Medical Tourism, Access to Health Care, and Global Justice

AuthorI Glenn Cohen
PositionProfessor and Director, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School
(2015) 1 CJCCL
Medical Tourism, Access to Health
Care, and Global Justice
I Glenn Cohen*
Medical tourism – the travel of patients from one (the “home”) country to another
(the “destination”) country for medical treatment – represents a growing business. A
number of authors have raised the concern that medical tourism reduces access to health
care for the destination country’s poor and suggested that home country governments or
international bodies have obligations to curb medical tourism or mitigate its negative
e ects when they occur.
  is article is the  rst to comprehensively examine both the question of whether this
negative e ect on access to health care occurs for the destination country’s poor, and
the normative question of the home country and international bodies’ obligations if
it does occur. I draw on the work of leading theorists from the Statist, Cosmopolitan,
and Intermediate camps on Global Justice and apply it to medical tourism. I also show
how the application of these theories to medical tourism highlights areas in which these
theories are underspeci ed and suggests diverging paths for  lling in lacunae. Finally,
I discuss the kinds of home country, destination country, and multilateral forms of
regulation this analysis would support and reject.
* Professor and Director, Petrie-Flom Center for Health Law Policy,
Biotechnology, and Bioethics, Harvard Law School. JD, Harvard Law
School.  anks to Maria Banda, Gabriella
Blum, John Blum, Rachel Brewster, Nathan Cortez, Nir Eyal, Larry
Gostin, Tim Greaney, Holly Fernandez Lynch, Michelle Meyer, Frank
Michelman, Martha Minow, Kevin Outterson, Mike Raavin, Mathias
Risse, Ben Roin, Ben Sachs, Brendan Salonger, Jed Shugerman, Jeremy
Snyder, Matt Stephenson, Jeannie Suk, Talha Syed, Nick Terry, Leigh
Cohen, Medical Tourism, Access to Health Care, and Global Justice
I. P
II. I
III. K  M T, K  E C
IV. T E C
V. T N Q
A. Self-Interest
B. Cosmopolitan eories
C. Statist eories
D. Intermediate eories
1. Cohen, Sabel & Daniels
2. Pogge
VI. C, D  P P
VII. C: F M T  H C G
I. Preface
When the editors of the Canadian Journal of Comparative and
Contemporary Law approached me about republishing my article
Medical Tourism, Access to Health Care, and Global Justice to share with a
Canadian audience, I welcomed the opportunity to add this short preface
that would allow me to focus on developments since I published the
original text.
Turner, and Mark Wu for comments on earlier drafts. For their
comments, I also thank participants at the Harvard Law School/Program
on Ethics and Health Population-Level Bioethics Reading Group on
January 6, 2011, the International Conference on Ethical Issues in
Medical Tourism at Simon Fraser University on June 25, 2010, and at
the Health Law Scholars Workshop of the American Society for Law,
Medicine & Ethics and the St. Louis University School of Law Center for
Health Law Studies on September 12, 2009. Excellent research assistance
was provided by Russell Kornblith, Katherine Kraschel, and Teel Lidow.
Originally published in the Virginia Journal of International Law: Glenn
Cohen, “Medical Tourism, Access to Health Care, and Global Justice”
(2011) 52:1 Va J Int’l L 1. Reproduced with permission. Copyright ©
2011 Virginia Journal of International Law Association; I Glenn Cohen.
(2015) 1 CJCCL
e rst development is conceptual, and relates to dialogue about
my work led by excellent colleagues in Canada. I will focus on three.
First, in their thoughtful paper in the Journal of Law, Medicine, and
Ethics, commenting on my own prior work on this subject, YY Brandon
Chen and Colleen Flood (of the University of Toronto) suggest that in
this paper, I have been wrong in the questions that I focus on:
[W]e argue that there is an a priori bias embedded in how Cohen (and
other commentators) has framed the problématique of medical tourism …
[In Cohen and other commentators’ writing,] the burden appears to rest on
opponents of medical tourism to prove its negative consequences on LMICs’
[low- and middle-income countries’] health care access before regulatory
actions may be considered. In contrast, we argue in this paper that the
evidentiary burden should be reversed. We contend that even when access to
health care in LMICs is not adversely a ected by medical tourism, there are
still equity-related concerns that in and of themselves render medical tourism
normatively problematic. As we discuss further below, this inequity can (and
often does) arise, for example, when access to primary and preventive health
services for the general LMIC populations maintains the inadequate status quo
while medical tourists from well-resourced developed countries are a orded
cutting-edge secondary and tertiary care. If equity is considered a relevant goal
for health care systems and one accepts our conclusion that medical tourism
in LMICs will likely have deleterious equity impacts, then the burden should
be borne by medical tourism’s proponents to demonstrate its bene ts on
health care access and to justify why some degree of government regulation is
ough I am not sure I completely agree with their read of my work,
Flood and Chen usefully press me to be clearer that there are three
distinct versions of the empirical question that will tie into various
potential approaches to global justice: (1) Are there disparities in access
to health care for the general population between destination countries
in the developing world and home countries in the developed world (call
this the equity question)?; (2) Do we have evidence that medical tourism
causes de cits or worsens inequities, or, at the very least, is it associated
with de cits or worsening inequities in access by home country citizens
to health care (call this the causation question)?; (3) Irrespective of what
1. YY Brandon Chen & Colleen M Flood, “Medical Tourism’s Impact on
Health Care Equity and Access in Low-and Middle-Income Countries:
Making the Case for Regulation” (2013) 41:1 JL Med & Ethics 286 at

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