Cross-border assisted reproduction care in Asia: implications for access, equity and regulations

'Womb for work' experiences of Thai women and gestational surrogacy practice in Thailand

Risks to gestational surrogates became a concern for public health. In commercial gestational surrogacy arrangements, gestational surrogates are commonly recruited from low- to middle-income countries. Thailand is well known as a surrogacy hub in this regard. However, little is known concerning Thai surrogacy practice and the risks that Thai gestational surrogates experiences. The semi-structured interviews with fifteen Thai women who had been gestational surrogates were conducted over the telephone in Thai between March and May 2020 and lasted approximately 30 minutes. Thematic analysis was applied to analyse the translated interviews. The findings indicated that 'womb for work' was perceived as a surrogacy career among Thai women. 'Womb for work' was defined as a superordinate theme that consisted of three subthemes: (i) gestational surrogacy arrangements in Thailand; (ii) the business model of gestational surrogacy arrangements in Thailand; and (iii) risk experiences of gestational surrogates. Clear deficiencies in surrogacy practice and regulations were identified, which put gestational surrogates at risk, including those associated with embryo transfer, transnational gestational surrogacy, and unsupported pregnancies. This study shows the urgent need to introduce regulations to protect women's health transnationally in this domain more effectively.

The Ethical Standards of Sunni Muslim Physicians Regarding Fertility Technologies that are Religiously Forbidden

This research project is pioneering in that it is the first to provide empirical data regarding the ethical standards of Sunni Muslim physicians toward religiously prohibited reproductive technologies, a topic which is considered taboo in Muslim society. A total of 689 Sunni Muslim physicians rated their acceptance of 14 fertility treatments. They expressed objections to assisted reproductive technologies entailing gender selection, egg, sperm and embryo donation, and surrogacy. The findings show that the Sunni Muslim medical establishment avoids fertility options that are considered in violation of Islamic law, and Sunni Muslim physicians tend to obey religious law.

Moral frameworks of commercial surrogacy within the US, India and Russia

In this paper, we draw on three ethnographic studies of surrogacy we carried out separately in different contexts: the western US state of California, the south Indian state of Karnataka, and the western Russian metropolis of St Petersburg. In our interviews with surrogate mothers, intended parents, and surrogacy professionals, we traced the meanings and ideologies through which they understood the clinical labour of surrogacy. We found that in the US, interviewed surrogates, intended parents and professionals understood surrogacy as an exchange of both gifts and commodities, where gift-giving, reciprocity, and relatedness between surrogates and intended parents were the major tropes. In India, differing narratives of surrogacy were offered by its different parties: whilst professionals and intended parents framed it as a win-win exchange with an emphasis on the economic side, the interviewed surrogate mothers talked about surrogacy as creative labour of giving life. In Russia, approaches to surrogacy among the interviewed surrogate mothers, professionals and intended parents overlapped in framing it as work and a businesslike commodity exchange. We suggest these three different ways of ethical reasoning about the clinical labour of surrogacy, including justifications of women's incorporation into this labour, were situated in local moral frameworks. We name them "repro-regional moral frameworks", inspired by earlier work on moral frameworks as well as on reproductive nationalisms and transnational reproduction. Building on these findings, we argue that any international or global regulation of surrogacy, or indeed any moral stance on it, needs to take these local differences into account.

Mapping transnational commercial surrogacy arrangements in South and Southeast Asia

Transnational commercial surrogacy is a form of medical tourism undertaken by intended parents in an attempt to seek surrogates in other countries. Most intended parents are from developed countries and seek their surrogates from developing countries, predominantly from South and Southeast Asia. This arrangement led to the establishment of surrogacy businesses in South and Southeast Asia, in countries such as India and Thailand. Subsequently, the business was banned in these countries, which led to a trend of moving it to neighbouring countries where there were no regulations or restrictions. This paper maps the movement of the industry and calls for attention to re-consider or re-frame commercial surrogacy in an international framework.

Development of assisted reproductive technology services in Thailand between 2008 and 2014 before the new law: Results generated from the National ART Registry, Royal Thai College of Obstetricians and Gynecologists

Background

While the assisted reproductive technology (ART) relieves the burden of infertility in many couples, it presents significant public health challenges due to the substantial risk for multiple birth delivery and preterm birth, which are associated with poor maternal and fetal health outcomes. For this reason, it is important to monitor the development and effectiveness of ART services in Thailand.

