Should Travel Medicine Professionals Police the Travel Plans of Their Clients

Compiled by Karl Neumann, MD

Travel health practitioners some times face ethical and moral dilemmas because clients plan trips that are unreasonably hazardous or morally questionable. How should such clients be approached?

To get opinions, we posted four questions on the ISTM ListServ. Thirty-five members from 11 countries responded. The following are representative responses.

Do we as travel health professionals have moral and/or legal obligations to attempt to dissuade clients from going on trips that we disapprove of? If yes, what do we do about it? Do we refuse to treat them if they insist on going?

"The ethics of travel medicine is an example of beneficent paternalism that is once again gaining favor over unrestricted patient (traveler) autonomy."

"A practical problem is that most patients come to see us too late in their planning stage for us to have a major impact on their trips. The few times that I have recommended major changes in their itineraries, they did not take my advice. The main reasons, I think, is that they had already finalized their plans, were excited about going, had told their friends and relatives, and had paid for their trips. We should find ways to convince travellers to see us earlier in the trip-planning process. Perhaps ISTM can work on this."

"I start with the principle that people are adults and free to make their own choices. My role is to allow them to make informed choices. Where the law is clearly to be breached and there is a remedy I will report it viz. paedophilic sex trips in certain countries (see below.) Where there is a moral rather than a legal issue, I leave this to the traveller to make his own mind up, once he is fully informed. Should he persist with his folly, I will do my best to offer maximum protection."

"We have an ethical responsibility to be good doctors, but not 'spiritual advisors.' If their minister or lawyer were to make objections to their plans, I might not think badly of that.  However, if they were to give them advice about malaria prophylaxis, that would probably bother me a bit." 

"It is so easy to give people advice they don't want, have not asked for, and almost certainly will not follow.  There is enough of that advice that already falls into the area of travel medicine to keep us busy.  Let's not stray too far away from our professional (medical) responsibilities to our patients." 

"For all my interest in travel medicine, I happen to think that traveling long distances by plane is irresponsible and perhaps immoral, certainly selfish, in view of the effect that jet travel has on the environment. But I keep my views to myself!"

"Legal: maybe only in the unlikely case of a paedophile. Moral: no. Their decision to travel is their choice and their business. They are consulting me as a health professional, not a priest. Do we refuse to treat them if they insist on going? Most definitely not. I would regard this as unethical."

"This question really grabbed my attention. We should be concerned about where people are traveling and protect them as well as possible. If the area is risky we must explain the precise risks in clear-cut terms and allow the traveler to decide. We should remain objective as possible. But we should be comfortable with what we say and prescribe, or not do it. We are not the travel police. That being said, we should fully document all discussions."

"Raising the consciousness of the traveler is the first step in pre-travel preparation. If a traveler's scenario seems risky to me, I believe it is important to share my concerns and the scientific basis for them. I tell the patient that I will chart that the vaccines were refused and/or that the recommendation was for the person not to travel.  I state in the note that I discussed the concerns with the patient."

How do you deal with clients who are likely traveling for the prime purpose of having sexual relations with local people, perhaps children?

"If paedophilic sex is suspected, and I am in a jurisdiction where travelling for this purpose is illegal, I would report it to the appropriate authorities. If not in such a jurisdiction, there would be little that could be done. If not paedophilic sex, I counsel them on the dangers, and how these can be avoided if they insist on going."

"I have never seen a patient who admitted this but I routinely counsel travelers about the risk of sexual encounters with local people. I cite our Swiss data that the risk of VD is 20 fold increased over casual sex in your own home town."

"Unpleasant situation.  If my patient asks my opinion about his/her sexual perversions, I'll probably tell him/her what I think.  It would be a good opportunity, of course, to inform him/her of the risks of sexual encounters in areas of the world which are not as "protected" as our own."

"I would tell them of the ethical issues and the risk of giving or getting an STD.  I would not treat them and I would consider reporting them to local police, the passport issuing agency, and to the consulate of the country they intend to visit. These people give up their rights by intent to take advantage of the weak and are an embarrassment to their country of origin."

"Interesting questions. They are not likely to tell me!  If they do, and they're paedophiles, I would report them to the police. If they intend to visit prostitutes, I will explain the dangers to them and make them aware of the consequences for local people. But I have no illusions that I will have much influence."

How do you deal with clients who have illnesses or conditions (pregnancy, for example) that may become problematic by being far from home?

"For pregnant women, not any differently than I would if the patient were planning to home deliver, is getting too fat during the pregnancy, or is ignoring my advice about BP control, etc.  Give my advice, the risks and benefits of following (or ignoring) my advice, and otherwise let her know that I am there to be their doctor." 

"I feel morally obligated to dissuade travelers from some trips because of risk and have done so, successfully, on several occasions. I deal with legal concerns by written acknowledgment that the patient has been informed."

"If the traveler does not intend to break the law, does not intend to harm host country people (as in the sex tour example) and understands the risks of travel created by disease, environmental hazards and political unrest, we will treat them.  If we feel that the itinerary carries unusual risk we should try to dissuade them but not refuse to treat them. If we disapprove of the trip, we must examine our reasons for disapproving and not interfere unless the traveler is very likely to harm others or him or herself."

