Medical tourism brokers play an important role in the medical tourism industry and have helped make traveling abroad for medical care a viable option for more people than ever before [6, 7, 11, 12, 14]. Through our assessment of 17 Canadian brokers' websites we have been able to gain an understanding of the quantity and quality of online information available to persons using Canadian brokers. Their websites were clearly designed to sell brokers' services to potential medical tourists. For this reason, the information provided through these websites is geared more toward promotional ends rather than helping to inform patients of the full range of their treatment options or communicating the potential risks inherent in medical tourism. Mason and Wright identified a similar trend in their analysis of 66 international medical tourism websites (which included broker and non-broker sites) . Crooks et al.'s thematic content analysis of promotional brochures from medical tourism hospitals in India also revealed a strong emphasis on characterizing credentials and accreditation, services, and specializations over issues such as cost and follow up care . When the findings of our analysis are considered in relation to these other studies it becomes clear that a lack of emphasis on risk communication in medical tourism marketing materials is not specific to Canadian brokers but, instead, is more likely an industry-wide phenomenon.
The findings shared above highlight many issues that hold significant implications for Canadian patients' informed consent when engaging in medical tourism, four of which we expand upon in this section. First, our review revealed that only 2 of the 17 brokerages had been certified by an accrediting body, while many websites had various logos signifying membership with the MTA and other groups. While these logos are meant to assure the patient of the broker's professional status, they do not typically guarantee any particular standard of operation. The risk generated by this lack of standardization is that it allows brokers with lower standards and who do less to mitigate and inform patients of risks to operate amidst competent brokers, with little means of differentiating between the two [6, 14]. This lack of clarity may compromise a patient's ability to make informed decisions regarding their treatment, thereby ultimately compromising informed consent, and puts them in a position where they may be unsure of the consequences of deciding to use a particular broker to book a procedure abroad.
A second issue related to informed consent emerging from the findings pertains to the role of terminology in clarifying what services patients are purchasing. More specifically, the terminology chosen by the brokers may factor into how a patient views their services. The term 'medical tourism' has been described as that which is most commonly used within the industry and by the media , and the majority of the brokers in this study adopted it on their websites. Bioethicists and other scholars have observed that the term itself may be problematic; the word 'tourism' evokes images of beaches and sightseeing, potentially undermining the seriousness of the medical procedure in the patient's mind [19, 31, 32]. As such, the term may under-represent the risks involved in going abroad for medical care. Related to this is a need to develop standardized role terminology. The websites we reviewed uniformly avoided the term 'broker' that is so oft used in popularized contexts. This is likely deliberate; the term 'facilitator' evokes the image of a helper, someone making life easier, while the term 'broker' brings to mind the world of business and money-making. Moreover, a 'facilitator' may be seen more to have the patient's interests at heart, thus reducing risks, while a 'broker' might be seen as engaging in more mercenary, risk-taking behaviour, making the broker's perceived role an important element in the communication and understanding of risk.
The messages conveyed by the Canadian medical tourism broker websites we reviewed were overwhelmingly positive, which raises a third issue regarding informed consent. Positive, if not glowing, patient testimonials were more frequently present than not, while acknowledgement of risks were notably rare. This finding is consistent with those of other studies that have examined promotional information in medical tourism and have ultimately questioned the trustworthiness of what is being reported and its ability to support patient decision-making [7, 14, 30]. While it is understandable that medical tourism brokers, in an effort to portray their product in the most favourable light possible, may be reluctant to address the issue of risk on their websites, this omission is potentially misleading and unethical. Brokers may be inclined to leave the discussion of risk until later in the process of arranging care abroad or until they meet with the patient in person, but the website is likely the first and possibly main source of information for many patients . In order to make a truly informed decision about whether or not to proceed with arrangements - and thus ultimately to give informed consent for medical care abroad - they ought to have access to balanced and accurate risk information at the beginning of their decision making process.
The final issue related to informed consent emerging from the findings of our thematic content analysis relates to information, or the lack thereof, about follow up care on the reviewed websites. Generally, follow up care details were rarely included in brokers' websites. This is concerning because when Canadians undergo surgery domestically, follow up care is commonly coordinated between the hospital and the family physician and is generally organized on behalf of the patient. Medical tourism disrupts this standard practice [33, 34]. Medical tourists will inevitably be moving between two different health care systems that are not connected, making it unclear exactly who should be responsible for organizing check-ups and rehabilitation after the procedure . If follow up care details are not shared with the patient initially, or if it is not noted explicitly that patients are expected to arrange for their own follow up care upon return home, they may decide to proceed with purchasing medical care abroad while being unaware of the amount of care needed once they have returned home. This poses a risk to medical tourists on many fronts. It may negatively impact their health should they not be in a position to navigate their home health care system upon return home without the support or referral of a domestic surgeon . It may also lessen the quality of care patients receive upon returning home in that they may underestimate the informational needs of service providers thereby compromising care quality. One way to address these concerns is to encourage patients to communicate their plans to engage in medical tourism to their family doctors before going abroad as this may lead to consideration of follow up care before departure . Such patients will have a broader range of sources from which they are gathering information and will be able to come to a more informed decision on whether or not they want to consent to the procedure.
As we have noted, ethical and legal debates about the regulation of the medical tourism industry exist in the scholarly literature [14, 35]. In our own research we have found that Canadian medical tourism brokers believe they have significant roles to play not only within the industry but to medical tourists specifically, particularly to ensure these patients' safety . The provision of informed consent falls naturally within the roles they espouse toward patients, but brokers' perspectives on this needs to be sought in order to ascertain whether or not they agree in both principle and practice.
The Canadian government is involved in protecting Canadian patients and ensuring their health through the public health care system, and as such is well positioned to address some of the issues that hold implications for medical tourists' informed consent that we have identified in this analysis. As brokers are involved in patient care, directly or indirectly, and have a unique relationship with the medical tourist, it would seem fitting that the government take steps to monitor their work and ensure they are meeting standards of care for patients. Turner has made a broad call for regulatory involvement by the American government in regard to medical tourism brokerage companies operating in the United States . While the insights gained from our study of broker websites does not support the full range of regulations suggested by Turner, some of which would not protect patient choice (e.g., restricting brokers from advertising services not approved in their local jurisdictions), certain areas of intervention are justified by our findings. More specifically, Canadian government intervention in the areas of medical tourism brokers' involvement in follow up care and risk communication seems warranted given the lack of apparent consideration given to these domains by brokers currently as assessed by our review of their websites. Such intervention need not be complex, and could include developing informational resources for Canadian medical tourism brokers or requiring brokers to disclose risk information on their websites. In general, government regulators have an obligation to oversee and set standards for the information available to potential medical tourists in order to ensure that the risks of this practice are understood and that false, misleading, or unverifiable claims are not made by brokers that would unethically undermine patient informed consent .