Medical tourism declines

Reports out if India -- a leader in medical tourism -- say that bookings for non life-threatening surgeries are down due to the worldwide economic slowdown.

Brokers who arrange the surgeries -- and the required flights, transfers and hotel rooms -- say inquiries from patients are down significantly from last year at this time. Dr Mikdad Ukaye, part owner of Vasai-based Royal Medical Tours, said patients are worried they may not be able to afford the surgery, and expects about a 50 per cent drop in business in the coming year.

“Earlier, we received least 2-3 calls per day from clients abroad, but this year it has come down to barely 1 or 2 calls in a week. ... They are reluctant to even transfer the deposit amount thinking what if they change their plans at the last moment.”

India has been a leader in medical tourism, offering surgeries at a fraction of U.S. prices -- and up to half the cost of some other destinations.

Until now, most reports and studies have predicted fast growth for the sector, with a growing number of U.S health insurance companies offering medical tourism packages as a way to keep rates down.

Singapore's Health Minister Khaw Boon Wan said last week that slower growth in the city-state's large medical tourism industry was due to a lack of capacity.

"I don't think it's because of demand, or we are losing competitiveness, but capacity is constrained...Both public and private hospitals are short of capacity...I think it's a situation of where demand has been curtailed because we don't have enough capacity to respond."

Singapore hopes to attract over 1 million international patients a year by 2012, nearly three times the current number.

Assisted suicide an "escape" few take: report

A report out of Oregon, which approved physician assisted suicide for terminally ill patients 11 years ago, says few patients actually use the option -- but like that it's there.

"Over the past 11 years in Oregon, 341 people have used the law, and the lethal medication provided by their doctors, to die."

That works out to about 1 in 1,000 deaths, according to the Oregon Health Division. The rate of talking about assisted suicide, however, is much higher. About 1 in 50 dying patients discuss assisted suicide with their doctors, according to the state, and one in six with their families.

"All this suggests that people just want to know that the escape is there if they need it, but very few decide that they do. It is powerful evidence that palliative care has come a long, long way since the Oregon measure took effect 11 years ago."

The report says palliative care -- health care for the terminally ill -- has done such a good job of making people's final days comfortable, that few patients want to end their lives early.

The Oregon Health Department is required maintain statistics on the law's uptake. The numbers provide an interesting glimpse into who uses such a law, and how. Over the past 11 years, 82 per cent of patients requesting assisted suicide had some form of cancer, and 93 per cent died at home. Top reasons for wanted assisted suicide were a loss of autonomy, a loss of dignity and an inability to still do things they always enjoyed.

Earlier this month, voters in neighbouring Washington state voted to approve a similar assisted suicide law for their state.

Medical ethics in an Obama White House

Medical ethicists in the United States are beginning to take stock of what a Barack Obama administration will mean to the medical community -- particularly as it relates to ethical questions.

Without doubt, the White House of George W. Bush has been very conservative when it comes to medical ethics.

But with the election of a more liberal Democrat, as well as the results of several state resolutions that were also on the ballot Nov. 4, American ethicists expect to see a loosening of attitudes.

Writing for MSNBC.com, Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, writes that "the 2008 election will be remembered not only for Obama becoming the first African-American president, but also for its impact on core bioethical topics that have long dominated American domestic politics."

"Divisive issues such as abortion bans failed to gain traction on state ballot initiatives, while newer bioethical concerns that are likely to dominate American politics for years to come, including physician-assisted suicide, emerged. The past eight years of the Bush White House have seen stem cell research and the status of embryos at the centre of the moral values debate. Obama’s election has brought the fight over embryonic stem cell research in the U.S. to an end."

On November 4, Michigan became the tenth state to approve embryonic stem cell research. The Bush White House has refused to fund such work, hampering research in the U.S. Calling the stem cell debate a "stalking horse" of the abortion debate (since objections to the use of embryonic stem cells are based on the same right to life arguments), Caplan points to Nov. 4 vote results in Colorado.

