Journal of Ethnic and Migration Studies

ISSN: 1369-183X (Print) 1469-9451 (Online) Journal homepage: https://www.tandfonline.com/loi/cjms20

Moralities in international medical travel: moral

logics in the narratives of Indonesian patients and
locally-based facilitators in Malaysia

Heng Leng Chee & Andrea Whittaker

To cite this article: Heng Leng Chee & Andrea Whittaker (2019): Moralities in international
medical travel: moral logics in the narratives of Indonesian patients and locally-based facilitators in
Malaysia, Journal of Ethnic and Migration Studies, DOI: 10.1080/1369183X.2019.1597476

To link to this article: https://doi.org/10.1080/1369183X.2019.1597476

Published online: 11 May 2019.

Submit your article to this journal

Article views: 33

View Crossmark data

Citing articles: 4 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=cjms20
JOURNAL OF ETHNIC AND MIGRATION STUDIES
https://doi.org/10.1080/1369183X.2019.1597476

Moralities in international medical travel: moral logics in the

narratives of Indonesian patients and locally-based facilitators
in Malaysia
a b
Heng Leng Chee and Andrea Whittaker
a
Centre for Research on Women and Gender (KANITA), Universiti Sains Malaysia, Penang, Malaysia;
b
Anthropology, School of Social Sciences, Faculty of Arts, Monash University, Melbourne, VIC, Australia

ABSTRACT KEYWORDS
This paper views international medical travel through the lens of International medical travel;
medical migrations and contextualises it within regional historical medical tourism; Malaysia;
linkages. Drawing from fieldwork with staff, facilitators, and Indonesian patients;
moralities
Indonesian patients in two Malaysian private hospitals, it frames
international medical travel as a moral endeavour, and aims to
uncover the premises that make this endeavour meaningful and
desirable. Understanding moralities as a field of embodied
predispositions created in the dynamics of social interaction, we
argue that a strand of moral logic underlies the practice of
medical travel. We call this the morality of need, which dictates
that people do whatever they can for themselves and their
families’ medical needs, including travelling abroad, as well as
‘help others’ by giving information and accompanying them
overseas for their medical needs. This moral logic co-exists in
tension with a morality of business that accepts the legitimacy of
generating earnings from people’s medical needs. Within this
moral framework, international medical travel is seen as a
necessary practice for sustaining health and well-being, and
extends beyond the family as social and moral support for others
facing similar predicaments.

Introduction
Earlier studies of contemporary international medical travel have largely approached it from
within the fields of policy, tourism, healthcare, ethics, and law, framing it as a mode of trade
in health services, a form of niche tourism and an outcome of particular failings of national
healthcare systems (Goodrich and Goodrich 1987; Pennings 2007; Connell 2011; Smith,
Álvarez, and Chanda 2011). Since then, a burgeoning literature, uncovering a diversity in
the types of mobilities and medical care-seeking that falls under its rubric, has used a
range of theoretical frames – such as transnational healthcare practices, medical migrations
and medical exile (Inhorn and Patrizio 2009; Roberts and Scheper-Hughes 2011; Bell et al.
2015) – to better explore and understand the phenomena and the experiences, subjectivities
and social meanings involved (Solomon 2011; Lunt, Horsfall, and Hanefeld 2015, xiv;
Ormond 2015; Whittaker 2015; Chee, Whittaker, and Yeoh 2017).

CONTACT Heng Leng Chee cheehengleng@gmail.com

© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 H. L. CHEE AND A. WHITTAKER

One strand in this literature uses the concept of ‘medical migration’ to think of
international medical travel as part of a wider range of health and healthcare-
related mobilities (Roberts and Scheper-Hughes 2011; Crush, Chikanda, and Mas-
wikwa 2012; Walton-Roberts 2015; Ormond 2016). Although international medical
travel is, strictly speaking, not ‘migration’, as it usually does not involve a relocation
of long duration or a change in residence, nevertheless it intersects with migration in
various ways. For example, diasporic migrant populations often return to their
countries of origin for medical care, and they are also actively sought by the govern-
ments in these countries to return as healthcare professionals and entrepreneurs so as
to contribute to further development of the medical tourism industry there (Ormond
2013).
By broadening the scope, the frame of medical migration also sets these mobilities in
the context of longer-term historical relations and flows, and the larger political economies
of the global distribution of healthcare resources. Walton-Roberts (2015, 238–239) high-
lights, for example, that the international travel of patients has to be understood together
with the mobilities of health workers as part of a circulation central to a health services
landscape that is increasingly global. Approaching international medical travel as
medical migration also enables us to borrow insights from the larger academic field of
migration, an example of which is the notion of ‘culture of migration’ applied to places
where travelling for health care has become a regular and commonplace occurrence due
to the unavailability or inadequacy of health care in countries such as Indonesia and
the Maldives (Knoll 2017; Whittaker 2017).

Moralities in international medical travel

While the literature on international medical travel has widened considerably, it has not,
by and large, focused on moralities or moral discourse. Nevertheless, as intrinsic aspects of
human behaviour and interaction, moralities have not been altogether absent in the eth-
nographic-based studies of international medical travel. As a form of ‘medical migration’
produced within ‘particular political-economic configurations of globalised bio-medicine,
which involve the disparate and unequal distribution of heath and sickness, health care,
and the maintenance of borders between bodies, social collectivities (classes, castes,
races), polities and nation-states’ (Roberts and Scheper-Hughes 2011, 4–5; Ormond and
Lunt 2019), the encounters within international medical travel carry particular moral
imperatives and logics.
It is not surprising that forms of international medical travel for treatments that are not
legally or normatively sanctioned in medical travellers’ own countries, such as organ trans-
plants, stem-cell treatments and assisted reproductive technologies, elicit explicit refer-
ences to morality and ethics. For example, Whittaker and Speier (2010, 364) explore
some of the tensions within travel for assisted reproductive services between the commo-
dification of reproductive bodies and body parts such as ova and the reduction of the
affective labour of reproduction to exchange value. Further examples are Song’s study
(2010, 393) of stem cell treatments in China which describes ‘the moral economy of cor-
poreal salvation’ in travelling patients’ confrontations with ethical questions over their
travel; and Inhorn’s (2011, 93) work on Middle Eastern Muslim couples who travel over-
seas in search of assisted reproductive technologies, which invokes the concept of ‘local
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 3

moral worlds’, to refer to ‘the commitments of social participants in a local world about
what is at stake in everyday experience’.
Although less explicitly, studies on international medical travel for other types of treat-
ment that are not considered illegal nor outside the bounds of normative sanctions have
also incorporated a consideration of moralities. For example, Kangas’ study (2002) of
Yemeni patients’ travel to India for treatment describes the ethics of care in families’
efforts to find treatment for family members at all costs. Likewise, Ormond (2011)
enters into an investigation of an ‘ethical playing field’ when she uses the concept of hos-
pitality to interrogate the Malaysian state and the private hospitals as ‘hosts’ and the
foreign patient-consumers as ‘guests’ in the context of regional, cross-border flows of
medical travellers across the Indonesia-Malaysia border (see also Ormond and Nah 2019).

