This will require training many family physicians in aerospace medicine if each person is to get an individual assessment of their fitness to travel. Under many human freedoms protected by laws, freedom of movement is one of them and thus it is that airlines can cater for wheelchair passengers, passengers with heart or pulmonary conditions that require supplemental oxygen, passengers with diabetes, blind or deaf people. Babies, who don't have mental acuity or even self motility can travel if they have an accompanying adult, and likewise, persons who have difficulty in traveling can have an aide travel with them. Airlines typically, when accepting such travelers, try to assist them as much as possible, but do not and should not accept responsibility for the effects of the aeronautical environment on their medical condition. What you have proposed does make sense, but it should not require a medical certificate to be presented to a common carrier...where will you draw the line? Bus, train or ship transport modes may all present environmental risks for certain suffering victims of diseases or disabilities. Age has very little to do with this so what you are saying is we must deny some old people the right to travel if people cannot prove the travel will not hurt them. Why not say no one should eat in a restaurant unless they can prove that food poisoning will not affect them?

This will require training many family physicians in aerospace medicine if each person is to get an individual assessment of their fitness to travel. Under many human freedoms protected by laws, freedom of movement is one of them and thus it is that airlines can cater for wheelchair passengers, passengers with heart or pulmonary conditions that require supplemental oxygen, passengers with diabetes, blind or deaf people. Babies, who don't have mental acuity or even self motility can travel if they have an accompanying adult, and likewise, persons who have difficulty in traveling can have an aide travel with them. Airlines typically, when accepting such travelers, try to assist them as much as possible, but do not and should not accept responsibility for the effects of the aeronautical environment on their medical condition. What you have proposed does make sense, but it should not require a medical certificate to be presented to a common carrier...where will you draw the line? Bus, train or ship transport modes may all present environmental risks for certain suffering victims of diseases or disabilities. Age has very little to do with this so what you are saying is we must deny some old people the right to travel if people cannot prove the travel will not hurt them. Why not say no one should eat in a restaurant unless they can prove that food poisoning will not affect them?

It is known that air travel is the safest means of transport but can have adverse physiological effects especially in patients with chronic pathologies and long flights (reduced cabin pressure, gas expansion, low moisture, immobility etc etc etc ..).

Patients with chronic illnesses should be evaluated by your family doctor to find out if their clinical condition allows them to travel. With a "fit to fly" is sufficient.

However, this is not always the case, as is desirable, and there are patients who travel with severe anemia, uncontrolled heart failure, low saturations in patients with chronic bronchitis, recent stroke, even people that do not use oxygen at home to fly, etc, etc, etc ... This happens due to ignorance and / or lack of judgment passenger not go to the doctor, do not ask and traveling. To avoid these situations and their consequences is what we must work towards solutions.

I think first of all the health policy makers must design a guideline for this purpose. The air travels, the altitude that airplanes should fly in in mountainous ways, the time of travel, the ability of different airplanes to maintain internal pressure and of course the risk factors of patients must be considered. and after that patients should be screened. undoubtedly such examination for all passengers of all air trips is expensive and impractical

I totally agree with Greg Fox!!!

What about communicable diseases? I was on an airplane from NYC to London and passengers lived in the bathroom- suggestive of norovirus since by the time we arrived everyone was complaining of abdominal pain. Not so sure you can regulate who flies and who does not.

Independently of the age, is correct ask for medical report to fly ? What is certain age in the actual era: 70,80,90 or more ? Which risk factors of patients must be considered ? I agree with Jean - we can't regulate who flies and who does not

Strongly agree with Greg’s point that who is traveling cannot practically and should not be regulated. And reasonable advice already exists re Communicable diseases http://www.who.int/ith/mode_of_travel/tcd_aircraft/en/index.html

The idea of a ‘fit to fly certificate’ has two sides:

1) In one way it already exists since all major airlines have a medical service where a person’s risk profile can be assessed and also help with providing additional oxygen etc. if needed.

2) How many doctors really have the aviation medicine expertise needed to make a proper assessment – how many are using the available guidelines? And which conditions is really a problem see http://www.asma.org/asma/media/asma/Travel-Publications/medguid.pdf

In addition the emergency kit carried by the airlines is actually quite sufficient for most emergencies

I think the discussion misses a very important aspect and that is how big a problem is it we are discussing. See for instance a resent paper on the topic http://www.nejm.org/doi/full/10.1056/NEJMoa1212052

So yes a theoretical scientific discussion is always stimulating when backed by evidence and luckily for the millions of passengers traveling each year our discussion does not seem to represent a major issue of concerns – actually data suggest it is a very minor problem.

