Legal considerations in reproductive medicine.

Legal issues affect reproductive medical practice throughout the entire world. The breadth and depth of this interrelationship extend far beyond the scope of one series of articles in Views and Reviews. Given this limitation, we have chosen to present five topics, all different, but illustrative of key concepts that influence our practice of reproductive medicine. Our hope is that this "medical-legal sampler" will both inform and provoke thoughtful consideration of the ways we can best and most responsibly practice and serve our patients.

Medical Tourism and the Best Interests of the Critically ill Child in the Era of Healthcare Globalisation.

In this article, we examine emerging challenges to medical law arising from healthcare globalisation concerning disputes between parents and healthcare professionals in the care and treatment of critically ill children. We explore a series of issues emerging in English case law concerning children's medical treatment that are signs of increasing globalisation. We argue that these interrelated issues present distinct challenges to healthcare economics, clinical practice, and the operation of the law. First, social media leverages the emotive aspects of cases; secondly, the Internet provides unfiltered information about novel treatments and access to crowdfunding to pay for them. Finally, the removal of barriers to global trade and travel allows child medical tourism to emerge as the nexus of these issues. These aspects of globalisation have implications for medicine and the law, yet child medical tourism has been little examined. We argue that it affects a range of interests, including children's rights, parents' rights as consumers, and the interests of society in communalised healthcare. Identifying putative solutions and a research agenda around these issues is important. While cases involving critically ill children are complex and emotionally fraught, the interconnectedness of these issues requires the law to engage and respond coherently to the impacts of healthcare globalisation.

Modulatory effects of ayahuasca on personality structure in a traditional framework.

Ayahuasca is a psychoactive plant brew containing dimethyltryptamine (DMT) and monoamine oxidase inhibitors (MAOIs). It originates from the Amazon basin, where it is used primarily for ceremonial purposes. Ayahuasca tourists are now entering certain communities seeking alternative physical or psychological healing, as well as spiritual growth. RATIONALE: Recent evidence has shown that the similar acting psychedelic compound, psilocybin, facilitated long-term increases in trait openness following a single administration. OBJECTIVES: This paper assesses the impact of ayahuasca on personality in a traditional framework catering for ayahuasca tourists. METHOD: Within a mixed design, we examined the effect of ayahuasca on participants' personality (measured by the NEO Personality Inventory 3 questionnaire) across time (pre- to post-ayahuasca administration, and 6-month follow-up), relative to a comparison group (who did not ingest ayahuasca). RESULTS: The results demonstrated significant increases in agreeableness pre- and post-ayahuasca administration and significant reductions in neuroticism in 24 participants, relative to the comparison group. Both of these changes were sustained at 6-month follow-up, and trait level increases were also observed in openness at this stage. Additionally, greater perceived mystical experience (measured using the Mystical Experience Questionnaire 30) was associated with increased reductions in neuroticism. CONCLUSIONS: These findings, which indicate a positive mediating effect of ayahuasca on personality, support the growing literature suggesting potential therapeutic avenues for serotonergic psychedelics.

The north-south policy divide in transnational healthcare: a comparative review of policy research on medical tourism in source and destination countries.

Medical tourism occupies different spaces within national policy frameworks depending on which side of the transnational paradigm countries belong to, and how they seek to leverage it towards their developmental goals. This article draws attention to this policy divide in transnational healthcare through a comparative bibliometric review of policy research on medical tourism in select source (Canada, United States and United Kingdom) and destination countries (Mexico, India, Thailand, Malaysia and Singapore), using a systematic search of the Web of Science (WoS) database and review of grey literature. We assess cross-national differences in policy and policy research on medical tourism against contextual policy landscapes and challenges, and examine the convergence between research and policy. Our findings indicate major disparities in development agendas and national policy concerns, both between and among source and destination countries. Further, we find that research on medical tourism does not always address prevailing policy challenges, just as the policy discourse oftentimes neglects relevant policy research on the subject. Based on our review, we highlight the limited application of theoretical policy paradigms in current medical tourism research and make the case for a comparative policy research agenda for the field.

Diasporic medical tourism: a scoping review of quantitative and qualitative evidence.

