Jeremy Snyder and Valorie A. Crooks explain why they avoid using the word “ethics” on their Medical Tourism website.

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We recently launched a website that aims to inform Canadians who are considering traveling abroad for medical care (often known as ‘medical tourism’) about some of the ethical issues associated with this practice. Our website uses stories inspired by the experiences of patients who have traveled abroad for medical care to inform people about some of the ethical dimensions of medical tourism, but we deliberately avoid using the word “ethics” on our site. This is because in our past interviews with former medical tourists, we encountered difficulties when we used the word “ethics” and its derivatives, or what we now refer to as the ‘e-bomb’.

Our research project explored the decision-making process of Canadian medical tourists, including whether ethical issues related to international medical travel influenced their decision-making. These ethical issues are varied, including problems with informed consent for the medical tourist, the danger of imposing new health risks and health resource burdens on members of the traveler’s home country, and concerns that medical tourism will increase health inequities by promoting the privatization of health care abroad. For this study, we developed an interview guide that probed the influence of these ethical issues on decision-making and we interviewed 32 participants from across Canada.

Photo by Angel Petropanagos

As an ethicist without any experience in qualitative empirical research (Snyder) and a health geographer without any training in ethical theory (Crooks), we did not foresee any problems with examining the ethical dimensions of the decision-making of former medical tourists. However, when discussing ethics with our interview participants we encountered two problems. First, when we asked about the influence of ethical issues on decision-making, many participants perceived that they were being accused of unethical conduct. As a result, we had difficulty getting participants to speak about whether the local impacts of medical tourism in the destination countries they visited influenced their decision-making. Instead, participants typically tried to defend their choices to go abroad for medical care by describing how the Canadian health system failed to meet their medical needs. Second, it became much more difficult to elicit detailed responses to subsequent questions unrelated to ethics, once the participants became defensive.

As academics very interested in discussing the influence of ethical concerns on decision-making, we were surprised by participants’ responses.  As a result, we modified our subsequent interview questions to dramatically reduce our use of the word “ethics”. We concluded that using the word “ethics” puts interview participants on the defensive, so we rephrased ethical questions in ways that avoided the e-bomb. For example, instead of ‘Did ethical issues, such as the impact of medical tourism on destination countries, make you less likely to engage in medical tourism?’, we now ask ‘Did issues such as medical tourism’s potential to reduce access to medical treatment abroad influence your decision-making in any way?’. By focusing on ethical issues without identifying them as such we’ve been able to probe the issues in more detail than when the e-bomb gets dropped. If we feel that using the word “ethical” is important, we now make sure to shift these questions to the end of the interview so that if the participant becomes more defensive as a result, it will not undermine the effectiveness of other questions on different topics.

We’re not sure if other researchers have similar experiences with the e-bomb. It is possible that there is something particular to our own research that makes dropping the e-bomb so problematic. Perhaps our phrasing around ethical issues was offensive to interview participants and less problematic phrasing is available (though we have tried various ways of putting these questions without better results). Maybe there is something about medical decision-making, or medical tourism in particular, that makes people less willing to talk about the impact of these decisions on others (though our participants seemed perfectly willing to talk about these issues – just less so when the word “ethical” was used).

For now, we plan to drop the e-bomb as little, and as late, as possible in our future interviews and projects. Other researchers should consider doing the same, particularly if, like us, they feel that their questions about ethics can be presented without using the word “ethics”. This approach was validated in a small way in the comments on a recent news article about our website that used the e-bomb extensively. Here, Jeremy Snyder was referred to as an “’ethics’ professor” and therefore “Professional guilt tripper.” While we love dropping the e-bomb, what we’ve learned is that the general public may not like having it dropped on them so much.

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Jeremy Snyder is an Associate Professor in the Faculty of Health Sciences at Simon Fraser University (@jeremycsnyder). Valorie A. Crooks is an Associate Professor in the Department of Geography at Simon Fraser University.