Biliary atresia in Uganda: Current ethical challenges and advancement of public policy

Biliary atresia is a progressive cholangiopathy in neonates, which often results in liver failure. In high-income countries, initial treatment requires prompt diagnosis followed by Kasai portoenterostomy. For those with a late diagnosis, or those in whom Kasai portoenterostomy fails, liver transplantation is the only lifesaving treatment. Unfortunately, in low- and middle-income countries, timely diagnosis is a challenge and liver transplantation is rarely accessible. Here, we discuss the ethical dilemmas surrounding treatment of babies with biliary atresia in Uganda. Issues that require careful consideration include: risk of catastrophic health expenditure to families, ethical dilemmas of transplant tourism, medical risks of maintaining the transplant in a low-resourced health system, and difficult decisions encountered by the surgeon caring for these patients. Four distinct models of the patient-physician relationship are applied to biliary atresia in Uganda. These models describe differences in patient and physician roles, and patient values and autonomy. Solid organ transplantation is a rapidly evolving segment of healthcare in Uganda and ongoing policy advancements may shift ethical considerations in the future.

Should Physicians Be Permitted to Refuse Follow-Up Care to Patients Who Have Received an Organ Transplant Through Organ Trafficking?

In 2018, the Istanbul Declaration stated that organ transplantation via organ trafficking is a crime. Since then, the number of medical institutions in Japan who refuse follow-up care to patients who have undergone unethical organ transplantation overseas has been gradually increasing. Deterring transplant tourism involving organ trafficking is an issue that must be addressed by the government, medical institutions, and individual physicians. The refusal of medical institutions and individual physicians to provide follow-up care after organ transplantation may challenge the idea of the incompatibility thesis; moreover, it may be ethically justified in the context of conscientious objection if it is based on the belief of deterring transplant tourism instead of punitive motives or a reluctance to support a criminal activity. However, conscientious objection based on a belief in fair transplantation care is conditional; according to the compromise approach, it is limited to particular conditions, such as that the patient's medical state does not require urgent care and that the patient is reasonably able to receive follow-up care at another institution.

Infectious complications related to medical tourism

BACKGROUND

Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

METHODS

A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

RESULTS

The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

CONCLUSIONS

There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Commercial kidney transplantation is an important risk factor in long-term kidney allograft survival

Transplant tourism, a form of transplant commercialization, has resulted in serious short-term adverse outcomes that explain reduced short-term kidney allograft survival. However, the nature of longer-term outcomes in commercial kidney transplant recipients is less clear. To study this further, we identified 69 Canadian commercial transplant recipients of 72 kidney allografts transplanted during 1998 to 2013 who reported to our transplant center for follow-up care. Their outcomes to 8 years post-transplant were compared with 702 domestic living donor and 827 deceased donor transplant recipients during this period using Kaplan-Meier survival plots and multivariate Cox regression analysis. Among many complications, notable specific events included hepatitis B or C seroconversion (7 patients), active hepatitis and/or fulminant hepatic failure (4 patients), pulmonary tuberculosis (2 patients), and a type A dissecting aortic aneurysm. Commercial transplantation was independently associated with significantly reduced death-censored kidney allograft survival (hazard ratio 3.69, 95% confidence interval 1.88-7.25) along with significantly delayed graft function and eGFR 30 ml/min/1.73 m(2) or less at 3 months post-transplant. Thus, commercial transplantation represents an important risk factor for long-term kidney allograft loss. Concerted arguments and efforts using adverse recipient outcomes among the main premises are still required in order to eradicate transplant commercialization.

Organ transplantation for nonresidents of the United States: a policy for transparency

A policy proposal relating to transplantation of deceased donor organs into nonresidents of the United States was jointly sponsored by the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) International Relations and Ethics Committees and approved by the OPTN/UNOS Board in June 2012. The proposal followed prior acceptance by the Board of the definitions of "travel for transplantation" and "transplant tourism" and the introduction in March 2012 of revised data collection categories for transplant candidates who are neither citizens nor residents. The most important aspect of the new policy concerns replacement of the previous so-called "5% rule" with the review of all residency and citizenship data and the preparation of a public annual report. The new policy does not prohibit organ transplantation in nonresidents. However, the policy and public data report will ensure transparency and support transplant center responsibility to account for their practices. Since the adoption of the policy, the first 19 months of data show that less than 1% of new deceased donor waitlist additions and less than 1% of transplantation recipients were non-US citizen/nonresidents candidates who traveled to the United States for purposes of transplantation. By adopting this policy, the US transplant community promotes public trust and serves as an example to the international transplant community.

The globalization of healthcare: implications of medical tourism for the infectious disease clinician

Travel abroad for healthcare has increased rapidly; interventions include organ transplant; cardiac surgery; reproductive care; and joint, cosmetic, and dental procedures. Individuals who receive medical care abroad are a vulnerable, sentinel population, who sample the local environment and can carry home unusual and resistant infections, documented in many reports. Medical tourists are at risk for hospital-associated and procedure-related infections as well as for locally endemic infections. Patients may not volunteer details about care abroad, so clinicians must inquire about medical procedures abroad as well as recent travel. Special infection control measures may be warranted. Healthcare abroad is associated with diverse financial, legal, ethical, and health-related issues. We focus on problems the infectious disease clinician may encounter and provide a framework for evaluating returned medical tourists with suspected infections. A better system is needed to ensure broad access to high-quality health services, continuity of care, and surveillance for complications.

Medical tourism

Searches of the literature or Internet using the term "medical tourism" produce two sets of articles: travel for the purpose of delivering health care or travel for the purpose of seeking health care. The first usage primarily appears in the medical literature and is beyond the scope of this article, which focuses on travel to seek health care. Still, there are some aspects these two topics have in common: both are affected by ease and speed of international travel and communication associated with globalization, and both raise questions about continuity of care as well as issues related to cultural, language, and legal differences; both also raise questions about ethics. This article describes some of the motivating factors, contributing elements, and challenges in elucidating trends, as well as implications for clinicians who provide pretravel advice and those who care for ill returning travelers.