Background

Historically, long-distance travel for medical purposes was limited to wealthy individuals or those desperate for recovery. In modern times, most physical, economic, and cultural barriers have been eliminated, resulting in increased international travel (1, 2). A 2015 study by Oxford Economics estimated that medical tourism involves approximately 16 million tourists annually and generates over 56 billion euros in revenue (3, 4). Between 2005 and 2007, the global medical tourism industry grew at an annual rate of about 20%, generating annual revenues around 60 billion US dollars. Nevertheless, more conservative estimates place the 2010 revenue closer to 40 billion dollars
(1, 5).The Global Wellness Institute estimated wellness tourism alone generated $651 billion in 2022, projected to grow to nearly $1 trillion by 2030 (6). In some countries, medical tourism contributes 2–5% of GDP. For example, Thailand earns over $5 billion annually from this kind of tourism (7).

Thus, medical tourism has recently become a prominent topic in economic, cultural, social, and even political discussions across countries. As a multifaceted and rapidly growing global phenomenon, it plays a key role in national health policy-making and is considered as one of the most influential sectors for evaluation and sustainable development worldwide (8, 9).

In general, medical tourism is defined as travelling to another country to seek health services that are either prohibitively expensive or inaccessible in the home country (8, 10). More broadly, the term is often employed in the tourism industry to describe patients crossing international borders to receive non-emergency medical interventions (3).

Several terms are applied to express this concept; however, the preference for the term "Health Tourism" (1, 8) over "Medical Tourism" (11), "Curative Tourism," or even "Wellness Tourism" (12)—all having their conventional uses—likely originates from its comprehensiveness and impact (1). Some scholars argue that the term "Health Tourism" is more inclusive as it encompasses broader perspectives, including tourism tailored to disabilities, age groups, and specific traveller categories (8). Another related term found in the literature is "healthcare tourism," covering travel related to medical procedures, health, and wellness goals, including medical tourism, cosmetic surgery, spa visits, and alternative therapies (1). Some scholars even consider recreational and ancillary activities along a patient's travel from one country to another as part of medical tourism (13).

Thus, health tourism is understood as patients travelling abroad to access various health services (14). These services include a wide range of treatments, and the activity can be called medical tourism. In this study, we adopt an established definition of "medical tourism" as a sector of the tourism industry involving patients travelling from one country to another to receive better, higher quality, more affordable, or faster non-emergency medical services. Naturally, medical tourists consider all or some of these factors when selecting their destination and accomplish all or some of these objectives.

Some scholars question the ethical foundations of health tourism. For instance, Harvard Law Professor Glenn Cohen, author of Patients with Passports: Medical Tourism, Law, and Ethics, cited examples from Bangladesh and India, underscoring serious challenges associated with the sale of body parts of low-income citizens. Overall, Cohen adopts a skeptical stance toward medical tourism, contending that "medical tourists from the UK and Sweden have brought antibiotic-resistant bacterial infections found in India, Pakistan, and the Balkans," He further argues that this, among other reasons, causes undeniable harm to the healthcare system of host countries (15).

Some writers, recognizing the potential influence of economic on health tourism, describe health tourists as "forward-looking individuals" who seek services that are better, more affordable, and more sustainable irrespective of location (3).

Beyond the undeniable economic cycle, the extensive cultural exchanges, ancillary services such as the need to ameliorate quality and adherence to international standards, patient safety concerns, political conflicts and balances, language barriers, as well as other factors each require detailed and analytical consideration (1).

For instance, differing legal frameworks can be a driving factor for travel to obtain health services. In some countries, variations in laws, even among states, encourage travel for services that are not permitted at the place of origin (8). Undoubtedly, this issue requires multiple standards and regulations, including ethical ones (16).

Regarding the influence of legal, religious, and social factors, some studies claim that such differences can significantly affect destination choices (17). Obviously, in spite of the necessity to adhere to internationally accepted ethical principles, reviewing, analysing, and proposing measures for the ethical management of medical tourism—tailored to each country’s laws, regulations, culture, and values could be helpful. Moreover, feasibility within existing conditions—is a pressing and essential need. Accordingly, most scholars acknowledge that ethics constitutes a critical dimension of medical tourism (16).

