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NEWS MEDIA REPORTS OF PATIENT DEATHS FOLLOWING ‘MEDICAL TOURISM’ FOR COSMETIC SURGERY AND BARIATRIC SURGERYdewb_320 21..34

LEIGH TURNER

Keywords bioethics, empirical ethics, medical ethics, Mexico, patient protection, health care

ABSTRACT Contemporary scholarship examining clinical outcomes in medical travel for cosmetic surgery identifies cases in which patients traveled abroad for medical procedures and subsequently returned home with infections and other surgical complications. Though there are peer-reviewed articles iden- tifying patient deaths in cases where patients traveled abroad for commer- cial kidney transplantation or stem cell injections, no scholarly publications document deaths of patients who traveled abroad for cosmetic surgery or bariatric surgery. Drawing upon news media reports extending from 1993 to 2011, this article identifies and describes twenty-six reported cases of deaths of individuals who traveled abroad for cosmetic surgery or bariatric surgery. Over half of the reported deaths occurred in two countries. Analy- sis of these news reports cannot be used to make causal claims about why the patients died. In addition, cases identified in news media accounts do not provide a basis for establishing the relative risk of traveling abroad for care instead of seeking elective cosmetic surgery at domestic health care facilities. Acknowledging these limitations, the case reports suggest the possibility that contemporary peer-reviewed scholarship is underreporting patient mortality in medical travel. The paper makes a strong case for promoting normative analyses and empirical studies of medical travel. In particular, the paper argues that empirically informed ethical analysis of ‘medical tourism’ will benefit from rigorous studies tracking global flows of medical travelers and the clinical outcomes they experience. The paper contains practical recommendations intended to promote debate concern- ing how to promote patient safety and quality of care in medical travel.

INTRODUCTION

Four years ago, while searching the internet for articles about medical tourism and globalization of health care, I discovered a news report describing the death of a woman from New Jersey who traveled to the Dominican Repub- lic for what the reporter described as a tummy tuck pro- cedure and liposuction.1 The article indicated that the

woman experienced respiratory problems following her operation and died six days later. I later found an article that described the deaths of three Americans who trav- eled to Mexico for cosmetic surgery, experienced compli- cations during or following their operations, and died after being transported to medical centers in California.2

I found these articles thought-provoking and troubling. The journalists provided disturbing accounts of the

1 V. Corderi. 2005. Plastic surgery tourism? Dangers of going under the knife on the cheap. Dateline MSNBC 18 March 2005. Available at: http://www.msnbc.msn.com/id/7222253/ns/dateline_nbc/. [Accessed 1 February 2011].

2 C. Clark & S. Dibble. 1996. When cosmetic surgery in Baja goes bad; Deaths raise questions about risks at clinics. The San Diego Union- Tribune 14 July: A1.

Address for correspondence: Leigh Turner, PhD, University of Minnesota Center for Bioethics, N504 Boynton 410 Church St SE, Minneapolis, MN 55455, USA. Email: [email protected]. Conflict of interest statement: No conflicts declared

Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) doi:10.1111/j.1471-8847.2012.00320.x Volume 12 Number 1 2012 pp 21–34

bioethics developing world

quality of care these women received at the international clinics they visited.

After reading these two news media accounts, I decided to see whether I could locate additional news reports of deaths of individuals who had traveled abroad for cos- metic surgery or bariatric surgery. To focus my search I placed four constraints upon the process of finding and analyzing news reports.

First, hoping to obtain basic demographic data, I decided to eliminate from my analysis news reports that mentioned deaths of medical travelers but provided little information about such details as individuals’ ages, their gender, the countries from which patients departed, the nations to which they traveled for surgery, and when patients died.

Second, I restricted my searches to several English- language databases. Though in one case I was able to supplement an English-language report with several news reports written in Spanish and published by media sources in Mexico, four English-language databases were my primary resource for conducting searches.

Third, I excluded from my analysis reports of individu- als who experienced post-operative complications but did not die after traveling abroad and undergoing cosmetic surgery or bariatric surgery. There are several reasons why I focused upon mortality rather than morbidity. Reports of complications following travel for cosmetic surgery and bariatric surgery have already appeared in peer-reviewed medical journals.3 In contrast, to date scholarship does not appear to have identified cases of mortality related to international travel for cosmetic surgery and bariatric surgery. In addition, while complications following travel for cosmetic surgery and bariatric surgery have potentially significant implications for patients and public health systems, in many instances physicians are able to address, at least to some extent, the post-operative complications described in these case reports. Reports in peer-reviewed medical journals describe post-operative care in which infections are treated and in some instances reconstructive surgery is performed in an effort to treat injuries and

scarring resulting from surgery and post-operative com- plications. In contrast, patients who die during surgery or in the post-operative period following cosmetic surgery or bariatric surgery suffer the ultimate loss. Furthermore, they die after undergoing elective procedures that did not have to be performed. I should note that while I searched for reports of mortality in medical travel for cosmetic surgery and bariatric surgery I found many news reports that described patients with post-operative complications after traveling abroad for cosmetic surgery or bariatric surgery. Had my analysis of news media sources included reports of both mortality and morbidity the list of cases would have increased in dramatic fashion.

Fourth, though I could have expanded my search to include reports of morbidity and mortality in all types of medical travel, I chose to restrict my search to accounts of deaths of individuals undergoing cosmetic surgery or bari- atric surgery. This decision meant that I did not seek articles describing morbidity and mortality in medical travelers undergoing such procedures as stem cell injec- tions, treatments for cancer, ‘Liberation therapy’ for Mul- tiple Sclerosis, and organ transplantation. Both news media reports and academic journals report cases of indi- viduals who have traveled to such countries as China, Egypt, India, Pakistan, and the Philippines, participated in commercial organ transplantation, and suffered mor- bidity or mortality following organ transplantation.4

News reports and articles published in peer-reviewed jour- nals also describe cases involving morbidity and mortality in patients who traveled abroad for stem cell injections.5

More recently, academic journals and popular news media have reported morbidity and mortality in individuals who after being diagnosed with multiple sclerosis engage in medical travel to obtain access to the procedure com- monly known as ‘Liberation therapy’.6 Rather than pursue the intimidating task of trying to identify reports of mortality associated with all types of medical travel, I

3 Nontuberculous mycobacterial infections after cosmetic surgery – Santo Domingo, Dominican Republic, 2003–2004. MMWR Morb Mortal Wkly Rep 2004; 53: 509; M. Newman, A. Camberos & J. Ascherman. Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter. Ann of Plast Surg 2005; 55: 107–110; M. Newman et al. Outbreak of atypical mycobacteria infections in U.S. Patients traveling abroad for cosmetic surgery. Plast Reconstr Surg 2005; 115: 964–965; J. Birch, R. Caulfield & V. Ramakrishnan. The complications of ‘cosmetic tourism’ – an avoidable burden on the NHS. J Plast Recon- str Surg 2007; 60: 1075–1077; A. Handschin, A. Banic & M. Constan- tinescu. Pulmonary embolism after plastic surgery tourism. Clin Appl Thromb Hemost 2007; 13: 340; D. Birch et al. Medical tourism in bariatric surgery. Am J Surg 2010; 199: 604–608; J. Snyder & V.A. Crooks. Medical tourism and bariatric surgery: more moral challenges. Am J Bioeth 2010; 10: 28–30; E. Furuya et al. Outbreak of Mycobac- terium abscessus wound infections among ‘lipotourists’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis 2008; 46: 1181–1188.

4 S. Kennedy et al. Outcomes of overseas commercial kidney transplan- tation: an Australian perspective. Med J. Aust 2005; 182: 224–227; M. Canales, B. Kasiske, M. Rosenberg. Transplant tourism: Outcomes of United States residents who undergo kidney transplantation overseas. Transplantation 2006; 82: 1658–1661; G. Prasad et al. Outcomes of commercial renal transplantation: a Canadian experience. Transplan- tation 2006; 82: 1130–1135. 5 B. Dobkin, A. Curt & J. Guest. Cellular transplants in China: obser- vational study from the largest human experiment in chronic spinal cord injury. Neurorehabil Neural Repair 2006; 20: 5–13; N. Amariglio et al. Donor-derived brain tumor following neural stem cell transplan- tation in an ataxia telangiectasia patient. PLoS Med 2009; 6: 221–231; C. Cohen & P. Cohen. International stem cell tourism and the need for effective regulation. Part I: stem cell tourism in Russia and India: clini- cal research, innovative treatment, or unproven hype? Kennedy Inst Ethics J 2010; 20: 27–49. 6 J. Burton et al. Complications in MS Patients after CCSVI Proce- dures Abroad (Calgary, AB). Can J. Neurol Sci 2011; 38: 741–746; C. Alphonso. Death of MS patient fuels debate over new treatment. The Globe and Mail 2010; 19 Nov.