I agree the magnitude of the problem is one of the main issues to be considered in taking the decision

Some airlines already restrict pregnant women during their last trimester. American Airlines, for example requires a doctors letter saying they are Ok to travel during the last 4 weeks of pregnancy. Yet there is no evidence that flying induces early labor. Most women, I suspect, would not want to travel during the last 4 weeks of pregnancy but emergencies do occur. Women are still targets for this type of discrimination.

In a hospice where I was employed, we encouraged our terminally ill patients to fly to see relatives, friends, even places they want to see. The families were encouraged to inform the airlines and we made arrangements for care at the landing site.

Airlines are in the business of transporting people from one place to another. I believe they have a responsibility to prepare for people emergencies as well as flight emergencies. However, the choice to take a risk to fly should remain with the person flying. The only people restricted from flying should be those who present a threat to other passengers, like terrorists and those with life threatening communicable diseases.

Its a good topic for this era where there is possible to visit multiple countries within a short period irrespective of age and health condition. It is the primary responsibility of the travelers to understand or be familiar with the consequences from the decision that they take to travel by air. However, it is also a part of professional and organizational policy together with its corporate social responsibility to take care of such travelers and make arrangements by providing first aid training to its crew members and emergency basic medicines and supplies. Best wishes to the travelers and airline companies.

Following this exchange of views, there is a very interesting work of

Michael Sand et al en http://ccforum.com/content/13/R3 which reads:

The rate of aircraft diversion in our study was 2.8% (279 diversions).

Other studies report diversion rates of 13% and 7.9%,

whereas Cathay Pacific reported 0.35% for the year 2005.

Besides its important medical impact, IMEs leading to

aircraft diversion also have a considerable economic and ecological

impact. A fully loaded Boeing 747 needs 23.5 litres

kerosene/100 km at the start phase on the ground, which is

about 2 km long and 3.4 litres kerosene/100 km on the climb

flight, which is about 100 km. In cases of flight diversion, the

impact of dumping fuel due to weight restrictions for landing is

an additional financial and ecological factor. Besides the logistical

challenge, aircraft diversion is also accompanied by a significant

financial loss. The total costs of a diversion depend on

the size of the aircraft, ranging from $30,000 to $725,000 per

diversion, which may encourage airlines to focus on improved

pre-flight screening of chronically ill patients.

Other recommended works

Medical issues associated with commercial flights. Siverman D, Gendreau M. Lancet 2008;373:2067-77.

Air travel in older people. Low JA, Chan DKY. Age and Ageing 2002;31:17-22

There is a problem, large or small according to what we want to see. But the train, bus and restaurants do not enter into this problem.

I am of the opinion that purchase of flight tickets for flights of over 2 hours should require filling in a simple questionaire and list of medications. A few years ago I was on a flight from London to New York. About 2 hours out of NY the crew called for the help of any physician on board. I seem to have been the only one. A passenger in 1st class travelling alone was unconscious and had occasional clonic contractins. He was travelling alone and we had no real information. Vital signs, BP and pulse were normal and he did not have a fever. The captain of the plane informed me that he could land in Halifax within half an hour and wanted to know my opinion. As I had no real equipment and did not know what was going on I suggested that he land. On landing the paramedic boarded and told me that they had a set protocol and the first item was to set up an infusion and give glucose. This was done and in a few minutes the passenger woke up. He then informed us that he was a diabetic but had never had an attack of hypoglycemia. The crew requested that he leave the plane according to accepted practice. The passenger refused to disembark and insisted to continuing his journey to NY. The subsequent discussions between the aircraft captain, the local authorities in Halifax and the medical officers of the air company went on for about 2 hours. It was then decided to allow him to continue, on condition he takes responsibility and on condition that I sit next to him for the rest of the flight. Had we known earlier of his condition it is possible that either I or the crew would have been able treat him without interrupting the flight. Needless to say the air companies take advantage of physicians on flights. I was given a bottle of champagne.

Think it will reduce the unnecessary complications to a certain extent and will not cause inconvenience to other passengers and physicians on flight.

