h Cross-Border Spine Surgical Treatment: Issues to Consider

Harwant Singh


In this modern age of an increasingly interconnected world, many patients travel across borders for surgical treatment, and many surgeons travel across borders to deliver surgical treatment. This situation raises many issues about the care that is delivered, and it is appropriate to discuss the rights of the patients and the protection of surgeons who deliver such care, and the consent for spine surgery in such situations. This chapter is not meant to be a text on surgical ethics and law but to introduce some concepts in consideration of cross-border surgical treatment, especially patients’ rights, surgeon protection, and informed consents. As this is a developing area, the suggestions in this chapter may change over time.

Categories of Cross-Border Treatments

Cross-border treatments are most pronounced in broadly two categories: medical tourism and outreach/teaching. Medical Tourism is defined as the process in which a patient travels outside his or her usual residence for the purpose of medical or surgical treatment [1]. This may be from a lesser developed region to a more developed region for the purposes of receiving technically complex procedures or, conversely, from a more developed, more expensive region to a less costly region for procedures that cost considerably less. The more common conditions for this type of travel for treatment are plastic/ cosmetic surgery and transplant surgery [2].

Medical tourism in the latter category is usually more common and are usually located in the emerging economies where more up-to-date health infrastructure exist and have the capacity to care for patients. This has a large revenue generating capacity for the economies concerned and sometimes are advertised formally. The major characteristic in this healthcare delivery is that the patient travels to the surgeon for treatment. The main driver for this type of medical tourism are patients seeking substantially lower costs abroad [3].

Outreach or teaching programmes are usually when surgeons travel to the patient to deliver specific or complex care that is not available in the host region. There is also a significant teaching component in delivering this complex care at the host institutes. Many professional surgical societies organise such training programmes as a social and educational responsibility. An example would be the Global Outreach programme [4] of the Scoliosis Research Society. The main driver for outreach and teaching programmes are the altruistic behaviour of surgeons and surgical societies in the interest of raising the standard of surgical care for the less fortunate.

Historical Perspective

Medical responsibility is a concept that has been around for at least 3,700 years. The Code of Hammurabi (6th Babylonian King reigning from 1792 to 1750 BC in Mesopotamia) had already enacted laws to that effect. The key development is the concept of holding the medical professionals accountable for deaths or injuries that could have been reasonably prevented. The Romans subsequently developed the legal foundation for compensation for medical injuries, which qualified the injuries as intentional and nonintentional [5]. Of course, medical mishaps are really unintentional injuries.

The wide adoption of Roman Laws in the European continent up to the Middle Ages led to the development of this concept in English Common Law and, subsequently, in the 1800s, greatly influenced the development of medical law and compensation in the American legal system [5]. Key to the development and implementation of a working system to help adjudicate medical injuries are the concepts of an expert witness to ascertain the quality and appropriateness of treatment in question and the concept of standard of care.

Basic Considerations

In the evolution of modern surgical ethics and consent to surgical treatment, the legal standard has shifted from what was defined as the ‘community professional standard - where a body of surgeons determine what to disclose to a recipient of surgical care’ to ‘the reasonable person standard - where the reasonable patient decides on what treatment he or she wants, based on all material risk disclosures and the outcome if the condition is not treated’. This is also known as ‘informed consent’, and is the standard seen in almost all legal jurisdictions in the world, as patient autonomy is increasingly the standard adopted [6].

The concept of ‘informed consent’ is primarily a development of surgical ethics and not initially a development of law, as most legal advocates would suggest. John Gregory, a Scottish physician and ethicist (1724-1773), is to be credited for the first concepts of a patient’s right to decide on the treatment proposed for him or her and the right to refuse treatment [7]. However, when it is the surgical procedure that has an unexpected or unsatisfactory outcome, legal authorities rely on the concept of medical evidence provided by an expert witness who will assist a court to determine if the standard of care was maintained in the treatment received by the patient.

Therefore, a framework of the ethical considerations should be in place when there is cross-border spine surgical treatment being contemplated. What is being discussed is just a suggestion. This is new territory, and the concepts are evolving. At the time of writing, the world is experiencing an unprecedented viral pandemic with major travel restrictions, and its impact on cross-border surgical treatments is yet to be seen.

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