22 Leigh Turner

decided to limit my search to reports of mortality in patients traveling abroad for cosmetic surgery or bariatric surgery. Though for practical reasons I have limited the scope of my study, the research methods identified in this article could be used to investigate news media reportage of both mortality and morbidity in all types of interna- tional medical travel.

DATABASES AND SEARCH TERMS

I conducted searches using ProQuest Newsstand, Google News, Google News Archive, and Google. In addition, I used Google Alerts to send to my email account updates related to deaths of patients who had traveled abroad for cosmetic surgery or bariatric surgery. Search terms com- bined the general concepts of ‘medical tourist’, ‘cosmetic surgery tourist’, and ‘bariatric surgery tourist’ with ‘death’. Specific search terms entered into databases included: death medical tourism, death medical tourist, medical tourist dead, medical tourist died, medical tourist investigation, medical tourist death investigation, medical tourist charges, medical tourist police, death cos- metic surgery tourism, death cosmetic surgery tourist, death lipotourism, death lipotourist, death lipo tourist, death lipo tourism, dead facelift medical tourist, died facelift medical tourist, died medical tourist pectoral implants, dead medical tourist pectoral implants, dead medical tourist breast implants, died medical tourist breast implants, dead medical tourist breast augmenta- tion, died medical tourist breast augmentation, death medical tourist lap band, death medical tourist bariatric surgery, and death medical tourist gastric bypass.

Despite my effort to identify appropriate search terms, searches generated many articles describing deaths of tourists by car and motorcycle crashes, electrocution, fires and explosions, drowning, falls, and other accidents. I discarded these articles and selected for analysis only those publications describing deaths of individuals who were reported to have died during or shortly after under- going cosmetic surgery or bariatric surgery. Searches pro- ceeded in an iterative manner. Once I identified an article that provided an account of someone who had traveled abroad for cosmetic surgery or bariatric surgery and died during or after his or her operation I then used that person’s name as a search phrase. In some instances that step generated additional articles for review.

NEWS MEDIA ACCOUNTS OF DEATHS OF MEDICAL TRAVELERS UNDERGOING COSMETIC SURGERY OR BARIATRIC SURGERY

To summarize information obtained from news media reports I provide brief descriptions of twenty-six reported

cases of mortality in individuals who traveled abroad and underwent cosmetic surgery or bariatric surgery at inter- national medical facilities. Standard practice in peer- reviewed academic journals is to conceal identities of patients. Although the names of individuals are disclosed in news media reports and therefore in the public domain, I have replaced the names of individuals with patient numbers. Cases are reported in chronological order and extend from 1993 to 2011.

Patient 1 traveled from California, USA to Tijuana, Mexico and underwent plastic surgery in 1993.7 She went into cardiac arrest in the recovery room following surgery and subsequently was transported to a medical center in San Diego. Life support was discontinued two weeks after she was hospitalized in San Diego. Two weeks following discontinuation of life support the patient died.

Patient 2 traveled from California, USA to a clinic in Tijuana, Mexico in March 1996.8 There, she underwent a ‘tummy tuck’ procedure. The patient experienced compli- cations from surgery and was transported to a medical facility in San Diego. Life support was discontinued a few days after her arrival and she died within a week of having surgery.

Patient 3 traveled from California, USA to Tijuana, Mexico in April 1996.9 She underwent liposuction and vaginal reconstruction at the same clinic Patient 1 visited. Following surgery, clinic staff members found the patient was unconscious and not breathing. The patient was transported to the same medical center to which Patient 2 was sent, declared comatose, and admitted to ICU. Ven- tilator support was discontinued eight days after her operation and the patient died three days later.

Patient 4 twice traveled from California, USA and underwent breast implantation procedures at a small clinic in Tijuana, Mexico.10 The patient’s incisions became infected following her first surgical procedure; her implants were then removed. The patient returned to the clinic for a second breast implant procedure in October 1996. The patient experienced a complication and died a short time following the operation. Family members contacted Baja California State Prosecutors. I was unable to locate reports documenting the outcome of this investigation.

Patient 5 traveled from New York, USA to the Dominican Republic and underwent liposuction at a

7 C. Clark & S. Dibble. 1996. When cosmetic surgery in Baja goes bad; Deaths raise questions about risks at clinics. The San Diego Union- Tribune 14 July: A1. 8 Ibid: A1. 9 Ibid: A1.

10 S. Dibble. 1996. Death after operation stirs probe; Tijuana plastic surgeon’s credentials questioned. The San Diego Union-Tribune 20 October: B1.

Reports of Patient Deaths Following ‘Medical Tourism’ 23

medical clinic in June 1998.11 Fat extracted during the liposuction procedure was injected into the patient’s but- tocks. The patient died at the clinic. The surgeon was charged with involuntary manslaughter. I was unable to determine how this case was resolved.

Patient 6 traveled from Puerto Rico to the Dominican Republic and underwent liposuction at a medical clinic in August 1998.12 Fat removed during the liposuction pro- cedure was injected into her calves. The patient experi- enced complications following surgery and was flown back to Puerto Rico and admitted to intensive care. Below-the-knee amputations were performed in an attempt to treat her life-threatening condition. The patient died approximately two weeks following admis- sion to intensive care. The surgeon was arrested for two days and then released. It appears that no further legal action was taken.

Patient 7 traveled from Puerto Rico to the Dominican Republic and had a breast reduction operation in Sep- tember 1998.13 The patient had to be hospitalized for an infection following the procedure. Two weeks after the operation the patient died. An investigation was initiated in Puerto Rico. There are no publicly accessible reports documenting how the investigation was resolved.

Patient 8 traveled from Illinois, USA to Guadalajara, Mexico for liposuction in 2001.14 Surgery was performed at a private clinic. The patient died after experiencing an adverse reaction following administration of an anaes- thetic agent.

Patient 9 traveled from California, USA to Tijuana, Mexico for liposuction and a ‘tummy tuck’ operation in 2002.15 The patient returned home following the proce- dure but began feeling ill. She returned to Tijuana and sought treatment for an infection. She died – reportedly of a pulmonary embolism and cardiac arrest–while undergoing a second surgical procedure.

Patient 10 traveled from New Jersey, USA to the Dominican Republic in November 2004.16 There, she underwent liposuction and a ‘tummy tuck’ procedure at a clinic. One week after surgery the patient died. She is

reported to have died of a blood clot in her lungs. The Santo Domingo Attorney General initiated an investigation. There is no record of the outcome of the investigation.

Patient 11 traveled from Austria and underwent lipo- suction surgery in western Hungary in January 2005.17

The patient died a day after surgery. An investigation was initiated in Hungary; there is no account of how it concluded.

Patient 12 traveled from Ireland to New York, USA in March 2005.18 At a Manhattan clinic she had cosmetic surgery on her face, nose, neck, eyelids and lips. The morning following surgery the patient collapsed in the recovery room and went into cardiac arrest. Attempts to resuscitate her were unsuccessful and she was transported by ambulance to a nearby hospital. She was removed from life support and died three days after the operation. At the time of the patient’s death the treating surgeon had settled 33 malpractice lawsuits. Following the investiga- tion of this patient’s death, the surgeon surrendered his medical license and can no longer practice medicine in New York. In 2010 the surgeon paid $2.1 million to settle the malpractice suit resulting from the death of this patient.

Patient 13 traveled from Nigeria to Marbella, Spain and underwent liposuction at a clinic in October 2005.19

Following significant blood loss during surgery the patient was transported from the clinic to a nearby hos- pital. The patient was declared dead upon arrival at the hospital. According to the verdict delivered by Spanish Court, the patient died as a result of the liposuction canella puncturing the liver and colon. The physician was sentenced to one year imprisonment for manslaughter, fined 120,000 Euros, and had his medical license sus- pended for three years.

