HSS4331 Introduction to International Health Theory - PowerPoint PPT Presentation

Loading...

PPT – HSS4331 Introduction to International Health Theory PowerPoint presentation | free to download - id: 6b19-MGEyM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

HSS4331 Introduction to International Health Theory

Description:

Often tied to other tourist activities ... Currently, parts of the USA are the most popular destinations for 'reproductive tourists' ... – PowerPoint PPT presentation

Number of Views:112
Avg rating:3.0/5.0
Slides: 69
Provided by: deona
Learn more at: http://classes.deonandan.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: HSS4331 Introduction to International Health Theory


1
Reproductive (Medical) Tourism HSS 2121
April 1, 2009
Raywat Deonandan, PhD
ray_at_deonandan.com Assistant Professor,
Health Sciences, University of Ottawa Former
Chief Scientific Advisor, Assisted Human
Reproduction Canada
2
You can download this presentation at
classes.deonandan.com
3
We are going to talk about -Medical tourism
(what is it?) -Reproductive tourism (what is
it?) -The ethics of the above (what is ethics?)
4
(No Transcript)
5
  • The words, expletives, guttural moans and
    occasional odours coming out of my mouth do not
    necessarily reflect the opinion of Assisted Human
    Reproduction Canada

6
(No Transcript)
7
In General.
  • What is medical tourism?

1. The act of (typically Western) medical
professionals doing abroad to do good work, but
in reality functioning as gawking tourists 2.
The act of (typically Westerners) going abroad
(to typically developing countries) to seek
medical care.
8
The First Type
  • The act of (typically Western) medical
    professionals doing abroad to do good work, but
    in reality functioning as gawking tourists
  • The danger of every international health project
  • Whom does it really benefit?
  • cowboy global medicine
  • Sustainable?

9
The Second Type
  • The act of (typically Westerners) going abroad
    (to typically developing countries) to seek
    medical care.
  • Growing in popularity
  • Often tied to other tourist activities
  • Negative downstream consequences may not be
    immediately obvious

EXAMPLE Reproductive medical tourism
10
Summary of the Ethical Issues
11
Summary of the Ethical Issues
  • Misdirection of financial resources those who
    seek services abroad deny their resources (i.e.,
    outgoing funds) to their home community
  • Misdirection of medical resources those who
    provide services to tourists are denying their
    services to their home community
  • Implications of insufficiency the act of
    seeking services abroad implies that services are
    insufficient, in quantity, type, timing or
    affordability, in the home community
  • Criminality if service seeking abroad is done
    to avoid laws at home, should the international
    community consider this criminal behavior? Is the
    provision of services therefore the abetting of
    such criminal behavior?
  • Quality control if the health and welfare of
    tourists is a concern, how do we control for
    the quality and validity of medical services
    provided outside of ones administrative
    jurisdiction?
  • Robustness of informed consent are tourists
    provided with adequate and accurate
    representation of actual risks and probable
    success rates? Brokers may misrepresent facts.

The above may apply to all types of medical
tourism
12
We will revisit those ethical issues when we
discuss the specific case of Reproductive
Tourism In 43.21.
13
(No Transcript)
14
Terminology
  • Infertility
  • One year of unprotected sex without conceiving a
    child
  • Includes both sterile and subfertile people
  • Sterile
  • Will never conceive without medical assistance
  • Subfertile
  • May still conceive without medical assistance

15
Infertility
  • About 15 of couples will be defined as
    infertile
  • But this only accounts for those who actually
    seek services likely an underestimate
  • -1990 estimate 1 billion women worldwide are
    affected by infertility
  • -only covers those of reproductive age who have
    been diagnoses
  • On the increase in Western nations

16
Why Is Infertility On The Rise?
  • People waiting till later in life to have kids
  • Obesity and diabetes are on the rise
  • Environmental contaminants may be affecting
    hormone levels

17
The Available Infertility Services
  • Fertility drugs
  • IUI
  • IVF
  • ICSI
  • Gamete donation
  • Surrogacy

18
Fertility Drugs
19
IUI
  • Intra-uterine insemination
  • Artificial presentation of sperm into the vaginal
    canal
  • turkey baster method

20
IVF
  • In Vitro Fertilization
  • Creation of embryo in a dish, and returning it to
    the womb
  • test tube babies
  • Considered the vanguard ART technology

21
(No Transcript)
22
Louise Brown, Born July 25, 1978
23
The OctoMom!
24
My Halloween costume next year
Dennys Octomom special 14 eggs, no sausage, and
the guy at the next table pays for it.
25
(No Transcript)
26
ICSI
  • Intra cytoplasmic sperm injection
  • Done in conjunction with IVF
  • Grab a sperm and force it into an egg
  • Used when sperm just cant get the job done by
    themselves

