Most passengers are surprised to learn a cruise ship is not required under international maritime law to provide medical services. The only legal requirement, under the Standards of Training, Certification and Watchkeeping for Seafarers (SCTW) Conven- tion, is that identified crewmembers have various levels of first aid and medical train- ing. Regardless, modern cruise ships maintain an infirmary and almost all have a physician and nurse on staff. These medical professionals work under contract as concessionaires and receive a fee plus commissions on medical services, prescriptions and medical supplies. The precise qualifications of onboard medical care providers can vary widely. A 1996 survey administered by two Florida physicians to 11 cruise lines found not just inconsistencies across cruise lines, but also that 63% of ships had no blood testing equipment for diagnosing heart attacks, and 45% lacked mechanical ventilators or external pacemakers (Frantz, 1999). The study concluded that the quality of maritime medical care was inadequate, from the medical facilities to nurse and physician credentials. This led the American Medical Association (AMA) to call for greater awareness of the limited medical services available onboard ships and for the US Congress to develop medical standards for cruise ships. However, the cruise industry successfully kept the issue off the Congressional agenda, and instead adopted industry guidelines for medical facilities and personnel on cruise ships. These guide- lines, written by the American College of Emergency Physicians, are voluntary and therefore not enforced. While they serve a purpose in public relations and for defusing critics, they do not establish predictable standards of care for the industry. As they state, ‘they reflect a consensus among member lines of the facilities and staffing needs considered appropriate aboard cruise vessels’ (Cruise Lines International Association (CLIA), 2015).
These guidelines have serious gaps. For example, they do not require certification in emergency or critical care, which is significant given that 90% of deaths on cruise ships are caused by a heart attack. However, the greatest weakness is the wide vari- ation in actual equipment onboard a ship. While the guidelines suggest one infirmary bed per 1000 passengers and crew, one intensive care unit bed per ship, and a variety of equipment, there is no guarantee that these are in place. Actual equipment onboard varies according to itinerary, size of ship and anticipated demographic makeup of pas- sengers, as well as by cruise line.
Onboard infirmaries are equipped to deal with minor injuries, including crew workplace injuries, and stabilizing a patient experiencing a heart attack or other acute condition. Realistically, they are more like a neighbourhood clinic than a hospital emergency room, and can most effectively deal with routine problems such as scrapes and cuts, sunburn and indigestion. They also serve as the ‘family doctor’ for the crew, treating anything from colds and influenza to high blood sugar and hypertension. This is reflected in the types of problems ship infirmaries tend to deal with; the most common passenger diagnosis is respiratory illness (26–29%). Injuries, most frequently sprains, and superficial wounds and contusions also account for a significant propor- tion of shipboard medical visits (10–18%), as do gastrointestinal illnesses (9–16%).
Generally, the rate of medical consultation on cruises is higher than on shore. Crew- members, although significantly younger than passengers, make proportionately more medical visits (Committee to Advise on Tropical Medicine and Travel (CATMAT), 2005, pp. 2–3).
The medical staff
There is wide variation in the training and background of medical personnel. Some cruise lines draw their physicians and nurses from the UK, the USA and/or Canada, and pay $10,000 or more a month; all are board certified in one of these countries. In contrast, personnel on other cruise lines are drawn from a range of countries, have salaries reportedly as low as $1057 a month, and are not necessarily board certified.
A 1999 New York Times article reports that only 56% of doctors on Carnival Cruise Lines’ ships had board certification or equivalent certifications, and 85% of the phys- icians on Royal Caribbean Cruise Lines were board certified (Frantz, 1999).
Board certification itself may not be altogether reassuring. For example, the phys- ician on one cruise ship had 30 years of practice experience as an anaesthesiologist, but his expertise in emergency responses was untested. Another physician was special- ized in oncological colorectal surgery, and although well respected within his special- ization, was not regularly required to exercise skills in emergency medicine. It is not intended to question the competence of all onboard physicians, but to illustrate that the quality of medical qualifications and facilities varies widely from ship to ship and from cruise line to cruise line.