BACKGROUND: There is a growing recognition of the significance of the diasporic dimension of medical travel. Explanations of medical tourism are increasingly presented in a wider context of transnationalism, diaspora and migration. Yet diaspora and cross-border travellers rarely get through the broader narrative of medical travel. OBJECTIVE: Our aim in this scoping review was to extend the current knowledge on the emerging subject of diasporic travels for medical purposes. Specifically, we reviewed the existing literature on what is known about the determinants and motivational factors of diasporic medical tourism; its geographic scope and its quantitative estimation. METHODS: Using a scoping review methodology, we conducted the search in seven electronic databases. It resulted in 210 records retrieved. Ultimately, 28 research papers and 6 non-research papers (published between 2002 and 2019) met the following criteria: 1) focus on healthcare and health-related practices, 2) transnational perspective, 3) healthcare consumption in the country of origin (homeland) while being a resident of another country, 4) published in English. RESULTS: The findings from our review highlighted the importance of diasporic medical patients who had been researched and analysed on four continents. Even though quantitative evidence has been scarce, the data analysed in the scoping review pointed to the existence of non-negligible level of diasporic medical tourism in Northern America, and in Europe. Various motivational factors were enumerated with their frequency of occurrence: medical culture (12), time availability ("by the way of being home") (9), communication (6), dissatisfaction with the current system (6), healthcare insurance status (5), quality of healthcare (5), second opinion (3), and value for money (3). CONCLUSION: Diasporic medical tourists constitute an attractive segment of consumers that is still not well understood and targeted. They are part of transnational communities that cultivate the links between the two nations. They simultaneously participate in bi-lateral healthcare systems via return visits which impact the health systems of sending and receiving countries in a substantial way. In the current globalised, connected and migratory context, transnationalism seems to represent an answer to many local healthcare-related barriers. Sending and receiving countries have put in place an array of programmes and policies addressed to the diasporic medical travellers.

Assessing the Potential Impact of the Declaration of Istanbul 2008 on Internet Reporting of Human Organ Transplantation-Related Crimes Using Interrupted Time Series Analysis and Meta-Analysis Approaches.

BACKGROUND: A severe shortage in donor organs is the major driver for organ transplantation-related crimes. The Declaration of Istanbul 2008 (DOI) was created to stop such crimes. We investigated the impact of DOI on Internet reporting of transplantation-related crimes. METHODS: We conducted Google Advanced Searches to collect data on "kidney trade," "kidney sale," "organ trafficking," and "transplant tourism" in 15 original participant and 10 nonparticipant countries, 6 years prior through 8 years after the promulgation of DOI. The data were normalized for population and transformed to a logarithmic scale. Interrupted time series analysis (ITSA) was applied to estimate the changes in slopes of the outcome variables before and after DOI, and then the overall intervention impact was calculated by meta-analysis. RESULTS: The combined results indicated that the overall impact of DOI on the reporting of "organ trafficking" and "transplant tourism" was statistically negative (reporting reduced significantly) as intended but on "kidney sale" and "kidney trade" was statistically positive (reporting increased significantly), and the increase was higher in the nonparticipant countries compared to the participant countries. The rate of reporting on "transplant tourism" declined in the participant countries more pronouncedly than in the nonparticipant countries. CONCLUSIONS: DOI has a positive impact on the reporting of "organ trafficking" and "transplant tourism" but not on the reporting of "kidney sale" and "kidney trade." The increased reporting of "kidney sale" and "kidney trade" can be indicative of an impact of DOI on public awareness and increased reporting of the residual transplantation-related crimes.

Birth Tourism Among Chinese Women.

PURPOSE: To explore the reasons why some Chinese women travel to the United States on a tourist visa specifically to give birth, also known as birth tourism. STUDY DESIGN: Qualitative, exploratory design. METHODS: Using convenience and snowball sampling, Chinese women were recruited from the waiting rooms of obstetricians known to care for birth tourists. Participants completed demographic data and provided answers to questions about their reasons for traveling to give birth and their birth experience while in the United States. Qualitative content analysis methods were used to extract themes from participant narratives. RESULTS: Twelve married, college-educated women, aged between 26 and 39 years, self-identifying as birth tourists from China participated in this study. Content analysis revealed two themes: (1) positive perceptions of childbirth in the United States; and (2) securing a future for their child. CLINICAL IMPLICATIONS: Study findings suggest Chinese birth tourists come to the United States for a better childbirth experience, and to secure future opportunities for their children. Nurses should be aware of the current political climate on immigration and birth tourism in order to promote a safe and judgment-free environment when providing care to this unique population of women.

Medical Travel among Non-Seoul Residents to Seek Prostate Cancer Treatment in Medical Facilities of Seoul.

PURPOSE: This study aims to investigate the trend in medical travel by non-Seoul residents to Seoul for treatment of prostate cancer and also to investigate the possible factors affecting the trend. MATERIALS AND METHODS: This study represents a retrospective cohort study using data from theKoreanNationalHealth Insurance System from 2002 to 2015. Annual trends were produced for proportions of patients who traveled according to the age group, economic status and types of treatment. Multiple logistic analysiswas used to determine factors affecting surgeries at medical facilities in Seoul among the non-Seoul residents. RESULTS: A total of 68,543 patients were defined as newly diagnosed prostate cancer cohorts from 2005 to 2014. The proportion of patients who traveled to Seoul for treatment, estimated from cases with prostate cancer-related claims, decreased slightly over 9 years (28.0 at 2005 and 27.0 at 2014, p=0.02). The average proportion of medical travelers seeking radical prostatectomy increased slightly but the increase was not statistically significant (43.1 at 2005 and 45.4 at 2014, p=0.26). Income level and performance ofrobot-assisted radical prostatectomy were significant positive factors for medical travel to medical facilities in Seoul. Combined comorbidity diseases and year undergoing surgery were significant negative factors for medical travel to medical facilities in Seoul. CONCLUSION: The general trend of patients travelling from outside Seoul for prostate cancer treatment decreased from 2005 to 2014. However, a large proportion of traveling remained irrespective of direct distance from Seoul.