Descriptive moralities
In this paper, we explore how, rather than being dictated by a single market logic, inter-
national medical travel is laden with moral concerns articulated by patients, doctors, hos-
pital personnel and medical travel facilitators. Here, we are not writing about the ethics of
international medical travel as defined through the principles of Western bioethics (i.e.
autonomy, beneficence, non-maleficence, truth-telling and justice [see Turner 2003]) or
the normative moralities of how things ought to be. Rather, we are interested in the every-
day concerns and negotiations that take place within these settings and articulations of
these moralities by the people within them, i.e. the descriptive moralities or socially-con-
structed codes of conduct that people relate to in their behaviour, practices and
interactions.
Viewing international medical travel in relation to a migration frame of reference, we
borrow insights from the migration literature that examine socially-grounded moralities in
the discourses, behaviour, practices and interactions of migrants, migration brokers and
non-migrants. Carling (2008, 1457–1462) for example, explains that an underlying
moral dimension governs migrants’ transnational practices and relationships. In a
‘moral economy of social belonging’, shared values among the Cape Verdean emigrants
and non-migrants in his study speak of non-migrants’ intrinsic entitlement to support
from migrant relatives, driving practices such as remittance sending, gift-giving or even
just the maintenance of social relationships through phone calls, communication and
visits. In this literature, how moralities work on the ground is shown in relation to
norms, values and obligations. In another example, Alpes’ (2011) study of Anglophone
Cameroon shows how relations of trust between aspiring migrants and migration
brokers are shaped by societal norms and values as well as by the larger context of restric-
tive migration policies in countries where aspiring migrants hope to migrate and the cul-
tural and social dynamics that play out in aspiring migrants’ ‘hopes for global belonging’.

Morality of need
In this paper, we describe a ‘morality of need’ as well as a ‘morality of business’ underlying
the talk of our informants. As Howell (1997) notes, within ethnographic work, the field of
the ‘moral’ is variously defined. Our understanding of morality is drawn from the anthro-
pological literature that approaches it ‘as a field of cultural predispositions informing and
4 H. L. CHEE AND A. WHITTAKER

creating … social relations between groups and persons’ (Howell 1997). Morality, there-
fore, is situated in social interaction, constitutive of both discourse and practice.
Understanding a particular social context as being made up of ‘a unique local moral and
ethical assemblage’, constituted by institutional and public discourses of morality as well as
‘the embodied dispositions that allow for non-consciously acceptable ways of living in the
world’, Zigon (2010, 8) explains that morality as embodied disposition is ‘unreflective and
unreflexive, … . not thought out beforehand, … . It is simply done’ (Zigon 2010, 8).
Encoded morality or ethics, on the other hand, comes into play when something
happens to force a person to reflect on how to respond appropriately. Zigon’s theory
gives us a way to structure our enquiry into moralities from either unspoken references
that shape practice, behaviour and attitudes, or verbalised discourse in relation to
experiences.
The morality of need that we describe in this paper has resonance with Mol’s (2008)
logic of care, in which the ‘crucial moral act is not making value judgements, but engaging
in practical activities’ (75). In a rational scheme of things, judgement precedes action, but
in the logic of care, the reality of dealing with disease makes it impossible to act only after
moral closure has been achieved, and ‘action itself is moral’ (78). Likewise, in our concept
of a morality of need, we point to an underlying premise of one’s need to do something, all
that one can do, in the face of disease and ill-health.
Mol (2008) articulates her logic of care by contrasting it with a logic of choice, teasing it
out of good care practices among patients living with diabetes, carers and healthcare pro-
fessionals, and distinguishing it from the logic that underlies a present-day discourse of
patient choice and autonomy. The logic of care is compared to two versions of the logic
of choice: first, a market version, where ‘people are interpellated as customers who
choose a product to their liking’ (11), and second, a civic version, where ‘people are inter-
pellated as citizens who govern themselves and one another’ (12). Mol argues that in good
care practices, decisions are made step-by-step by patients, carers and healthcare pro-
fessionals working together in a way that calls into question the assumptions of personal
choice, individual autonomy and independent judgement that are present in the two ver-
sions of the logic of choice.
Unlike Mol’s study (2008) which delves into ethnographic details of clinical encounters,
our study is limited to non-clinical encounters among patients, accompanying family
members, medical facilitators and hospital staff. The morality of need in our study
derives from the discourse of patients and family carers surrounding the reasons given
for travelling abroad for health care. It reflects, in a sense, a variant of Mol’s logic of
care that attends the specific case of international medical travel when patients and
their families are unable to find the health care that they need within their own country.
In juxtaposition to the morality of need, we also identify another strand of moral logic
in our interlocuters’ discourse, which we call the morality of business, using it to refer to a
normative understanding and acceptance of how things work in a market economy. While
our morality of business may be compared to Mol’s market variant of logic of choice in
reflecting a market rationale that lauds the availability of choice, it differs nevertheless
in focus: rather than privileging autonomy and equality in making independent choices,
it instead expresses an acceptance of commercial relationships within health care,
shaping patients’ practices in accessing private health care within a market economy.
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 5

As anthropologists have described, medical encounters are also moral endeavours

(Kleinman 1999; Lock 2001). Moral experience involves the flow of interactions between
people and what anthropologists term their ‘local moral worlds’. Within such a view, the
experience of seeking and providing medical care is intersubjective and interpersonal and
hence necessarily involves encounters between local moral worlds. Zigon (2008, 7) has
argued that such anthropological investigations of local moralities are best served by
focussing narrowly upon particular practices or spaces of moral interactions.
In this article, the discourses and practices within Malaysian hospitals serving Indo-
nesian patients form the space of such an investigation. Within this space, we explore
the ways in which the various and sometimes competing moralities expressed by
patients, facilitators and hospital staff are imbued with concepts derived from the
history, power relations, competing interests, laws, market forces and institutional
incentives particular to the location and people involved – what Lock (2001) described
as ‘situatedness’. The hospitals themselves may be understood as ‘ethical locations’ (Sto-
nington 2012), imbued with a set of concepts available to those who inhabit it. Con-
centrating on the ways in which patients, facilitators and staff express the moral
logics of international medical travel, and viewing the act of international medical
travel as a moral endeavour, our aim is to uncover the ‘implicit and explicit premises’
that make this endeavour ‘meaningful and desirable’ within the social context of the
actors involved (Howell 1997, 2).