Objective

To analyze the trends of ART services in Thailand between 2008 and 2014.

Methods

ART clinics in Thailand are required to submit data to the Royal Thai College of Obstetricians and Gynecologists via the National Reporting System. The data from 2008 to 2014 were collected and analyzed.

Results

The number of ART centers was increased from 35 to 47. The total fresh ART cycles were also increased from 3,723 to 6,516. The percentage values of intracytoplasmic sperm injection (ICSI), in vitro fertilization, gamete intrafallopian transfer, and zygote intrafallopian transfer cycles were changed from 77.87 to 95.59, 21.43 to 4.31, 0.21 to 0.09, and 0.45 to 0.05, respectively. The clinical pregnancy rates were 28.79–33.19, 22.84–51.34, 14.29–42.86, and 0.00–26.67, respectively. The clinical pregnancy rates in fresh vs. frozen-thawed cycles were 31.01–36.33 vs. 31.54–37.34 (P < 0.05). The clinical pregnancy rates in female age <35 vs. 35–39 vs. ≥40 years were 36.97–40.70 vs. 32.74–33.42 vs. 21.08–31.34, respectively (P < 0.001), and the percentage values of multifetal pregnancy rate were 18.75 vs. 13.30 and 13.69, respectively (P < 0.001). There were increasing preimplantation genetic screening (PGS) cycles, with the percentage of the clinical pregnancy rate (25.90–42.63, P < 0.05). The clinical pregnancy rates in medium-sized ART centers (100–300 cycles per year) vs. in small and large centers were 30.79–41.14 vs. 28.01–34.04 and 8.70–40.35, respectively (P < 0.001). Trends of increasing percentage of ART birth rate to total birth rate ratio were 0.24–0.34 (P < 0.05).

Conclusions

There were higher clinical pregnancy rates in frozen-thawed cycles. Higher multifetal pregnancy rate and clinical pregnancy rate were also found in younger females. There were increasing uses of ICSI and PGS. A trend toward increasing ART birth to total birth ratio was observed.

Globalised quests for assisted conception: Reproductive travel for infertility and involuntary childlessness

The global movement of people across international borders to undergo assisted reproductive treatment is common, although there is little accurate data. In this article, we synthesise findings from our own empirical research on reproductive travel in addition to a review of clinical, ethical, legal, and regulatory complexities from studies on reproductive travel since 2010. Motivations for travel include legal and religious prohibitions; resource considerations; lack of access to gametes and reproductive assistors; quality and safety concerns; and personal preferences. Higher risks to mothers and children are associated with multiple embryo transfer and subsequent multiple and higher order pregnancies and the average older age of women undertaking reproductive travel. The potential exploitation of other women as providers of oocytes or surrogacy services, the lack of equity in access to assisted reproduction and the ambiguous legal status of children conceived from international reproductive travel are important ethical considerations. A range of significant legal issues remain given variable and limited international regulation. Scholarship on this trade necessarily engages with issues of power and gender, social inequities, global capitalism and the private decision-making of individuals seeking to form families. Research gaps remain given recent changes in the organisation, demands and destinations of the trade.

Protection for Children Born Through Assisted Reproductive Technologies Act, B.E. 2558: The Changing Profile of Surrogacy in Thailand

The National Legislative Assembly of Thailand has enacted on February 19, 2015 the Protection for Children Born through Assisted Reproductive Technologies Act (ART Act). Its primary objective aims at protecting children born through assisted reproductive technologies and providing the legal procedures that the intended parents must follow. The focus of this article is to discuss the ongoing issues involving assisted reproduction in Thailand. After reviewing the past legal framework surrounding surrogate motherhood and the downsides of the assisted reproductive technology market in Thailand, the article will discuss the new ART Act and its regulatory framework. It will conclude that although the new law contains some flaws and limitations, it has so far been successful in tackling surrogacy trafficking and preventing reproductive scandals from occurring again.