Very interesting experience sharing. In many occasion, service provider purposefully generate situation that allows them to ensure benefit without single possibility of the loss.

Another simple and clarifying work is to Qureshi A, Porter KM Emerg Med J 2005; 22:658-659 where they conclude among other things

Exacerbation of pre-existing medical problems accounted for

the majority of in-flight emergencies. Pre-flight advice,

screening and an increased awareness by ground staff may

recognise passengers who are medically unfit to fly.

Information posters in the check-in area to remind passengers

to carry their regular medication on their person may

prevent some of the in-flight medical emergencies.

Categories of problems (n=507)

Exacerbacion of pre-existing problem 65%. New medical problem 28%. Traumatic injury 7%.

I still think that the family doctor has an important role for these problems are reduced gradually in the future. Advise patients, warning them of their limitations and of their responsibility when traveling against your doctor's opinion.

Totally agree with the opinions of Drs Boner and Syburra

Patients' education will be the best and in case of doubt, practionner's opinions and informations must be sufficient. For pregnant women flying within their last trimester, obstetrician opinions should be required, whereas i believe that "high risk" pregnant women should not travel

Whilst I can understand Luis Landin's general economic viewpoint, the original question posed was age related, rather than condition/ disease related. The ethics of forcing elderly travellers to provide a health certificate is contentious, and may become more so with an increasingly ageing population. What hard evidence is there that elderly passengers are responsible for the majority of diversions ? (The Low and Chan article in Age and ageing merely speculates that there might be increasing problems) . In relation to conditions, as already mentioned there are EASA European Aviation Safety Agency published regulations regarding passenger's health conditions and their inpact on flight safety; EASA.2008.C.25 (http://easa.europa.eu/rulemaking/docs/research/EASA%202008.C.25%20Final%20report%20Issue%201.1.pdf). The logistics, economics and governance issues relating to training and certifying a cadre of global doctors to reliably provide these putative certificates in a valid and reproducible manner are also not to be underestimated - this may out weigh any benefits in preventing a proportion of diversions; I say a proportion of diversions, because as already hinted, some diversions will be unforseeable, irrespective of any certificate provided.

advanced age? The definition will not be consensual. Some advanced age may have any disease, whereas severy ill patients may be younger such as diabetes or COPD patients ?

informations and education of the patients by practionners , seems, for me to be the best

We may have a prospective study on this issue. A study using different age groups, with and without chronic conditions, short trips, long trips, with medical permission, without permission etc, etc ... It would be very interesting to perform this type of work and see what it brings. I have doubts if airlines could collaborate on this project for the inconvenience that customers would suffer

Enjoy a lively debate; however some comments could be viewed form different perspectives as well – as is always the case in an academic discussion.

@Boner ‘Needless to say the air companies take advantage of physicians on flights. I was given a bottle of champagne.’ My view as a very frequent 8 – 10 hours traveler is that it actually protect medical qualified persons stepping forward on calls for assistance in that the ‘no payment policy’ protects us from the possible litigation that ‘we did it for profits’ – hence the legal context of a profit motive – when deciding to advise for a diversion/ or to continue. Bottom line keeping the ‘Good Samaritan’ principle in aviation protects those of us who like to help our fellow travelers as opposed to your comment which could be interpreted as advocating for a ‘fee for service’ principle. Might add that I have had the experience that airlines/the insurance companies when asking for a written report on the inflight incidence have compensated quite generously for ‘ the total service’ – so the payment issue seems to be carrier specific as well.

@Landin ‘think that the family doctor has an important role for these problems are reduced gradually in the future. Advise patients, warning them of their limitations and of their responsibility when traveling against your doctor's opinion’. Two questions that have not been discussed that in my opinion need some discussion as already raised by Datta:

1) Are the GP's qualified to give the advice with whatever training they have today – or is specific training needed?

2) Is it a fee for service payment – hence increases the doctors’ income and adding to the total cost of traveling? Another way of asking the same question is that what you propose represent in economic terms an opportunity cost regardless of how you look at it – who is the payer?

I like your last comment implying that we should compile all the data (big data approach) that we know is out there and lets apply a rigor analyzes.

