Medical Tourism Facilitators: Ethical Concerns about Roles
and Responsibilities
This publication should be cited as: Snyder, J., V.A. Crooks, A.
Wright, and R. Johnston (2012) Medical Tourism Facilitators:
Ethical Concerns about Roles and Responsibilities. In J. Hodges,
L. Turner, and A. Kimball (eds.) Risks and Challenges in Medical
Tourism: Understanding the Global Market for Health Services.
Praeger. Chapter 13.
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CHAPTER 13
Medical Tourism Facilitators:
Ethical Concerns about Roles and Responsibilities
Jeremy Snyder,
1
Valorie A. Crooks,
2
Alexandra Wright,
1
and Rory Johnston,
2*
Introduction
Within the medical tourism industry are a number of key stakeholders – groups and
individuals who champion the development of the industry, provide services within the
industry, use the services of the industry, and/or are directly or indirectly impacted by the
industry - who contribute to its expansion. One such group is facilitators, private agents who
broker medical travel and foreign care arrangements between patients and destination
facilities but are not employed by these facilities.
1
Key to this element of the medical tourism
industry is the Internet; facilitation companies in many countries have a strong web presence
and rely primarily on websites (and secondarily on word-of-mouth) to advertise their
services.
1-4
Medical tourism brokers’ responsibilities toward medical tourists can include securing
travel and accommodation needs, suggesting and booking facilities and surgeons abroad,
contacting destination clinics, overseeing translation of medical records, arranging for tourist
1
Faculty of Health Sciences, Simon Fraser University.
2
Department of Geography, Simon Fraser University.
* This research was funded by a Catalyst Grant awarded by the Canadian Institutes of Health
Research.
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activities, and transferring medical records.
5
These brokers can play an essential role in
facilitating communication, providing information, and securing overall quality control by
assessing the reputability and reliability of international facilities.
3
It appears, however, that
only a fraction of medical tourists actually use the services of brokers.
1
Brokers themselves
have indicated this, noting that patients wanting to go abroad for care sometimes seek them
out as an informational resource even though they never actually intend to book care through
them.
3
There is no single business model for medical tourism facilitators. This is perhaps not
surprising given the range of roles and responsibilities they may take on. Some facilitators
refer patients to a number of countries, while others refer only to one or two trusted
international facilities.
3
Some arrange care for hundreds of medical tourists each year, while
others do so for less than twenty clients per year.
3
Some specialize in arranging care abroad
for a particular procedure or group of procedures, while others have no stated limitations on
procedures for which they are willing to arrange care.
3
These are but a few of the fundamental
differences between medical tourism facilitators’ business practices. While some facilitators
view themselves as patient advocates and change agents, playing an involved role in patient
care coordination and putting forth calls for domestic health system reform, others see their
roles and responsibilities as much more limited, primarily focusing on the logistics of
securing care abroad.
5
In general, medical tourism facilitation remains relatively fluid and
undefined as a profession. There is also no overarching professional organization providing
mandatory monitoring of facilitators and their practices.
6
In this chapter we review ethical concerns that have been raised in the medical tourism
literature with regard to the specific roles and responsibilities of medical tourism facilitators,
including as they relate to business practices. We also examine the evidence available in the
scholarly literature to support or refute these concerns. As we outline below, most of the
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scholarly literature that offers primary data-based insights on facilitators’ roles and practices
uses facilitator websites, interviews with facilitators, or legal cases as empirical sources. We
compare the ethical concerns raised in the ethical and legal literature to the empirical findings
about facilitators’ roles and practices in reviews of facilitator websites, interviews, and legal
cases to identify which ethical concerns have been borne out thus far. Finally, we use the gaps
that emerge between these two bodies of scholarly literature to assess proposed regulation
(i.e., the creation of an institutional framework, such as laws or operating regulations) of
medical tourism facilitators and to identify future research directions. In doing so, we aim to
present the current state of knowledge about the ethical issues raised by medical tourism
facilitation and guide continued research on this topic.
