host country, positive effects of medical tourism include potential increases in revenue and economic growth (Bookman and Bookman, 2007, pp. 177–178). Theoretically, medical tourism could generate revenue for countries and facilities, money that could be used to support and improve services for the local population. Medical tourism could also provide more income and opportunities for physicians and other health workers and thereby make it less likely that they will leave the country (Mattoo and Rathindran, 2006, p. 367). Although medical tourism can reduce external brain drain to other countries, it can increase internal brain drain by encouraging health workers to leave public facilities for better-paying jobs in private facilities that cater to wealthy patients. As stated by the director of WHO’s Department of Human Resources for Health, “it does not augur well for the health of patients who depend largely on the public sector for their services as the end result does not contribute to the retention of well-qualified professionals in the public sector services” (Chinai and Goswami, 2007, p. 165).
In addition, medical tourism could have other negative effects on the health system of the host country. Medical tourism could perpetuate two standards of care—one for medical tourists and one for the local population. Writing in the Indian Journal of Medical Ethics, Thelma Narayan (2005) stated that the “policy of ‘medical tourism for the classes and health missions for the masses’ will only lead to a deepening of the inequities already embedded in our health care system.” Other potential negative effects on the host country include increased local prices for health care services as a result of additional demand by medical tourists (Mattoo and Rathindran, 2006, p. 367), “crowding out” of domestic patients as more resources are shifted to serving the medical tourism market (Bookman and Bookman, 2007, pp. 175–177), and diverting government resources to attract international patients and subsidize the growth of medical tourism (Bookman and Bookman, p. 176; Cortez, 2008, p. 110).
For the host country the ultimate impact of medical tourism depends on whether the government of that country uses the revenues from medical tourism effectively to improve public health services for the local population (Mattoo and Rathindran, 2006, p. 367; Cortez, 2008, pp. 110–111; Bookman and Bookman, 2007, p. 179). For example, “governments could cross-subsidize care for the poor by taxing these export revenues or by requiring providers also to extend care to the poor” (Mattoo and Rathindran, p. 367). However, the experience so far in that regard has not been encouraging. Generally, it does not appear that host country governments have used revenues or taxes from medical tourism to subsidize public health services, nor have they generally required private facilities that cater to foreigners to also provide significant volumes of care for the poor (Cortez, 2008, pp. 110–111). In order to accomplish those goals, it would be necessary to implement effective systems of regulation and taxation, with explicit earmarking of funds for the use of public health facilities and their staff (Chinai and Goswami, 2007, p. 165).
The effect of medical tourism on the patient’s home country is less complex but still potentially serious. Health care facilities in the patient’s country could suffer financial losses from the reduction in patient volume as well as from reductions in economies of scale (Mattoo and Rathindran, 2006, p. 365). In the United States, hospitals use patient revenues to cross-subsidize their indigent care, a process that might be jeopardized to some extent by the loss of patients to hospitals in other countries (Cortez, 2008, p. 109). Medical tourism could also impose a financial burden on the home country’s health system, because health care providers in that country are obligated to provide follow-up care after the patient’s return, especially in cases of transplant tourism. Moreover, obtaining an organ transplant in a developing country could pose a risk to public health in the patient’s home country if the patient were to become infected with a communicable disease (Budiani-Saberi and Delmonico, 2008, p. 927; Bramstedt and Xu, 2007, p. 1700). In addition, because patients pay cash to donors in other countries for their organs, transplant tourism could also have a negative effect on the system of altruistic organ donation in the patient’s home country (Budiani-Saberi and Delmonico, p. 928).
For the individual patient, medical tourism can promote autonomy to choose goods and services that would not be available in the patient’s home country, such as a wider choice of reproductive health services (Cortez, 2008, pp. 111–113). However, the increased autonomy for that particular patient is arguably unfair to other patients who are unable to travel to another country. Moreover, the opportunities for treatment in another country might discourage people from trying to reform their own health systems (Cortez, pp. 107–113).
Nevertheless, medical tourism can increase access to care, especially for people who lack adequate health insurance coverage (Cortez, 2008, pp. 107–108). There is some risk to the patient in traveling to another country for treatment, as there is in the performance of any medical procedure. However, individual patients should have the right to make their own decisions, after complete disclosure of the risks. In deciding whether to travel to another country for care, individuals should not be subjected to coercion or undue financial incentives from their health insurance plans or their employers (Bramstedt and Xu, 2007, p. 1700).
It is also important to consider the interests of those individuals in the host country who are personally affected by providing services to the medical tourist. In transplant tourism, some patients have received organs from executed prisoners, with serious questions about the donors’ informed consent (Bramstedt and Xu, 2007, p. 1699; Biggins and others, 2009, p. 832). Other transplant tourists have purchased organs from live donors, who are referred to as commercial living donors (CLDs). Budiani-Saberi and Delmonico (2008) have explained that for these transplant tourists, the “source of their allografts is mainly from the poor and vulnerable in the developing world. These vendors or commercial living donors resort to an organ sale because they have virtually no other means to provide support for themselves or their families. Selling kidneys may be a consideration of ‘autonomy’ in academic debate but it is not the coercive reality of experience when a kidney sale is a desperate alternative available to the poor” (p. 925). In fact, researchers have documented negative effects on CLDs after the transplant procedure, including health problems, continued financial difficulties, and regret about their organ donation (Budiani-Saberi and Delmonico, pp. 927–928).
The system of payment for organs in transplant tourism is also unfair to residents of the host country who have been waiting for organ transplants (Bramstedt and Xu, 2007, p. 1700). In transplant tourism, wealthy foreigners essentially “jump the queue” to obtain organs before local patients, who may have been waiting for many years and may die for lack of transplants.
On libertarian grounds, some people argue that individuals should be allowed to sell their organs and should be allowed to purchase organs from other people. However, others strongly disagree with the concept of an organ market, because of the unfairness to potential transplant recipients who have less money and because of the serious potential for coercion of donors, among other reasons. Merely for purposes of argument, we could assume that it might be possible to develop a lawful organ market with sufficient protections, within the limited confines of a well-regulated, industrialized country. Even with that assumption, however, it is clear that it would not be possible to provide sufficient protections in the context of a global organ market, where patients from wealthy countries would purchase organs from poor individuals in developing countries. In a global market for organ transplants, the ethical and practical problems would be insurmountable.
The movement of patients across national borders is part of the globalization of health care services. This phenomenon raises important ethical issues for health care professionals and organizations. As explained in this chapter, health care providers are attempting to balance their need to limit costs with their ethical obligation to provide services to individuals in need, regardless of their immigration status. Some health care providers have adopted restrictive policies on the treatment of undocumented aliens. Other providers have decided to serve all people in need, even when that required them to stand up against their own government authorities and thereby set an inspiring example for health care professionals and organizations throughout the world. The movement of patients across national borders also includes the modern practice of medical tourism, which raises another set of complex ethical problems. This chapter has evaluated the ethical problems of medical tourism from the perspectives of the host country, the patient’s home country, the individual patient, and those individuals in the host country who would be personally affected by providing services to the medical tourist. For some types of medical tourism, the ultimate effect depends on the extent to which the government of the host country uses medical tourism revenues to promote the health of the entire population. In the case of transplant tourism, however, a global market for organ transplants raises far too many ethical and practical problems.
commercial living donors (CLDs)
General Agreement on Trade in Services (GATS)
limited English proficiency
medical tourism
transplant tourism
undocumented aliens
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