"The voters of Colorado were given the chance to put that view into law with the proposed Amendment 48. The so-called “Personhood Amendment” sought to define fertilized eggs as human beings, extending them constitutional rights. Coloradoans defeated this amendment by a margin of three to one."

Caplan later adds:

"Like it or not -- and I am well aware that many are not ready to let go of these issues -- the nation may be starting to move past the endless battles over stem cells, embryos and abortion."

Also, in Washington state, voters approved a resolution to allow physician-assisted suicide.

Bernard Lo, a professor of medicine and medical ethics director at the University of California San Francisco, for instance, has some advice for the new president, saying he should replace Bush's President's Council on Bioethics when its mandate expires next year.

A National Bioethics Advisory Council can help the American public and the new administration understand the ethical issues and choices that new biomedical advances present and think through the appropriate policy responses. Now is the time to consider this new national Council because the charter for the current President's Council on Bioethics expires next year and the incoming president will have the opportunity to form a new advisory body. The new Council can identify policy options, explain their pros and cons, and make recommendations to policymakers.

That would be a very different body from the current President's Council, which advises only the president and has been used by the White House to find ways to implement pre-determined policy -- such as a recent instruction from Bush to find a way around a California court decision that a doctor cannot refuse in vitro fertilization to a lesbian couple because of his personal religious beliefs.

The President's Council meets this week.

More than Obama

Besides helping elect Barack Obama as the first black president of the United States, voters in Washington state also voted yesterday to make their state the second in the country to allow physician-assisted suicide.

Under the resolution, terminally ill people can get lethal prescriptions to hasten their deaths. Late Tuesday night, the "death with dignity" measure was leading with 58 per cent of the vote to 42 per cent. Patients would have to ask their doctors for a prescription giving them enough medication to kill themselves.

Neighbouring Oregon has had a similar measure for more than a decade.

"We feel like the voters of Washington have agreed to give terminally ill and their families the dignity that they've asked for," said Anne Martens, a spokeswoman for the Yes campaign.

Opponent Chris Carlson said, "It appears that the voters of the state of Washington have, unfortunately, started down a path that I believe with historical hindsight they'll come to regret."

Washington was one of the states carried by Obama in the presidential election.

Sex selection in Turkey

Parents who want to pick the sex of their babies need only to travel to Turkey and pay for in-vitro fertilization there, an undercover BBC report has found.

As in Canada, sex selection is illegal in Britain is illegal, unless for medical reasons. For instance, if your family has a genetic disorder affecting only males, you can chose to have a girl.

Ironically, similar rules apply in Turkey, and yet the Jinemed Center, a fertility clinic in Istanbul, has proven a popular destination for patients wanting to pick the gender of their baby.

BBC reporter Colette McBeth took her husband and a hidden camera to a meeting with representatives from the centre and made it clear they wanted to have a girl. A video of the meeting shows the couple discussing with the representative ways to get around the law by pretending a heriditary desorder runs in their family.

The Turkish government is now investigating the centre, but the incident shows the ease with which medical tourism allows people to flout health laws in their own country.

The argument for paying egg donors

A top fertility doctor in Singapore has come out against recommendations this morning that the city state not compensate women who donate their eggs to research, beyond out-of-pocket expenses.

Dr Suresh Nair, medical director at Parkway Fertility Centre, said a woman is taking a risk by donating, so deserves to be paid.

"She's subjecting herself to some procedure that's potentially dangerous. How are you going to value that? For a start, it should be those young, healthy women who are not really involved in fertility treatment. For the time being, don't include the fertility couples as yet because they are already burdened."

Singapore's Bioethics Advisory Committee released a report this morning saying women donating eggs for use in stem cell research should only be paid for expenses incurred in making the donation -- such as for transportation or lost wages.

Committee chair Lim Pin said to do any more could turn egg donating into a business.

"We want to make sure that the amount that is reimbursed is not so large that it becomes an inducement."

The donated eggs are used in stem cell research.

No money for egg donation

Warning that egg donating could become a "business opportunity," Singapore's Bioethics Advisory Committee says women donating eggs for stem cell research should only be compensated for out-of-pocket expenses.