Ethics and regulation of inter-country medically assisted reproduction: a call for action

The proliferation of medically assisted reproduction (MAR) for the treatment of infertility has brought benefit to many individuals around the world. But infertility and its treatment continue to be a cause of suffering, and over the past decade, there has been a steady growth in a new global market of inter-country medically assisted reproduction (IMAR) involving 'third-party' individuals acting as surrogate mothers and gamete donors in reproductive collaborations for the benefit of other individuals and couples who wish to have children. At the same time there is evidence of a double standard of care for third-party women involved in IMAR, violations of human rights of children and women, and extreme abuses that are tantamount to reproductive trafficking. This paper is the report of an inter-disciplinary working group of experts who convened in Israel to discuss the complex issues of IMAR. In Israel too IMAR practices have grown rapidly in recent years, mainly because of restrictions on access to domestic surrogacy for same sex couples and a chronically insufficient supply of egg cells for the treatment of couples and singles in need. Drawing upon local expertise, the paper describes documented practices that are harmful, suggests principles of good practice based on an ethic of care, and calls for action at the international, national and professional levels to establish a human rights based system of international governance for IMAR based on three regulatory models: public health monitoring, inter-country adoption, and trafficking in human beings, organs and tissues.

Investigation of Personality Traits between Infertile Women Submitted to Assisted Reproductive Technology or Surrogacy

Background

Personality traits affect human relationships, social interactions, treatment procedures, and essentially all human activities. The purpose of this study is to investigate the personality traitsincluding sensation seeking, flexibility, and happiness among a variety of infertile women who were apt to choose assisted reproductive technology (ART) or surrogacy.

Materials and Methods

This is a cross-sectional study that was performed on 251 infertile women who visited Isfahan and Tehran Reproductive Medicine Center. These fertility clinics are located in Isfahan and Tehran, Iran. In this study, 201 infertile women who underwent treatment using ART and 50 infertile women who tended to have surrogacy were chosen by convenience sampling. Zuckerman’s Sensation Seeking Scale Form V (SSS-V), Psychological Flexibility Questionnaire (adapted from NEO Personality Inventory-Revised) and Oxford Happiness Questionnaire (OHQ) were used as research instruments. All participants had to complete the research instruments in order to be included in this study. Data were analyzed by descriptive-analytical statistics and statistical tests including multivariate analysis of variance (MANOVA) and Z Fisher. Statistically significant effects were accepted for P<0.05.

Results

In the sensation-seeking variable, there was a meaningful difference between under-study groups. However, the flexibility and happiness variables did not have a significant difference between under-study groups (P<0.001). Interaction between education, employment, and financial status was effective in happiness of infertile women underwent ART (P<0.05), while age, education and financial status were also effective in happiness of infertile women sought surrogacy (P<0.05). A positive meaningful relationship was seen between sensation seeking and flexibility variables in both groups (P<0.05). And a negative meaningful relationship was seen between sensation seeking and happiness in infertile women who sought surrogacy (P<0.05). The difference in rate of relationship between sensation seeking and flexibility was meaningful in infertile women who sought either ART or surrogacy (P<0.05).

Conclusion

Sensations seeking as a personality trait is lower in infertile women who underwent treatment using ART compared women who tended to have surrogacy. This study shows that demographic variables are effective in happiness of infertile women. Also, there is a significant relation among sensation seeking, flexibility and happiness in infertile women.

Security giving in surrogacy motherhood process as a caring model for commissioning mothers: A theory synthesis

AIM

Despite the increasing use of surrogacy, there are no caring theories/models that serve as the basis for nursing care to surrogacy commissioning mothers. This study has designed a model for caring of surrogacy commissioning mothers in 2013.

METHODS

The theory synthesis of Walker and Avant's strategies of theory construction (2011) was used to design a caring model/theory. The theory synthesis includes three stages: (i) selection of focal concept (the concept of "security giving in motherhood" was selected); (ii) review of studies in order to identify factors related to focal concept relevant studies (42 articles and 13 books) were reviewed, statements and concepts related to focal concept were then extracted and classified, and their relations were specified; and (iii) organization of concepts and statements within a relevant general and effective manifestation of the phenomenon under study which led to developing of a model.

RESULTS

In this caring model/theory, entitled "security giving in surrogacy motherhood", nurses roles were conceptualized within the conceptual framework that includes three main roles: (i) coordination; (ii) participation; and (iii) security giving (physical, emotional, and legal support; empowerment; presence; relationship management between both parties and advocacy). Training surrogacy specialist nurses and establishment of surrogacy care centers are important factors for implementation of the model.

CONCLUSION

This model could help to provided better caring for surrogacy clients, especially for commissioning mothers.