Existing ethical concerns about medical tourism facilitators
Through our review of the ethical and legal literature about medical tourism, we identified
five areas of ethical concern most commonly discussed about the roles and responsibilities of
facilitators. These areas are: 1) facilitator training and accreditation (i.e., facility- or
organizational-level systems for enacting and assessing standards); 2) facilitator conflicts of
interest; 3) transparency and patients' consent to risks; 4) problems with continuity of care and
follow up care; and 5) liability for harms. In the remainder of this section of the chapter we
outline the scope of the ethical concerns in each of these areas and then examine the extent to
which the empirical medical tourism literature confirms that these problems actually are
occurring. Table 1 provides an overview of the data available in the empirical sources we
discuss.
Table 1. Overview of Empirical Sources Reviewed
Source Title
Authors
Year
Source(s) of Data
The Potential for Bi-lateral Agreements in
Medical Tourism: A Qualitative Study of
Stakeholder Perspectives from the UK and India
Alvarez,
Chanda,
Smith
2011
30 medical tourism stakeholder
interviews (10 in United
Kingdom, 20 in India), of
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which 2 were facilitators
Medical Travel Facilitator Websites: An
Exploratory Study of Web Page Contents and
Services Offered to the Prospective Medical
Tourist
Cormany,
Baloglu
2011
website review (reviewed 57
websites of facilitators--24 N.
American, 11 Asian, 8
European, 8 Central and S.
American, 6 African)
Patients Without Borders: The Emerging Global
Market for Patients and the Evolution of Modern
Health Care
Cortez
2008
legal review (including
consideration of specific
facilitator websites)
An Industry Perspective on Canadian Patients’
Involvement in Medical Tourism: Implications
for Public Health
Johnston,
Crooks,
Adams,
Snyder,
Kingsbury
2011
12 interviews with Canadian
medical tourism facilitators
Systematic review of web sites for prospective
medical tourists
Lunt, Carrera
2011
website review (reviewed 50
English language websites of
facilitators)
Framing Medical Tourism: An Examination of
Appeal, Risk, Convalescence, Accreditation, and
Interactivity in Medical Tourism Web Sites
Mason,
Wright
2010
website review (reviewed 66
websites of United States-based
facilitators)
International medical travel and the politics of
therapeutic place-making in Malaysia
Ormond
2011
49 medical tourism stakeholder
interviews in Malaysia, of
which 7 were facilitators
Risk Communication and Informed Consent in
the Medical Tourism Industry: A Thematic
Content Analysis of Canadian Broker Websites
Penney,
Snyder,
Crooks,
Johnston
2011
website review (reviewed 17
websites of Canadian
facilitators)
The ‘Patient’s Physician One-Step Removed’:
The Evolving Roles of Medical Tourism
Facilitators
Snyder,
Crooks,
Adams,
Kingsbury,
Johnston
2011
12 interviews with Canadian
medical tourism facilitators
Selling Medical Travel to US Patient-Consumers:
The Cultural Appeal of Website Marketing
Messages
Sobo,
Herlihy,
Bicker
2011
website review (reviewed 27
websites of United States-based
facilitators)
Medical Tourism: Protecting Patients from
Conflicts of Interest in Broker’s Fees Paid by
Foreign Providers
Spece
2010
legal review (including
consideration of specific
facilitator websites)
Facilitator Training and Accreditation
The global nature of medical tourism complicates patients’ abilities to assess the credentials
of the hospitals, physicians, and other health workers they may encounter in distant facilities.
Patients often must navigate a bewildering array of regulatory environments, accreditation
systems and facilities in deciding whether and where to seek care. This problem extends to
distinguishing the quality of medical tourism facilitators, upon whom patients may depend for
help in guiding their medical decision-making.
3
So while facilitators might, in principle, help
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patients to overcome difficulties in assessing the quality of the care they will receive abroad,
patients may first find it difficult to assess the quality of facilitators and facilitation companies
themselves.
While some facilitators specialize in and have detailed knowledge about specific
destinations, there is no limit to the destinations – and thus different regulatory and
accreditation environments - to which they may direct their clients.
6
Similarly, while some
facilitators have a medical background, such training is not required for entry into the
profession. It has been speculated that many facilitators come from a tourism background,
with experience booking vacations, flights, and other tourist services, but lack the background
to help facilitate medical tourists' medical needs.
7
This lack of training is part of a wider area
of ethical concern regarding facilitators’ roles and responsibilities, namely the lack of
universal standards of training and accreditation for members of this profession and, more
strikingly, a lack of barriers to entering the facilitation industry, including any requirement
that facilitators receive training or accreditation.