Surgical Management of Cosmetic Surgery Tourism-Related Complications: Current Trends and Cost Analysis Study of the Financial Impact on the UK National Health Service (NHS).

BACKGROUND: Cosmetic surgery tourism is thriving. Lower costs and all-inclusive cosmetic surgery holiday packages have led to more patients seeking cheaper aesthetic surgery abroad. However, limited postoperative care results in patients frequently presenting to UK National Health Service hospitals with postoperative complications requiring surgery. OBJECTIVES: The authors sought to identify current trends and the financial impact of surgically managed complications from cosmetic surgery tourism. METHODS: A retrospective review of consecutive surgically managed patients attending a London Teaching Hospital between 2006 and 2018 with complications following cosmetic surgery abroad was performed. Patient demographics, procedure characteristics, and length of stay were determined and a comprehensive cost analysis was performed. RESULTS: Twenty-four patients presented with complications. Twenty-two were females aged a mean of 36 years (range, 25-58 years). Gluteal enhancement was the most common procedure (38%) and infection (92%) was the primary complication. Most procedures were undertaken in Turkey (29%) and performed in the last 5 years (63%). Twenty-one patients were inpatients and mean length of stay was 8 days (range, 1-49 days); abdominoplasty patients stayed the longest. The total cost to the hospital was $406,233, leading to an average cost per patient of $16,296 (range, $817-$41,778). Complications from abdominoplasty resulted in the highest cost per patient of $20,404. CONCLUSIONS: Cosmetic surgery tourism is on the rise as patients travel for cheaper aesthetic surgery. There is urgent need to better address this issue to help reduce the growing financial strain on the National Health Service, safeguard patients, and optimize the use of valuable resources.

Cross-border spatial accessibility of health care in the North-East Department of Haiti.

BACKGROUND: The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border. METHODS: To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios. RESULTS: The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans. CONCLUSION: The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

The role of the 2011 patients' rights in cross-border health care directive in shaping seven national health systems: Looking beyond patient mobility.

Reports on the implementation of the Directive on the application of Patients' Rights in Cross-border Healthcare indicate that it had little impact on the numbers of patients seeking care abroad. We set out to explore the effects of this directive on health systems in seven EU Member States. Key informants in Belgium, Estonia, Finland, Germany, Malta, Poland and The Netherlands filled out a structured questionnaire. Findings indicate that the impact of the directive varied between countries and was smaller in countries where a large degree of adaptation had already taken place in response to the European Court of Justice Rulings. The main reforms reported include a heightened emphasis on patient rights and the adoption of explicit benefits packages and tariffs. Countries may be facing increased pressure to treat patients within a medically justifiable time limit. The implementation of professional liability insurance, in countries where this did not previously exist, may also bring benefits for patients. Lowering of reimbursement tariffs to dissuade patients from seeking treatment abroad has been reported in Poland. The issue of discrimination against non-contracted domestic private providers in Estonia, Finland, Malta and The Netherlands remains largely unresolved. We conclude that evidence showing that patients using domestic health systems have actually benefitted from the directive remains scarce and further monitoring over a longer period of time is recommended.

Transplant tourism following the declaration of Istanbul: Poor outcomes and nephrologist dilemma.

AIM: Transplant tourism (TT) violates many international laws and documents. Despite all efforts, TT seems to be increasing. The aim of this study is to review outcomes of recipients of commercially transplanted kidneys since the Declaration of Istanbul. METHODS: All recipients of kidney transplantation done abroad and then returning to our centre, from September 2008 to December 2015, were included (tourists). Demographics and outcomes were collected from patients' charts. All data were compared with all recipients of living donor kidney transplants done at our centre (locals). RESULTS: A total of 86 tourists and 365 locals were included. Both groups had similar age and gender. Re-grafting rates were the same, however, more pre-emptive transplants were done abroad. TT increased over time. Tourists presented early after TT, median 17.5 (IQR 7-30) days, and 47.7% were encountered initially in the emergency department. One-year graft and patient survivals were significantly lower among tourists compared with locals (87.2% vs. 98.0%, P < 0.001 and 90.7% vs. 98.0%, P < 0.001, respectively). Tourists had a significantly higher rate of acute cellular rejection (19.8% vs. 7.1%, P < 0.001), and they sustained significantly higher rates of serious viral, bacterial and fungal infections compared with the locals. CONCLUSION: Transplant tourism seems to be increasing despite international condemnation and efforts to stop it. Outcomes are significantly worse when compared to local transplant recipients. Concerted effort is needed to better inform patients about the ethical and physical harms related to TT, and to point them towards ethically sound and medically safer alternatives.