Methods
This paper draws from our fieldwork material and interviews with patients, care-givers,
hospital staff and medical travel facilitators in two private hospitals on the island of
Penang in Malaysia, and forms part of a larger project on international medical travel
in Malaysia and Thailand. Observation and interviews were carried out in the two hospi-
tals, Hospital A and Hospital B,1 from January 2013 until April 2014, and again in January
and April 2015 by two field researchers.2 Hospital executives, staff members and medical
travel facilitators in the two study hospitals were interviewed.3
During fieldwork, the field researchers stationed themselves at the customer service
counters, hospital lobbies and clinic waiting areas, interacted with customer service staff
members, and observed the workings of the hospital and the interactions of hospital
staff, medical travel facilitators, patients and accompanying family members. They
carried out interviews with inpatients and/or their families in the wards, and with outpa-
tients in the clinic waiting areas while they were waiting to see the doctor.
In Hospital A, we obtained 30 recordings with orthopaedic, surgical and heart patients
(25 inpatients, 5 outpatients) and/or their accompanying family members. In Hospital B,
we recorded 21 inpatient (and/or family member) interviews in the medical and surgery
wards and 40 outpatient (and/or family member) interviews which included orthopaedic
and heart patients, and patients who came for other reasons including medical check-ups.
Most of the interviewees signed consent forms for recorded interviews, but some preferred
to give their consent verbally. The field researchers conversed with the informants in a
mixture of Malay and Indonesian, or in Mandarin or Hokkien (a Chinese dialect),
which was the language of preference of some of our Chinese Indonesian respondents.
These interviews were transcribed and translated into English.
6 H. L. CHEE AND A. WHITTAKER

In both hospitals, the first author, who was given access to the inpatient wards, con-
ducted all the in-patient interviews. The senior nurse or sister in charge of each ward
helped her identify all the foreign (all Indonesian) medical traveller-patients on the
days that she visited the ward, and then checked that the patients were well enough to
talk and willing to be interviewed, or their accompanying family members were willing
to be interviewed. For outpatients in Hospital B, however, the field researcher solicited
interviews without the help of hospital staff members, hence encountering more
difficulty in gaining trust and acquiescence of the people that she approached, including
patients, accompanying carers and medical travel facilitators.
Our Indonesian patient and carer interviewees viewed the interviewers primarily as
Malaysians who do not understand the situation in Indonesia nor the reasons why they
need to travel out of the country for medical care. Some of the Chinese Indonesian inter-
viewees related to the interviewers as co-ethnics, speaking in terms of ‘we’ (referring to
themselves and the interviewers) and ‘they’ (referring to the other Indonesian patients
and hospital staff members who were not ethnic Chinese).

Penang and Indonesian patients

Since 1998, Malaysia has positioned itself as a medical tourist destination offering inexpen-
sive high-quality medical treatment. The foundations of its healthcare system were built in
the 1960s and 1970s by a post-colonial state that had embarked on nation-building with a
mission to establish its legitimacy and popularity. Private hospital sector expansion from
the 1980s onwards led eventually to these hospitals seeking new markets overseas, particu-
larly during the 1997 Asian financial crisis when large numbers of private patients shifted
back to public hospitals (Chee 2010).
The majority of medical travellers to Malaysia come from neighbouring Indonesia,
despite private hospital and governmental efforts to diversify source countries. Out of a
total of 671,727 foreign patients in 2012, more than three-quarters were Indonesian
(76.6% in 2011) (Malaysian Healthcare Travel Council 2014).
The top medical tourist destination in the country is the state of Penang, where the esti-
mated share of foreign patients is about 60%. Seven private hospitals formed the Penang
Health Group in 2004 to actively market abroad under the ‘Penang brand’. In these hos-
pitals, our interviews with hospital executives reveal that the proportion of foreign patients
ranges from 30% to 40% of total patients, and Indonesians typically account for more than
90% of the foreign patients.
Who are the foreign patients who travel to use medical services in Penang? There are no
available statistics that provide demographic and socio-economic information of foreign
patients in the country. Our study participants, 57 women and 34 men, are all Indonesians,
aged between 23 and 82, although most are between 50 and 60 years old (average age 56
years).
They have a wide spectrum of occupations and family backgrounds, with many in
businesses, ranging from small farms, coffee shops or grocery stores to larger businesses
in trading, transportation and drug manufacturing. Some are either employees or depen-
dents of employees in the private sector – engineers, bus drivers, salesmen and bank
employees; others are linked to the public sector – nurses, college lecturers, teachers,
civil servants and retirees. There is a predominance of ethnic Chinese from areas in
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 7

Indonesia geographically proximate to Penang. More than half (50/91) of our interviewees
are Chinese Indonesians; the others are Indonesians of other ethnicities including Aceh-
nese, Batak and Karo. At least half (46/91) come from Medan (Sumatra) or its vicinity and
two-thirds of these are ethnic Chinese, while others are from Aceh and other parts of Indo-
nesia like Sumatra, Java, Sulawesi, Riau and Kalimantan.
The socio-economic profile of our study participants bears a strong similarity to those
of Ormond and Sulianti’s (2017) study on overland cross-border medical travel from West
Kalimantan (Indonesia) to Kuching in Sarawak (Malaysia). In their study, the Indonesian
medical travellers are from the lower middle classes and they travel repeatedly and fre-
quently for routine kinds of health care. The researchers point out that these people com-
muting on a regular basis for treatments, prescriptions and check-ups is indicative of
intra-regional medical travel becoming increasingly the means by which Indonesian
patients manage chronic care needs, and is evident of the growing middle classes’ dissa-
tisfaction with Indonesian health care – which they perceive to be lacking in quality, tech-
nology, expertise and bedside manner.
While private hospitals’ marketing, state policies, country differences in healthcare
quality, and the relative affordability and ease of transportation are important motivating
factors, it should be noted that this intra-regional medical travel is also embedded within
historical flows of trade and social, cultural and linguistic ties (see also Rouland and
Jarraya 2019). Migration between Indonesia and Malaysia is characterised by a migration
system with multi-faceted types of linkages connecting the two countries (Wong 2006). In
addition to settled (and naturalised) migrants from over the decades, Indonesians are
present in Malaysia as students, foreign spouses and migrant workers.
The regional hub of Penang has long-existing trade, cultural and economic links with
places such as Medan and Aceh on the island of Sumatra in Indonesia (Whittaker, Chee,
and Por 2017). The ethnic Chinese populations of Penang (42% of 1.7 million) (Malaysia
Department of Statistics 2015) and Medan (11% of 1.9 million) (Whittaker, Chee, and
Por 2017, 5) speak a similar type of Hokkien that originated from Fujian, China.
Through the years when Chinese education and culture was suppressed in Indonesia,
there was a small but steady stream of Chinese Indonesian children sent to the private
secondary Chinese schools in Penang. Contemporary movements for health care there-
fore may be seen as a continuation of historical flows linked to trade, education and cul-
tural ties. Movements by Indonesian patients to Penang thus occur within specific local
frames of reference.

Moral logic of need

The moral logic of need calls for one to do all that is needed to care for self and family,
including travelling abroad to seek the best treatment available and accessible. In countries
with poorer health care, the elite have long travelled abroad for their medical needs (Lunt,
Horsfall, and Hanefeld 2015, 4). Travelling abroad for medical treatment is only seen as
transgressing ‘normative boundaries delimiting appropriate spaces of care and responsi-
bility’ in a context where the nation-state is naturalised as the ‘container’ for health
care (Ormond 2015, 2). When as researchers we question this practice, we call attention
as much to our own assumptions as we do on the appropriateness or excessiveness of those
who engage in it. So, when we asked Ibrahim (51 years old, private sector employee) why
8 H. L. CHEE AND A. WHITTAKER

he comes to Malaysia for treatment, he retorted, ‘Many people say that treatment is better
here, why should we look for it in Indonesia? Might as well just come here’.
This ‘common-sense logic’ of need is evident in many of our patient-narratives. Con-
sider the narrative of Ibu Tjoa’s daughter. Her mother, 71 years old, had just undergone a
double knee replacement surgery.
[W]e do not want to take risk in Indonesia. If the operation fails, she would be paralysed. Dr
Eu [in Hospital A] has much experience in such operations; he is an expert. You hardly hear
of people having knee operations in Indonesia; then how would you dare to risk doing that in
Indonesia? It’s not that Indonesian doctors are not professional; it’s our own decision not to
take risks.