7
Meanwhile, facilitators can play a
substantial role in patient decision-making about the care they will receive. Facilitators who
see giving medical advice as falling within their roles may suggest certain medical
interventions, advise patients on the safety and outcomes of these interventions, and help
guide, with substantial advice and influence, patients' health care decisions. Consequently,
there is danger that potential medical tourists will make treatment decisions without the
benefit of direct consultation with medical professionals and rely instead on the
recommendation of facilitators who may lack medical training, or even clear standards for
what information they should provide to patients.
There has been little consideration of how aware medical tourists are about facilitators'
level of training. If this awareness is minimal, they are likely not in a position to judge the
quality of advice that they receive from these individuals. Facilitators have the word ‘medical’
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in their titles, make seemingly informed claims about the success rates of procedures and
quality of care in specific facilities and by specific physicians, and take on the role of patient
advisor and even advocate.
1,5
These roles may easily confuse patients, thereby leading them to
put unjustified weight on facilitators’ advice. If patients are not willing to discuss their
decision to seek medical care abroad with their own physicians (or even other members of
their social networks) or do not have access to a physician due to financial constraints, then
the facilitators' perspectives will not be balanced by other, less financially interested views.
Just as other medical providers, including hospitals, physicians, and private clinics, are
regulated to instil practices that do not harm the health and safety of patients, it has been
argued that medical tourism facilitators should be similarly regulated based on some kind of
accreditation standards.
6
The content of these accreditation standards are still a matter of
debate; for example, it is not immediately clear whether facilitators should be required to
obtain some degree of medical training or whether requiring limits on the advice they give to
clients would be sufficient to protect clients’ interests. Without accreditation requirements, as
is presently the case, there are no restrictions on who can take on the role of facilitator or
repercussions for those who violate professional norms.
In a content analysis of Canadian facilitation company websites, Penney et al.
observed that the websites did not consistently refer to a single facilitator organization that
represents a comprehensive monitoring body.
1
This was confirmed in Mason and Wright’s
analysis of facilitator websites, which found that website logos that appeared to signify
quality were typically branding devices rather than evidence of facilitator certification.
8
Of the
websites Penney et al. examined, 35.3% contained logos or representations of various
organization memberships, but only rarely were these evidence of facilitator certification (i.e.,
individual-level training and credentialing) by any regulatory organization. Although some
sites referred to external accreditation bodies, those bodies' reputability and assessment
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standards are not always clear to medical tourists. This particular analysis also found that the
sites generally did not indicate which of the hospitals they recommended were accredited,
although 52.9% of websites provided information on physicians and their credentials.
1
Mason and Wright reported that 29.3% of the reviewed sites gave evidence of some
form of accreditation for preferred destination hospitals, such as indications that the facilities
have met the standards of the Joint Commission International (JCI) or the International
Organization for Standardization.
8
JCI accreditation has been used as a marker of quality and
safety in the medical tourism industry and is often highly sought by facilities seeking to attract
international patients.
6
But the display of hospital accreditation information on facilitator
websites may confuse potential clients. Medical tourists may feel confident accepting a
facilitator’s services based on the mistaken belief that a preferred destination facility’s
accreditation also applies to the facilitator and/or facilitation company when, in fact, it says
nothing about the facilitator's qualifications or knowledge.
1
Facilitator Conflicts of Interest
Medical tourism is characterized by patients arranging for private medical services that they
typically pay for out-of-pocket.
3
As we explained earlier, facilitators are private operators
who are paid in exchange for the services they provide to those seeking this private care. But
patients may not be aware of how much or in what manner facilitators are paid, since patients
may not pay directly for facilitators’ services. These services may be covered by referral fees
paid for by the destination hospital or as part of an overall ‘package deal’ that does not
include a detailed cost breakdown. Consequently, the financial structures of medical tourism
as they relate to facilitators’ involvement may be opaque to individual patients.
Because medical tourism facilitators receive fees to arrange for medical services, there
is potential for a conflict between the interests of the facilitators and those of patients. While
some facilitators receive fees directly from their clients, and so align their interests more
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directly with those of the client, other facilitators receive fees or other benefits from medical
facilities or physicians abroad with whom they book procedures.
9
Thus, in some cases, the
facilitator has an incentive to book procedures independent of any benefit to the patient. This
conflict of interest can take the form of supplier-induced demand, in which the facilitator
encourages the client to purchase specific forms of medical care, introduces the client to new
options for care, or even alerts the client to previously unknown medical conditions or
perceived medical needs, all while receiving payment from providers for the provision of
these services.
