Article Text
Abstract
Dental tourism is patients travelling across international borders with the intention of receiving dental care. It is a growing phenomenon that raises many ethical issues, particularly regarding the dentist–patient relationship. We discuss various issues related to this phenomenon, including patient autonomy over practitioner choice, patient safety, continuity of care, informed consent and doctor–patient communication, among other factors. In particular, patients partaking in medical tourism should be informed of its potential problems and the importance of proper planning and post-treatment care to guarantee high-quality treatment outcomes.
- Professional Misconduct
- Applied and Professional Ethics
- Autonomy
- Clinical Ethics
- Informed Consent
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Introduction
Medical tourism, involving patient travel from a home country to another country for the purpose of seeking medical treatment, is a phenomenon that raises many ethical and legal issues, especially related to the doctor–patient relationship.
The mobility of dental patients may be a growing phenomenon in Italy, although it is difficult to assess accurately: ‘since many dental patients pay out of their own pocket for this treatment, … it is even more difficult to record’.1 Although official data do not exist, some authors have postulated that large numbers of Italian patients travel to Eastern European countries (eg, Hungary, Rumania, Poland) to receive dental treatment, numbering approximately 25 000–30 000 annually.2
Regarding dentistry, the primary reason for patient mobility is the relatively low cost of dental care in some countries that have a lower cost of living.
A recent study3 used a questionnaire posted on the website of the main Italian consumer association for patients with previous experience of dental treatment abroad. It evaluated the type of treatment received, reasons for their travel, and degree of satisfaction with their care, among other elements. The main motivation for dental tourism was to save money. Another leading reason was the full rehabilitation offered over a short time span, while some reported past negative experiences with Italian dentists. Most patients who participated in the survey were very satisfied with the dental care they received abroad. The authors concluded that these data suggest that Italian patients are attracted by dental tourism because of its low prices but also negative experiences with dentists in Italy: ‘probably most Italian patients who manage to build up a trustful relationship with their dentist won't feel the need to search for dental treatment elsewhere’.
Dental tourism: ethical issues
In the area of dental care, it is the patients themselves who usually choose to seek treatment abroad, and their decision is not normally based on medical need, lack of availability of the treatment at home, or a search for higher quality abroad, but mainly to obtain cheaper treatment.
Dental tourism is not devoid of problems, especially regarding the doctor–patient relationship. In particular, fundamental concepts of ethics and medical deontology dictate that the formation of a therapeutic alliance is based on both the autonomy of the healthcare professional and awareness and autonomy of the patient. Postoperative care is not always available for patients who go abroad to receive their dental care, which often involves extensive treatment over a short period of time. As such, possible complications and the need for proper follow-up visits for patients who have returned to their home country are some of the main concerns associated with dental tourism.4 ,5
The dental field is presenting an ethical question, as determination of the quality of treatment abroad is difficult and refusal by local dentists to deal with complications has to be addressed with a recommendation of increased care in taking notes on dental status and devoting more time to informed consent.
Every patient has the right to choose the healthcare professionals for their dental treatment. In fact, it is a matter of self-determination, and every dentist has a duty to respect patient rights. The Code of Ethics for Dentists in the European Union,6 approved by the Council of European Dentists on 30 November 2007, reports, in section 1.1, that the dentist must ‘respect the dignity, autonomy and choices of the patient’ (1.1) and that ‘the dentist must uphold the principle of free choice of practitioner by the patient’ (2.4). In addition, the Italian Code of Medical Ethics,7 approved by the National Federation of the Orders of Medical Doctors and Dentists on 16 December 2006 (enforced since March 2007), establishes in section 27 that the citizen's free choice of healthcare professionals and treatment locations is the basis of the doctor–patient relationship. As such, in both public and private clinics, choice of doctor is a citizen's basic right. However, dental tourism results in the dentist in the home country being caught in a situation between the patient and the foreign dentist. Because the latter is not always available, the former may need to take care of the patient, especially as ‘clinicians in their home country may be warranted with managing complications and giving second opinions’.8 If complications arise after the patient has returned home, ‘the patient cannot easily visit the same dentist again’ and ‘there is also a risk that local dentists may then refuse to correct the complications for fear of legal action against them if the complications become more severe’.1
In this respect, the ethical obligation of the local dentist to act in the patient's best interest should be protected with notes in his records of the patient's state after previous treatment.
Undoubtedly, space and time limitations associated with dental tourism create difficulties with continuity of care, as well as the trust and confidence between dentists and patients, both of which are fundamental elements of a healthy doctor–patient relationship.
As the internet plays an increasingly powerful role in advertising dental procedures to international patients,9 it becomes more important to evaluate the information contained in dental tourism marketing: ‘Information in these advertisements is usually full of enticements to attract patients to have the medical treatment without informing them about the number of problems associated with medical tourism, including follow-up care complications, side-effects and post-operative care’.10
Information on medical tourism sites may be presented ‘in a vacuum, ignoring for example, issues such as post-operative care and support’. This raises ‘questions about the quality and veracity of the information used’ and ‘questions with regard to how consumers assimilate and synthesise the information they retrieve from website searches, and how they take into account commercial interests and bias when making decisions’.11
In the relationship between healthcare professional and patient, correct and complete information is very important, as well as awareness of the patient about his self-determination: ‘while informed decision-making about care is always complicated for patients, the international dimension of medical tourism heightens this problem, underscoring the need for reliable information for these patients’.12
In this context, linguistic differences, as well as the inability to communicate in a common language, can further complicate the decision-making process. The Code of Ethics for Dentists in the European Union states that ‘good communication is fundamental to the dentist–patient relationship. The dentist must enable the patient… to give informed consent for the treatment… and must provide information about the proposed treatment, other treatment options, relevant risks, as well as costs, so as to enable the patient to make an informed choice’. (2.5)
In dental care, appointments and related treatment can sometimes last months or even years, as ‘dental treatment often requires a series of visits to the dentist to build a trusting dentist–patient relationship and to better ensure a safe outcome.’ For complicated treatment, such as implants with crowns, after preliminary consultation with the patient, several visits to the dentist over a number of months may be necessary, and follow-up and post-treatment care as necessary are important components of the whole treatment plan.1
With regard to dental implantology, establishing a trusting doctor–patient relationship is necessary to provide adequate information to the patient and, especially regarding clinically unnecessary interventions subject to complications, to evaluate ‘the patient's motivations’ and ‘his psychological profile, which could have a negative effect on the outcome of the operation or be responsible for the non-observance of the maintenance protocol or indispensable rules of hygiene’.13
Continuity of care is a very important issue even in the Code of Ethics for Dentists in the European Union, sections 2.6 and 2.7, which states that ‘the dentist must inform the patient of any complications or of failed treatment and discuss the options for resolving them’. In addition, ‘the dentist must facilitate continuity of care where a treatment of a patient ceases’. In addition, the Italian Code of Medical Ethics establishes, in section 23 (‘Continuity of care’), the need for the healthcare professional to guarantee continued care and, in the case of impossibility, impediment or care interruption, to ensure a replacement and inform the citizen.
Conclusions
In summary, patients have the right to choose to receive dental treatment outside of their home country. However, it is important that they have access to full information about the possible disadvantages of dental procedures received in the context of dental tourism. In particular, patients should be informed that high-quality treatment depends on properly planned care with scope for post-treatment care.1
Moreover, doctors in the home countries may have a unique opportunity to inform patients seeking healthcare information before they travel abroad for care.14
Footnotes
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Contributors AC: study conception; guarantor of integrity of whole study. PD: literature search; manuscript preparation and editing. LL: manuscript revision. CP: study design; final approval of the version to be published.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.
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