From our study, we found that for at least a segment of people in Sumatra, travelling to
Penang for medical care is ‘natural’ and normative, and frequently undertaken. For
example, we talked to Ria Suwati (29 years old, the youngest of five siblings) who was at
the hospital to check on her heart because she was feeling uncomfortable. The first time
she had travelled to Penang for a medical check-up was in 2011. A month prior to our inter-
view with her, she had accompanied her mother to Penang for a double knee replacement.
All her older brothers and sisters-in-law regularly travel to Penang for medical care. When
we asked if she had seen a doctor in Indonesia before travelling to Penang, she said,
We never do any medical check-ups in Indonesia. There, a lot of people do not get better after
treatment, so it is better for us to be aware of that than to waste our money. … If it is a light
illness, that’s alright; but for operations, definitely not there.

Many of our narrators travel abroad for medical care as a matter of course. They may
weigh the choices in terms of financial resources or logistical concerns, but not from
the perspective of ethics. Most of the time, these moralities are not explicitly verbalised,
but carried in ‘embodied dispositions’, created in the dynamics of everyday discourse
and social interaction (Zigon 2010, 8). It is only at the point when the researchers ask
for a reason behind this practice that the informants reflect, and in their replies, they
justify their travel by stating that medical services are better in Malaysia in terms of equip-
ment, facilities, drugs and, especially, doctors.
Many narratives contain stories of Indonesian doctors’ incompetence, negligence or
unethical practices. Some say that they travelled for medical care only after they had
experienced incorrect diagnoses or treatment. Others talk of knowing or hearing about
someone – a family member, relative or friend – who had gone through a bad experience
or had suffered or even died at the hands of doctors in Indonesia.
For example, Louisa (68 years old, housewife, husband a bank employee, two adult sons
and five grandchildren) who was accompanying two friends to the hospital, claimed that
she was on the edge of death after receiving treatment in Indonesia:
In 1981, I had stomach pain, … seriously ill, … I went to see doctor in Indonesia, but they
could not detect the problem. I was warded in the hospital, still they could not find anything
… . Finally, taken to Singapore, I was already half dead from the treatment [by the Indone-
sian doctors]. … I was in Singapore for two months, taken in on a stretcher. Finally, I had to
undergo surgery. It was a tumour in my uterus. … The doctor in Indonesia was unable to
detect the problem, just telling me ‘no big deal, no big deal’. He had misdiagnosed me as
having kidney problem. … that is why, … many of our Indonesian people have been endan-
gered by the doctors there, they are terrified, … whatever problem, they will go abroad.
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 9

The narratives are a moral indictment of the doctors in Indonesia. The reasons given for
having to travel abroad for medical care are that the Indonesian doctors are incompetent
(e.g. they cannot diagnose properly, misdiagnose and are not able to treat illnesses), incon-
sistent, sometimes even incoherent, and do not explain to patients what is wrong. The logic
of need implies the justification of the common-sense necessity of travel to obtain medical
care within a shared understanding of the risks and fears of seeking care in Indonesia.
Mardhia (39-year-old Batak woman from Medan with three children, husband and
herself are employees in a private university) has a thyroid problem and was treated
twice in Indonesia. Since she was not showing any signs of getting better, she readily
agreed to her friend’s suggestion to travel to Penang:
[I]n Indonesia, no explanation given for my illness, none at all, only here [in Penang], there is
[explanation given]. … [T]here, no explanation. We go in, the doctor treats, we are given an
injection, then we buy the medicine. What is the cause of the illness, I do not know. …
When we reach here [Hospital B in Penang], we consult [with the doctor] first, then he tells
us to do a blood test, come again the next day. … From the outcome of the blood test, we
know the diagnosis. … [It is] not that I want to say bad things about my own people; no.
There, dosage is by trial and error, without checking, [it’s like] ‘oh, the hormone is high,
give this dose’, just like that.

Travel as betraying the nation

Moralities are connected in complicated ways to societal norms and values, elements that
structure culture and society; moralities are therefore lived, created and reproduced as a
part of cultural reproduction (Robbins 2007). There are times when individuals are con-
fronted with a conflict in values – moments of ‘moral breakdown’ – when disjuncture
occurs to disturb the ‘unreflective moral dispositions of everyday life’, leading to an
‘ethical moment’ when ethics must be performed to move from a situational relationship
of discomfort and disconnect back into the ‘unreflective comfort of the familiar’ (Zigon
2007, 137–138).
Despite the sense of a self-evident logic of need, hints of a ‘moral breakdown’ appear in
these retrospectively reflective narrations such as ‘ … not that I want to say bad things
about my own people’ (Mardhia). Ormond (2015) writes of Indonesian patients’ regrets
of having to spend money abroad and that many display an awareness of the impact of
their ‘reluctant exit’ on home health services, which is suggestive of a sense of nationalism
and civic responsibility. Indeed, from our narratives, the regret seems to be associated with
a sense of having to betray ‘our own people’ or bangsa, ‘nation’ in Indonesian.
For example, Ong, a 50-year-old Chinese Indonesian businessman, was diagnosed with
a heart problem by a private specialist in Jakarta in 2010, but instead of following through
with treatment there, he decided to travel to Penang, and has been seen at Hospital B since
then. When we asked why he did not want to receive treatment in Jakarta, he explained:
Of course, it is because we do not have confidence. It is because our doctors there, they cannot
give us a proper diagnosis. So, we have to travel abroad, it is to make us feel safer, more guar-
anteed. … . It is not that we do not trust Indonesian doctors, there are also very good doctors
in Indonesia, but we feel safer to go outside.

Here Ong is equivocating between describing the need to feel safe by travelling for care and
the self-conscious caveat that ‘it is not that we do not trust Indonesian doctors … ’. In such
10 H. L. CHEE AND A. WHITTAKER

statements, our informants are attempting to present the moral logic of need against their
desire not to be seen as deserting or criticising their nation.
Hormat (61 years old, Karo Muslim from Medan, businessman, four children) was at
Hospital B with his wife and daughter. Three years ago, he underwent an angioplasty in
this hospital and, since then, he has returned for check-ups, once every three months
within the first post-operation year and every six months thereafter. He told us:
I did not get treatment in Indonesia, as I had already made up my mind to come to Penang;
because the feeling is that Penang is more advanced, the cost is lower, the facilities better.
That’s it. … There are those who have already come here before who inform us; it’s not
that I want to belittle my own nation.