While prior studies have addressed fragmented ethical aspects, this review integrates multidisciplinary perspectives into a unified framework.

Objectives

This study aims to identify ethical considerations in medical tourism and provide actionable recommendations for policymakers to promote responsible and effective practices.

Methods

This systemized review was performed to find answers to the question: “What are the ethical considerations governing medical tourism worldwide?” Our aim was to develop a comprehensive and acceptable set of ethical considerations associated with medical tourism globally.

In May 2024, we conducted a comprehensive search for literature and related texts without applying any geographical or chronological restrictions. The search was carried out in scientific databases including PubMed, Scopus, Google Scholar, and SID, as well as in official reports and governmental documents. Keywords utilized in this process were “health tourism,” “medical tourism,” “ethical considerations,” “ethical challenges,” and “ethical guidelines,” applied to both Persian and English literature. To illustrate our systematic search approach, an example of the strategy used in PubMed is presented: (“health tourism” OR “medical tourism”) AND (“ethical considerations” OR “ethical challenges” OR “ethical guidelines”), with filters applied for English and Persian publications. The same strategy was consistently applied across all other databases. The detailed search algorithm is displayed in Figure 1.

We included studies, reports, books, and official documents addressing medical or health tourism and discussing ethical considerations, challenges, or guidelines, in either English or Persian, with no restrictions on geography or publication year. Studies with no focus on medical tourism, lacking discussion of ethical aspects, published in other languages, as well as conference abstracts, editorials, letters, and unpublished theses were excluded.

An initial search of article titles and abstracts using the specified keywords across reputable sources yielded 981 scholarly articles along with six additional sources from other groups. After removing duplicates, 810 records remained. Screening of abstracts resulted in the exclusion of 772 articles unrelated to our research topic. Grey literature and non-English studies were excluded in order to ensure the methodological rigor, replicability, and accessibility of the included sources. From the 39 remaining references, full-text review indicated that three, despite sharing similar keywords, were not relevant in content. Ultimately, 36 references were included in this study, with their details presented in Appendix 1.

Subsequently, codes pointing to ethical considerations of medical tourism were extracted. Two researchers independently coded 20% of documents; discrepancies were resolved through consensus. Following in-depth group discussions among the research team, a framework was developed comprising 5 themes with 15 subthemes (Table 1).

Results

We identified meaning units pointing to ethical considerations of medical tourism and categorized them into 276 codes, 15 subthemes, and 5 themes.

The included literature was independently analyzed and coded by multiple researchers. Any discrepancies or disagreements in coding were resolved through group discussion and consensus, ensuring reliability and consistency in the thematic analysis. Table 1 shows the Classification of Extracted codes.

Table 1. Classification of Extracted codes

Theme 1: Stakeholders' Rights (156 codes, 56.5% of total)

This group classification includes the broadest and most frequent extracted codes. Since “stakeholders” in this study refers to all individuals involved in every stage of the medical tourism process, from implementation to outcome, and covers three subthemes, this indicates that much attention has been paid to the rights of stakeholders in the reviewed literature.

1-1) Rights of Service Recipients (141 codes, 91%): This group includes recipients of services at any part of the service delivery cycle, including medical tourists. Among various stakeholder groups, the majority of extracted ethical points addressed the rights of service recipients. Given the breadth and diversity of findings, frequent subcomponents were defined, including patient-provider communication, service quality and safety, quality of travel facilities, privacy and confidentiality, continuity of care and post-treatment follow-up, provision of appropriate information, access to service, as well as accountability. The research team delineated specific content examples for these subcomponents.

1-2) Rights of Service Providers (12 codes, 7.7%): This group includes all individuals involved in healthcare delivery and ancillary sectors serving the first stakeholder group, such as healthcare staff and travel facilitators. Ethical considerations considering these individuals’ rights have remained far less unattended in existing studies compared to service recipients.

Rights of 3-1 Other Stakeholders (3 codes, 1.3%): Certain individuals, including organ donors (in living organ transplants) or surrogate mothers assisting in infertility treatments, though not being patient themselves, play significant roles in medical tourism programs. Their rights are recognized as part of the stakeholders in this healthcare industry.