10
The potential for conflict of interest in medical tourism facilitators’ business practices
extends to facilitators recommending or encouraging clients to obtain procedures that are
unavailable or illegal in their home countries. If facilitators receive booking fees, they have an
incentive to encourage their clients to receive these procedures regardless of whether they are
legal in the client's home country. The international dimension of medical tourism allows
facilitators to promote and aid their clients in escaping the legal jurisdiction of their home
countries, which undermines the ability of countries to regulate access to medical care at
home.
11
While such regulations may exhibit ethically problematic paternalistic attitudes, or
state enforcement of public morality on individuals (e.g., in reproductive decisions), states do
have a legitimate interest in regulating the medical care provided to citizens to promote
patient safety and public health.
12
In some cases, states with high regulatory thresholds for
patient safety will make certain treatments unavailable out of concern for efficacy, side
effects, or other threats to health. By enabling patients’ access to these treatments outside of
domestic regulatory frameworks, facilitators can expose clients to risks that they would not
have faced in their home health systems.
6
At the same time, access to unavailable, illegal, or
experimental treatment such as experimental stem cell therapies can be highly desirable for
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patients who are well informed about their associated uncertainties and risks; and in some of
these cases, facilitators are crucial to enabling such access.
Unfortunately, there is little empirical evidence to support or refute claims that
medical tourism facilitators face conflicts of interest in enacting their roles and
responsibilities. In a legal review, Spece found that information about facilitators’ fees is
generally not provided up-front to clients.
9
As a result, some clients may assume that
facilitators are working on a non-profit basis. The likelihood for misunderstandings regarding
facilitators’ referral fees received from medical tourism providers and fee structures charged
to patients can be heightened by clients’ unfamiliarity with medical referral fees, in light of
the prohibition of referral fees in some domestic health care contexts. Johnston et al.
confirmed this in their study, in which Canadian facilitators speculated that Canadian patients
may find the notion of paying a facilitator to assist with booking and coordinating care to be
off-putting since Canada's public health care system does not require citizens to pay out-of-
pocket for any aspect of necessary medical care.
3
Transparency of and Consent to Risks
Medical tourism has been associated with a range of risks to the patient, including deep vein
thrombosis (blood clots) due to flying soon after surgery, exposure to infectious disease, poor
quality of care, and the creation of a discontinuous medical record.
13
Informed consent
requires that patients receive and comprehend information pertaining to treatment options,
success rates, and risks of complications prior to undergoing care. Patients may not be aware
of the risks associated with medical tourism, and therefore may not be able to give fully
informed consent to be exposed to these potential complications.
1
Facilitators’ websites are thought to be a key, initial source of information about
medical tourism for many patients.
1-4
These websites serve as a means of advertising
facilitation services to potential clients, and so there is likely to be a great incentive to inform
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people of the potential benefits of medical tourism and to assuage any fears associated with
traveling abroad for medical care. These positive messages may not be balanced against
information about the risks inherent in medical travel, so patients may not receive the
information necessary to give informed consent to these risks. Many patients opt for medical
tourism based on the lower price of the treatments offered abroad.
13
Since cost savings are
often associated with inferior quality,
14
facilitators’ websites may feature an abundance of
quality assurance messages as an anticipatory strategy to head-off potential clients’ concerns
about whether these lower costs reflect poor quality.
7
Facilitators’ use of branding techniques in advertising their services, including noting
that physicians at preferred destination facilities have trained in North America and Europe,
and partnering with internationally recognized hospital and university brands, can help to
reassure patients about the quality of care abroad. Similarly, use of accrediting agencies like
the JCI may signal quality and safety to potential customers. Advertising high staffing levels
and excellent customer service abroad also helps to assuage the concerns of potential medical
tourists. Facilitators’ references in their promotional materials to state-of-the-art medical
devices and technologies available in destination hospitals counter concerns that lower levels
of economic development in host countries mean lower standards of care and less
technologically advanced medical equipment.
7
Again, these messages reflect facilitators’
concerns with reassuring medical tourists about the quality of care received abroad, and may
not accurately represent the risks associated with medical travel.