These expressions of not wanting ‘to belittle my own nation’ (Hormat) or that ‘it’s not that
we do not trust Indonesian doctors’ (Ong) highlight how the moral logic of need justifies
the travel despite the exhortations by Indonesian government officials to the Indonesian
public not to travel abroad for medical care because it leaches large sums of money
from the Indonesian economy (Candra 2011).
Furthermore, the hospital staff and medical travel facilitators’ narratives also draw from
Indonesian patients’ logic of need, viewing Indonesians as disenfranchised – unable to
obtain the necessary appropriate quality and safety of medical care at home. A spokesper-
son for the private hospitals shared his insight with us:
It’s very simple, as far as marketing is concerned. … You have something that you can offer to
someone who needs the thing, not want it, but need it, and they need it because they don’t
have it where they are, so they come. … As I said, need is different from want. … When it
comes to needs, any price will go. … It’s something that you cannot go without. … But
after a time, a need may become a want.

In this case, the need he refers to translates into a marketing opportunity in which ‘any
price will go’ but then he suggests that what begins as a necessity may become a
desired commodity that carries other values.
The discerned ‘need’ referred to above stems from a social and historical situatedness
giving rise to certain expectations, attitudes, beliefs and practices related to the mainten-
ance of health and life, treatment of illness and disease, and care for self and others. From
the vantage point of a socially-connected and well-informed middle class in Indonesia, the
medical care available to them in their own geographical location is, at this particular point
in time, inadequate for maintaining health and providing care. Additionally, their ‘need’
for medical care abroad arises from a social and historical confluence of connectedness
through direct flights, transnational linkages and cultural familiarity and relative
economic standing in the hierarchies of social class and nations (Whittaker, Chee, and
Por 2017).

Moral logic of need as social action

The expense and effort required to travel for medical care also points to how these acts of
care-seeking for family members constitute moral acts of cultural reproduction. Family
solidarity, respect and the care of the elderly are important social values in the region
demonstrated through the mobilisation of resources for care. When one member falls
ill, the entire family is mobilised to acquire the money needed and to accompany the ill
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 11

member to seek care. Physical accompaniment is itself an essential dimension of the moral
and social support given to patients (Bochaton 2015, 369). Rarely did we encounter any
patient, especially warded patients, without an accompanying relative. Younger patients
are accompanied by parents or siblings; elderly patients by children, grandchildren,
sons and daughters-in-law, who sometimes take turns to take leave from their jobs, or
bring their young children with them.
In her Yemeni cases, Kangas (2002, 140–141) observes that families need to be seen to
have tried everything possible for their sick and dying relatives as a concrete and costly
demonstration of love, and in many cases, the ‘moral cost of coming up short’ is
deemed to be greater than the financial costs of international medical travel. The ‘morality
of need’ discourse in our study resonates with Kangas’ (2002, 140) observation that for the
Yemeni families in her study, sending their ill relatives abroad for medical care, even when
not medically recommended, reassures them that ‘they did everything possible to relieve
their suffering’. Kangas (2002, 140–142) describes these acts as resulting not only from a
sense of hope, but also from ‘the voice of one’s conscience’, and ‘the voice of caring’, reas-
suring family members that they care for them.
Similarly, among the Indonesian patients in Penang, the moral logic determining the
need for travel entails social demonstrations of support. For example, Tomas (retired
army general, teaching as a retirement job) was being treated in the army hospital for a
kidney ailment, but he did not recover and had become very weak. His wife consulted
with their daughters and, together, all four of them brought him to Penang. When they
were told by the Hospital A doctors that he has a heart problem, and had to undergo
surgery, requiring a longer hospital stay than they had expected, his wife stayed on with
him, while their daughters took turns to take leave from their jobs to accompany them.
Likewise, Ibu Melee (82 years old, 10 children, double knee replacement surgery
patient) was accompanied by her husband and two sons. Even Ibu Ding, who is 68
years old and single, was accompanied by her nephew (son of eldest brother) and his
wife, her knee replacement surgery having been financed by her youngest brother.
The moral action of caring is not limited to family members, even though the examples
above are from within families. It is extended beyond the family through the practices of
giving information to other people, recommending good doctors to them, and bringing
them for medical check-ups or treatment. Louisa (68 years old, familiar with Penang
because her sister married and settled here in the 1970s) and her two friends (sisters)
whom she had brought to see a particular doctor, were chatting and joking:

Louisa: I charge a commission … . [everyone laughed]

Linda: Yes, when we see a doctor that is good, we will help to introduce to people. First, we
are helping people, second, so that people can find the appropriate doctor for their
needs, and do not waste money.

Bochaton (2015) notes that social networks among Laotian patients who seek medical
care in Thailand do not only provide material and logistical resources but also moral
support. The Laotian Ministry of Health has criticised the movements of Laotians to Thai-
land for medical care as unpatriotic: ‘Lao people should help the Lao economy by using the
local medical services (…). Economic development in Laos is still the duty of Lao people’
(Bochaton 2015, 369). Similarly, in Indonesia the government has instituted public cam-
paigns to discourage people from travelling to Malaysia and elsewhere for medical care.
12 H. L. CHEE AND A. WHITTAKER

For example, in a public statement reported on 1 August 2012, then-President Susilo

Bambang Yudhoyono publicly criticised Indonesians who were travelling overseas for
medical treatment, stating that it was economically disadvantageous for the country
(Fathoni 2012). The Indonesian context for our study participants is arguably less author-
itarian compared to Bochaton’s (2015) Laotian case; but the argument is similar – accom-
panying patients, giving information, and extending support are social actions that speak
to a moral logic of need, and are part of a collective process that provides legitimation of
what citizens are doing in the face of governmental disapproval.

The logic of business

While teasing out the moral logic of need from patients’ narratives, we became cognisant
of a ‘moral logic of business’ that was also evident in these narratives. This was articulated,
for example, by a 75-year-old woman who was accompanying her daughter at Hospital B,
speaking about various facilitators who could be found in the hospital lobby offering
services:
Just now, the lady whom you talked to, she is Ah Gaik. She has a unit at Halaman, 104, but I
stay at 100, we rented from Ah Hean. There are a lot people like Ah Gaik here [her finger
pointing to the lobby], they invite people to rent their rooms. Many people are doing this,
they also refer patients from Indonesia to see certain doctors or visit certain hospitals in
Penang. People need to make a living; there is nothing wrong in doing this.