Patient 14 traveled from England to Cyprus in Novem- ber 2005.20 She had a facelift at a private medical clinic. Following surgery the patient experienced complications as well as symptoms of dizziness and breathlessness. She was transferred to a nearby hospital and died there two

11 K. Ross. 1998. Quest for Physical Perfection Becomes Sad, Caution- ary Tale. The Washington Post 12 September: A03. 12 Ibid. 13 Wire services. 1998. Plastic Surgery Deaths Raise Serious Questions. Orlando Sentinel 18 September: 4. 14 2001. Woman Dies During Liposuction Surgery. Guadalajara Reporter 16 March. 15 B. Hitt. Surgery South of the Border. CBS13. 3 November 2008. Available at: http://sacramento.cbslocal.com/investigations/tijuana. surgeries.south.2.855666.html [Accessed 10 Jan 2012]. 16 M. Sherman & Y. Betances. 2003. The price of perfection. The Eagle-Tribune. Available at: http://lopeztallaj.com/enlosmedios/ publicaciones/paginasexternas/eagletribune/eagletribune.htm, [Accessed 10 Jan 2012]; V. Corderi. Plastic surgery tourism? Dateline MSNBC 18 March 2005. Available at: http://www.msnbc.msn.com/id/ 7222253/ns/dateline_nbc/ [Accessed 10 Jan 2012].

17 Associated Press. 2005. Hungarian police probe death of Austrian patient who died after liposuction. 1 February. 18 S. O’Driscoll. 2005. Cosmetic surgery was ‘significant’ in NY death. Irish Times 26 May: 10; W. St. John. 2005. The Irish Patient and Dr. Lawsuit. The New York Times 24 April: 9.1; J. Eligon & C. Moynihan. 2010. Verdict After Fatal Surgery Surprises a Victim’s Family. The New York Times 1 May: A15. 19 E. Davies & G. Keeley. 2005. Nigerian President’s wife dies after plastic surgery operation in Spain. The Independent. 25 October; G. Tremlett. 2005. Spanish look into death of Nigerian first lady after cosmetic surgery. 25 October: 18; J. Clayton & E. Owen. President’s wife died in coma after surgery ‘for slimming’. The Times. 25 October: 38. 20 Bristol woman died after facelift. Bristol Evening Post. 14 November 2008: 9; Western Daily Press. Woman died after facelift in Cyprus. 14 November 2008: 21.

24 Leigh Turner

days later. After four years, police in England ended their investigation due to their inability to obtain medical documents from Cyprus.

Patient 15 travelled from Rhode Island, USA to Mumbai, India in May 2006.21 The patient underwent a breast reduction and ‘tummy tuck’ procedure. She died four days after the operation. A family member claimed that the patient’s physicians attributed her death to a blood clot that reached her lungs and caused a pulmo- nary embolism.

Patient 16 traveled from Oregon, USA to Curitiba, Brazil in July 2006.22 There, the patient underwent gastric reduction duodenal switch surgery. Three days following surgery the patient died. In news media coverage a family member attributed the cause of death to a pulmonary embolism.

Patient 17 traveled from Florida, USA to Ensenada, Mexico for gastric bypass surgery in June 2007.23 The patient returned to Florida five days after surgery. Less than twenty-four hours following her return home the patient’s fiancée found her struggling to breath. The patient died a short time later. The Palm Beach County Medical Examiner’s Office concluded that the patient died of peritonitis.

Patient 18 travelled from Wellington, New Zealand to Kuala Lumpur, Malaysia for lap band surgery in June 2007.24 Two weeks after surgery, while recovering at a Malaysian resort, the patient is reported to have col- lapsed and died. Family members requested an investiga- tion by the local coroner; lack of access to medical records hampered the investigation.

Patient 19 travelled from Ireland to Bogota, Colombia for liposuction and cosmetic surgery on his face in 2007.25

The patient is reported to have died on the operating table after experiencing heart failure. The patient’s spouse noted the possibility that the patient had con- sumed cocaine and alcohol the day before surgery. The Irish state pathologist indicated that the death should be classified as ‘per operative’ and the County Coroner in Ireland concluded that the death was ‘caused by cardiac

failure related to prolonged surgery’. These decisions had no practical effect because the treating physician was based in Colombia and outside the legal jurisdiction of the Dublin County Coroner’s office.

Patient 20 travelled from the US to Guadalajara, Mexico for breast reduction surgery in July 2007.26 The treating surgeon reportedly performed a full mastectomy and then inserted breast implants. The patient’s incisions opened and became infected after surgery and she spent over a month in hospital. She is reported to have died of a heart attack in October 2007. According to news reports, the physician was arrested and charged with fraud, medical irresponsibility, severe damages, and pro- fessional usurpation. At the time of his arrest 43 patients had filed complaints against him. The doctor was jailed for one year.

Patient 21 traveled from California, USA to Tijuana, Mexico for liposuction and a breast lift in July 2008.27

Her operation was performed at a clinic located within a hotel complex. The patient experienced heart failure during surgery and died at the clinic. Family members filed a complaint with the Attorney General. It is unclear how the investigation concluded.

Patient 22 traveled from Texas, USA to Panama for liposuction in June 2009.28 The patient traveled there with a group of other U.S. patients. Surgery was performed at a private clinic. The patient reportedly had surgery, was transferred to a recovery room, and then died after suf- fering respiratory failure. Family members requested a medical forensic investigation. There is no record of how the investigation concluded.

Patient 23 traveled from Mattersburg, Austria to Hungary for liposuction in January 2009.29 The patient experienced severe pain following the operation and died later that month. The Austrian Municipal Prosecutor’s Office ordered an investigation of the case. The outcome of the investigation is unknown.

Patient 24 traveled from Belarus and underwent a breast enlargement procedure at a private clinic in Dubai,

21 T. Mooney. 2006. Cosmetic surgery overseas ends in death for R.I. woman. The Providence Journal 19 May 2006: A01; J. Wolff. 2007. Passport to Cheaper Health Care? Good Housekeeping 1 September. 22 J. Wolff. 2007. Passport to Cheaper Health Care? Good Housekeep- ing 1 September. 23 A. Ceron & J. Schwartz. 2007. Infection Killed Woman Who Got Gastric Bypass in Mexico. Palm Beach Post. 30 August; B1. 24 K. Meade. 2007. Death raises warning on overseas surgery. The Australian: 29 October: 2; Woman dies after trip for stomach op. 2007. Sunday Star Times. 27 October. 25 S. Carroll. 2008. Coroner warns on dangers of cosmetic surgery. The Irish Times 2 July: 6; Anonymous. 2008. Family granted leave to seek to quash inquest verdict on son’s death. The Irish Times 28 August: 6; T. Healy. 2010. A Fresh Inquest has been ordered into the death of a Dublin man who died while undergoing cosmetic surgery in Colombia. Irish Independent 21 May: 21.

26 Associated Press. 2007. Mexican doctor charged with posing as plastic surgeon, botching dozens of operations. International Herald Tribune 28 December; J. Bernstein-Wax. 2008. Scam artists taint medical care in Mexico. Los Angeles Times 6 January: A6. 27 Death and Funeral Notices. 2008. The San Diego-Union Tribune. 20 July; Dies woman during plastic surgery in Tijuana. 2008. Que Pasa Baja 11 July. Available at: http://quepasabaja.com/?p=552 [Accessed 10 Jan 2012]; R. Morales. 2008. Investigan muerte de una dama. El-Mexicano 09 July; Fallecio en una cirugia estetica. 2008. 10 July. 28 Jose Vasquez. 2009. American ‘Medical Tourist’ Women Dies in David After Undergoing Liposuction. The Boquete Times Newspaper 22 June. 29 Hungary Around the Clock. 2009. Austrian dies after liposuction in Hungary. Hungarian Portal. 30 January. Available at: http:// www.caboodle.hu/nc/news/news_archive/single_page/article/11/ austrian_die/?cHash=7f191cec8d [Accessed 10 Jan 2012].

Reports of Patient Deaths Following ‘Medical Tourism’ 25

UAE in 2010.30 Two days after undergoing the procedure the patient experienced complications, was hospitalized, and then died. The private clinic was ordered closed by the Dubai Misdemeanors Court and the treating physi- cian was convicted for unlawfully operating on the patient and being responsible for her death. The sentence was a fine and one year jail sentence. Sentencing occurred after the accused physician had already left the country.

