Originally published July 2016
Patients travelling across borders in pursuit of medical care is an evolving global trend in healthcare that has surged in recent years.1 This phenomenon, known as medical tourism, can lead to healthcare delivery challenges with potential ethical and medical-legal risks for Canadian physicians. Physicians should be aware of the issues associated with medical tourism, and know how to manage the risks posed when their patients seek medical care abroad and when medical tourists from other countries seek treatment in Canada.
Factors influencing medical tourism
The globalization of healthcare markets and other factors are contributing to the desire amongst some to travel to seek medical care in a foreign jurisdiction.
Patients look for care abroad for many reasons, from avoiding long wait times to finding lower cost treatments to obtaining care not available in their home jurisdiction.2 The treatments and procedures they are looking for range from cosmetic surgery to oncology.
Some countries actively promote and compete for medical tourism. Asian countries are top destinations for medical tourists, and Middle Eastern and Latin American countries are developing hospital facilities to specifically attract international patients.1
Improving medical tourism guidelines and trusted international accreditation standards for some healthcare destinations have become significant drivers in the growth of medical tourism.3 In addition, advances in technology, such as the availability of the Internet, give patients easy access to medical tourism operators, brokers, or third party purchasers of healthcare.4
Foreigners, tourists, and non-residents travel to Canada to receive medical care for various reasons. For instance, some non-resident women come to give birth. This activity, known as "birth tourism" or "passport babies," can facilitate these children acquiring citizenship by being born on Canadian soil.
The Canadian picture
Inbound and outbound medical tourism expenditures in Canada remain relatively small compared to other countries.1 More Canadians are travelling abroad for medical treatment than foreign visitors coming to Canada.1 An estimated 52,513 Canadians received treatment abroad in 2014, an increase of 26% from 2013 (41,838).2
Medical-legal risks when Canadians travel abroad for care
Canadians travelling as medical tourists can present concerns and medical-legal risks for Canadian physicians.
When contemplating travelling for care, patients can be influenced by the information on healthcare destination websites, which can be ambiguous or incomplete. They may have problems obtaining reliable information about procedure success rates and the quality of care in destination facilities.5,6 This can result in patients giving consent without being informed.7 Patients may ask their physician to provide information on or a referral for an out-of-country treatment. Physicians may be reluctant to do so if they do not have knowledge of a particular procedure, including the potential risks and benefits.
If physicians do provide professional advice and choose to advocate for the out-of-country procedure, this may create a duty of care within the existing doctor-patient relationship and include the physician in the coordination of care. If the patient experiences poor health outcomes as a result of the treatment, physicians may be exposed to the risk of a legal action being brought in the foreign jurisdiction. This could raise questions about the physicians’ eligibility for CMPA assistance.
Once Canadian patients have reached their healthcare destination, they may be at risk for substandard care due to inadequate international regulations in the medical tourism industry and the variability of quality of care around the world.5,6,8 Moreover, some patients may have received out-of-country procedures that are illegal, untested, or unavailable in Canada. It can be difficult for Canadian physicians to provide follow-up care for procedures that may have been done poorly or for which they have little or no knowledge or experience.5
Continuity of care can be further disrupted when patients return home with incomplete or no clinical documentation and little information on their out-of-country procedure.6,8 Inefficient systems for transferring health records between medical tourists and their physicians in Canada and in destination countries5 can make it hard to obtain documentation on the procedure. As well, "international and unregulated transfer of health records might threaten patient privacy."5
Minimizing medical-legal risks
Providing care to Canadians travelling abroad for care
When providing care to patients who have returned after receiving care abroad, physicians should consider the following to minimize their medical-legal risks:6
- Physicians should respect patients’ autonomy in seeking out-of-country procedures and other decisions regarding their healthcare.6
- Where appropriate, physicians should try to address to the best of their ability and knowledge questions from patients who are considering care abroad.7,8 They can also help patients minimize health risks associated with travel to certain countries, for example by suggesting patients obtain vaccinations.5,6
- Physicians should keep the lines of communication with patients open, for example by asking them to provide information about the medical treatment abroad, including their foreign medical record, and ensuring the transfer of records is complete.5,6
- Any discussion concerning the out-of-country procedure should be documented in the patient’s medical record.
- Guidelines created by the Government of Canada may assist both physicians and patients to mitigate the risks associated with receiving medical care abroad.6,9
- Physicians may want to consider information from their provincial or territorial medical regulatory authority (College) on medical tourism.