In stating ‘there is nothing wrong’ in making a business venture out of people seeking care,
the speaker suggests that there may be criticism from others for such ventures. This asser-
tion reflects a moral framework in which the generation of a livelihood in the context of
the market is accepted and perhaps even valorised. Health care is a consumption good, and
if people can make a living by generating a demand for it, well, ‘it’s business’.
The moralities of need and of business are not contradictory. However, the capitalist
logic of business sits in an uneasy tension in relation to the logic of need, to notions of
health care as a social good and to the social reproduction of care. These tensions were
made apparent in an early stage of our fieldwork in a private hospital. As the market-
ing executive walked us through the wards, she told us that they were on track to
getting a record number of patients that year, and she hoped that they would not
be derailed. Then, as if realising that she had said something she should not, she apol-
ogised and explained that she often feels a tinge of regret whenever she finds herself
hoping for more patients, because somehow it seems wrong to hope for people to
fall ill.
At that time, we did not think too much of this unsolicited off-hand remark. But as we
had more encounters with players in the international medical travel industry – from
high-level executives to facilitators – we were to hear similar kinds of protestations. For
example, we would encounter medical travel facilitators who emphasise to us that what
they are doing is not really a business, that they are actually helping people. On the
other hand, patients and accompanying carers would often say, even without our
asking, that it is not wrong to procure patients because ‘people need to make a living’.
Patients are aware that they are involved in a business relationship with the private hos-
pitals they attend. It is this strand of moral logic that underpins some patients’ underlying
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 13

subtext of self-conscious awareness that they are (high-)paying customers, that it is good
they do not depend on their government for medical care and commendable that they are
able to afford to travel abroad for their medical needs. One may speculate that such a sen-
timent stems from a proclivity for communal self-dependence on the one hand and dis-
tancing from authorities on the other hand, nurtured through centuries of trade, business
and entrepreneurial ways of life within the ethnic Chinese communities of Penang and
surrounding Indonesian states (see, for e.g., the articles in Yeoh et al. 2009).
Part of the desirability of travelling to Malaysia is the assurance that private hospitals
are competing for patients on price and quality, and as ‘brands’, they are understood as
prestigious. This ‘morality of business’ structures patients’ behaviour in at least three
ways. First, it is reflected in the practice of ‘shopping around’. Many times, we were
told (usually by marketing or customer service staff) that what distinguishes Indonesian
patients from local Malaysian patients is that the Indonesians ‘shop around’ and they
already know a lot about doctors and private hospitals in Penang prior to their arrival.
Second, some patients argue that travelling to Penang for medical treatment would in
the end be cheaper than being treated in Indonesia because of the high risk of botched
treatment there. The choice is therefore presented as a well-calculated financial one that
takes the factor of risk into account. Third, the morality of business underpins the Indo-
nesian medical travellers’ view of themselves as patrons who help to build the hospitals in
Penang. As expressed by Linda (68 years old, family-run garment factory, four adult chil-
dren), ‘It’s not an exaggeration to say that Penang hospitals are built by the Medanese’, a
significant statement alleging the dependence of the hospitals’ businesses upon their Indo-
nesian customer-patrons, but reflecting also an awareness of the historical ties between
Penang and Medan.

Productive interplay of logics

In distinguishing the moralities of need and business at play in Indonesian-Malaysian
medical travel, we do not wish to give the impression of a binary division between the
two, with a moral realm removed from monetary exchange. Rather, these moral logics
of need and business are in productive interplay; they are constantly blurred in practice
and in dispositions. The international medical travel industry operates in tension
between these logics – on the one hand, the opportunity to provide medical care and
help to those in need (even though selectively limited to those who can pay) and, on
the other, a commercial transaction.
Such tensions between moralities of need and business are not unique to medical
travel, but common and familiar within privatised healthcare settings. The work
taking place in these hospitals (e.g. providing medical interventions, caring for sick
bodies) as well as the work done by medical travel facilitators (e.g. recommending
doctors, ensuring travel arrangements and providing suitable accommodation) are
affective at the same time as involving a fee for service (Hochschild 2003). It carries
characteristics of various forms of intimate labour: ‘work that involves embodied and
affective interactions in the service of social reproduction’ (Boris and Parreñas 2010,
7) that also involves the exchange of money and is subject to market forces. In the
case of hospitals, the commercial aspect of their care is quite clear; in the case of facil-
itators, the lines may be somewhat indistinct.
14 H. L. CHEE AND A. WHITTAKER

The blurring of moral logics between need and business within a discourse of general
reciprocity and ‘help’ in response to ‘need’ are evident in facilitators’ and medical staff’s
talk. One hospital executive tells us that there are two types of facilitators: ‘One type
will say that they want to help the patients, but while I am doing that, the hospital pays
me. … [T]he other type are those who are strictly professional. It’s a business, and their
job is just that’. She says that she can tell them apart from their behaviour, because facil-
itators who want to help will sometimes take out their own money to help the patients who
find themselves short of cash.
The rhetoric of ‘helping others’ appears prominently in the narrative of Ah Yeow, the
Indonesian medical representative of Hospital A. She and her elder daughter, who is
married to a Malaysian and based in Penang, run the services at the Indonesian desk in
Hospital A. Her second daughter operates their company in Medan. When we asked
her when she started her business in Medan, she replied:
[N]o, this is not a business, we are helping people. … If you sit here [and observe], you will
know what we are doing, we are not making profit, we are just being busybodies, we are
helping people. … We never ask for commission, we only ask the doctors to treat the patients
‘from their hearts’. Even those patients who come here without our help, all should be treated
well.

Ah Yeow’s narrative reveals a tension between the profit motive in her business and her
relationships with the patients whom she services. The more patients she is able to solicit
for the hospital, the more profits she makes and the more successful her business becomes.
For her, making money from people who are in unfortunate circumstances situates her in
a relationship of discomfort and disconnect, a disjuncture in her moral frames of refer-
ence. Yet this is also a productive relationship, which allows her to make a living. The
underlying tension surfaces in an ethical moment when she reconciles the moral logic
of need and business through her rationale of ‘helping others’.
The productive tensions are displayed in the marketing of these hospitals. The pro-
motion of Penang hospitals as medical travel destinations draws upon the moral logic
of need towards its ends as a business selling a product to customers. They are consciously
creating new ‘needs’, for example in the generation of demand for ‘medical check-up
tours’, where facilitators and well-wishers bring customers to consume medical services
in the form of health screenings. The business of medical tourism therefore focuses the
generation of demand on people who are not sick, the so-called ‘worried well’; it is not
just about servicing people who need medical care. Hospital A, for example, sees on
average 20–25 Indonesian medical tourists every day for medical check-ups alone.
The moral logic of business, however, does have boundaries for what is considered fair
and equitable. Overcharging by hospitals, lack of expected service from staff or over-servi-
cing by doctors are examples of practices beyond the limits of what is morally acceptable in
the business of health care. Given that exchanges between patients and the hospitals take
place across national borders, suspicions of unacceptable practices also take on racialised
narratives. As Malaysian researchers, the interviewers sometimes elicited explanatory
responses to an underlying sub-text, reflecting the ambivalence with which Indonesian
patients view (and relate to) Malaysians. For example, in some of the conversations that
we observed or participated in, the Indonesian patients spontaneously made it known
that they believe they are being charged more, or are being taken advantage of, and that
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 15

this is because Malaysians think Indonesians, particularly Chinese Indonesians, are rich.
On other occasions, other patients displayed indignation, alleging that some Malaysian
hospital staff members treat them poorly because these Malaysians look down on Indone-
sia as a less developed country and a supplier of domestic maids to Malaysia. These sen-
sitivities illustrate how the social relations within the spaces of these hospitals negotiate a
broader social and historical context of relations between Indonesia and Malaysia.