Recent trends in reproductive tourism and international surrogacy: ethical considerations and challenges for policy

Reproductive tourism, or "cross-border reproductive care", is the phenomenon of people crossing international borders to access reproductive technologies. One of the fastest-growing categories of cross-border reproductive care is international surrogacy, the act of infertile clients traveling internationally to engage the paid services of foreign surrogates to carry their babies to term. It is a multibillion-dollar global industry presenting unique legal, ethical, and risk-management challenges. Clients tend to be price-sensitive, middle-income individuals seeking services from surrogates who in the global market are thought to be of quite low socioeconomic status. Risks are experienced by all parties involved in the transaction, including the client's countries of origin and destination. The risks to the surrogate evolve from the potential to exploit her economic vulnerability in order to encourage both consent and unfair pricing. Opportunities for policy development are explored.

Research protocol: a realist synthesis of cross-border patient mobility from low-income and middle-income countries

INTRODUCTION

People are increasingly mobile for numerous reasons, including healthcare. Patient mobility has vast implications for individuals, communities and whole populations and yet, to date, research on patient mobility has been quite limited. Only a small body of evidence exists on patient mobility between low-income and middle-income countries, instead having focused primarily on cross-border movement between high-income and low-income countries. In this paper, we present a protocol for examining this under-studied phenomenon.

METHODS AND ANALYSIS

We propose to examine patient mobility between low-income and middle-income countries using a realist synthesis approach. Specifically, we aim to document why patients from low-income and middle-income countries cross international borders for healthcare, by identifying the mechanisms through which patients decide to cross-borders, and the contextual characteristics of domestic health markets that influence this choice. An underlying theory was established, based on the lead author's experience and a brief literature review, which will provide the basis to analyse search results in a subsequent paper. Search results will be obtained from databases (Ovid Medline, EMBASE, Scopus, EconLit, Web of Science) and the grey literature. An expert committee will be enlisted, prior to screening results, to review search results to ensure comprehensiveness. Based on this preliminary theory, we propose that, in some low-income and middle-income country markets, the interaction between demand-side and supply-side determinants results in market imperfections that, in turn, lead to patient movement across borders.

ETHICS AND DISSEMINATION

The study does not involve primary research and, therefore, does not require formal ethical approval; we do, however, follow the relevant standards of utility, usefulness, feasibility, propriety, accuracy and accountability. The standards of realist and meta-narrative evidence synthesis (RAMESES) will be adhered to in reporting the findings of the review. Once completed, the findings of the resulting manuscript will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

This protocol has been registered with PROSPERO, registration number CRD42014014391.

Motivations and experiences of patients seeking cross-border reproductive care: the Australian and New Zealand context

OBJECTIVE

To explore the motivations, clinical care, counseling, and support experiences of Australian and New Zealand participants considering or having participated in cross-border reproductive care (CBRC).

DESIGN

Questionnaire-based study.

SETTING

Not applicable.

PATIENT(S)

One hundred thirty-seven Australian and New Zealand participants aged 23-53 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES(S)

Quantitative and qualitative responses to an anonymously completed online questionnaire.

RESULT(S)

Quantitative responses from participants indicated that motivations for engaging in CBRC included limited availability of gamete donors in their home state, difficulty in meeting treatment eligibility criteria, and treatment being legally prohibited. Experiences of CBRC were generally rated positively in terms of medical needs (91.2%), safety (89.4%), and costs (85.7%), although rated more conservatively to emotional needs being met (57.9%). Less than half the sample (47.5%) had accessed some form of CBRC-related counseling. Themes identified in qualitative analysis reflected gamete supply and demand issues, the importance of donor information and disclosure, the personal impact of legislation, and ongoing support needs after CBRC treatment.

CONCLUSION(S)

A greater percentage of participants agreed that their CBRC clinic satisfied their overall medical needs and treatment expectations in comparison with overall emotional needs. Participants indicated access to post-treatment support counseling particularly with regard to their emotional well-being and disclosure issues to donor-conceived children would be useful. The implications of our findings for the provision of best-practice psychosocial counseling support and development of counseling guidelines are highlighted.

National self-sufficiency in reproductive resources: An innovative response to transnational reproductive travel

Transnational reproductive travel is symptomatic of insufficient supplies of reproductive resources, including donor gametes and gestational surrogacy services, and inequities in access to these within domestic health-care jurisdictions. Here, we argue that an innovative approach to domestic policy making using the framework of the National Self-Sufficiency paradigm represents the best solution to domestic challenges and the ethical hazards of the global marketplace in reproductive resources.