- Physicians treating patients who have received care from outside of Canada should be mindful of the patient’s need for follow-up care upon returning to Canada, including emergent care. Physicians in these circumstances should consider the urgency of the treatment required and their ability to provide information and follow-up care to the best of their ability and within the limits of their clinical knowledge.6
Providing care to non-residents travelling to Canada for care
The following can help physicians reduce their medical-legal risks when treating non-resident patients and medical tourists in Canada.
- Before providing care or treatment, physicians should make reasonable efforts in the circumstances to have non-resident patients sign the CMPA’s Governing Law and Jurisdiction Agreement. CMPA members should discuss the purpose of the agreement, which is to ensure that any potential legal actions against the physician that arise from the care provided will be brought in Canada.10
- Physicians should familiarize themselves with hospital and College guidelines, policies, and protocols on medical tourism and providing care to non-residents.
- Physicians should document discussions with and care of non-residents in medical records.
Extent of assistance principles for providing care to non-residents
Canadian physicians who provide care to non-residents of Canada are at increased risk of medical-legal difficulties arising outside of Canada. Those members who are considering treating non-residents of Canada should be familiar with the Association’s principles of assistance for members who provide care to non-residents of Canada:
- While CMPA members are generally eligible for assistance with medical-legal difficulties arising in Canada as a result of providing medical care in Canada, the Association is not structured to assist when medical-legal actions are instigated by non-residents outside of Canada.10
- The CMPA will exercise its discretion and assist members with legal actions brought inside or outside Canada if the care provided in Canada was for an emergent or urgent circumstance, if the required care is not reasonably available in the patient’s own country, or in other exceptional circumstances.10
- The CMPA will not consider extending assistance outside Canada when a member, directly or indirectly, solicited, actively undertaken, or offered to undertake the treatment of a non-resident patient, such as in obstetrical care, whether through medical tour operators or other third parties, or encouraged the creation of a doctor-patient relationship.10
Physicians are encouraged to contact the CMPA for advice regarding any questions on medical tourism and the circumstances under which members may be eligible for assistance.
- Bounajm F, Labonté R, Runnels V. Should Canada's Hospitals Open their Doors to Medical Tourists? Health Care in Canada: An Economic Growth Engine [Internet]. The Conference Board of Canada; 2015. Available from: http://www.conferenceboard.ca/temp/ed187248-7790-4a0d-a466-4be44fed34df/7003-%20international%20trade%20in%20health-br.pdf
- Barua B, Ren F. Leaving Canada for Medical Care, 2015 [Internet]. Fraser Institute. 2015 [cited 2016 Mar 1]. Available from: https://www.fraserinstitute.org/sites/default/files/leaving-canada-for-medical-care-2015.pdf
- Medical Tourism Statistics & Facts [Internet]. Patient Beyond Borders. 2014 [cited 2016 Mar 10]. Available from: http://www.patientsbeyondborders.com/medical-tourism-statistics-facts
- Lunt N, Smith R, Exworthy m, Green S, Horsfall D, Mannion R. Medical Tourism: Treatments, Markets and Health System Implications: A scoping review [Internet]. Paris: OECD; 2011[cited 2016 Mar 1]. Available from: http://www.oecd.org/els/health-systems/48723982.pdf
- Valorie A. Crooks J. Medical tourism: What Canadian family physicians need to know. Canadian Family Physician [Internet]. 2011 [cited 2016 Mar 16];57(5):527. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093576/
- The impact of medical tourism on Canadian physicians [Internet]. Canadian Medical Protective Association. 2012 [cited 2016 Mar 15]. Available from: https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/the-impact-of-medical-tourism-on-canadian-physicians
- Snyder J, Adams K, Chen Y, Birch D, Caulfield T, Cohen I, Crooks V, Illes J, Zarzeczny A. Navigating physicians’ ethical and legal duties to patients seeking unproven interventions abroad. Canadian Family Physician [Internet]. 2015 [cited 2016 Mar 16];61(7):584-586. Available from: http://www.cfp.ca/content/61/7/584.full
- Turner L. Medical tourism: Family medicine and international health-related travel. Canadian Family Physician [Internet]. 2007 [cited 2016 Mar 16];53(10):1639-1641. Available from: http://www.cfp.ca/content/53/10/1639.full
- Receiving medical care in other countries [Internet]. Government of Canada. 2015 [cited 2016 Mar 17]. Available from: http://travel.gc.ca/travelling/health-safety/care-abroad
- Treating non-residents [Internet]. Canadian Medical Protective Association. 2013 [cited 2016 Mar 15]. Available from: https://www.cmpa-acpm.ca/-/treating-non-residents-of-canada