Conclusion
Viewing international medical travel through the lens of medical migrations and regional
historical linkages and connections, this paper points to the importance of socialities, and
cultural inflections and nuances in understanding the motivations of patient-travellers.
Patients cross the border for basic medical procedures and health screenings that are a
routine part of modern life. These practices of border crossings for health care are
embedded in family and social support networks that together form a collective
process, and are based on a moral logic that we have identified as a morality of need.
Within this moral framework, international medical travel is seen as a necessary practice
for sustaining health and well-being, and extends beyond the family as social and moral
support for others facing similar predicaments.
When cross-border utilisation of medical care is seen as such an integral and necessary
part of everyday life, and when collectively undertaken, forms dense transnational flows
and networks between two countries, then further examination of the subjectivities and
moral logics underlying this phenomenon complicate our understandings of migrant,
non-migrant and transnational social life. This study supports the recent emphasis on
the cultural values and ideas that motivate the movements and subjectivities of migrants
and potential migrants (Walton-Roberts 2015; Chan 2017). In the case of patients travel-
ling for medical care, the cultural meanings of care, perceived inadequacies of the Indone-
sian system and desires to receive what is perceived as higher quality care are all evoked
through the ‘morality of need’. This moral logic is readily understood by others in Indo-
nesia and recognises the shared precarities and ever-present possibilities that anyone may
require such cross-border care. This expands our current understandings and definitions
of who are typically understood as migrants and migration beyond a special category of
people to a social field of action formed through the circulation of ideas and cultural
values.

Notes
1. Pseudonyms are used for the study hospitals and all interviewees.
2. The first author and a research assistant. In 2015, the first author was accompanied by a
Chinese Indonesian field assistant.
3. Not audio-recorded, with the exception of the interview with the medical representative of
Hospital A.

Acknowledgements
Ethical clearance for this study was obtained from the University of Queensland Behavioural Social
Science Ethical Review Committee, the Monash University Human Research Ethics Committee and
16 H. L. CHEE AND A. WHITTAKER

the Medical Research and Ethics Committee, Ministry of Health Malaysia. We thank the hospitals,
staff and patients for their participation in this research, and numerous individuals who helped us
along the way.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research was funded by the Australian government through an Australian Research Council
Discovery Project Grant [grant number DP 1094895] and by the Asia Research Institute, National
University of Singapore through a supplementary grant.

ORCID
Heng Leng Chee http://orcid.org/0000-0001-6731-8724
Andrea Whittaker http://orcid.org/0000-0002-2616-9651

References
Alpes, Maybritt Jill. 2011. “Migration Brokerage, Deception and the Limits of the Law: Credibility
within the Moral Economy of Departure in Anglophone Cameroon.” Paper presented at the
workshop on “Moralities of Migration,” Peace Research Institute of Oslo, December 13–14.
Bell, David, Ruth Holliday, Meghann Ormond, and Tomas Mainil. 2015. “Transnational
Healthcare, Cross-Border Perspectives.” Social Science and Medicine 124: 284–289. doi:10.
1016/j.socscimed.2014.11.014.
Bochaton, Audrey. 2015. “Cross-border Mobility and Social Networks: Laotians Seeking Medical
Treatment Along the Thai Border.” Social Science and Medicine 124: 364–373. doi:10.1016/j.
socscimed.2014.10.022.
Boris, Eileen, and Rhacel Salazar Parreñas. 2010. “Introduction.” In Intimate Labors: Cultures,
Technologies and The Politics of Care, edited by Eileen Boris and Rhacel Salazar Parreñas, 1–
12. Stanford: Stanford University Press.
Candra, Asep. 2011. Berobat ke Luar Negeri, Rp 100 Triliun Hilang [Rp 100 Trillion is Lost Due to
Indonesian Medical Travellers]. Kompas, March 4. Accessed January 9, 2019. http://health.
kompas.com/read/2011/03/04/16405422/Berobat.ke.Luar.Negeri.Rp.100.Triliun.Hilang.
Carling, Jorgen. 2008. “The Human Dynamics of Migrant Transnationalism.” Ethnic and Racial
Studies 31 (8): 1452–1477. doi:10.1080/01419870701719097.
Chan, Carol. 2017. “In Between Leaving and Being Left Behind: Mediating the Mobilities and
Immobilities of Indonesian non-Migrants.” Global Networks 17 (4): 554–573. doi:10.1111/
glob.12161.
Chee, Heng Leng. 2010. “Medical Tourism and the State in Malaysia and Singapore.” Global Social
Policy 10 (3): 336–357. doi:10.1177/1468018110379978.
Chee, Heng Leng, Andrea Whittaker, and Brenda S. A. Yeoh. 2017. “International Medical Travel
and the Politics of Transnational Mobility in Asia.” Asia Pacific Viewpoint 58 (2): 129–135.
doi:10.1111/apv.12164.
Connell, John. 2011. Medical Tourism. Wallingford, Oxfordshire: CABI.
Crush, Jonathan, Abel Chikanda, and Belinda Maswikwa. 2012. Patients Without Borders: Medical
Tourism and Medical Migration in Southern Africa. Cape Town: Southern African Research
Centre.
 JOURNAL OF ETHNIC AND MIGRATION STUDIES 17

