The Canadian Medical Protective Association is cautioning doctors about providing medical services to birth tourists coming here to have babies in order to acquire Canadian citizenship for their newborns.
“Canadian physicians who provide care to non-residents are at increased risk of medical-legal difficulties arising outside of Canada,” says a notice from the CMPA. “The Association is not structured to assist when medical-legal actions are instigated by non-residents outside of Canada.”
The CMPA is the legal defence organization for doctors; it provides and pays lawyers and settlements when doctors are sued for malpractice by Canadian patients. The new bulletin to physicians regarding medical tourism is relevant and timely, given a local trend where an ever-increasing number of non-residents (from 18 in 2010 to 339 last year) are having their babies, mostly at Richmond Hospital. The Vancouver Sun and The Province have reported that the provincial government is now aware of more than two dozen “birth houses” where pregnant women stay prior to, and after, the births of their babies, before returning to China.
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Birth tourism brokers marketing their services show photos of Lower Mainland hospitals and lists of Mandarin speaking doctors to deliver babies.
The CMPA statement — titled “Emerging trends and medical-legal risks in medical tourism” — warns that while there are still more Canadians travelling abroad for medical treatment than foreign visitors coming here, there are risks to think about for both patient groups. Doctors should ensure foreign patients sign agreements promising not to sue outside of Canada and they should also make sure they fully document discussions with non-residents and the care provided to them.
The CMPA said it cannot share information about the number of doctors sued by birth tourists. But it is attuned to the broader trend of medical tourism.
“We have published guidance for physicians on the medical-legal risks associated with medical tourism and the steps they can take to mitigate risks associated with this practice,” said Dr. Doug Bell, a managing director at CMPA.
The CMPA uses its discretion when deciding whether to assist doctors with legal actions started by foreign patients. The care provided in Canada must be for an emergent or urgent circumstance or the type of care not available in the patient’s own country “or in other exceptional circumstances.” It will not give assistance to doctors who directly or indirectly offer treatment of non-resident maternity patients through medical tour operators or other third parties, or to those doctors who encourage the creation of a doctor-patient relationship.
In Toronto, another city grappling with birth tourism, Sunnybrook Hospital went on record discouraging birth tourism because of liability and insurance coverage issues. But in B.C. there have been no such statements and the minister of health was unavailable for comment because he is on holidays. Richmond Hospital delivered nearly one non-resident baby a day in the last fiscal year, the vast majority to mothers from China.
Clay Adams, spokesman for Vancouver Coastal Health, said all non-resident patients are required to sign documents consistent with what CMPA recommends. And VCH has “sought the advice of CMPA” at various times as to whether pregnancy care is elective or urgent medical care.
“While we recognize that birth tourism exists, we are not actively trying to promote it or increase the current level of non-resident patients. There are many challenges with such patients I am told, including the ability to provide the level of ongoing and follow-up care they require. As you know, while maternity diversions are rare, we are looking at ways to reduce such situations,” he said, referring to occasions when local women are asked to go to other hospitals when there are bottlenecks in their nearest hospitals. Predicting when hospital resources will be strained is “not a perfect science … but our objective is to continue to meet the needs of those who arrive seeking care, whether it be trauma-related or to give birth, based on need.”
Last year, the Conference Board of Canada published a report on medical tourism that estimated Canadians who travelled to other countries for medical treatment spent about $450 million in 2013, compared to foreign visitors who came here and spent $150 million. The report warns one risk of allowing foreigners to get treatment here is increased wait times for local residents. Louis Theriault, public policy vice-president with the conference board, said the medical tourism industry must not compromise access care for Canadians.
Among the report’s recommended guiding principles: Canadians should receive priority in hospitals at all times, international patients must be charged more than Canadians and hospitals must report the number of patients treated and revenues received.
Jeremy Snyder, an associate professor at Simon Fraser University and expert in the area, said while birth tourism, per se, hasn’t been explored by the SFU group, the most glaring concern about the growth is how it may undermine access to health care by local residents. “The only way something like this can not have detrimental impacts is if it is really planned out. And right now, it seems like everything is happening on an ad hoc basis.”
Snyder said it would seem that a policy implemented in Hong Kong about three years ago, in which the government banned mainland Chinese women from crossing borders to have their babies in Hong Kong, may be having a ripple effect here. Children born in Hong Kong to mainland Chinese women get rights of abode and other benefits. But the flood of women going there strained hospital resources so much that the Hong Kong government banned the cross-border “anchor baby” entitlement about three years ago.
In Richmond, only about 14 couples have been diverted to other hospitals due to lack of space in the past year and a half, according to VCH, and only a handful of couples have complained publicly about being told to go to to other hospitals like Langley and Lion’s Gate when Richmond Hospital was too full.
Snyder said VCH should ensure local residents are never turned away because of too many self-paying, foreign patients and must avoid the appearance of “selling maternity ward” services. His colleague, Valorie Crooks, said the fact that mainland Chinese women are being denied maternity care in Hong Kong means they must be looking elsewhere.
“We don’t have proof that this is why more women are coming here, but it’s logical to think that they are looking for other venues … and having babies here is a method of effectively finding a way to buy citizenship. This offers them hope and opportunity,” said Crooks, referring to the instant Canadian citizenship gained by babies born in Canada. But the SFU pair said since heath human resources are so strained in Canada — with shortages of nurses, doctors and beds — health care leaders should think hard about deterring the growth of birth tourism.
“I don’t think we want to look like we condone this. We should perhaps be looking to find ways to reduce the motivation of people coming here,” Snyder said.
As to whether the provincial government’s new tax on real estate purchases by foreigners may lead to tax skirting in real estate purchases by putting properties in the names of babies who become instant Canadians, the province said its new law is written to prevent that. Jessica McLachlin, spokeswoman for the ministry of finance, said the act is “designed to capture transactions that are structured to avoid the tax in an audit.”
“Anti-avoidance rules will be enforced to ensure all foreign entities report and pay the additional tax as required,” she said, adding that when a minor is named on the property’s title, it will be flagged for audit. Purchasers are supposed to be adults in order to sign contracts.
Sun and Province Health Issues reporter
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