Patient 25 traveled from California, USA to Tijuana, Mexico and underwent liposuction in May 2010.31

Shortly after the operation concluded the patient experi- enced heart failure; efforts to revive her were unsuccess- ful. The Baja California Attorney General’s Office opened an investigation into the case and in July 2011 the surgeon was charged with manslaughter, arrested, and taken to a state penitentiary in Mexico. At present there is no record of a trial verdict.

Patient 26 traveled from California, USA to Tijuana, Mexico for lap band surgery in May 2011.32 Following surgery, the patient reportedly suffered a cardiac arrest and died. Significant blood loss is reported to have occurred before the patient’s cardiac arrest. The family filed a compliant with the Baja California Attorney Gen- eral’s Office and the Attorney General’s Office has initi- ated an investigation. At present the investigation appears to remain in progress.

Table 1 provides a summary of information extracted from news media accounts of deaths of twenty-six indi- viduals who left their local communities and traveled abroad for cosmetic surgery procedures. Columns iden- tify reported age of individuals at time of death, gender, identified surgical procedures, departure nation (country from which individual left for medical care), destination nation (country in which surgery was performed), and year of death.

OVERVIEW OF REPORTED DEATHS

Of the twenty-six reported deaths, twenty-five of the indi- viduals were women. The youngest person reported to

30 B. Za’za. 2010. Woman dies of organ failure after breast enlargement operation. Gulf News. 2 March; B. Za’za. 2010. Doctor, cosmetician held liable for woman’s death from botched surgery in Dubai. Gulf News 29 March. 31 K. Darce & S. Dibble. 2010. Officials in Baja close clinic where U.S. woman died. The San-Diego Union-Tribune 29 May: B1; Doctor Claims He Was Not At Fault in Woman’s Liposuction Death. 2010; 25 May. Available at: http://www.10news.com/news/23677779/detail.html [Accessed 10 Jan 2012]; Doctor’s Credentials Questioned After Woman’s Liposuction Death. 2010; 25 May. Available at: http:// www.10news.com/news/23676557/detail.html [Accessed 10 Jan 2012].

32 S. Dibble. 2011. Family seeks answers after woman’s Lap-Band death. The San Diego Union-Tribune 9 June. Available at: http:// www.signonsandiego.com/news/2011/jun/09/family-seeks-answers- after-womans-lap-band-death/ [Accessed 10 Jan 2012].

Table 1. Chronological Summary of Cases

Patient Age Gender Procedure Departure Nation Destination Nation Year of Death

Patient 1 65 F plastic surgery California, USA Tijuana, Mexico 1993 Patient 2 38 F tummy tuck California, USA Tijuana, Mexico 1996 Patient 3 57 F Liposuction, vaginal reconstruction California, USA Tijuana, Mexico 1996 Patient 4 23 F Breast implants California, USA Tijuana, Mexico 1996 Patient 5 36 F Liposuction, fat injected into buttocks New York, USA Dominican Republic 1998 Patient 6 26 F Liposuction, fat injected into calves Puerto Rico Dominican Republic 1998 Patient 7 26 F Breast reduction surgery Puerto Rico Dominican Republic 1998 Patient 8 37 F Liposuction Illinois, USA Guadalajara, Mexico 2001 Patient 9 X F ‘tummy tuck’, liposuction California, USA Tijuana, Mexico 2002 Patient 10 43 F ‘tummy tuck’, liposuction Newark, New Jersey Dominican Republic 2004 Patient 11 31 F Liposuction Austria Hungary 2005 Patient 12 42 F Facelift, surgery on nose, eyelids, chin, lips Ireland Manhattan, New York 2005 Patient 13 59 F Liposuction Nigeria Marbella, Spain 2005 Patient 14 62 F Facelift England Lanarca, Cyprus 2005 Patient 15 35 F tummy tuck, breast reduction Rhode Island, USA Mumbai, India 2006 Patient 16 44 F gastric reduction duodenal switch surgery Roseberg, Oregon Curitiba, Brazil 2006 Patient 17 21 F Gastric bypass surgery Palm Beach, Florida Ensenada, Mexico 2007 Patient 18 42 F Lap band surgery Wellington, New Zealand Kuala, Lumpur, Malaysia 2007 Patient 19 33 M liposuction, facial surgery Dublin, Ireland Bogota, Colombia 2007 Patient 20 39 F breast reduction USA Guadalajara, Mexico 2007 Patient 21 55 F Liposuction, breast lift California, USA Tijuana, Mexico 2008 Patient 22 30 F Liposuction Houston, USA David, Panama 2009 Patient 23 57 F Liposuction Austria Hungary 2009 Patient 24 24 F breast implants Belarus Dubai 2010 Patient 25 48 F Liposuction California, USA Tijuana, Mexico 2010 Patient 26 33 F Lap band surgery California, USA Tijuana, Mexico 2011

26 Leigh Turner

have died was 21 and the eldest was 65. Eleven individu- als died after receiving health care in Mexico. Eight of these deaths occurred in Tijuana. Of the remaining patients, four died after receiving care in the Dominican Republic, two died after undergoing surgery in Hungary, and single deaths were reported to have occurred in Brazil, Colombia, Cyprus, India, Malaysia, Panama, Spain, the United Arab Emirates (Dubai), and the United States. Identified surgical interventions included thirteen liposuction procedures, four tummy tucks, three breast implants/breast lifts, three breast reductions, two facelifts, two injections of fat into buttocks or calves, two lap bands, one gastric bypass, one gastric reduction duodenal switch, one vaginal surgery with the specific type of procedure unspecified, one facial surgery with the specific type of surgery unstated, one plastic surgery with the specific procedure unspecified, and one patient reported as having surgery to her nose, chin, lips, and eyelids. There were more surgical procedures than there were individuals because nine patients underwent more than one surgical procedure. Law enforcement officials including state pathologists, state Attorney Generals, local public prosecutors, and local police were reportedly contacted in fourteen of twenty-six cases. In most instances there was no additional information describing outcomes of investigations by law enforcement authori- ties. In three cases physicians settled lawsuits, spent time in jail, surrendered their license to practice medicine, and/or paid fines. In one court decision the treating phy- sician was sentenced to jail and fined but left the country prior to sentencing. One investigation is presently under- way and the physician is charged with manslaughter and in a state penitentiary awaiting trial.

MIDDLE INCOME AND HIGH INCOME MEDICAL TRAVEL DESTINATIONS

The World Bank sorts national economies into the four broad categories of low income, lower middle income, upper middle income, and high income nations.33 Classi- fying countries according to 2010 gross national income (GNI) per capita, GNI in low income countries is $1005 or less, lower middle income is $1006–3975, upper middle income is $3976–12275, and high income is $12276 or more. Whatever the limits of this mode of distinguishing among countries, it provides one metric for broadly cat- egorizing national economies. Using this scheme, The World Bank classifies India as a lower middle income nation; Mexico, Dominican Republic, Brazil, Colombia,

Malaysia, and Panama as upper middle income nations; Cyprus and United Arab Emirates as high income, non OECD nations; and Hungary, Spain, and the United States as high income OECD nations. Of the twenty six deaths of medical travelers that are noted in this article, one death occurred in a low middle income nation, nine- teen deaths occurred in upper middle income nations, two deaths occurred in high income, non OECD coun- tries, and four deaths occurred in high income OECD nations.

There might be a temptation to assume that risks to medical travelers increase as patients move from ‘high income’ to ‘low income’ nations, ‘developing’ to ‘devel- oped’ countries, or ‘developed’ economies to ‘emerging’ economies. The news media reports that I located suggest the possibility of a somewhat more complicated scenario. Approximately 73% (19/26) of reported deaths occurred in upper middle income nations, approxi- mately 23% (6/26) of deaths occurred in high income nations, and 4% (1/26) occurred in low middle income nations. If risks to patients are assumed to be lower in high income countries and greater in low middle income nations, then searches of news media databases might have found more reports of deaths of medical travelers at health care facilities based in low middle income nations and fewer news reports describing deaths of medical travelers who sought cosmetic surgery or bari- atric surgery at health care facilities located in high income nations. Study of news media reports does not reveal true incidence of mortality in medical travel des- tinations. Nonetheless, the reports of deaths of medical travelers raise the possibility that there is no straightfor- ward risk gradient in which medical travelers are at low risk of mortality when receiving care in high income nations, higher risk of mortality when being treated at facilities in upper middle income nations, and even greater risk of mortality when undergoing procedures in low middle income nations. Perhaps many factors such as how health care professionals are regulated, how effectively medical facilities are inspected and accred- ited, and how competent regulatory bodies are at removing from practice clinicians with histories of being disciplines for offering substandard care, are involved and it is important to examine the complex interplay of all relevant factors when considering risks to medical travelers at particular international health care facilities. While risks to medical travelers might increase when they visit specific health care facilities located in select upper middle income nations, it is important to avoid developing an overly simplistic model of medical travel in which medical procedures in middle income countries are assumed to be ‘risky’ and procedures obtained in high income settings are presumed to be ‘safe’. Instead, it seems plausible that more fine-grained analyses are needed.