At the same time, it should be recognized that the Cruise Vessel Security and Safety Act of 2010 includes minimal requirements for medical care after a sexual as- sault. Not only is a cruise ship required to maintain in-date supplies of anti-retroviral medications and other medications to prevent sexually transmitted diseases after an assault, but it must also have medical staff with a current physician’s or registered nurse’s licence and at least 3 years of postgraduate or post-registration clinical prac- tice in general and emergency medicine. It is unclear whether these standards are en- forced or even monitored.
Liability for medical care
No doubt there are cases of malpractice on cruise ships. Americans and Canadians may assume they have the same rights and protections as they would on land when something goes wrong, but that is not the case. Even though a physician wears the uniform of a senior-ranked officer, is introduced to passengers onboard as the ship’s physician (implying he, like the Captain, is an employee of the cruise line), and like other senior officers may host a dinner table for invited guests, the cruise lines (without exception) say the physician is a private concessionaire and as such they accept no li- ability for mistakes made. This is a hard concept to grapple with, considering that the service is offered by the cruise ship (and which collects the fees), but it was supported by the Florida Supreme Court in February 2007 and the US Supreme Court in Oc- tober 2007.
The case in question began 10 years’ prior to the Court’s decision in March 1997.
Fourteen-year-old Elizabeth Carlisle was on a Caribbean cruise on the Carnival Des- tiny with her family, when on the second night out of Miami she developed severe abdominal pain. She consulted the ship’s physician, Dr Mauro Neri, who had finished medical school in his native Italy in 1981, had held nine medical jobs in Italy, Africa and England in the 15 years before joining Carnival Cruise Lines, and was earning
$1057 a month from the cruise line. Dr Neri advised that Elizabeth was suffering from
influenza and sent her on her way, but her pain became worse. On the third visit to the infirmary, after Elizabeth’s parents specifically asked whether the problem could be appendicitis, Dr Neri conducted his first physical exam and responded that he was sure the problem was not the girl’s appendix. When the pain increased, Elizabeth’s parents called their family physician in Michigan, who advised they return home.
They took this advice and shortly after arriving home Elizabeth underwent emergency surgery to remove her ruptured appendix. The infection had rendered the 14-year-old sterile and caused lifelong medical problems. Elizabeth sued Carnival Cruise Lines in Florida state court, a case she lost on Carnival’s motion for summary judgment. The cruise line claimed it was not responsible for the medical negligence of the doctor onboard and pointed to the fine print in the passenger cruise contract to support its position.
The family appealed the Circuit Court’s decision to Florida’s Third District Court of Appeal where the parents argued the cruise line was vicariously liable for the doc- tor’s negligence. Judge Joseph Nesbitt agreed and reversed the lower court’s decision.
The judge held that the cruise line had control over the doctor’s medical services for agency law purposes; the doctor was to provide medical services to passengers and crew in accordance with the cruise line’s guidelines. And as it was foreseeable that some passengers at sea would develop medical problems (and the only realistic option was treatment by the ship’s doctor) the cruise line had an element of control over the doctor–patient relationship. As such, the cruise line’s duty to exercise reasonable care under the circumstances extended to the actions of a ship’s doctor placed onboard by the cruise line. As an agent of the cruise line, the doctor’s negligence was imputed to the cruise line, invalidating the cruise ticket’s purported limitation of liability for the negligence of its agents.
Judge Nesbitt’s decision was groundbreaking, being the first case where a cruise line was held responsible for care provided by its physician. Not surprisingly, Carnival appealed the case to the Florida Supreme Court. While the court almost agreed with the lower court’s assertion that a doctor’s negligence at sea also shows negligence by the cruise line, it ultimately found in favour of Carnival. Justice Peggy Quince wrote in her opinion:
We find merit in the plaintiff’s argument and the reasoning of the district court. However, because this is a maritime case, this Court and the Florida district courts of appeal must adhere to the federal principles of harmony and uniformity when applying federal maritime law. (Supreme Court of Florida, 2007, pp. 18–19)
The case was appealed to the US Supreme Court, which refused to hear it. This dir- ectly impacts the more than four malpractice cases filed each year (Chen, 2007, D1).