Since facilitators will be motivated to communicate the potential benefits of medical
tourism, it is possible for a medical tourist to book care through a facilitator and never receive
a comprehensive list of the risks and dangers associated with this practice; in fact, the patient
may only receive an account of the high quality of the care available abroad or at a specific
facility. The accuracy of this information may be very difficult for the medical tourist to
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verify. Because norms and legal requirements for informed consent vary by country, the
patient may have expectations for receiving information about risks that are not shared by the
facilitator.
7
This problem is exacerbated by the lack of a single set of professional norms
about communicating risks in the industry and an overall lack of oversight.
In reviews of facilitator websites, risk information – which is necessary for informed
consent - has been found to be limited. For example, Penney et al. found that only 17.6% of
Canadian medical tourism facilitator websites addressed possible risks and negative
outcomes, and those that did most often did so in the ‘facts’ or ‘disclaimer’ pages.
1
Mason
and Wright also found that websites rarely addressed risks and concerns on their main pages.
Their study found only 4.9% of websites addressed postoperative care, 1.1% legal recourse,
2.2% complications, and 2.2% procedural risk.
8
An additional study found 16% of reviewed
facilitator websites mentioned possible risks, but these risks were again consistently
downplayed in favor of positive outcomes and benefits of medical travel.
15
Sobo et al.
observed the theme of a “worry free experience” was particularly evident among medical
tourism websites. Prospective clients were depicted as empowered to take control of their own
medical care, with the companies’ facilitators being available to assist. Risks were often
addressed in ‘Terms and Conditions’ pages of websites.
16
These reviews confirm that,
“[d]espite great importance of postoperative care, procedural risk and potential medical
complications when making informed decisions about undergoing a medical procedure, the
issues appear to be discussed in limited ways, if at all, on the websites”.
8(p.173-174)
They also
show that discussion of risk is rarely given ‘front-page’ coverage on these websites.
Facilitators are commonly focused on increasing patient confidence and the
attractiveness of medical tourism destinations in terms of quality, experience, and price.
1
To
heighten patient confidence, facilitators usually focus on statements of accreditation, training
and experience of physicians, statements of advanced technology used in the hospitals, patient
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testimonials and enjoyable environments and tourist activities.
1,16
Facilitators’ marketing
materials consistently demonstrate an emphasis on the likely benefits of seeking treatment
abroad. As such, there is a focus on characterizing positive experiences, benefits and
outcomes of medical tourism. Penney et al. found that any mention of risk in facilitators’
websites was carefully worded to emphasize the unlikelihood of negative outcomes in order to
maintain a generally positive message. Some websites are careful to remind patients that
similar risks occur when seeking medical treatment in their own country, which is another
strategy for minimizing risk messages in marketing materials.
1
Problems with Continuity of Care and Follow-Up Care
Medical tourism can undermine both informational continuity of care (i.e., the maintenance of
a continuous and complete medical record) and access to care following treatment.
13
When
medical tourism involves international travel, medical records must be transferred between
countries. The geographical, cultural, and linguistic distances involved in these transfers may
complicate continuity of care; the patient’s medical records may become discontinuous,
different groups of caregivers may have difficulty communicating with one another, or the
patient may be subjected to multiple, potentially conflicting standards of care. Similarly, the
self-directed nature of medical tourism means that patients may have difficulty accessing
follow-up care, including for unexpected complications. The patient’s domestic care providers
may be unfamiliar with the care received abroad or reluctant to provide follow-up care out of
a concern for legal liability for complications arising from this care--if the patient has access
to care at home at all.
Facilitators may not have the capacity or background necessary to help patients
arrange for continuity of care and follow-up care. Facilitators may not inform their clients of
the need to work with their home country physician to arrange for medical record transfer and
follow-up care if needed. They may not be aware of the need to take these steps, or might be
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concerned that emphasizing these care coordination logistics will detract from the appeal of
their services.
7
Depending on the facility, there may or may not be international patient
coordinators (i.e. staff employed by the destination facility to oversee the off- and on-site
logistics of treating international patients) with which the facilitator can work to ensure
continuity of the patient’s care.
17
In some cases, attempts to facilitate continuity of care are
limited to suggestions that patients communicate with their home country doctors before and
after receiving care abroad.
17
Patient-initiated conversations of this kind can however be
limited if patients are ill-informed about the care they will be receiving abroad or hesitant
about speaking with their regular physicians about leaving the country for care because they
fear that the physician will disapprove.