Theme 2: Resource Allocation (16 codes, 5.8% of total)

The second theme, pertaining to the ethical considerations in resource allocation by policymakers, is split into two subthemes. (Due to its significance, this section has been separated from other policy actions and placed in the final theme).

2-1) Financial Resource Allocation (6 codes, 37.5%): This deals with issues such as distributive justice and prioritization of resources. This group is distinct from the theme of financial fields and contains a significant number of codes. However, owing to the emphasis of the texts on justice in allocation, this section has been considered separately.

2-2) Non-Financial Resource Allocation (10 codes, 62.5%): Although financial resources are prominent in principles of justice, ethical sensitivity in the allocation of other resources, including transplant organs or the capacities of the healthcare system in the host country, were more salient in the literature.

 Theme 3: Financial Aspects (27 codes, 9.8% of total)

This theme captures patient costs, financial support, and impacts of expenditures on public health, categorized into four subthemes. This group comprises items that are generally associated with individual costs, support systems, or impacts on public expenditures. While it interacts reciprocally with the previous group and they influence each other, their definitions remain distinct.

3-1) Medical Tourist Insurance (7codes, 26%): The expectation of insurance coverage for medical services, including treatment and follow-up care, is addressed with associated ethical considerations.

3-2) Patient Costs Including Treatment, Accommodation, and Ancillary Expenses (17 codes, 63%): Financial concerns arise both in medical services and ancillary travel facilities while constituting the largest share of extracted codes in this part.

3-3) Government Financial Support (2 codes, 7.5%): Governmental responsibilities for supporting patients, including non-native medical tourists, extend to non-insurance supports such as loans and other facilities.

3-4) Large-scale national costs (1 code, 3.5%): This subtheme concerns justification and explanation for national budget allocation to medical tourism programs.

Theme 4: Cultural, Political, and Social Contexts (31 codes, 11.2% of total)

This theme includes ethical points associated with cultural, political, and social contexts influencing and influenced by medical tourism programs, with the following subthemes:

1-4) General Culture, Language, and Religion
(24 codes, 77.5%): Effective communication between tourists and host country agents plays a substantial bilateral role in quality, continuity, and success of medical tourism.

2-4) Physicians and Medical Culture (2 codes, 6.5%): This subtheme refers both to individual traits of healthcare teams and the broader medical community perspective forming the ethical foundation of this industry.

3-4) Patient Perspective (5 codes, 16%): The health tourist’s viewpoint, motivating their actions, plays a major role in effective communication.

Theme 5: Policy making (46 codes, 16.7% of total)

The breadth of this topic has placed it in the second place, indicating the attention of experts to examples such as legislation, supervision, and the establishment of guidelines, where a number of authoritative guidelines have also been included in our list of sources. It has three subthemes, with its details outlined in Table 2 according to their importance.

1-5) Administrative Efficiency (1code, 2%): Necessity of responsive and operational administrative structures for organizing medical tourism programs.

2-5) Legal Issues (15 codes, 33%): The undeniable overlap between legal and ethical issues, emphasizing that ethical analyses are incomplete while overlooking legal frameworks.

3-5) General Policy Considerations (30 codes, 65%): This section, capturing a significant portion of ethical issues related to policymaking, practically addresses
the actions expected from planners and implementers of the health system’s overarching programs in the
field of medical tourism, at both national and international levels.

Table 2. Policymaking theme

Discussion

A review of the literature suggests that ethical concerns in medical tourism have received notable scholarly attention. While some themes appeared more frequently, this does not necessarily reveal their superior ethical weight. Rather, such patterns often emanate from contextual factors and methodological choices influencing issue visibility and prioritization.

1. Rights of Stakeholders

The most prominent theme involves the rights of stakeholders—namely patients, providers, and other participants. Many studies reference bioethical principles in patient rights. For instance, Mogaca and colleagues, along with other researchers, highlight autonomy, informed consent, and accountability as essential ethical elements (11, 18). In the U.S., K. R. Matthews and A. S. Iltis stress autonomy in policy-making but caution that autonomy does not ensure delivery of promised treatments (19). In Iran, Mustafavi et al. highlight the ethical behavior and competence of hospital staff in attracting international patients (14).