@Datta I agree with you that the EASA.2008.C.25 is a central reference for this discussion. Another resource to add to the discussion is ‘Comprehensive Medical Topics’ resource list

http://www.faa.gov/passengers/fly_safe/health/comprehensive/

Is it time for this discussion to be divided into several treats? – Certainly many interesting issues have been touched upon?

Definitely support more research in this area as Louis Landin has suggested. One of the issues of concern in this type of research that has not been discussed is normal occurrences on the ground and distinguishing them from air travel events. For example, we know that 1/3 of all individuals over the age of 65 will fall every year. Every day 1.73 million people take a flight in the US. A certain percentage of them are over 65. It will be important to calculate if those seniors fall, what is the percentage that can be attributed to air flight and what percentage would have happened no matter the circumstances? We may find fewer fall during air travel.

This same issues applies to all medical events. Medical events happen all the time. We always hear air travel is safer than car travel. Maybe there are fewer medical events occurring in the air than the same population would experience on the ground.

We would need a baseline of medical events that occur more frequently during air travel than what would normally occur on the ground. Then it would be possible to look at what medical events airlines, doctors etc should be alert to and prepared for as well as how to advise passengers.

Patients with pulmonary hypertension or cor pulmonale are routinely ordered not to fly by their physicians. Clearance to fly should be a matter between the individual and their physician.

NO for short distance fly

YES for long distance IF there is enough data to support safety concern/fear of the flight!

In answer to questions from Dr. Nielsen.

In countries where there is Social Security, such as Spain, people have free health care and therefore no additional costs.

The family physician, knowledgeable about the pathologies of patients, "advises", depending on the clinical situation if air travel is appropriate to do so or it is better to use other means of transportation. In terms of training, I think you do not need special preparation. I speak not of official certificates and authorizations. This would be another approach.

1. Airlines should not seek medical report for passengers of advanced age or with chronic diseases. It is the responsibility of the passenger not to expose himself to a risk, after consulting his physician, attributed to airline trip or even car travel. To protect the airlines companies, a warning should be issued to passengers to consult their physicians for their protection from any factor viewed by the physician as endangering their health or life. Airlines are not practicing preventive medicine.

2. Airplanes are pressurized, so that the plane will maintain its normobaric pressure, hence its partial oxygen pressure will not change or decrease. No excessive risk is thus exposed to COPD or pulmonary hypertension patients compared to other population as there is no lower partial oxygen pressure

3. It is wise to refer to medical accidents data base over the last 10 or 20 years to retrieve the people most endangered by air flight. It would give an idea, which people should be given special care

4. Flight risks in certain patients due to transportation in a non-medical milieu, should be minimized by special medical devices/ procedures/ assistance coordinated by the airline company and the physician in charge of patient. It is performed by most, if not all, airline companies. Sometimes the flight is still justifiable even if the risk cannot be totally abolished, viewing the higher exposed risk if the particular patient is not transported.

@ Landin: Agree that in countries with socialized medicine the cost of a consultation regarding air-travel advice is not paid by the patient but by society – in that I assume that doctors working in countries with socialized medicine are paid a salary either as a lump sum, fee for service or a combination. Even if you argue the doctors will do it for free accordingly to economic theories that translates into increased service for unchanged paid i.e. decreased pay for the service as it was provided before travel advice was added as a service since you now have an added extra service for the same price. Of cause in societies with private insurance the traveler will carry the full cost (I’m using Smith classification of healthcare systems).

Therefore I’m maintaining the claim that the preflight assessment proposed for aging travelers represents an opportunity cost regardless of how it is organized or in which type of healthcare system it is implemented.

Of cause the economical part of the discussion opens a whole new domain; whether one want to apply health technology assessment, Health needs assessment or cost benefit analysis to assess the impact of the proposed intervention and one needs to assess the impact on different types of healthcare systems as well.

Regarding training/certification I would argue that the discussion in this forum clearly have revealed that a general upgrade of knowledge would be required in order to make sure the aging traveler would be given evidence based advice.

@ Schapera: thanks - cabin pressure issue well summarized and documented – might add that the newest planes on the marked (both Boing and Airbus) have cabin pressures not exceeding the equivalent to 6000 ft. SL – so doctors might want to advice their patients to use carriers using new and modern planes .

Thanks to Schapera for adding the references about cabin pressurization. You are correct, this would make, compromised patients intolerant to lower oxygen pressure.