Why do medical tourists travel to where they do? The role of networks in determining medical travel

Evidence on medical tourism, including patient motivation, is increasing. Existing studies have focused on identifying push and pull factors across different types of treatment, for example cosmetic or bariatric surgery, or on groups, such as diaspora patients returning 'home' for treatment. Less attention has been on why individuals travel to specific locations or providers and on how this decision is made. The paper focused on the role of networks, defined as linkages - formal and informal - between individual providers, patients and facilitators to explain why and where patients travel. Findings are based on a recently completed, two year research project, which examined the effects of medical tourism on the UK NHS. Research included in-depth interviews with 77 returning medical tourists and over sixty managers, medical travel facilitators, clinicians and providers of medical tourism in recipient countries to understand the medical tourism industry. Interviews were conducted between 2011 and 2012, recorded and transcribed, or documented through note taking. Authors undertook a thematic analysis of interviews to identify treatment pathways by patients, and professional linkages between clinicians and facilitators to understand choice of treatment destination. The results highlight that across a large sample of patients travelling for a variety of conditions from dental treatment, cosmetic and bariatric surgery, through to specialist care the role of networks is critical to understand choice of treatment, provider and destination. While distance, costs, expertise and availability of treatment all were factors influencing patients' decision to travel, choice of destination and provider was largely the result of informal networks, including web fora, personal recommendations and support groups. Where patients were referred by UK clinicians or facilitators these followed informal networks. In conclusion, investigating medical travel through focus on networks of patients and providers opens up novel conception of medical tourism, deepening understanding of patterns of travel by combining investigation of industry with patient motivation.

Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches

Background

The study examined the implications of inward and outward flows of private patients for the NHS across a range of specialties and services.

Objectives

To generate a comprehensive documentary review; to better understand information, marketing and advertising practices; examine the magnitude and economic and health-related consequences of travel; understand decision-making frames and assessments of risk; understand treatment experience; elicit the perspectives of key stakeholder groups; and map out medical tourism development within the UK.

Design and participants

The study integrated policy analysis, desk-based work, economic analysis to estimate preliminary costs, savings and NHS revenue, and treatment case studies. The case studies involved synthesising data sources around bariatric, fertility, cosmetic, dental and diaspora examples. Overall, we drew on a mixed-methods approach of qualitative and quantitative data collection. The study was underpinned by a systematic overview and a legal and policy review. In-depth interviews were carried out with those representing professional associations, those with clinical interests and representative bodies (n = 16); businesses and employees within medical tourism (n = 18); NHS managers (n = 23); and overseas providers. We spoke to outward medical travellers (46 people across four treatment case studies: bariatric, fertility, dental and cosmetic) and also 31 individuals from UK-resident Somali and Gujarati populations.

Results

The study found that the past decade has seen an increase in both inward and outward medical travel. Europe is both a key source of travellers to the UK and a destination for UK residents who travel for medical treatment. Inward travel often involves either expatriates or people from nations with historic ties to the UK. The economic implications of medical tourism for the NHS are not uniform. The medical tourism industry is almost entirely unregulated and this has potential risks for those travelling out of the UK. Existing information regarding medical tourism is variable and there is no authoritative and trustworthy single source of information. Those who travel for treatment are a heterogeneous group, with people of all ages spread across a range of sociodemographic groups. Medical tourists do not appear to inform their decision-making with hard information and consequently often do not consider all risks. They make use of extensive informal networks such as treatment-based or cultural groups. Motivations to travel are in line with the findings of other studies. Notably, cost is never a sole motivator and often not the primary motivation for seeking treatment abroad.

Limitations

One major limitation of the study was the abandonment of a survey of medical tourists. We sought to avoid an extremely small survey, which offers no real insight. Instead we redirected our resources to a deeper analysis of qualitative interviews, which proved remarkably fruitful. In a similar vein, the economic analysis proved more difficult and time consuming than anticipated. Data were incomplete and this inhibited the modelling of some important elements.

