Exemption for ‘essential’ medical travel confuses doctors, patients
The coronavirus pandemic has changed how we live, where we go, and who we spend time with. These changes are shaped by government policies that have evolved as the pandemic continues. And when we get used to new policies and procedures, they change again in response to shifting circumstances and further information.
Perhaps the most talked about recent policy changes are the new testing and quarantine measures put in place at Canada’s international borders as of Feb. 22. Along with providing proof of a negative polymerase reaction chain (PCR) test within 72 hours before departure, arrivals by air must quarantine in a designated hotel for three nights at their own expense until they receive the results of a PCR test taken upon arrival. They then complete the required 14-day quarantine at home if their test result is negative or in a government-designated facility if it is positive.
These requirements are coupled with new land border measures. Non-essential travelers must show proof of either a negative PCR test taken within 72 hours or a positive COVID-19 test conducted between 14 and 90 days before arrival. Within 24 hours of arrival, a traveler is tested at either a land border crossing or quarantine location (using a self-swab). A self-swab test is used again on day 10. The traveler may bear the costs for some of this testing.
Exemptions for essential care
In mid-February, the Canadian government clarified which groups are exempt from these measures and thus spared the costs and logistics involved. One exemption is for people who have gone abroad for “essential” medical services or treatment. This exemption requires travelers to provide written evidence from a licensed healthcare practitioner in Canada stating that the treatment or service sought is essential. It also requires similar documentation from a provider in the destination country upon return to Canada.
International air travelers load their luggage onto a shuttle bus to take them to one of the quarantine hotels on Feb. 22, 2021, in Montreal. THE CANADIAN PRESS/Ryan Remiorz
While intending to provide clarity regarding who should be exempt from these new border measures, this particular exemption instead compounds uncertainty. No guidelines for what constitutes “essential” medical care are provided. And there has already been criticism of the lack of clarity as to what constitutes “essential” travel during this pandemic.
We are a team of researchers and physicians with expertise in international health travel and pandemic border measures. Our research suggests the lack of clarity around what constitutes essential medical treatment can pose ethical dilemmas for physicians. While some cases may be clear-cut, such as a cancer patient registered in a clinical trial who must travel to the United States monthly, others are not.
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Physicians are normally strong advocates for patients and accept fiduciary responsibility for their care. This requires physicians to balance the benefits of treatment with the risks inherent in traveling during a pandemic.
Ambiguous cases will present ethical dilemmas for physicians. They will need to weigh the potential harms and benefits for patients wanting to contravene general public health orders and travel abroad for medical care during the pandemic.
Patients who travel for medical care may unwittingly endanger the lives of themselves or others. New variants of concern are spreading quickly around the world. This is particularly serious for those with certain underlying medical conditions who are already known to experience worse COVID-19 outcomes.
People returning from medical treatments may also act as vectors, bringing more contagious variants back home. This is a real risk. Physicians who believe the risks to public health outweigh the likely benefits to a patient may, for ethical justifications, decline to write a letter in support of a testing and quarantine hotel exemption.
International air travelers wait to enter one of the quarantine hotels on Feb. 22 in Montreal for the mandatory three-day quarantine. THE CANADIAN PRESS/Ryan Remiorz
Asking physicians to decide what is essential or non-essential medical care also risks devaluing some treatments. This can create disagreements about how to categorize medicines important to patients’ quality of life.
How “essential” are treatments for conditions that are not immediately life-threatening but cause pain or impact on well-being, such as joint replacement, bariatric surgery, mental health and addictions care, in-vitro fertilization, and dental procedures? What about diagnostic testing?
Some physicians will also find it ethically problematic to write exemption letters in support of care that is untested and unproven, causing further conflict with patients who may already present with symptoms of uncertain cause despite extensive investigation.
Long-term patient-physician relationships are the foundation of the highest quality care. Having physicians, and not policies, as the adjudicators of what constitutes “essential” medical care may harm these very relationships.
Just as border experts have called for greater definitional clarity on “essential” travel, we must do the same for the new exemption on journeys for “essential” medical purposes.
After more than one year into this pandemic, unclear and ambiguous policies risk causing harm to physicians and patients alike.