"I had a brave young lady journalist with Crohn's in remission come to me to prepare for an assignment in Iraq as a "ride along" on a tank!  Near the end of her assignment she developed a severe salmonella infection and I assisted by phone with the air-evac.  Upon her recovery she contacted me and expressed her appreciation for my help and she is on to her next adventure."

"Years ago, I had an elderly man with chronic congestive heart failure who wanted to see the Great Wall before he died.  His cardiologists said definitely do not go.  I asked him and his wife if death or hospitalization would be an acceptable adverse outcome of the trip. They both said yes.  He traveled the Great Wall in a wheel chair and died 2 years later in his bedroom with photos of him and his wife in China on the bed stand."

"Part of the pre-travel assessment in our corporate health services setting is to inquire about underlying health issues.  Depending upon the individual's concerns, we may make suggestions (such as the need for people with food allergies to carry an Epi-pen) and wherever possible we refer people to their primary care providers for planning travel needs appropriate to the underlying health concern. I discuss the importance of thinking "What do I do next?" if there is a flare up, a problem with the pregnancy, etc.  In many cases, I work with the patient to assemble the resources needed so that s/he is ready for what may occur and does not have to struggle, while ill, to find help."

"Pregnancy is a special issue since another potential person is involved. I feel that women have the right to abortion but do not have the right to put their unborn baby at real risk if the risk is avoidable.  Most tourism in developing countries can be safe during an uncomplicated pregnancy and I do accept these mothers as travel patients.  If I feel that the risk is excessive, I refuse to accept them and give the reasons."

"If tickets haven't already been purchased, rarely does a client go ahead and travel if given the reasons to delay that particular itinerary." 

"When indicated, I write to the client's primary care provider giving them the information I have and ask if the provider feels that this client is a candidate for this particular activity. The provider knows the patient so much better than I do and I know I may not be getting the "whole" picture from the client."

How do you deal with parents who are excessively risking their children's health and safety to further their own careers, practice their religious and political convictions, or fulfill their sense of adventure?

"I counsel against travel that exposes children to excessive risk. If they persist, I offer the children maximum protection. If the trip is unwise and it is being undertaken for an employer, I advise the employer against it."

"I simply make the parents fully informed and require the mother and father to acknowledge what they have been told in writing."

"First, I assess the real level of risk and the willingness to follow the recommended schedule of immunizations and prophylactic measures. For example, if they are convinced that DEET is poisonous and that alternative remedies prevent and cure malaria, I will not work with them and I tell them why.  If they are adventurous and reasonable, and if I feel that their desire for adventure is not greater than their concern for their children, I will accept them as patients." "I do think we have moral obligations to attempt to dissuade clients from going on trips that may cause risk to their children's health and safety. I point out the risks of disease, problems with vaccines and medications, lack of adequate medical care, and that the small children are too young to enjoy the trip. If necessary, I try to make them understand that what they are planning is close to child abuse."

"When an adult's health is at risk, our approval/disapproval should not apply as long as they have full information. However, if others, especially innocent children, are put at risk, or if they intend to do something illegal, I don't see any reason why a physician should assist in their activities."

"Many parents seem to want their children to be vaccinated and given antimalarials while declining them for themselves. When I point out that they themselves are still susceptible, many still decline because of cost. It seems that they do care about their children's health but may only have a partial understanding of the diseases."

"I worry much more about parents living in America who ignore their children when both work and the children are left alone at home to fend for themselves.  We have lots of weird religious characters living right here in America.  We don't have to go overseas to find them.  In my own experience, those children growing up overseas receive much better upbringing than was available to most families here.  I don't caution my Stateside-based families of the dangers of rearing children in America (perhaps I should), so I don't think it makes much sense to do that for families who plan to live overseas.  There are differences, but it is certainly not worse than here." 

"Each case has to be individualized. If parents brought their children to one of our hospital clinics and told the staff that they are going to purposely subject their children to serious disease and bodily dangers, the staff would probably call Child Welfare and the children might be taken from the parents. But travel medicine is different."

"As a parent myself, I have decided that if a client comes to me for advice, by gosh I am going to give it to them... regardless of the positive or negative aspects.  I do put the child first and the parents second since the children have no choices.  I don't care if it is for career, religious or political convictions or adventure.  Sometimes the clients aren't happy with my assessment but I really don't care.  To give them a full picture of possible problems is my job and they "asked for it"

"With regard to the effects of adult travel/expatriate assignments on the children, I always have a discussion with the parents to raise consciousness about the fact that children may suffer because of the parents' desire to travel. Travel may interfere with children's important socialization; older children don't want to leave friends and school, for example.  Many people just assume the children will adapt and are surprised to hear about the possibility that the adaptation may not be smooth. Knowing that there may be issues with the children helps parents anticipate those concerns. I tell the parents to make the extra effort to maintain good communications with their children and in some situations initiate counselor sessions so that fears and concerns can be discussed openly. Also, adaptation concerns are very different for children at different ages."

Karl is the editor of ISTM NewsShare.