27
(No Transcript)
28
(No Transcript)
29
Sperm Donation
  • Relatively simple
  • Donors are usually friends or family
  • Anonymous donors are rare and in demand

30
Egg donation
  • Very invasive
  • Expensive procedure
  • Hard to find donors

31
Surrogacy
  • A surrogate mother is a woman who agrees to
    gestate and give birth to a baby for someone else
  • Scenarios
  • Surrogate receives sperm via IUI and uses her own
    egg
  • Surrogate donates egg, embryo created via IVF
    (with or without ICSI)
  • Another egg is used, embryo created via IVF (with
    or without ICSI)

32
(No Transcript)
33
Other Technologies
  • PGD pre-implantation genetic diagnosis
  • IVM in vitro maturation
  • flash freezing of eggs
  • Hybrids and cybrids

34
Statistics
  • Canada
  • about 6500 IVF embryo transfers per year
  • USA
  • About 120,000 IVF procedures per year
  • UK
  • About 35,000 IVF procedures per year
  • Europe
  • About 300,000 IVF procedures per year

35
Costs
  • One attempt at IVF costs 8000-16000
  • ICSI costs extra
  • Donated sperm costs 200-600 (from US centre)
  • Donated egg costs 500-20000 (from US source)
  • Surrogate services cost 50,000 or more

36
Canadas Assisted Human Reproduction Act (2004)
  • Human cloning prohibited
  • Sex selection prohibited
  • In vitro gene alteration prohibited
  • Transplanting non-human gametes or embryos into a
    human is prohibited
  • Transplanting human gametes/embryos into a
    non-human for the purposes of creating a human
  • Create chimeras/hybrids

37
Canadas Act
  • No payment for surrogacy
  • No paid brokerage for surrogacy
  • No payment for gametes
  • No paid brokerage for gametes
  • etc

38
The Law
  • Laws in different countries vary dramatically
  • In the US, it varies from state to state
  • In Australia, only one state has clear
    regulations
  • In UK, rules are well defined and monitored
  • In Israel, its the wild wild west
  • Etc.

39
So.
  • Lets say youre an infertile couple in Canada
    who wish to
  • Select sex of your baby
  • Pay for a surrogate mother
  • Pay for a sperm or egg donor
  • Pay less for a baby

What do you do?
40
You Go Abroad
  • Example
  • In Virginia Mason medical centre in Seattle, 33
    of patients are Canadian, most seeking to buy
    donor eggs
  • In India, reproductive tourism is a 450
    million industry

41
Reproductive Tourism
  • The phenomenon of going abroad to seek
    reproductive technologies
  • Might be considered a form of Medical Tourism

42
South Asia
  • Currently, parts of the USA are the most popular
    destinations for reproductive tourists
  • But India is fast becoming an important
    destination

43
India
  • Surrogate mother in India costs
  • Plethora of doctors, all English-speaking
  • Case study
  • A British couple in 2006 spent 60,000 pounds on
    IVF in the UK without success, so they went to
    India and paid 3,300 for a surrogate mother

44
Why India?
  • Cost of IVF is 1/50th compared to USA
  • Generally believed that Indian women smoke and
    drink less (foetal health)
  • Enormous NRI community, who are now wealthy and
    infertile
  • Very few (in any) laws
  • Open acceptance of sex selection techniques

45
Why India?
  • In India, infertility is seen as a curse, so many
    surrogates report that they are doing charitable
    work by providing a child for an infertile couple

46
Nine of the 45 surrogates available at the
Akanksha clinic in Anand, India, where at least
one Western woman visits every day seeking a
surrogate.
47
  • Akanksha clinic
  • Among the most famous in the industry
  • Surrogates are cloistered in secret locations
  • Clearly, there is some civil discontent
  • Surrogates rent their wombs for food, healthcare
    and cash amounting to about 6000
  • A fortune for many of them quite affordable for
    us

48
So, Whats The Problem?
  • From an international health/development point of
    view, what are the issues?

49
The Issues
  • Protection for couples travelling abroad
  • Protection for women selling services in poor
    countries

50
The Issues
  • Couples are bypassing the laws of their own
    countries should they be prosecuted?
  • Informed consent how informed are these women?
  • Choice. In many places, how can we guarantee
    that women are not being forced to participate?