3
Moreover, patients may not be aware of the potential
expenses associated with receiving follow-up care upon return home, further complicating
coordinating after-care.
17
In short, there is no guarantee that patients seeking care abroad will
consult with a physician before or after travel or that facilitators will aid them in doing so.
6
Empirical studies presenting the findings of interviews with facilitators show that their
roles in arranging follow-up care vary greatly.
3,5
Johnston et al. recorded a diverse spectrum
of facilitator approaches to follow-up care. Some interviewees reported arranging follow-up
care by request of the client only. Other interviewees frequently contacted clients upon return
home from medical care abroad to discuss follow-up arrangements.
3
Facilitators who
demonstrated the most involvement in follow-up care reported only accepting clients once
such care had been secured. Even when facilitators want to take a role in arranging follow-up
care, their efforts may be restricted in cases when clients’ regular physicians do not support,
or even openly disapprove of, the pursuit of care abroad and thus decline to provide the
necessary tests or referrals.
3,5
In a content analysis of 17 websites, Penney et al. found that facilitation companies
claimed a wide variety of responsibilities regarding the transfer of medical records and
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coordination of follow-up care. Some websites clearly stated that the facilitator has no role in
monitoring patient care upon arrival home. Others offered a range of services, including
“arranging phone calls between the patient and specialist abroad, having report sent to home
physician, organizing rehabilitation, telehealth consultations, and answering questions”
1
However, whether these services would require additional fees or specific requests was
typically not made clear. Additional website analyses support the findings of Penney et al.
that follow-up care is not consistently addressed. For example, Lunt and Carrera found that
although pre-operative consultations were often offered to potential patients, only 10% of
websites addressed follow-up care.
15
Mason and Wright found only 4.9% of websites
addressed follow-up care on the main page of their site, with 18.2% addressing follow-up care
on other pages.
8
Legal Liability for Harms
When patients seek care abroad, they may be subjected to unfamiliar legal environments.
Legal protections for patients and medical liability standards differ greatly from jurisdiction to
jurisdiction. Low malpractice insurance costs have been cited as one factor allowing some
medical tourism destinations to offer less expensive care,
18
but patients may find it
challenging to factor the value of decreased malpractice protection into their decision-making.
Facilitators can help patients navigate these issues, but they too inhabit a murky international
arena complicated both by the relatively unregulated status of medical tourism facilitation and
the international dimension of the practice.
Some facilitators try to insulate themselves from the legal risks of medical tourism--
including suits for malpractice, poor quality of care, or any complications that might arise
from seeking medical care abroad--by distancing themselves from actual medical provision,
and instead framing themselves as merely facilitating contact with medical facilities and
physicians abroad and arranging for travel to these facilities.
7
Then if complications arise
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from the care provided, the responsibility for these problems theoretically would be shifted to
the physician and medical facilities abroad instead of the facilitators themselves.
7
In this way,
if facilitators simply provide clients with information and contacts, along with a warning to
beware of the complications that may arise from receiving medical care abroad, patients take
on the responsibilities for the outcomes of their own decisions.
19
Facilitators' attempts to limit their own liability sometimes take the form of statements
warning patients that the facilitator has no legal liability for malpractice or complications
arising from treatment received abroad or dissatisfaction with the care received. In other
instances, facilitators require clients to sign contracts that waive the facilitator's legal liability
in the event of complications.
7
When this occurs, the facilitator not only warns patients that
they are on their own when risking medical treatment abroad, but also creates a legal barrier
against seeking redress from the facilitator. While facilitators may encourage patients to seek
legal redress from their medical providers abroad, doing so is problematic in two respects.
First, pursuing a legal course of action abroad may be very expensive and difficult. Doing so
requires navigating a foreign legal system, possibly using a language other than the patient’s
own.
20,21
If the patient is required to return to the country where the care was received in order
to pursue damages, this creates additional burdens and costs. Second, adequate legal recourse
may not even be available to the patient if the host country has limited medical malpractice
protections for patients.
17,21
For a more detailed discussion of the issues surrounding legal
liability in medical tourism, see Chapter 9
Interviews with Canadian facilitators show that they emphasize to clients that they are
not medical professionals, and are instead offering information and referrals that patients have
requested.