33 The World Bank Country and Lending Groups. Available at: http:// data.worldbank.org/about/country-classifications/country-and- lending-groups [Accessed 10 Jan 2012].

Reports of Patient Deaths Following ‘Medical Tourism’ 27

PROTECTING MEDICAL TRAVELERS FROM RISK OF HARM

The twenty-six case reports that I have identified suggest numerous points to consider when exploring how to protect medical travelers from risk of harm or death while undergoing cosmetic surgery or bariatric surgery. These practical considerations are proposed as recommenda- tions based upon my review of news accounts of deaths of medical travelers as well as contemporary scholarship examining deaths and post-operative complications in individuals having cosmetic surgery or bariatric surgery at domestic facilities. These accounts of medical travel ending in deaths of patients deserve serious consider- ation. In particular, they should direct attention to what steps might be taken to minimize risks to medical travel- ers and also ensure that they are aware of both risks and benefits when considering whether to travel abroad for care.

First, it is important to note that twenty-five of the twenty-six deaths of individuals traveling abroad for cos- metic surgery or bariatric surgery were women. This finding corresponds with contemporary surveys tracking cosmetic surgery procedures within the United States. According to the American Society for Aesthetic Plastic Surgery, in 2009 over 90% of cosmetic surgery procedures in the U.S. were performed on women.34 If state and federal health agencies, patients’ rights associations, and other organizations are interested in promoting public awareness of risks of undergoing cosmetic surgery both domestically and at international health care facilities, it is important to ensure that such messages are directed at women. Many of the news media reports that I reviewed indicate that cost savings were a key reason why women traveled to Mexico, the Dominican Republic, and else- where for comparatively low cost surgery. One report for example, describes young woman using cash, twelve post- dated cheques, and three credit cards to purchase her weight loss surgery in Mexico.35 Though additional sources of evidence are needed to buttress the case for this claim, if public health officials in various countries are concerned about the quality of care offered by some international medical facilities it might be prudent to place particular emphasis upon targeting public safety messages about risks of cosmetic surgery procedures to low and middle income women.

Second, many of the deaths described in news media reports appear to have occurred outside hospital settings. Several studies of cosmetic surgery procedures in the United States report that there is an estimated 10-fold increase in adverse incidents and deaths when cosmetic surgery procedures are performed in office settings rather than in ambulatory surgery centers.36 Both domestic and international deaths associated with undergoing cosmetic surgery and bariatric surgery might be reduced by man- dating that most cosmetic surgery procedures and all bariatric surgery procedures must be performed in hos- pitals and ambulatory medical centers rather than in small clinics and offices of physicians. Eight deaths are reported to have occurred at clinics in Tijuana. Addi- tional studies are needed to see whether particular fea- tures of cosmetic surgery clinics there might put patients at risk of morbidity and mortality. The four deaths in the Dominican Republic, combined with reports of an out- break of infections in U.S. patients who underwent cos- metic surgery in the Dominican Republic, also suggests the importance of examining practice environments and regulation of health professionals in this setting.37

Third, in many countries physicians who are not trained as board-certified plastic surgeons routinely perform cosmetic surgery procedures. The news media reports describing deaths of cosmetic surgery tourists do not reveal whether the physicians involved in these cases were board-certified in plastic surgery or had equivalent professional credentials. Nonetheless, domestic and international cases of deaths occurring during or shortly after cosmetic surgery suggest the importance of ensuring that cosmetic surgery is performed according to demand- ing standards of practice.38 The same exacting standards must be applied to performance of bariatric surgery. Perhaps morbidity and mortality rates in cosmetic surgery and bariatric surgery at both domestic and inter- national health care facilities might be reduced by limit- ing the types of physicians permitted to perform most cosmetic surgery and bariatric surgery procedures.

Next, of the twenty-six reported deaths, four fatalities occurred in the Dominican Republic. Two of these deaths

34 The American Society for Aesthetic Plastic Surgery. 2009. Cosmetic Surgery National Data Bank Statistics. Available at: http:// www.surgery.org/sites/default/files/2009stats.pdf [Accessed 10 Jan 2012]. 35 A Ceron & J. Schwartz. 2007. 8 Days After Surgery in Mexico, Bride’s Dreams Die With Her. Palm Beach Post 15 July: 1A; A. Ceron & J. Schwartz. 2007. Infection Killed Woman Who Got Gastric Bypass in Mexico. Palm Beach Post 30 August: B1.

36 M. Quattrone. Is the physician office the wild, wild west of health care? J Ambul Care Manage 2000; 23: 64–73; H. Vila et al. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch. Surg 2003; 138: 991–995; J. Horton et al. Patient safety in the office-based setting. Plast Reconstr Surg 2006; 117: 61e–80e. 37 E. Furuya et al. Outbreak of Mycobacterium abscessus wound infec- tions among ‘lipotourists’ from the United States who underwent abdominoplasty in the Dominican Republic. Clin Infect Dis; 46: 1181– 1188. 38 A. Goodwin, I. Martin, H. Shotton et al. On the Face of It: A review of the organizational structures surrounding the practice of cosmetic surgery. National Confidential Enquiry into Patient Outcome and Death 2010. Available at: http://www.ncepod.org.uk/2010cs.htm [Accessed 10 Jan 2012].

28 Leigh Turner

involved individuals traveling from the United States and two deaths involved persons from Puerto Rico. Accord- ing to the U.S. State Department website, ‘The U.S. Embassy in Santo Domingo and the CDC are aware of several cases in which U.S. citizens experienced serious complications or died following elective cosmetic surgery in the Dominican Republic.’39 Though I did not locate reports of U.S. citizens dying during or after having cos- metic surgery in Peru, the U.S. Department of State website for Peru states, ‘Over the last few years, at least five American citizen visitors have died during liposuc- tion operations in Peru. Others have suffered from serious complications including coma. While some of these deaths or complications occurred in ill-equipped, makeshift clinics, travelers are urged to carefully assess the risks of having this type of surgery performed over- seas, even when opting for a treatment at one of the better-known clinics.’40 If consular and embassy officials encounter cases in which citizens from their countries experience serious complications from surgery at interna- tional medical facilities it is important that they docu- ment and publicize this phenomenon. If the cases I review are part of a trend noticed by embassy employees in particular countries then government officials could play an important role in protecting medical travelers by better documenting and disclosing these cases. Further- more, if officials staffing embassies located in destinations for medical travel are encountering increased numbers of citizens harmed while traveling abroad for medical care, it is not evident that public awareness is increased by posting information to the U.S. Department of State website or the Centers for Disease Control and Preven- tion website. The CDC’s, ‘Health Information for Inter- national Travel 2010, or ‘Yellow Book’ as it is more commonly known, mentions variations in international quality of care and regulation of medical facilities and provides practical advice for individuals considering trav- eling abroad for health care.41 However, it is unclear whether most prospective medical travelers are familiar with this book or consult the U.S. State Department website. If government agencies in the U.S. and elsewhere have credible grounds for concern about the quality of care their citizens are likely to receive when traveling to particular health care destinations they should reassess how to publicize this information. Of course, without better tracking of clinical outcomes there will be little

reliable information available to communicate and limited prospects for informed public debate about indi- vidual and public implications of medical travel.