Conclusions

In 2010 at least 63,000 residents of the UK travelled abroad for medical treatment and at least 52,000 residents of foreign countries travelled to the UK for treatment. Inward referral and flows of international patients are shaped by clinical networks and longstanding relationships that are fostered between clinicians within sender countries and their NHS counterparts. Our research demonstrated a range of different models that providers market and by which patients travel to receive treatment. There are clearly legal uncertainties at the interface of these and clinical provision. Patients are now travelling to further or ‘new’ markets in medical tourism. Future research should: seek to better understand the medium- and long-term health and social outcomes of treatment for those who travel from the UK for medical treatment; generate more robust data that better capture the size and flows of medical travel; seek to better understand inward flows of medical travellers; gather a greater level of information on patients, including their origins, procedures and outcomes, to allow for the development of better economic costing; explore further the issues of clinical relationships and networks; and consider the importance of the NHS brand.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Attitudes towards cross-border reproductive care among infertile Japanese patients

OBJECTIVES

The attitudes towards cross-border reproductive care (CBRC) held by infertile Japanese patients have not been explored. The objective of the present study was to examine interest levels, preferred destinations, motivations, and sources of information related to CBRC. Our findings provide a general outline of CBRC and the future of reproduction and assisted reproductive technology (ART) in Japan.

METHODS

The study used a cross-sectional design. Data were collected from 2,007 infertile Japanese patients from 65 accredited ART clinics in Japan (response rate, 27.4 %) via anonymous questionnaires.

RESULTS

Most of the infertile Japanese patients who responded denied using CBRC. However, by group, 171 (8.5 %) patients in non-donor in vitro fertilization, 150 (7.5 %) in egg donation, 145 (7.2 %) in pre-implantation genetic diagnosis, and 129 (6.4 %) in surrogacy said that, depending on the situation, they might travel abroad in the future. Older respondents were more likely to express an intention to travel overseas for egg donation in the future. The most popular destination for CBRC was the United States. Popular reasons for interest in CBRC among those considering or planning using this approach to third-party reproduction were that egg donation or surrogacy was unavailable or that obtaining ethical approval takes too long in Japan, whereas these processes are legal and affordable overseas. However, high cost was the most common reason for hesitancy regarding CBRC. Among the participants who were considering or planning to travel abroad for this purpose, TV, medical agencies, print media, and message boards on websites were popular sources of information, whereas doctors, friends, and patient self-help groups were not.

CONCLUSIONS

Although CBRC among infertile Japanese patients is not at present common, the demand for and use of this approach may increase in the future in the context of the increasingly aging population. Lack of regulation and unavailability of third-party reproduction is a major cause of CBRC among Japanese patients. Health care provider faces an urgent need for giving useful information for patients regarding CBRC.

Commercial surrogacy: how provisions of monetary remuneration and powers of international law can prevent exploitation of gestational surrogates

Increasing globalisation and advances in artificial reproductive techniques have opened up a whole new range of possibilities for infertile couples across the globe. Inter-country gestational surrogacy with monetary remuneration is one of the products of medical tourism meeting in vitro fertilisation embryo transfer. Filled with potential, it has also been a hot topic of discussion in legal and bioethics spheres. Fears of exploitation and breach of autonomy have sprung from the current situation, where there is no international regulation of surrogacy agreements--only a web of conflicting national laws that generates loopholes and removes safeguards for both the surrogate and commissioning couple. This article argues the need for evidence-based international laws and regulations as the only way to resolve both the ethical and legal issues around commercial surrogacy. In addition, a Hague Convention on inter-country surrogacy agreements is proposed to resolve the muddled state of affairs and enable commercial surrogacy to demonstrate its full potential.

Medical tourism's impact on health care equity and access in low- and middle-income countries: making the case for regulation

There is currently an evidentiary gap in the scholarship concerning medical tourism's impact on low- and middle-income destination countries (LMICs). This article reviews relevant evidence that exists and concludes that there are signs of correlation between medical tourism and the expansion of private, technology- intensive health care in LMICs, which has largely remained out of reach for the majority of the local patients. In light of this health care inequity between local residents and medical tourists in LMICs, we argue that the presumption should not be in favor of medical tourism and that governments have a legitimate interest in seeking to regulate this industry to ensure that the net effects for their citizens is positive. Moreover, sending countries, particularly those in the developed world, have the responsibility to adopt public policies to diminish demand on the part of their citizens for medical tourism and to work with LMICs to ensure that the growth of medical tourism does not occur at the expense of the poorest of the poor.