5
In this sense, facilitators do not view themselves as being responsible for adverse
outcomes that occur as a result of patients acting on the information or referrals. Some
facilitators do perform certain actions that could help lessen the risk of liability issues and
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patient complications. For instance, one facilitator reported visiting potential destination
facilitates to see, first-hand, if the facilitator would feel comfortable referring patients there.
5
However, since facilitators lack standardized professional training, their capacity to discern
quality medical locations from unsafe ones is questionable. In website analyses, very few
facilitator sites addressed issues of legal recourse for patients. For example, Mason and
Wright found only 6.1% of websites that they examined addressed legal concerns,
8
while Lunt
and Carerra reported that three of the five sites they examined stated that it was the surgeon’s
responsibility to address post-operative complications.
15
Discussion
Our review of ethical concerns tied to the practice of medical tourism facilitation and the
emerging body of empirically-based research on facilitators confirms, gives context to, and
enhances our understanding of certain of these ethical concerns. At the heart of these concerns
is the pressing question that many health systems confront: who holds responsibility for
managing patient care across the continuum? As we have emphasized above, in the case of
medical tourism, this continuum extends across countries, legal systems, regulatory
approaches, and sometimes even languages.
It is clear that potential medical tourists face challenges in their informed decision-
making. Reviews of facilitator websites consistently show that patients are not made
sufficiently aware of the risks associated with medical tourism through these sources alone.
As these websites are initial and formative sources of information, this lack of information
raises questions about patients’ ability to give fully informed consent to face these risks. Other
information gaps undermine informed decision-making as well. Should decisions be based
solely on publicly-available information through facilitator websites, potential medical
tourists are likely to be confused about facilitators’ pay structures, among other factors.
Moreover, reviews of facilitator websites give evidence that most do not offer clear guidance
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on the legal protections afforded to medical tourists if they choose to travel abroad for care.
Statements and waivers of facilitator liability vary among websites and patients are not likely
to be in a position to judge the enforceability of these waivers, particularly if they have not yet
been tested in court. Moreover, these websites lack information on the variability of
malpractice protections in host countries, further compromising patients' ability to make
informed decisions.
The lack of a requirement for accreditation reinforces ethical concerns around the
roles and responsibilities of medical tourism facilitators. For example, our review
demonstrated a lack of clear protocols for providing follow-up care and ensuring
informational continuity of care, a problem due in part to a lack of standardization among
facilitators. While some facilitators oversee follow-up care for their clients and facilitate
continuity of care, the treatment of these issues on facilitators’ websites suggests the quality
and scope of these services is uneven. The lack of accreditation undermines patients’ ability to
assess facilitators’ training and qualifications. While symbols of accrediting agencies and
other signifiers of quality were common on facilitator websites, they generally did not pertain
to accreditation of the facilitators themselves. This can be misleading or confusing for
medical tourists attempting to evaluate facilitators.
However, our review of the literature on medical tourism facilitators shows that a
number of commonly-cited ethical concerns have yet to be evidenced in practice. For
example, while concerns have been raised that payments from destination facilities to
facilitators for referrals creates a potential conflict of interest and may negatively impact
patient care or motivate unnecessary or overly expensive treatments, we do not yet have
evidence of whether or how this conflict of interest has influenced facilitators'
recommendations for care. While the financial incentive referrals create may work against
patients’ interests, facilitators also have an interest in developing and maintaining a reputation
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for quality service and satisfied customers that may outweigh those incentives. Furthermore, it
is difficult to assess the legal vulnerability of patients given the lack of case law around
facilitator liability waivers. While the findings of website review studies make us suspect that
the content of these waivers is variable, we do not have access to the content of these
statements since they are generally not made public. We also do not know how common
signed waivers are in the industry. Finally, evidence of the negative health impacts of
engaging in medical tourism and of gaps in continuity of and follow-up care is lacking. While
anecdotes of complications emerging from medical tourism are common and alarming, as are
examples of problems with continuity of and follow-up care, more data are needed in order to
identify and assess trends. Importantly, complications and risks created by medical tourism
are likely to vary by procedure and location, making it difficult to issue blanket statements
about the safety of this practice.
The ethical concerns associated with medical tourism facilitation highlight the need
for greater regulation and transparency.
6,22
The emerging literature on facilitators clearly
supports the need for greater transparency to help patients understand the risks medical
tourism entails, as well as facilitators’ potential for conflicts of interest.