Fifth, drawing upon the news media reports that I identify and summarize, it is not possible to reach con- clusions about the quality of information provided to the twenty-six individuals reported to have died after travel- ing abroad for medical care. The news reports prompt questions about information disclosure and the extent to which patient decision-making was informed but they do not provide insight into what information individuals received before deciding to have surgery. However, several recent publications raise troubling questions about the quality of information provided by websites of medical tourism companies and destination medical facilities.42 These articles suggest that when prospective medical travelers turn to websites for information about risks and benefits of medical travel they are likely to encounter information that emphasizes benefits of medical care and pays limited attention to risks associ- ated with surgery.43 Reports of post-operative complica- tions experienced by medical travelers as well as accounts of deaths reveal the importance of disclosing procedure- related risks. Government agencies tasked with regulat- ing advertising practices could play a role in investigating content of websites of medical tourism facilitators and destination hospitals and clinics. Though government agencies lack capacity to regulate websites and other pro- motional materials outside their domestic legal jurisdic- tions, they nonetheless could alert citizens if international medical tourism companies and destination health care facilities are failing to disclose risks and making mislead- ing claims about benefits of surgical procedures, patient safety, and quality of care. More effective, targeted responses by government regulatory bodies to the mar- keting of health care at international medical facilities might increase the likelihood that prospective medical travelers have better access to information required to make informed choices when deciding whether to have particular procedures.44

39 U.S. Department of State. Dominican Republic Country Specific Information. Available at: http://travel.state.gov/travel/cis_pa_tw/cis/ cis_1103.html [Accessed 10 Jan 2012]. 40 U.S. Department of State. Peru Country Specific Information. Available at: http://travel.state.gov/travel/cis_pa_tw/cis/cis_998.html [Accessed 10 Jan 2012]. 41 Centers for Disease Control and Prevention. CDC Health Informa- tion for International Travel 2010. Available at: http://wwwnc.cdc.gov/ travel/content/yellowbook/home-2010.aspx [Accessed 10 Jan 2012].

42 R. Nassab et al. Cosmetic tourism: public opinion and analysis of information and content available on the Internet. Aesthet Surg J 2010; 30: 465–469; A. Mason & K. Wright. Framing Medical Tourism: An Examination of Appeal, Risk, Convalescence, Accreditation, and Inter- activity in Medical Tourism Web Sites. J Health Commun 2010 Dec 15: 1–15. E. Sobo, E. Herlihy & M. Bicker. Selling medical travel to US Patient-Consumers: The cultural appeal of website marketing messages. Anthropology & Medicine 2010; 18. 43 K. Penney et al. Risk communication and informed consent in the medical tourism industry: A thematic content analysis of canadian broker websites. BMC Medical Ethics 2011; 12: 17. N. Lunt and P. Carrera. Systematic review of websites for prospective medical tourists. Tourism Review 2011; 66: 57–67. 44 J. Gilmartin. Contemporary cosmetic surgery: the potential risks and relevance for practice. J Clin Nurs 2010; 20: 1801–1809.

Reports of Patient Deaths Following ‘Medical Tourism’ 29

Sixth, reports of complications and deaths related to cosmetic surgery and bariatric surgery in both domestic and international settings should prompt public debate about the routinization and normalization of such pro- cedures as liposuction, breast augmentation, and lap band surgery.45 Though widely performed, these proce- dures can result in surgical complications and even deaths of patients. Better tracking of patient outcomes in both domestic and international medical facilities might lead to evidence-based calls for more restrictive use of particu- lar surgical techniques. Practices of informed consent ensure that risks and benefits are disclosed to prospective patients but prior to information disclosure it is impor- tant to ask the question of whether patients should be exposed to some risks. Rather than asking whether patients face greater risks when having cosmetic surgery at international facilities instead of local medical centers, it might be time to encourage a broader public conversa- tion about risks patients face when undergoing various cosmetic surgery procedures in both domestic and inter- national settings.

Finally, news reports of the deaths of medical travelers at facilities in Mexico combined with the absence of reports of medical travel-related deaths from many well- known destinations for medical travelers suggests the importance of developing effective strategies for tracking flows of medical travelers, documenting what procedures they undergo, identifying what types of facilities they visit, verifying the qualifications of treating physicians, and evaluating the safety of particular practice environ- ments. Though news media reports do not provide insight into the relative risk of traveling to particular health care destinations, I was struck by how many deaths are reported to have occurred in Mexico and the absence of reports of deaths of medical travelers in such countries as Singapore and Thailand. This finding might be a product of the search strategies I utilized, the databases I used, or other factors. However, it is tempting to speculate whether a relatively high number of cases of mortality in cases traveling abroad for cosmetic surgery might occur in a modest number of destination sites. If so, perhaps it is possible to develop ‘channels’ or ‘gates’ that will help protect medical travelers and increase the prospect that they seek care at facilities recognized for promoting patient safety.46 Steering medical travelers toward par- ticular international medical facilities and away from spe- cific hospitals and clinics might reduce the incidence of morbidity and mortality in medical travelers. Rigorous empirical research is needed to address this issue.

IMPORTANCE OF DOCUMENTING CLINICAL OUTCOMES IN MEDICAL TRAVEL

Despite sustained public and academic interest in medical travel, or ‘medical tourism’ as the phenomenon is more popularly known, there is limited academic analysis of clinical outcomes in medical travelers.47 Proponents of medical travel emphasize cost savings, high quality of care at international facilities, expedited access to treatment, choice in health services, and other benefits.48 In contrast, critics express concerns that medical travelers enter a poorly regulated global marketplace, are at risk of inad- equate pre-operative counseling, substandard medical care, and poorly coordinated post-operative treatment, and exacerbate health inequities in the countries they visit.49 Both proponents and critics of medical travel have a limited body of case reports and very little comparative research that they can use to support their claims.

The main reason why it is impossible to make informed, evidence-based judgements about quality of care and patient safety in medical travel is that there are no databases tracking global flows of patients and docu- menting clinical outcomes in individuals who leave their local communities and arrange care at international facilities. For example, despite various claims about the annual number of U.S. residents travelling to medical facilities outside the United States, there is no registry tracking how many U.S. citizens leave the country for care, why they go abroad for treatment, what kind of treatment they seek, and what happens as a result of obtaining health care outside the U.S. According to one widely cited report produced by Deloitte, in 2007 approximately 750,000 US residents sought health care outside the United States and an estimated 648,000 trav- eled abroad in 2009.50 In contrast, drawing upon data from the US Bureau of Economic Analysis and US Inter- national Trade Administration as well as survey data, Johnson and Garman estimate that between 50,000 to 121,000 US residents sought medical care outside the United States in 2007.51 There are significant variations in

45 B. Coldiron, C. Healy & N. Bene. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg 2008; 34: 285–291. 46 I.G. Cohen. Protecting Patients with Passports: Medical Tourism and the Patient-Protective Argument. Iowa Law Review 2010; 95: 1467–1567.

47 N. Lunt & P. Carrera. Medical tourism: assessing the evidence on treatment abroad. Maturitas 2010; 66: 27–32. 48 D. Herrick. Medical Tourism: Global Competition in Health Care. 2007; NCPA Report No. 304. Available at: www.ncpa.org/pdfs/ st304.pdf [Accessed 10 Jan 2012]; A. Mattoo & R. Rathindran. How health insurance inhibits trade in health care. Health Aff 2006; 25: 358–368. 49 A. Whittaker. Pleasure and pain: Medical travel in Asia. Global Public Health 2008; 3: 271–290. 50 Deloitte Center for Health Solutions. Medical tourism: update and implications – 2009 report. Deloitte. 2009. 51 T. Johnson & A. Garman. Impact of medical travel on imports and exports of medical services. Health Policy 2010; 98: 171–177; B. Alleman et al. Medical Tourism Services Available to Residents of the United States. J Gen Intern Med 2010; 26: 492–497.

30 Leigh Turner

estimates of how many U.S. residents seek health care outside the U.S. every year. The situation is the same in Australia, Canada, and elsewhere. Speculative claims about the number of individuals traveling abroad for care are widespread and rigorous quantification of medical travel is scarce. Most health-related databases are built for monitoring domestic medical care; they are not designed to track patients across national borders. Devel- oping databases capable of monitoring transnational medical travel is challenging because the global market- place for health services is decentralized and many pro- cedures are performed in private, for-profit health care facilities that do not report data to domestic databases. Medical travelers make individual arrangements with destination medical facilities or plan their trips with the assistance of medical travel facilitators.52 They do not organize trips with the aid of some centralized transna- tional body or report their travel plans to domestic gov- ernment agencies. Some cross-border medical care involves government participation, such as when provin- cial health systems in Canada make arrangements for Canadian citizens to receive care at select facilities in the United States. However, it appears that most medical travel is based upon individual decisions to pay out-of- pocket for care at international medical facilities. As a result, building databases and better tracking medical travelers and their clinical outcomes will be very challenging.

