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A world away and here at home: a prioritisation framework for US international patient programmes
  1. Emily Berkman1,2,3,
  2. Jonna Clark1,2,3,
  3. Douglas Diekema2,3,4,
  4. Nancy S Jecker3
  1. 1 Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
  2. 2 Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
  3. 3 Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
  4. 4 Division of Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
  1. Correspondence to Dr Emily Berkman, Pediatric Critical Care, Seattle Children's Hospital, Seattle, WA 98105, USA; emily.berkman{at}


Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients’ home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children’s hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.

  • distributive justice
  • allocation of health care resources
  • ethics
  • interests of health personnel/institutions

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  • Contributors The initial concept was developed by EB and NSJ. It was further developed by DD and JC. All authors contributed to the writing of the manuscript from initial draft through to its current state.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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