Interestingly, medical care and medical malpractice are not addressed in the CLIA Passenger Bill of Rights (Cruise Ship Passengers Bill of Rights, 2015) that was issued in 2013 (see Klein, 2013 for an analysis of the Passenger Bill of Rights). Passenger rights when there is medical malpractice, was put into flux in November 2014 with a US Court of Appeals for the Eleventh Circuit decision in Franza vs Royal Caribbean Cruises (D.C. Docket No. 1:13-cv-20090-JAL; Case 13-13067). In this case a pas- senger was again misdiagnosed and the provision of medical care inordinately de- layed, both contributing to the passenger’s death. The decision effectively removed a cruise line’s ability to claim a shipboard physician is an independent concessionaire and that it was therefore not liable for that physician’s actions. Instead, the cruise line
can now be held liable for medical malpractice (Dickerson and Cohen, 2015). As stated by Justice Stanley Marcus in the court’s decision:
Here, the roots of the Barbetta rule snake back into a wholly different world. Instead of nineteenth-century steamships, we now confront state-of-the-art cruise ships that house thousands of people and operate as floating cities, complete with well-stocked modern infirmaries and urgent care centers. In place of truly independent doctors and nurses, we must now acknowledge that medical professionals routinely work for corporate masters.
And whereas ships historically went ‘off the grid’ when they set sail, modern technology enables distant ships to communicate instantaneously with the mainland in meaningful ways. In short, despite its prominence, the Barbetta rule now seems to prevail more by the strength of inertia than by the strength of its reasoning. In our view, ‘[t]he reasons that originally led’ other courts to adopt ‘the rule have long since disappeared.’ The rule rests on three basic arguments that a shipowner cannot exercise meaningful control over its medical staff. But as we see it, none withstands close scrutiny.
The impact of the ruling in Franza vs Royal Caribbean Cruises remains to be seen.
There is an opportunity now for passengers to believe they may have success in suing a cruise line for medical malpractice, but whether they will succeed and under what conditions remains to be seen.
Conclusion
A cruise ship is like a small town, with the largest ships afloat carrying nearly 9000 people. As in any town, there will be health issues, including illness outbreaks, sexual assaults and other crimes, and issues around medical care. Because cruise lines typic- ally hide these issues, claiming a cruise is safe and carefree, most passengers and crew- members board cruise ships without knowing the problems and without taking simple precautions. One purpose of this chapter is to provide information that may help passengers, staff and crew to take steps to protect their safety, security and health. An awareness of crime makes it easier to take steps for crime prevention, knowledge of how illness outbreaks begin and progress makes it easier to take steps to avoid illness, and having a clear set of expectations of the nature of health care on a cruise ship al- lows one to make informed decisions.
References
Ando, T., Noel, J.S. and Fankhauser, R.L. (2000) Genetic classification of Norwalk-like vir- uses. Journal of Infectious Disease 181, Suppl 2, S336–S348. doi:10.1086/315589 Bonifait, L., Charlebois, R., Vimont, A., Turgeon, N., Veillette, M., Longtin, Y., Jean, J. and
Duchaine, C. (2015) Detection and quantification of airborne norovirus during outbreaks in healthcare facilities. Clinical Infectious Diseases April 21, 299–304. doi: 10.1093/cid/civ321.
CDC (2002) Telebriefing transcript: outbreak of gastrointestinal illness aboard cruise ships, 12 December. Centres for Disease Control, Atlanta, Georgia. Available at: www.cdc.gov/
media/transcripts/t021127.htm (accessed 22 October 2015).
CDC (2015) Guidelines for the prevention and control of norovirus gastroenteritis out- breaks in healthcare settings, 2011. Centres for Disease Control, Atlanta, Georgia. Avail- able at: www.cdc.gov/hicpac/norovirus/011_norovirus-evidence-review.html (accessed 22 October 2015).
Chen, S. (2007) Trouble at sea: free-agent doctors. Wall Street Journal 24 October. D1. Avail- able at: www.wsj.com/articles/SB119318197257869091 (accessed 22 October 2015).
CLIA (2008) Market Profile Study. Cruise Lines International Association, Fort Lauderdale, Florida.