Given the absence of databases tracking movement of patients and documenting clinical outcomes in medical travel, there is at present no credible basis for making three types of empirical claims. First, it is not possible to make accurate statements about how many individuals leave their local community and travel abroad for medical care. Second, there is no basis for making evidence-based assertions about how many medical trav- elers experience clinical benefits and how many experi- ence surgical complications, infections, and other treatment-related health problems. Third, because there are no databases tracking how many individuals partici- pate in medical travel and how many of these persons experience benefits or harms as a result of traveling abroad for care, there is considerable uncertainty con- cerning whether individuals traveling to particular loca- tions are at greater risk of experiencing complications from treatment when they travel for care instead of vis- iting domestic medical facilities.

Acknowledging that clinical registries and systematic outcomes data in medical travel do not exist, and recog- nizing that reliable quantitative studies are needed to make judgements about relative patient safety and

quality of care when comparing medical travel to the quality of care individuals should expect to receive at domestic health care facilities, analysis of news media articles describing the reported deaths of twenty-six medical travelers reveals the importance of better docu- menting clinical outcomes in medical travel. This analy- sis, though it documents reported deaths of medical travelers, cannot and should not be used to claim that domestic medical care is ‘safe’ and medical travel is ‘unsafe’. Indeed, during my research I was struck by the number of reports I found that described patients who experienced serious complications or died after undergo- ing cosmetic surgery in domestic health care facilities. Noting the need for systemic efforts to track clinical out- comes in medical travel, I hope this study provides a meaningful complement to peer-reviewed publications that describe medical complications in cosmetic surgery travelers and individuals who have gone abroad for cos- metic surgery but provide no accounts of patients who died during surgery or shortly after receiving treatment. If these news media accounts are accurate then peer- reviewed publications are failing to identify, document, and analyze deaths of patients who have traveled abroad for cosmetic surgery and bariatric surgery. By describing these cases I hope to promote increased interest in track- ing medical travelers, studying clinical outcomes in medical travel, and addressing in an empirically-informed manner the many ethical, legal, and social issues gener- ated by the emergence of a global marketplace in health services.

CHALLENGES IN USING NEWS MEDIA REPORTS

Numerous challenges are associated with attempting to analyze news media accounts of deaths of medical trav- elers. First, if journalists writing these narratives made errors when crafting their accounts, these mistakes are reproduced in the information I extracted, recorded, and categorized. Journalists have limited time to prepare news stories; the pressure to meet deadlines along with other factors can lead to inaccurate reportage. Second, when extracting information from news media accounts I used the language reporters used when describing medical procedures. For example, several articles describe patients undergoing ‘tummy tucks’. I retained this lan- guage even though the more accurate clinical term for this procedure is ‘abdominoplasty’. It is possible that terms used by reporters provide misleading descriptions of the medical procedures individuals underwent. Third, after searching for news media reports I was in some cases able to supplement news media accounts by finding obituaries, web-based posts written by individuals claiming to be family members of deceased individuals,

52 N. Lunt, M. Hardey & R. Mannion. Nip, tuck and click: medical tourism and the emergence of web-based health information. Open Med Inform J 2010; 4: 1–11.

Reports of Patient Deaths Following ‘Medical Tourism’ 31

contributions to cosmetic surgery discussion boards, and, in one case, detailed court records. In most instances, I was unable to locate independent sources corroborating claims made in news media accounts. In short, I acknowl- edge that there are identifiable disadvantages to using news media accounts when attempting to track deaths of medical travelers. In future I hope to address some of these constraints by contacting family members and friends of the individuals identified in these news reports. Interviews with them might generate insights unavailable in the newspaper reports I analyze and confirm whether various details in news reports are accurate.

SEARCH TERMS, DATABASES, SOURCES CONTAINED IN DATABASES, AND BIAS

Decisions concerning choice of search terms inform what articles are found in databases. Though I entered many different search terms into the databases I used it is pos- sible that my use of search terms introduced bias into the search process and influenced the particular types of news media reports that I found. In addition, decisions to search particular databases presumably had an impact upon what reports I found.

By conducting searches using ProQuest NewsStand, Google, Google News, and Google News Archive, I attempted to take a ‘wide angle’ approach to locating reports of mortality in medical travel for cosmetic surgery and bariatric surgery. However, use of these databases likely introduced bias into my findings. For example, at present ProQuest NewsStand includes 1394 news sources from all over the world.53 The database contains such major US news media sources as The New York Times, Los Angeles Times, Wall Street Journal, and Washington Post. It also contains articles from such ‘international’ newspa- pers as The Guardian, The Globe and Mail, The Hindu, Jerusalem Post, and South China Morning Post. Though the database contains news sources from around the world, it appears to have more news sources from the U.S. than from other countries. While I did not deliberately seek to find reports of patients who originated in particu- lar countries and traveled to specific destinations, I think it likely that my choice of English language databases com- bined with the many U.S. news sources in the ProQuest NewsStand database contributed to the number of reports I found that described mortality in medical travelers from the United States. It is possible that searches of databases containing more newspaper articles from news media sources based in countries other than the United States

might find additional reports of mortality in medical trav- elers originating from countries other than the U.S.

I did not deliberately seek to find reports of deaths of medical travelers in particular medical tourism destina- tions. Though I did not focus on Mexico as a destination for medical travelers, my searches identified numerous reports of medical travelers from the U.S. who died during or after having cosmetic surgery or bariatric surgery in Mexico. Sandra Dibble, a reporter for The San Diego Union-Tribune, has for many years alone and with her colleagues written articles about Californians who have traveled to hospitals and clinics in Mexico and either died during or after surgery or returned to the U.S. with post- operative complications. Several articles by Dibble are used as sources for cases described in this article. What I am unable to determine is whether news media coverage of morbidity and mortality in medical travel is connected to the actual incidence of morbidity and mortality at particu- lar international medical facilities. It is conceivable that Dibble has recognized a significant health news story, understands that many residents of California travel to Mexico for cosmetic surgery, dental care, and other pro- cedures, and provides detailed coverage of cases where U.S. citizens experience post-operative complications or die after having surgery at clinics in Mexico. It is also possible that journalists based in other settings are unaware of incidents involving medical travel and mortal- ity at medical facilities in countries other than Mexico, decide not to write about such cases, or are aware of reports of mortality in medical travelers but select other stories to cover. Use of particular databases, choice of search terms, and sources captured by these databases pre- sumably all have an effect upon the news media reports that I have identified. Given the number of reports describ- ing mortality associated with surgery performed at medical facilities in Mexico there is reason to be concerned about the quality of care provided to some medical travelers at particular medical facilities in Mexico. However, use of databases to identify news media reports cannot be used to establish with certainty whether some destinations for medical travel are riskier and offer lower-quality care than other international hospitals and clinics. What analysis of news media reports can do is demonstrate the importance of developing rigorous tools to assess clinical outcomes in medical travel for cosmetic surgery and other procedures. Though not the main purpose of this paper, I hope that my choice of search terms, choice of which databases to search, and findings prompt debate about how to effec- tively track clinical outcomes in medical travel.

CORRELATION IS NOT CAUSATION

My summary of news reports of deaths of medical travel- ers might lead some readers to assume that medical errors,

53 ProQuest Newspapers. Available at: http://proquest.umi.com.ezp1. lib.umn.edu/pqdweb?RQT=317&TS=1321759744&clientId=2256& SQ=*&PageNum=1&link=1 [Accessed 10 Jan 2012].