Given the consensus—such as that by Qing Xu et al. in South Korea—that quality, affordability, and access are principal drivers of medical tourism (20), the ethical need for safe, high-quality care is clear. As tourism progressively blends leisure, prevention, and treatment (21), ethical infrastructure and planning become essential. Karimi Badrabadi et al.’s research in Iran reported that patients demand confidentiality (22). Also, Mogaka et al. emphasize that disclosure of risks and benefits is ethically vital (11). As such, timely and comprehensive patient information is not just ideal—it is an ethical right (23-25).

Beyond patients, institutions need to be accountable as well (26, 27). Iranian scholars such as Nikraftar et al. highlight that access to technology and cost-efficiency are crucial for both patient attraction and responsible policy-making (28). Likewise, providers require ethical protections. For example, South Korea’s malpractice insurance for institutions treating foreign patients supports both ethics and competitiveness (20). Issues such as international insurance and accreditation, as discussed by Delgoshaei et al. (29), affect both parties.

A third group—"other stakeholders"—includes individuals such as surrogates. Del Rio and Zammi state that financial pressure can compromise their autonomy (30). Host communities have also rights, with guidelines stressing that visitors must respect local laws and norms (31).

Among all themes, stakeholder rights were the most widely recognized, consisting of autonomy, safety, quality, and ethical communication (32). Growing public awareness—amplified by digital media—has increased expectations (27). Patients now demand greater participation in decision-making, supported by accurate, transparent information. The decline of paternalistic models reinforces the need for ethical communication (33).

Ethical obligations also extend to intermediaries and facilitators. In complex treatments such as organ transplants or fertility services, donors and surrogates constitute another ethically significant group whose rights need to be protected.

1. Resource Allocation

Resource allocation is another major ethical issue. Medical tourism, as a continuous service model, consumes both financial and non-financial resources. While overlapping with financial concerns, this category merits distinct ethical attention under the principle of justice.

African scholars mention distributive justice, experimental treatments, and transplantation as major issues (11), warning that prioritizing foreign patients could neglect local needs. This concern is echoed globally, as unrestricted access for non-citizens may strain national systems (16). In Iran, Mustafavi et al. warn that tourism could compromise justice by compromising services for locals (14). Daniel and Elena Baldusco raise similar alarms (1).

Ethical frameworks underscore dignity and equal respect for all, regardless of nationality or background (34). A dilemma arises when systems have to balance taxpayer-funded care for citizens with revenue-driven services for foreigners. Both paths have ethical merit—beneficence and non-maleficence apply either way.

1. Financial Aspects

Financial concerns form the third core theme. Since affordability is a key motivation in medical tourism, financial ethics are of great importance.

Insurance is a recurring topic. In this respect, Matijesen et al. identify insurance as one of eight key drivers (35). Nevertheless, post-treatment costs can be staggering: P. B. McAuliffe et al. estimate U.S. follow-up expenses between $15,083 and $154,700 (36).

In Iran, Karimi Badrabadi et al. note that short wait times and specialization attract patients, but inadequate insurance and weak digital marketing are major gaps (22). Tourists also factor in travel, lodging, and support costs—studies demonstrate that affordability of these services is critical (11, 37). Ambiguity in third-party insurance coverage is also an issue (19) .

National budgets may be strained by complications if care is subpar. Wessh J warns of costly outcomes burdening public systems (16). A utilitarian view supports efficient resource utilization for maximum benefit, while a principlist approach emphasizes financial ethics grounded in beneficence and minimal harm.

1. Cultural, Social, and Political Contexts

Cultural, religious, linguistic, and political factors heavily influence ethical interactions. Indonesian scholars (Abanit Asa et al.) found that religious and cultural factors have a great impact on patients' destination choices (38). Mathijsen also noted ethical strain from communication barriers and cultural mismatch (35, 39, 40).