CLIA (2011) 2011 CLIA Cruise Market Overview. Cruise Lines International Association, Fort Lauderdale, Florida.
Committee to Advise on Tropical Medicine and Travel (2005) Statement on cruise ship travel.
Canada Communicable Disease Report 31, ACS 8 and 9 (15 October).
Cramer, E.H., Gu, D.X. and Durbin, R.E. (2003) Diarrheal disease on cruise ships, 1990–2000.
American Journal of Preventive Medicine 24(3), 227–233.
Cramer, E.H., Blanton, C.J., Blanton, L.H., Vaughan, G.H., Jr, Bopp, C.A. and Forney, D.L.
(2006) Epidemiology of gastroenteritis on cruise ships, 2001–2004. American Journal of Preventive Medicine 30(3), 252–257. doi: http://dx.doi.org/10.1016/j.amepre.2005.10.027 Cruise Junkie (2015a) Your resource for the other information about the cruise industry. Avail-
able at: www.cruisejunkie.com (accessed 22 October 2015).
Cruise Junkie (2015b) Cruise and ferry passengers and crew overboard 1995–2015. Available at: www.cruisejunkie.com/Overboard.html (accessed 22 October 2015).
Cruise Law News (2015) Jim Walker’s cruise law news: Breaking news and legal commentary regarding cruise ship passenger and crewmembers around the world: CDC Press Re- lease for Cruise Industry backfires. Available at: www.cruiselawnews.com/2014/06/
articles/norovirus/cdc-press-release-for-cruise-industry-backfires (accessed 22 October 2015).
Cruise Lines International Association (2015) Medical facilities. Available at: www.cruising.
org/about-the-industry/regulatory/industry-policies/health/medical-facilities (accessed 22 October 2015).
Cruise Ship Passengers Bill of Rights (2015) Cruise Ship Passengers Bill of Rights. Available at: www.cruiselawyers.com/sue-a-cruise-line/cruise-ship-passengers-bill-of-rights ( accessed 22 October 2015).
Dickerson, T.A. and Cohen, J.A. (2015) Medical malpractice on the high seas. New York Law Journal (3 March). Available at: www.newyorklawjournal.com/id=1202719354971?
keywords=barbetta&publication=New+York+Law+Journal (accessed 4 March 2015).
Dishman, L. (2007) Laurie Dishman. International Cruise Victims Association. Available at:
www.internationalcruisevictims.org/LatestMemberStories/Laurie_Dishman.html (accessed 22 October 2015).
FOIA (2011) FOIA request #09-4707: Linda Griesman Christopherson; requesting the Coast Guard cost that was incurred in the search for Michelle Vilborg, letter dated 15 October 2011.
Frantz, D. (1998) On cruise ships, silence shrouds crimes. New York Times, 16 November.
Available at: www.nytimes.com/1998/11/16/us/sovereign-islands-a-special-report-on- cruise-ships-silence-shrouds-crimes.html?pagewanted=all (accessed 22 October 2015).
Frantz, D. (1999) Getting sick on the high seas: a question of accountability. New York Times, 31 October. Available at: www.nytimes.com/1999/10/31/us/sovereign-islands-special- report-getting-sick-high-seas-question-accountability.html?pagewanted=all (accessed 22 October 2015).
Gadher, D. (2001) Cruise liners face tougher hygiene tests. Sunday Times, 6 May, Times News- papers Ltd, London.
Klein, R.A. (2008) Paradise Lost at Sea: Rethinking Cruise Vacations. Fernwood Publishing, Halifax, Nova Scotia, Canada.
Klein, R.A. (2012) Testimony before the Senate Committee on Commerce, Science, and Transportation. Hearings on ‘Oversight of the Cruise Industry’. 1 March.
Klein, R.A. (2013) Testimony before the Senate Committee on Commerce, Science, and Transportation. Hearings on ‘Cruise Industry Oversight: Recent Incidents Show Need for Stronger Focus on Consumer Protection’. 24 July.
Klein, R.A. (2015) Crime at sea: a comparison of crime on Carnival Cruise Lines, 2007–2011.