32 Leigh Turner

poor quality of care, or specific actions performed by treating physicians must have caused the patients to die during or shortly after surgery. To the contrary, while the news reports I located generate serious concerns about the quality of care some medical travelers receive when they go abroad for surgery, news media accounts do not provide a basis for establishing causality and legal responsibility and cannot be used to make claims about medical negligence or professional standards of care. Determinations of medical negligence are established through legal proce- dures and rules of evidence. According to news media accounts, in four instances physicians were deemed to have contributed to the deaths of patients. In a fifth case a physician is charged with manslaughter but a verdict has not yet been delivered. Whatever the merits of drawing upon news media accounts, these narratives identify cor- relations between surgical procedures and deaths and prompt questions about quality of care, medical profes- sionalism, and adequacy of treating facilities. However, they do not establish causation. With the exception of the four instances that resulted in successful legal action against treating physicians, causality, the role of treating health care providers, and the extent to which the health care environment exposed patients to risk or helped shield them from harm remain unknown. Many of the news reports offered sharp criticisms of the care patients received. While these accounts prompt legitimate con- cerns about quality of care and treatment of cosmetic surgery travelers, they do not lead to definitive conclusions about conditions in clinics, patient selection and screening criteria used prior to performing surgery, surgical tech- nique, or post-operative care. It is conceivable that the patients had underlying medical conditions and these pre- viously unknown health problems played a deciding role in the deaths of these individuals. In addition, it is possible that adverse events occurred but treatment received by the medical travelers fell within a reasonable, professional standard of care. In short, it is important to exercise caution when considering these news accounts. Having noted this caveat, if these news reports are accurate, they document twenty-six deaths that are nowhere acknowl- edged or addressed in peer-reviewed scholarship concern- ing medical travelers. Acknowledging the need for caution in interpreting these news media reports, these cases prompt questions about whether steps could have been taken to better protect these patients from harm and reduce risk of a fatal outcome following elective surgical procedures.

CASE REPORTS DO NOT ESTABLISH RELATIVE RISK

Just as it is important to avoid the error of confusing correlation with causation, it also is important to note

that analysis of reports of deaths of medical travelers cannot be used to support the claim that medical travel poses greater risks to patients than obtaining care at domestic health care facilities. While searching for articles describing deaths of medical travelers I found numerous news media reports summarizing deaths of individuals who had undergone liposuction, breast aug- mentation, and other cosmetic surgery procedures in their home states within the U.S as well as in Australia and Canada.54 Accurate datasets providing information about clinical outcomes in patients undergoing care at domestic health care facilities and in individuals obtain- ing medical care at international sites are needed to make credible assertions about whether relative risk of morbid- ity and mortality is increased by leaving particular social contexts and traveling to particular international clinics and hospitals. Again, having noted this caveat, without providing insight into relative risks these case reports suggest that prospective medical travelers need to be aware that elective cosmetic surgery procedures at inter- national medical facilities have resulted in both morbidity and mortality. The case reports also give credence to the concept of developing strategies intended to minimize risks individuals face when they travel abroad for medical care.

CONCLUSION

Drawing upon news media accounts, I review twenty-six reported cases of medical travelers who died during or after undergoing cosmetic surgery or bariatric surgery. Eleven of these individuals died after having cosmetic surgery or bariatric surgery in Mexico and four died after undergoing cosmetic surgery in the Dominican Republic. In short, more that half of all identifiable cases can be connected to health care facilities in two countries. In four cases, physicians were fined, sued, or jailed. In a fifth case, the physician is charged with manslaughter and awaits trial. In the remaining cases it is not possible to make assertions about medical negligence or malpractice. Rather than asserting that most of these deaths were caused by the quality of care patients received it is impor- tant to note that claims must be limited to recognition of a correlation between surgical interventions and patient

54 E. Fernandez & L. Williams. 1998. ‘If liposuction were a drug, it would have been pulled from the market’. San Francisco Chronicle 13 September; E. Fernandez. 1998. When the desire to be thin is last wish on Earth. San Francisco Chronicle 14 September 1998; S. Hewitt. 2007. Cosmetic surgery death probe. Herald Sun 28 January; C. Blatchford. 2010. Prosecution portrays stunning failures in lipo death. The Globe and Mail 22 July: A9; R. Cribb. 2010. Lipo death spurs look at hazy rules. Toronto Star 24 July: GT1; J. Omarnicki. 2011. Inquiry opens on plastic surgery death. Calgary Herald 19 January 2011; D. Lett. The search for integrity in the cosmetic surgery market. CMAJ 2008; 178: 274–275.

Reports of Patient Deaths Following ‘Medical Tourism’ 33

deaths. If these news media reports are accurate, they should be considered in conjunction with case reports of post-operative complications in medical travelers. Though it is not possible to claim on the basis of these news media accounts that medical travelers are at greater risk when obtaining medical care abroad than they are at domestic health care facilities, it is possible to assert that if these reports are credible then since 1993 at least twenty-six medical travelers are reported to have died during or after undergoing elective cosmetic surgery or bariatric surgery. These deaths should prompt reflection upon what strategies might improve patient safety, quality of care, disclosure of information, quality of advertising, and protection of patients in the global mar- ketplace for health services. In addition, reports of these deaths in news media but not in scholarly publications should prompt questions about whether current peer- reviewed scholarship addressing clinical outcomes in medical travel is underreporting patient mortality.

Whether individuals die after undergoing cosmetic surgery or bariatric surgery in domestic health facilities or in international hospitals and clinics, it is important to pose questions about whether patients are being adequately protected and what might be done to reduce the likelihood of additional cases of post-operative com- plications and deaths. Both cosmetic surgery and bariat- ric surgery are sometimes assumed to involve ‘minor’ procedures that do not generate concerns about patient safety. To the contrary, both morbidity and mortality can result from these procedures. Individuals considering cos- metic surgery or bariatric surgery must be aware of the possibility of risks to health and complications from surgery in both domestic and international health care facilities.

In the existing body of peer-reviewed articles on travel for cosmetic surgery and bariatric surgery travel there are no reports of deaths of patients at international medical facilities. Rather, case reports are limited to instances of patients returning to their local communities with post- operative complications. This analysis of twenty-six news media reports of travel for cosmetic surgery and bariatric surgery suggests that accounts of post-operative morbid- ity must be supplemented by reports of mortality. Perhaps patients in both local and international settings could be better protected from risk of injury and death if cosmetic surgery and bariatric surgery were subjected to better regulatory oversight. In addition, reports of deaths of cosmetic surgery patients and bariatric surgery patients are relevant to larger public conversations about whether surgical techniques that have become routinized and normalized need to be subjected to public debate and better government scrutiny. Deaths of patients undergo- ing elective surgical procedures, whether they occur in domestic facilities or international hospitals and clinics,

should prompt us to ask whether they might have been avoided.

The news reports that I review suggest the importance of tracking clinical outcomes in medical travel. In addition, they suggest the possibility that there is a serious gap in contemporary scholarship addressing medical travel for cosmetic surgery and bariatric surgery. The emergence of a global marketplace in health services has not been accompanied by the development of regulatory bodies tasked with monitoring and regulating transnational medical travel. At present, clinical databases and health researchers are not systematically tracking global flows of medical travelers and documenting clinical outcomes. Better insight into the consequences of medical travel would make a significant contribution to ethical analysis of ‘medical tourism’. Critics of my effort to use news media reports will argue that news accounts of deaths of medical travelers consist of nothing more than unsubstantiated anecdotes or exercises in sensationalistic journalism. I appreciate the disadvantages associated with using news media reports to document deaths of medical travelers. Acknowledging the caution with which findings drawn from news reports must be used, I suggest that the risks of using these reports are outweighed by the risk of dismiss- ing news reports of deaths of medical travelers.

Whatever the advantages and disadvantages of using news reports describing deaths of medical travelers, this approach suggests the value of using both normative analyses and empirical research methods to address such ethical issues as quality of information disclosure, adequacy of patient consent, safety of particular surgical procedures, and quality of post-operative care in medical travel. If ‘what isn’t counted doesn’t count’, as some health researchers state, there is a need to begin ‘count- ing’ medical travelers and clinical outcomes and better understanding what is happening in the global market- place for medical travel.

Acknowledgements

The author wishes to thank Jeremy Snyder, Valorie Crooks, and an anonymous reviewer for the feedback they provided in response to an earlier version of this article. In addition, the author wishes to acknowl- edge the reportage of the journalists who crafted the news media accounts examined in this article.

Biography

Leigh Turner, PhD, is an Associate Professor at the University of Min- nesota’s Center for Bioethics, School of Public Health, and College of Pharmacy. His research examines ethical and social issues related to transnational medical travel and globalization of health care. He is co-editor of the forthcoming book, Medical Tourism: Risks and Con- troversies in the Global Healthcare Market. Praeger will publish the volume in 2012.

34 Leigh Turner

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