For instance, shared values draw Bangladeshi patients to India. Physicians’ ethics—shaped by local norms—can affect care quality. Patient expectations, dietary restrictions, and treatment attitudes are also significant matters (37, 41, 42).

International medical travel offers opportunities for ethical growth—if managed carefully. Legal and cultural differences need to be acknowledged, with dignity and preference of all parties respected. Upholding principles of beneficence, justice, non-maleficence, and autonomy is essential. Ethical tourism is contingent upon mutual respect embedded in communication and governance.

1. Policy-making

The final theme was policy-making. The wide scope of ethical concerns requires system-level attention (43). In Iran, inefficiencies such as delayed responses, lack of transparency, as well as poor coordination hinder development (44), undermining both service quality and speed.

Ethical and legal challenges often overlap. In this regard, Abolhasani highlights persistent legal uncertainties in areas such as malpractice, insurance, licensing, and medical technology access (45). Discrepancies between countries—on PGT, stem cells, or transplants—complicate regulation (46-48). Ignoring host laws can have serious consequences. Ethical standards can ban criminal acts by patients (31). Some travel abroad to bypass legal bans, creating dilemmas in areas such as DNR or futile care (11).

Policy-makers need to address these gaps. Feedback mechanisms—largely absent—could reduce unethical practices (36). Qing Xu warns that lack of oversight and market-driven approaches threaten ethics, urging international standards for legal, medical, and commercial integration (20).

Organizations such as WHO and PAHO can help create shared ethical guidelines, especially for sensitive services like surrogacy (49). Meanwhile, unlicensed providers and misleading digital platforms threaten public trust (19). Without oversight, unethical practices thrive—particularly under purely commercial models (1, 50).

In Iran, challenges include poor infrastructure, weak marketing, and no formal ethical codes (14, 28). Even though the 2020 Strategic Document mentions ethical values (32), no binding code governs the sector.

Policymaking and its associated ethical considerations in this domain appear to exert a significant influence on other stakeholders, especially in countries where healthcare services are predominantly state-managed, where such effects tend to be more pronounced. Resource allocation—whether financial or non-financial—maintains a bidirectional relationship with policymaking, and within the medical tourism service delivery cycle, each has the potential to either reinforce or undermine the other. This finding has been approved by the research team.

Evidence-based policymaking can prevent the waste of resources and minimize potential biases in resource allocation. This process should be reinforced through developing appropriate and enforceable regulations. Conversely, resource allocation grounded in sound principles establishes an environment that strengthens effective policymaking and fosters innovation, while appropriate feedback mechanisms help eliminate ineffective or impractical policies.

Likewise, in upholding ethical principles tailored to the cultural and social context and safeguarding the rights of all stakeholders, policymaking exerts both short-term and long-term effects.

Recommendations: The involvement of ethics experts through training and consultation at all stages of planning, implementation, and oversight can offer substantial benefits to medical tourism programs, including protecting stakeholders’ rights, promoting positive cultural, political, and social outcomes, as well as supporting effective policy development alongside economic growth. Continuous updating of ethical guidelines provides a crucial first step. Addressing these considerations is necessary to prevent future challenges; as Quing Zou notes, inadequate regulations may deprive low-income populations of their rights and create financial inconsistencies affecting society. With advances in novel treatments, such as transplantation and infertility therapies, ethically guided research and development is becoming increasingly important. Further, examining cultural interactions across diverse local contexts offers valuable opportunities for applied research.

Limitations: This study had several limitations. Inclusion of Persian-language sources (SID) may have introduced regional bias, and restricting the search to English and Persian publications could have excluded relevant literature in other languages. As noted in the Recommendations section, future studies could deal with these limitations by expanding the search to additional languages as well as databases.

Conclusion

In conclusion, medical tourism confronts significant ethical gaps due to limited regulation, oversight, and overly commercial approaches. As some scholars suggest, this stems from a lack of ethical orientation among policymakers (1, 11, 22, 50-52). Bridging this divergence requires a principled, collaborative approach—balancing commercial goals with core values of dignity, justice, and transparency.

Our study’s five-theme structure offers policymakers a holistic tool for ethical gap analysis and can be employed to achieve their medical tourism developmental goals.