51
More Issues
  • India is popular also because of its familial
    laws
  • In UK, a surrogate mother can change her mind and
    claim the baby as her own any time within the
    first 2 years of life
  • In India, the surrogate loses all rights to the
    baby at the point of delivery

52
More Issues
  • Is remuneration fair? Should surrogates be paid
    global market rates?
  • Social stigma of carrying the child of a man who
    is not your husband
  • Loss of control of ones body, as client and
    doctor have a vested interest in the surrogates
    nutrition and activities

53
Even More Issues
  • Must protect vulnerable infertile Westerners from
    being fleeced by dishonest doctors and surrogates
  • In instances of extreme poverty, is there really
    such a thing as choice for a surrogate?
  • Compare to instances of choice for an
    impoverished woman who chooses prostitution

54
Even More Issues!
  • What kind of health follow-up are surrogates
    given?
  • Are they given post natal care, especially after
    the baby has been given up?
  • What reproductive effects do surrogates suffer
    from?
  • Giving birth is dangerous
  • Potential for surrogate to become infertile

55
Disease Issues
  • Reproduction is a vector
  • Fluid associated with donated eggs and sperm may
    be infected with HIV, Hep C, etc... Maybe even
    Mad Cow Disease (unlikely)

56
Cases
  • Despite dramatic shortages of altruistically
    donated sperm in the Western world, a gay man in
    New Zealand was not permitted to donate because
    he was from a high risk group for HIV
  • Currently a case in the USA of an egg donor with
    Tay-Sachs disease she has already produced 3
    children

57
Legal Issues
  • A child born to a surrogate mother in India what
    are the legal steps to get it into the country of
    the client?
  • Formal adoption procedures?
  • Can a surrogate mother in India benefit from
    parental laws of the clients country?
  • Does she have the 2 year leeway in the UK?

58
Cross Border Reproductive Care
  • Why is this the preferred terminology?

59
(No Transcript)
60
(No Transcript)
61
Reminder of Ethical Issues
  • Misdirection of financial resources those who
    seek services abroad deny their resources (i.e.,
    outgoing funds) to their home community
  • Misdirection of medical resources those who
    provide services to tourists are denying their
    services to their home community
  • Implications of insufficiency the act of
    seeking services abroad implies that services are
    insufficient, in quantity, type, timing or
    affordability, in the home community
  • Criminality if service seeking abroad is done
    to avoid laws at home, should the international
    community consider this criminal behavior? Is the
    provision of services therefore the abetting of
    such criminal behavior?
  • Quality control if the health and welfare of
    tourists is a concern, how do we control for
    the quality and validity of medical services
    provided outside of ones administrative
    jurisdiction?
  • Robustness of informed consent are tourists
    provided with adequate and accurate
    representation of actual risks and probable
    success rates? Brokers may misrepresent facts.

62
  • Are there additional ethical issues that apply
    specifically to reproductive tourism?

63
  • Robustness of informed consent this issue, as
    it pertains to the surrogate, is quite separate
    from that pertaining to the tourist. Social
    downstream impacts must also be communicated (eg,
    is a conservative society ready for a woman to
    carry baby for two gay men will husband respond
    well to wife carrying the baby of another man
    specific religions eg, Muslim- concerns)
  • Custody rights rights vary from country to
    country. To what extent is the industry
    affecting the drafting of custody rights
    legislation?
  • Cultural appropriateness see (a) economic
    attraction of the industry may bring it to
    societies presently unprepared for some of the
    implications, eg gay parents, single mothers,
    carrying a child that is not your husbands
  • Quality of care surrogates physical health is
    maintained, but only to the extent that it
    benefits her pregnancy. What of social and
    mental health? What of her removal from
    care-giving milieu of her own community? If
    clinic provides her diet, does she still cook for
    her family?

64
  • Limits of care While the surrogates medical
    health is of prime importance during pregnancy,
    does this care end upon birth of the child? Is
    there an investment in post-partum care? To what
    extent does economics affect this trend? (Eg, a
    regular surrogate should be maintained in good
    health due to her ability to perform again.)
  • Remuneration one reason tourists seek service
    is reduced cost abroad. But while remuneration
    for the surrogate is likely above what she would
    otherwise earn, it is likely below global market
    rates.
  • Abortion selective reduction is a common
    occurrence in ART. Is surrogate aware and
    culturally responsive to this likelihood?
  • Medical advocacy clinician responds to needs of
    the tourist. Is it a conflict of interest to
    also be care-giver to the surrogate?

65
What We Are Doing
  • Step 1 bring together ART regulatory bodies
    from key nations
  • Step 2 agree that these are issues worth
    considering
  • Step 3 Collect data!
  • Step 4 to be determined

66
Achievable Goal
  • Establishment of international body to
  • Monitor extent of reproductive tourism
  • Set forth international guidelines for
    appropriate ART/AHR care
  • Monitor quality control for doctors offering
    services to international clients
  • Monitor rights abuses of local women offering
    their reproductive tissue and services

67
Conclusions
  • Reproductive freedom is a complex concept
  • Is reproductive tourism a win-win scenario,
    wherein the provider of a biological function is
    amply rewarded for sharing her gifts with the
    inferitle?
  • Is reproductive tourism exploitative, wherein the
    bodies of poor women are commodified for use by
    rich Westerners?
  • The best we can hope for right now is to maximize
    informed consent and empowerment of choice

68
Quotes
About PowerShow.com