And even then, as little as possible.

BAC chairman Lim Pin said the committee did not want human egg donation to become a "business opportunity," where women made money by trading their eggs.

However, he said, expenses such as for travel and lost wages should be compensated.

“A guiding principle for the BAC is one of fairness, in that an altruistic donor should not be expected to suffer any financial loss from her donation, in the form of out-of-pocket expenses, loss of time and earnings, and cost of treatment for any medical complications that may arise. Reimbursement to ensure that she does not suffer financial loss from having contributed to the greater good of society is consistent with altruistic giving to research.”

The committee also called on the Ministry of Health to introduce regulation, even legislation, specifying how human eggs for research are handled. At the moment, the ministry only regulates hospitals and clinics that provide assisted reproduction services.

As well, the committee said, women should be allowed to withdraw their consent for their eggs to be used in research at any point, even after the eggs have been taken from their bodies.

Human eggs can be used in creating stem cells that have the ability to become any other type of cell in the body.

Cloning debate slow

Whether a United Nations body will recommend that some human cloning be allowed is -- at this point -- still too close to call, according to a Canadian researcher who just returned from Paris where the group is meeting.

"It could go either way," Rosario Isasi, a postdoctoral fellow at the Centre de recherche en droit public at the University of Montreal and a law and bioethics expert, told me this afternoon.

Isasi, who had to return to Canada before the International Bioethics Committee could make a decision, has been working the phones and sending e-mails to find out what happened. No announcement has been made by the committee, which is part of UNESCO.

Isasi was an expert witness when the United Nations last dealt with the issue in 2005 in the form of a vote in the General Assembly that led to a complete ban on human cloning. She said attitudes among member nations seem to have changed little in the ensuing years.

Stem cell researchers have held out hope that the UN would move to allow therapeutic cloning, which they could use in their research, while still banning reproductive cloning. Religious groups, particularly the Catholic church, have opposed any cloning.

Canada is set to review next March its laws banning all human cloning.

Placebo effect

Some interesting ethical questions are being raised about doctors prescribing placebos to patients, following a study was released last week in the British Medical Journal on the issue.

Like, what right do patients have to know details of what they are being prescribed, and what impact do placebos have on general public health?

University of Pennsylvania ethicist Arthur Caplan warns that the so-called placebo effect -- people getting better simply because they believe a medicine will work -- could be undermined by doctors prescribing them so much. The doctor-patient relationship could also be hurt.

"The real issue is whether widespread analysis of the practice of using placebos will undermine the value of placebo...and whether patients in any way begin to distrust their doctors suspecting them of resorting to placebos and thus lying to them."

The problem is that telling people they are getting a placebo would also likely undermine the effect, so  honesty suffers along with a patient's right to know.

The study found that few of the placebos prescribed are actually "sugar pills."

Many, in fact, are antibiotics that doctors know won't work in all cases -- such as for viral infections. But by prescribing them when they are not needed, doctors may be contributing to the over-presence of anti-biotics in society -- which many blame for the emergence of so-called superbugs resistant to anti-biotics. Caplan would like to see more discussion about what constitutes a placebo.

"Too many doctors give antibiotics as a kind of placebo, especially to kids of demanding or helicoptering parents -- knowing they don't work against viral diseases (and) thereby creating real public health problems!"

Doctors and faith in the US

The US President's Council on Bioethics meets in a few weeks to discuss the right of doctors to refuse to provide treatment based on their personal beliefs, including religious.

The meeting, Nov. 20 and 21 in Arlington, Va., will also discuss medical futility, and the future of public bioethics and national bioethics commissions in the United States.

The question of a doctor's right to refuse treatment has been a hot topic lately, after a California court ruled a doctor could not refuse to artificially inseminate a lesbian.

In Ontario, the Ontario College of Physicians and Surgeons was heavily criticized by Ontario Medical Association and the Catholic church after it released a policy paper on the issue warning doctors about the risks in refusing service.