Medical practices in Thailand are changing and causing ethical dilemmas for Thai medical practitioners. Traditionally, Thais ascribed to Asia-based medical models, which were influenced by Buddhist, Chinese Taoist and animist beliefs. These medical models were accessible to the predominantly rural Thais and were practised by Buddhist monks, Thai and Chinese practitioners and shamans or healing specialists.

The western medical model was an appendage of western colonisation of Asian countries in the 19th century. Thailand was prompted to modernise its society as a way of thwarting western imperialism (1). It was mainly Christian missionaries who brought western medicine to Thailand (2). By the mid-20th century western medicine had become the predominant medical model.

The cause and effect model of western medicine was foreign to Thai traditional beliefs of health and illness. The Buddhist-based Thai approach is holistic: human beings are seen as being comprised of physical, mental, emotional and spiritual elements. These aspects are interwoven with one’s social and physical environments (3). Health is viewed as the harmonious interplay of all these forces in accordance with the eightfold path of Buddhism. Consequently, disease is considered as an expression of disharmony, which prevents an individual from living in a holistic manner (3).

According to the Thai Buddhist approach, disease may also result from surrogate agents such as ghosts, demons, jinn or ancestors, who may possess or afflict the person. This approach involves a series of rituals, which are usually overseen by a shaman or Buddhist monk who mediates between the human and spirit worlds.In addition, the concept of karma contributes to an individual’s state of health and illness. Health and disease are interpreted as the effects of positive or negative karma which has accumulated from previous lives. Thai Buddhism prescribes that human beings practise morality (sila), discipline (samadhi), and wisdom (panna) in order to diminish accrued negative karma and its resultant effects on health (3).

In contrast, the western biomedical model is based on a Cartesian approach, which separates body and mind. Moreover, the western biomedical model tends to view “the body in terms of its parts” and as a “vessel that contains the rational self” (4).

A growing market in medicine

Doctors practising medicine in Thailand receive their medical training either in Thailand or abroad. A concomitant aspect of their medical training has been the learning of western values, which privileges materialism and self-interest. The medical ethicist Pinit Ratanakul has cautioned that this trend may lead to medicine becoming a “profit-making enterprise” (1).

Perhaps nowhere is the market-oriented ideology more evident than in the area of medical tourism, which Thailand leads in the Asian-Pacific region. Medical tourism accounts for more than US$2.3 billion in Thailand, with an annual rise of 40 per cent in the last few years (5). Estimates of medical tourists entering Thailand vary from 400,000 to 1.1 million annually (6).

Medical tourists are drawn to Thailand from all parts of the world because of good medical care at comparatively cheaper rates. The cost of surgery in Thailand can be one-tenth or less of what it is in the United States or Western Europe (7). In addition, Thailand has at least 450 hospitals with internationally trained medical staff who specialise in neurosurgery, dental surgery, heart surgery, and cosmetic surgery (8).Thailand’s growing medical market offers services to tourists in 26 languages. In June 2004, the Thaksin government, at the vanguard of promoting medical tourism, created a strategic plan that would offer medical services to at least two million tourists by the year 2008 (9). The government hopes to promote Thailand as a favoured tourist place in south-east Asia due to its accessibility from major cities such as Kuala Lumpur, Jakarta, Sydney, Tokyo, Shanghai, Beijing, and Singapore. The focus on big business has lead to the privatisation of many Thai hospitals in four major collaborations: Bumrungrad, Bangkok, Thon Buri, and Phyathai are now the leading medical tourist centres (10). The Bangkok Dusit Medical Services is a major collaborative group. It owns the chain of 14 hospitals of the Bangkok Hospital Group (10). The chain offers a range of deluxe services and amenities on par with five star hotels.

A perusal of the internet reveals an array of package deals which include “dental spas”, massages, and other tourist-type services with the intent of alluring affluent foreigners. The advertising often also involves travel to “exotic” Thai locations as part of a medical package. This conflation between medical services and non-medical tourist travel has now become a normal part of medical tourism. In this burgeoning medical tourist market, ethical considerations are likely to be sidelined.While medical tourism is injecting income into Thailand’s gross national product, several critics point out that it is diminishing the delivery of medical services to ordinary Thais. For instance, the push towards privatisation has negatively impacted the public health sector. It has led to the closure of many provincial public hospitals that have been unable to finance medical services. The much higher medical expenses and better professional care in private hospitals are beyond the financial capacity of most Thais, many of who work for less than 200 Thai Baht (US$5) per day. This problem is coupled with the shortage of medical practitioners. Only 25,815 out of 31,039 physicians’ positions were filled in 2005 (9).

A major reason for this shortfall is the high number of medical practitioners who are leaving Thailand for countries that offer more lucrative rewards (9). Few measures have been taken so far to solve this problem. As Loff, Hofman and Muthuswamy point out, medical research and advance in developing countries frequently does not benefit those that it ought to benefit (11).

Cosmetic surgery and the ethics of beautyThailand is one of the leading countries in Asia offering cosmetic surgery services. From only 10 cosmetic physicians in the entire country in the 1970s, more than 200 cosmetic surgeons claiming to be board certified in the US now operate in Bangkok (7).

Cullen explains that the cosmetic surgery industry in Asia is a continuation of age-old beautification practices such as Chinese foot binding, Indian nose reconstructions and neck distending among Karen women. The difference here is the infiltration of western aesthetic values and their influence on Asian ideas of beauty (12). Many Thai women are undergoing cosmetic surgeries in order to “look more Caucasian”. Incessant global media images have promoted western ideal types of femininity as the measure of beauty. As a result, “Asians are increasingly asking their surgeons for wider eyes, longer noses and fuller breasts-features not typical of the race (12). “For many young and older middle class Thai women who have appropriated western aesthetic values, the aim is to create a body which is not viewed as being physically deficient.

The Tourism Authority of Thailand has caught on to the lucrative cosmetic surgery market by promoting the Bumrungrad hospital chain to foreigners, who constitute one-third of its patients. The lavish 12-storey hospital has a Starbucks cafe, internet access, and even kosher meals (13). The growth in cosmetic surgery in Thailand is further promoted by cultural and religious factors, which extol the beauty of form. Van Esterik claims that Thais encourage “an essentialism of appearances or surfaces”, while Thai Buddhism links physical beauty to “moral purity” (13). So improving upon one’s physical appearance can have added spiritual benefits.One of the many ethical issues this raises is to what extent does the Thai medical cosmetic industry reinforce gendered body types. This is even more problematic when one examines Thai notions of transgender. Thailand’s large population of transgender people, known as kathoey (ladyboy), fuel the thriving male-female sex reassignment surgery. Kathoey embody an ideal of Thai feminine beauty, which is depicted in the annual Miss Tiffany kathoey pageant in Pattaya. Many kathoey are willing to undergo multiple and expensive surgeries in their relentless pursuit of physical beauty. The tantalising beauty of many of Thailand’s katheoy is not only evidence of the wonders of cosmetic surgery but suggests a way in which the body is meticulously managed in a consumer culture. An irony here is that high profile kathoey personify a type of transcendent beauty that ordinary Thai women can only aspire to through cosmetic intervention.

So far, the issue of whether cosmetic surgeons contribute to unjust social norms or to male-dominated ideas of how women should look has remained an ethical quagmire. Thai society requires more attention to ethics from the medical and social sectors.