Adipose-Derived Stem Cells in Aesthetic Surgery: A Mixed Methods Evaluation of the Current Clinical Trial, Intellectual Property, and Regulatory Landscape.

BACKGROUND: Adipose tissue, which can be readily harvested via a number of liposuction techniques, offers an easily accessible and abundant source of adipose-derived stem cells (ASCs). Consequently, ASCs have become an increasingly popular reconstructive option and a novel means of aesthetic soft tissue augmentation. OBJECTIVES: This paper examines recent advances in the aesthetic surgery field, extending beyond traditional review formats to incorporate a comprehensive analysis of current clinical trials, adoption status, and the commercialization pathway. METHODS: Keyword searches were carried out on clinical trial databases to search for trials using ASCs for aesthetic indications. An intellectual property landscape was created using commercial software (Thomson Reuters Thomson Innovation, New York, NY). Analysis of who is claiming what in respect of ASC use in aesthetic surgery for commercial purposes was analyzed by reviewing the patent landscape in relation to these techniques. Key international regulatory guidelines were also summarized. RESULTS: Completed clinical trials lacked robust controls, employed small sample sizes, and lacked long-term follow-up data. Ongoing clinical trials still do not address such issues. In recent years, claims to intellectual property ownership have increased in the "aesthetic stem cell" domain, reflecting commercial interest in the area. However, significant translational barriers remain including regulatory challenges and ethical considerations. CONCLUSIONS: Further rigorous randomized controlled trials are required to delineate long-term clinical efficacy and safety. Providers should consider the introduction of patient reported outcome metrics to facilitate clinical adoption. Robust regulatory and ethical policies concerning stem cells and aesthetic surgery should be devised to discourage further growth of "stem cell tourism."

"Stay cool, sell stuff cheap, and smile": Examining how reputational management of dental tourism reinforces structural oppression in Los Algodones, Mexico.

Los Algodones, Mexico is characteristic of other medical border towns whose proximity to the Mexico-United States border enables American and Canadian patients to take advantage of economic asymmetries on either side of the border to access desired health care. Los Algodones is unique, however, in its focus on the provision of dental care and claims by local residents that it has the highest concentration of dentists per capita in the world. In this paper, we present an analysis of interviews with employees working in Los Algodones' dental tourism industry to examine interviewees' participation in practices related to reputational management of the industry site. Drawing on our interview discussions, we argue that many of these reputational management practices reinforce structural injustices and raise concerns for structural exploitation in the industry. This analysis nuances ethical considerations for medical tourism by highlighting structural factors informing unjust practices within the industry, factors which might be relevant to other medical tourism contexts.

Assessing the use of assisted reproductive technology in the United States by non-United States residents.

OBJECTIVE: To study cross-border reproductive care (CBRC) by assessing the frequency and nature of assisted reproductive technology (ART) care that non-U.S. residents receive in the United States. DESIGN: Retrospective study of ART cycles reported to the Centers for Disease Control and Prevention's National ART Surveillance System (NASS) from 2006 to 2013. SETTING: Private and academic ART clinics. PATIENT(S): Patients who participated in ART cycles in the United States from 2006 to 2013. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Frequency and trend of ART use in the U.S. by non-U.S. residents, countries of residence for non-U.S. residents, differences by residence status for specific ART treatments received, and the outcomes of these ART cycles. RESULT(S): A total of 1,271,775 ART cycles were reported to NASS from 2006 to 2013. The percentage of ART cycles performed for non-U.S. residents increased from 1.2% (n = 1,683) in 2006 to 2.8% (n = 5,381) in 2013 (P<.001), with treatment delivered to residents of 147 countries. Compared with resident cycles, non-U.S. resident cycles had higher use of oocyte donation (10.6% vs. 42.6%), gestational carriers (1.6% vs. 12.4%), and preimplantation genetic diagnosis or screening (5.3% vs. 19.1%). U.S. resident and non-U.S. resident cycles had similar embryo transfer and multiple birth rates. CONCLUSION(S): This analysis showed that non-U.S. resident cycles accounted for a growing share of all U.S. ART cycles and made higher use of specialized treatment techniques. This study provides important baseline data on CBRC in the U.S. and may also prove to be useful to organizations interested in improving access to fertility treatments.