In: Papathanassis, A. (ed.) Cruise Business Development – Safety, Design and Human Capital. Springer, Berlin, pp. 17–28.
Klein, R. and Poulston, J. (2011) Sex at sea: sexual crimes aboard cruise ships. Tourism in Marine Environments 7(1), 67–80.
Korten, T. (2000) Carnival? Try Criminal: What happens when a female passenger is as- saulted on a cruise ship? Not much. Miami New Times, 3–9 February. Available at: www.
miaminewtimes.com/2000-02-03/news/carnival-try-criminal (accessed 22 October 2015).
LaMendola, B. and Steighorst, T. (2002) Cruise line blames passengers for 3rd viral outbreak on ship. Sun-Sentinel, 12 November. Available at: www.gpo.gov/fdsys/pkg/CHRG- 113shrg94526/html/CHRG-113shrg94526.htm (accessed 22 October 2015).
Lindesmith, L., Moe, C., Marionneau, S., Ruvoen, N., Jang, X., Lindblad, L., Stewart, P., LePendu, J. and Baric, R. (2003) Human susceptibility and resistance to Norwalk virus infection. Nature Medicine 9(5), 548–553.
Morbidity and Mortality Weekly Report (MMWR) (2001) Norwalk-like viruses. Morbidity and Mortality Weekly Report 50, RR-9, 1 June.
Supreme Court of Florida (2007) Carnival Corporation vs Darce Carlisle, Case No. SC 04-393, 15 February.
US Congress (2013) Cruise Ship Crime: Consumers Have Incomplete Access to Cruise Crime Data. 24 July. Senate Committee on Commerce, Science, and Transportation, Washington, DC.
Widdowson, M.-A., Sulka, A., Bulens, S.N., Beard, R.S., Chaves, S.S., Hammond, R. and Glass, R.I. (2005) Norovirus and foodborne disease, United States, 1991–2000. Emerging Infectious Diseases 11(1), 95–102.
Introduction
The economics of cruise shipping is about the economic mechanisms operating in the cruise industry and within cruise shipping businesses, about the contexts which trigger them and the outcomes they produce. People unfamiliar with cruises tend to believe that the cruise industry is profitable because cruises are so expensive. This claim is routinely rejected by cruise experts, including experienced passengers, who argue instead that the price tag of mass market cruise holidays is not much different from that of land-based hotel accommodation of similar standard with full board in popular tourist destinations, and that cruises include a range of additional amenities, tilting the balance in favour of cruises. It has even been suggested that cruise ships could serve as cost-efficient alternatives to land-based assisted living facilities for the elderly (Lindquist and Golub, 2004).
Interestingly, the laypeople’s view is both contestable and defensible. When unin- formed commentators stress the high price level of cruises, their judgement reflects prejudice (‘cruises are for the rich’) and misunderstanding (‘the ticket price is what you pay for your cruise’). Yet, as Kurt Tucholsky (1931) wrote, ‘The people get most things wrong, but feel most things right’ (p. 500; author’s translation), and so it is here. Cruises are expensive, but not so much for their price tag as for the many extras that passengers are seduced into buying before and during their vacation at sea, and for the significant service charges and gratuities, which are voluntary from a legal point of view, but morally and habitually compulsory. Cruises are also expensive in terms of the environmental and social costs that are externalized by cruise operators (Klein, 2011; Manning, 2012).
Studying the economics of cruise lines requires access to fairly detailed financial data. However, most cruise lines are privately held and not obliged to publish their financials. Fortunately, the two biggest players of the industry, Carnival Corporation (Carnival) and Royal Caribbean Cruise Line (RCCL) have been stock-listed for over 20 years. Much of their historic and recent financial and other data are publicly avail- able in their annual reports (Carnival, 2015; RCCL, 2015). What is more, Carnival and RCCL with their 142 ships and sales of US$24 billion in 2014 have a combined
7 Economics of Cruise Shipping:
The Need for a New Business Model
M
ichaelP. V
ogel*
Bremerhaven University of Applied Sciences, Institute for Maritime Tourism, Bremerhaven, Germany
*E-mail: [email protected]