Unpacking the financial costs of “bariatric tourism” gone wrong: Who holds responsibility for costs to the Canadian health care system?
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* Jeremy C. Snyder
* Diego S. Silva
* Valorie A. Crooks

## Summary

Canadians are motivated to travel abroad for bariatric surgery owing to wait times for care and restrictions on access at home for various reasons. While such surgery abroad is typically paid for privately, if “bariatric tourists” experience complications or have other essential medical needs upon their return to Canada, these costs are borne by the publicly funded health system. In this commentary, we discuss why assigning responsibility for the costs of complications stemming from bariatric tourism is complicated and contextual.

Recently in this journal, Kim and colleagues1 reported on the findings of a study of the financial costs to the health care system associated with patients travelling across international borders for bariatric procedures, which constitutes a form of medical tourism. Canadians are motivated to travel abroad for bariatric surgery owing to wait times for care and restrictions on access at home based on body mass index (BMI), among other factors.1 While such surgery abroad is typically paid for privately, if “bariatric tourists” experience complications or have other essential medical needs upon their return to Canada, these costs are borne by the publicly funded health system. Kim and colleagues1 conservatively estimated costs to the public health system of CAN$560 000 per year and CAN$9546.36 per bariatric tourist in Alberta alone. Their findings confirm those of an earlier study that reported bariatric tourism can create substantial costs for the Canadian health system.2

The CBC Radio program *The Current* recently featured an Alberta patient who wished to lose 35 pounds in order to improve her health.3 Because the patient was not sufficiently overweight according to the province’s standards, she did not qualify for bariatric surgery domestically. Instead, she travelled to Mexico to obtain surgery and paid for it out of pocket. The patient told *The Current* that the medical tourism facilitation company that arranged her treatment advised her to do her own research online and informed her that, while there is risk involved with any bariatric surgery, the risk of complications were greater in Canada and less than 1% at the Mexican facility.

Following her surgery, the patient experienced leakage from her stomach while still in Mexico but was eventually discharged to return to Alberta. Back home, she sought medical help, and it was discovered that the leakage had turned septic. The patient was near death, and much of her stomach was removed. She has since experienced considerable weight loss, expects soon to be placed on a feeding tube, and has been advised that she has lost 10 years of life expectancy. The patient expressed regret for her decision to go abroad because of its effects on her health and also because of the costs of her treatment for the Canadian health system. Estimating these costs at CDN $750 000 or higher, she told *The Current*, “what I did was wrong,” and “I apologize to the Canadian citizens for what it cost for tax dollars.”3 The patient’s experience highlights the types of negative outcomes from bariatric tourism examined by Kim and colleagues.1

What should we make of this apology to Canadian taxpayers, and more generally, how should we assign responsibility for the expenses created by bariatric tourists who experience postoperative complications that must be addressed upon their return to Canada? We believe, in fact, this question is quite ethically challenging.4 First, the motivation behind an individual’s decision to travel abroad for care must be assessed.5 As Kim and colleagues1 note, wait times for bariatric surgery are substantial and can impose costs on the health and quality of life of Canadians waiting for surgery. In these cases, bariatric tourists are arguably not being provided timely medical care that is essential to their health and may feel justified in their decision to go abroad. These motivations can be contrasted to those of individuals who are less clearly in need of bariatric surgery. For example, the patient interviewed on *The Current* noted a more responsible choice in hindsight would have been to seek weight loss through exercise and better nutrition.3 It could be argued that bariatric tourists seeking nonessential care have to bear some responsibility for the expenses created by any complications they experience. However, responsibility for these costs should not be laid solely at the feet of bariatric tourists — even those who seek nonessential care. As publicly funded health systems must ration care according to their available resources, failure to provide access to patients with nonessential cases is less ethically problematic, but we should be asking ourselves whether these patients have received adequate advice and support from the Canadian health system and from their communities to help them make healthy lifestyle choices, including diet and exercise. Local barriers to a healthy lifestyle, including abundant unhealthy food options, unsafe access to exercise and insufficient promotion of healthy living, can exist. Thus, for bariatric tourists with nonessential cases we need to examine the communities and supports to assess their responsibility for the consequences of seeking bariatric surgery abroad.

Finally, we should assess the responsibility of those who facilitate and provide bariatric surgery abroad. The patient interviewed on *The Current* was largely left on her own to research risks and was then given questionable information on the relative risks of receiving bariatric surgery in Canada compared with a facility in Mexico. While medical care, including bariatric surgery, can be of high quality throughout the world, it is clear that this patient’s case was not a success. We do not believe that in private health care the rule of caveat emptor should hold. Rather, medical professionals have a responsibility to give high-quality care, and both providers and facilitators have a responsibility to give accurate information to patients about the risks associated with their care.

Assigning responsibility for the costs of complications stemming from bariatric tourism is complicated and contextual. We should not simply stop at the point of blaming those who travel abroad for care. Rather, as we argue, there is plenty of blame to go around for these costs to the Canadian health system.

## Acknowledgements

V. Crooks holds the Canada Research Chair in Health Service Geographies and a Scholar Award from the Michael Smith Foundation for Health Research.

## Footnotes

*   **Competing interests:** None declared.

*   **Contributors:** All authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.

*   Accepted May 16, 2016.

## References

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3.  Tremonti AM.Bariatric medical tourism comes at a high cost for patients and Canada.The Current 2016March17Available: [www.cbc.ca/radio/thecurrent/the-current-for-march-17-2016-1.3495265/bariatric-medical-tourism-comes-at-a-high-cost-for-patients-and-canada-1.3495273](http://www.cbc.ca/radio/thecurrent/the-current-for-march-17-2016-1.3495265/bariatric-medical-tourism-comes-at-a-high-cost-for-patients-and-canada-1.3495273)accessed 2016 Oct. 14
    
    

4.  Snyder J, Crooks VA.Medical tourism and bariatric surgery: more moral challenges.Am J Bioeth 2010;10:28–30.
    
    

5.  Snyder J, Crooks V, Johnston R, et al.Beyond sun, sand, and stitches: assigning responsibility for the harms of medical tourism.Bioethics 2013;27:233–42.