Fathoni, Riza. 2012. Presiden Kritik WNI yang Berobat ke Luar Negeri [The president criticises
Indonesian medical travellers]. Kompas, August 1. Accessed January 9, 2019. http://health.
kompas.com/read/2012/08/01/15330915/Presiden.Kritik.WNI.yang.Berobat.ke.Luar.Negeri.
Goodrich, Jonathan N., and Grace E. Goodrich. 1987. “Health-care Tourism: An Exploratory
Study.” Tourism Management 8 (3): 217–222. doi:10.1016/0261-5177(87)90053-7.
Hochschild, Arlie Russell. 2003. The Managed Heart: Commercialization of Human Feeling.
Berkeley: University of California Press.
Howell, Signe. 1997. “Introduction.” In The Ethnography of Moralities, edited by Signe Howell, 1–
21. London: Routledge.
Inhorn, Marcia C. 2011. “Globalization and Gametes: Reproductive ‘Tourism,’ Islamic Bioethics,
and Middle Eastern Modernity.” Anthropology and Medicine 18 (1): 87–103. doi:10.1080/
13648470.2010.525876.
Inhorn, Marcia C., and Pasquale Patrizio. 2009. “Rethinking Reproductive ‘Tourism’ as
Reproductive ‘Exile’.” Fertility and Sterility 92 (3): 904–906. doi:10.1016/j.fertnstert.2009.01.055.
Kangas, Beth E. 2002. “The Lure of Technology: Yemenis’ International Medical Travel in a Global
Era.” PhD., dissertation, University of Arizona.
Kleinman, Arthur. 1999. “Experience and Its Moral Modes: Culture, Human Conditions, and
Disorder.” Tanner Lectures on Human Values 20: 355–420.
Knoll, Eva-Maria. 2017. “Archipelagic Genes: Medical Travel as a Creative Response to Limitations
and Remoteness in the Maldives.” Asia Pacific Viewpoint 58 (2): 148–161. doi:10.1111/apv.
12157.
Lock, Margaret. 2001. “Situated Ethics, Culture, and the Brain Death ‘Problem’ in Japan.” In
Bioethics in Social Context, edited by Barry Hoffmaster, 39–68. Philadelphia: Temple
University Press.
Lunt, Neil, Daniel Horsfall, and Johanna Hanefeld, eds. 2015. Handbook on Medical Tourism and
Patient Mobility. Cheltenham: Edward Elgar.
Malaysia Department of Statistics. 2015. “Population by States and Ethnic Group.” Accessed
January 9, 2019. http://pmr.penerangan.gov.my/index.php/info-terkini/19463-unjuran-populasi-
penduduk-2015.html.
Malaysian Healthcare Travel Council. 2014. Website. Accessed February 13, 2014. https://www.
mhtc.org.my/.
Mol, Annemarie. 2008. The Logic of Care: Health and the Problem of Patient Choice. Oxon:
Routledge.
Ormond, Meghann. 2011. “Medical Tourism, Medical Exile: Responding to the Cross-border
Pursuit of Healthcare in Malaysia.” In Real Tourism: Practice, Care and Politics in
Contemporary Travel Culture, edited by Claudio Minca and Tim Oakes, 143–161. Abingdon:
Routledge.
Ormond, Meghann. 2013. “Harnessing Diasporic Medical Mobilities.” In Migration, Health and
Inequality, edited by Felicity Thomas and Jasmine Gideon, 150–162. London: Zed Books.
Ormond, Meghann. 2015. “Solidarity by Demand? Exit and Voice in International Medical Travel–
The Case of Indonesia.” Social Science and Medicine 124: 305–312. doi:10.1016/j.socscimed.2014.
06.007.
Ormond, Meghann. 2016. “Knowledge Transfer in the ‘Medical Tourism’ Industry: The Role of
Transnational Migrant Patients and Health Workers.” In Handbook on Migration and Health,
edited by Felicity Thomas, 498–514. Cheltenham: Edward Elgar.
Ormond, Meghann, and Neil Lunt. 2019. “Transnational Medical Travel: Patient Mobility, Shifting
Health System Entitlements and Attachments.” Journal of Ethnic and Migration Studies. doi:10.
1080/1369183X.2019.1597465.
Ormond, Meghann, and Alice M. Nah. 2019. “Risk Entrepreneurship and the Construction of
Healthcare Deservingness for ‘Desirable’, ‘Acceptable’ and ‘Disposable’ Migrants in Malaysia.”
Journal of Ethnic and Migration Studies. doi:10.1080/1369183X.2019.1597477.
Ormond, Meghann, and Dian Sulianti. 2017. “More Than Medical Tourism: Lessons from
Indonesia and Malaysia on South–South Intra-Regional Medical Travel.” Current Issues in
Tourism 20 (1): 94–110. doi:10.1080/13683500.2014.937324.
18 H. L. CHEE AND A. WHITTAKER

Pennings, Guido. 2007. “Ethics Without Boundaries: Medical Tourism.” In Principles of Health
Care Ethics, Second Edition, edited by Richard Edmund Ashcroft, Angus Dawson, Heather
Draper, and John McMillan, 505–510. Chichester: Wiley.
Robbins, Joel. 2007. “Between Reproduction and Freedom: Morality, Value, and Radical Cultural
Change.” Ethnos: Journal of Anthropology 72 (3): 293–314. doi:10.1080/00141840701576919.
Roberts, Elizabeth, and Nancy Scheper-Hughes. 2011. “Introduction: Medical Migrations.” Body
and Society 17 (2–3): 1–30. doi:10.1177/1357034X11400925.
Rouland, Betty, and Mounir Jarraya. 2019. “From Medical Tourism to Regionalism from the
Bottom Up: Emerging Transnational Spaces of Care Between Libya and Tunisia.” Journal of
Ethnic and Migration Studies. doi:10.1080/1369183X.2019.1597475.
Smith, Richard D., Melisa Martinez Álvarez, and Rupa Chanda. 2011. “Medical Tourism: A Review
of the Literature and Analysis of a Role for Bi-lateral Trade.” Health Policy 103 (2–3): 276–282.
doi:10.1016/j.healthpol.2011.06.009.
Solomon, Harris. 2011. “Affective Journeys: The Emotional Structuring of Medical Tourism in
India.” Anthropology and Medicine 18 (1): 105–118. doi:10.1080/13648470.2010.525878.
Song, Priscilla. 2010. “Biotech Pilgrims and the Transnational Quest for Stem Cell Cures.” Medical
Anthropology 29 (4): 384–402. doi:10.1080/01459740.2010.501317.
Stonington, Scott D. 2012. “On Ethical Locations: The Good Death in Thailand, Where Ethics sit in
Places.” Social Science and Medicine 75: 836–844. doi:10.1016/j.socscimed.2012.03.045.
Turner, Leigh. 2003. “Bioethics in a Multicultural World: Medicine and Morality in Pluralistic
Settings.” Health Care Analysis 11 (2): 99–117. doi:10.1023/A:1025620211852.
Walton-Roberts, Margaret. 2015. “Migration: The Mobility of Patients and Health Professionals.”
In Handbook on Medical Tourism and Patient Mobility, edited by Neil Lunt, Daniel Horsfall, and
Johanna Hanefeld, 238–246. Cheltenham: Edward Elgar.
Whittaker, Andrea. 2015. “Outsourced Patients and their Companions: Stories from Forced
Medical Travellers.” Global Public Health 10 (4): 485–500. doi:10.1080/17441692.2014.998696.
Whittaker, Andrea. 2017. “Conceptualising Asian Medical Travel as Medical Migrations.” In
Routledge Handbook of Asian Migrations, edited by Gracia Liu-Farrer and Brenda S. A. Yeoh,
114–127. Abingdon: Routledge.
Whittaker, Andrea, Heng Leng Chee, and Heong Hong Por. 2017. “Regional Circuits of
International Medical Travel: Prescriptions of Trust, Cultural Affinity and History.” Asia
Pacific Viewpoint 58 (2): 136–147. doi:10.1111/apv.12158.
Whittaker, Andrea, and Amy Speier. 2010. “‘Cycling Overseas’: Care, Commodification and
Stratification in Cross-border Reproductive Travel.” Medical Anthropology 29 (4): 363–383.
doi:10.1080/01459740.2010.501313.
Wong, Diana. 2006. “The Recruitment of Foreign Labour in Malaysia: From Migration System to
Guest Worker Regime.” In Mobility, Labour Migration and Border Controls in Asia, edited by
Amarjit Kaur and Ian Metcalfe, 213–227. London: Palgrave.
Yeoh, Seng Guan, Wei Leng Loh, Salma Nasution Khoo, and Neil Khor, eds. 2009. Penang and Its
Region: The Story of an Asian Entrepot. Singapore: NUS Press.
Zigon, Jarrett. 2007. “Moral Breakdown and the Ethical Demand: A Theoretical Framework for an
Anthropology of Moralities.” Anthropological Theory 7: 131–150. doi:10.1177/
1463499607077295.
Zigon, Jarrett. 2008. Morality: An Anthropological Perspective. Oxford: Berg.
Zigon, Jarrett. 2010. “Moral and Ethical Assemblages: A Response to Fassin and Stoczkowski.”
Anthropological Theory 10: 3–15. doi:10.1177/1463499610370520.