4
Facilitators could
promote transparency by fully disclosing the source and amount of their fees and by
providing more information about the risks of medical tourism on their websites.
9
Requiring
facilitators to receive training and accreditation could help ensure that facilitators provide this
information about risks and funding sources to potential patients.
5,6
An accreditation process
could also help to provide uniform procedures for providing medical tourists with better
continuity and follow-up care. Other proposed regulations, including restrictions on
facilitators' contracts, requirements for travel insurance, patient compensation for malpractice,
and restrictions on the procedures that facilitators can advertise
6
are less directly supported by
the existing empirically-based literature. Additional research into the impacts of medical
Medical Tourism
Research Group
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tourism on patient health and the adequacy of patient information on the risks entailed by
medical tourism might support these additional regulatory interventions, and is thus needed.
In interviews, facilitators stated a desire for standardization and regulation as a way to
professionalize their practice.
5
However, it is not clear what organization or group should
assume this responsibility. Norms and standards of facilitator services have not yet developed,
no regulatory body has formed to oversee facilitator practices, and a code of practice has not
been adopted. Medical tourism facilitation companies work in a wide variety of legal and
regulatory contexts, and without the oversight of one professional accrediting body. The
international nature of medical tourism, where patients, providers, and facilitators may each
be based in different countries, makes regulation difficult to impose, especially given the
significant financial incentives to limit regulatory policies in medical tourism destinations.
Voluntary participation in an accreditation system akin to JCI accreditation for health
providers would be a first, feasible step toward greater regulation of the industry. While such
a system would be voluntary and thus limited in force, JCI accreditation is increasingly seen
as a de facto requirement for medical tourism providers targeting patients in North America.
Research Directions
Our review suggests several areas of research that are needed in order to expand our
understanding of the ethical dimensions of medical tourism facilitation. Most pressing is an
understanding of patient-facilitator interactions beyond what is known from public facilitator
websites. This information will help to bridge several gaps in our understanding of medical
tourism and of facilitators’ roles and responsibilities. These gaps include the limited
understanding of the degree to which facilitators convey information on the risks of medical
tourism, the content and presentation of liability waivers, and discussions of follow-up and
continuity of care. While ethical concerns about all of these areas are well founded, a better
understanding of the full range of patient-facilitator interactions will help to add detail to
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these concerns, illuminate differences in how facilitators interact with their clients, and
suggest interventions for overcoming or mitigating these concerns.
More data are needed on the numbers of medical tourists using facilitators to plan their
travel abroad for care, medical tourists choosing not to use facilitators, and patients who
interacted with facilitators but chose not to engage in medical tourism. This data will help to
better understand patients’ decision-making processes around medical tourism and
facilitators’ roles and responsibilities in this process. More data also are needed on patient
outcomes following travel abroad for medical care. This data could help differentiate
outcomes for those patients using facilitators and help to uncover facilitators’ roles in
improving or worsening health outcomes for medical tourists. It is possible that these
outcomes will differ by destination and procedure, and ideally such data would help to
determine whether facilitators who are accredited and have a medical background have better
outcomes than other facilitators.
Information is greatly needed on how patients, facilitators, and other industry
stakeholders, including physicians, perceive the facilitators' roles and responsibilities. While
this information is starting to appear through facilitator interviews, facilitator self-perception
may vary by location, thus creating the need for comparative insights. Moreover, our
understanding of patient and other stakeholders’ views of facilitators’ roles and is limited at
this time. A better understanding of facilitators' roles will help shape regulatory responses and
inform procedures for facilitator accreditation.
Given the dynamic nature of medical tourism and relative newness of facilitation as an
entrepreneurial venture within this global health services industry, the literature on ethical
concerns about this practice has been quick to develop. The expanding body of empirically-
based research on facilitation is helping to define our understanding of the ethical dimensions
of facilitation. Continued research along existing pathways and in the areas described here,
Medical Tourism
Research Group
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while logistically difficult and time- and money-intensive, will help to shape policy responses
to medical tourism generally and facilitation specifically. Medical tourism facilitation is a
business that is likely to continue playing a role in securing (or perhaps worsening) patient
health, thus making it clear that a better understanding of the practice of facilitation and
diversity of facilitators’ roles and responsibilities toward medical tourists and the industry is
needed.
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