Yes, because age above 50 years old has a high risk for vital sign alteration, therefore for above this age and in a specific condition for everyone , a physician should be ask about medical history. If may be, the experts make a detail guidlines about flight medical check list.

thank you Nwhator, many of people has hiden disorder then may be there is an increase risk for flight. what is your comments?

Whatever you can rationalize this issue, we cannot avoid serious medical problems during flights. As an example, I remember a case of a young woman who died during a European continental flight. She was not at her first experience on air, but the autopsy showed a big bronchogenic cyst that inflated hugely causing cerebral air emboli and death. No previous medial report had been able to alert that young woman she were at high risk to fly.

"medical report", not "medial report"

In my opinion it is the responsibility of the traveler, to get himself checked by his physician to evaluate whether or not he can travel. The airlines responsibility is to get passengers from point A to point B. The airlines may not be held responsible for passengers' illnesses. For that matter even if airlines ask for a medical report from the patient before travel, still there are chances that that patient may have some problems during the flight. Normally if there are any problems during the flight, it is obvious that in the interests of the patient airlines may ask for an onboard physician if any to provide any help and as a Good samaritan, he can provide whatever help he could or in case if no help could be available during the flight, the captain can make a decision to land and seek help. It is definitely an inconvenience for the other passengers. The airlines may try to different strategies to minimize inconvenience to other passengers without compromising emergency medical care for the patient.

I think it is the passenger's right to go on board and fly to the destination he/she wanted. I do agree with Omer Iqbal that this is the responsibility of the passenger to get him/herself checked prior to his/her flight. It's the duty of family physician, or travel medicine specialist, to assess whether he/she is fit enough to fly.

Lately, I've been thinking about adding a person in aircrew: physician with specialize training in aeromedicine.

My opinion. Passengers should be advised of the circumstances inherent in plane travel, along with the other recommendations before boarding. These cases may affect not only to elders but also to people sensitive to altitude, and they are probably not aware of that, but if they are and assume the risk, they are doing it involving passengers, crew and airline with that decision, that's when the question becomes relevant.

Persons with known cardiac and other debilitating illnesses must carry a medical certificate from certified medical doctor. Airlines cannot take up responsibilities for the online travel passengers. I have had an occasion to attend

To heart illness patient on my way to New York in Air India flight about 15 years back and fortunately an attedent his daughter was accompanying this person and I could successfully help the person. I feel knowing fully well that his travel was risky, I feel, he should not be traveling by air without a doctor's certificate containing what medications he was on. Please note that I became a new doctor for him and I really was in predicament whether I am certified to treat him as I am certified in India.

Since I was the only "doctor" at that time, I did what I thought was correct. There are persons who need to travel, but with very useful documents.

Dr. H. N. Madhavan. MD., PhD., FAMS.

There could be occasions when such questions are faced by the airlines for certain passengers with already compromised status of tissue oxygetation.whether due to age or illness. It is also possible that some such passengers could influence a medico to issue a biased report / certificate owing to their compulsion to travel. Although it is only a relative state of hypoxia (if it may be so caused) inherent in the commercial aircraft by keeping the cabin altitude at 6000 to 8000 ft AMSL very much tolerable, certain individual or patients already in the borderline 'oxygen compromised state' may be susceptible to gradual or acute onset of hypoxia related pathophysiologic event thus creating an in-flight emergency.

As the medical practice and faacility is advancing all over world, it may be a good idea to employ a specialist in Aerospace Medicine at least at the busy airports for their quick assessment and suggestion, if any.

Many of the issues discussed in this forum is fairly well covered in the IATA document https://www.iata.org/whatwedo/safety/health/Documents/medical-manual-2013.pdf

For this discussion ‘section 1.2 passengers health’ and ‘section 6 – passenger care’ is particular relevant.

It seems to me that many of the participants really have no feel of how the aviation industry is advised/ regulated on the issue of passengers’ health (IACO, IATA etc…) and the options/ solutions already available.

Let’s tighten up and get back to the original question: “Should airlines ask for a medical report from people of a certain age that indicates if they are able to fly?”

No. Firstly, it is ageist - age discrimination - not everyone who is "old" has medical problems, and there are younger passengers with potentially worse medical conditions. Secondly, what is the purpose? Is it so that the airline will get compensation back from the doctor if someone is certified OK but then gets ill on board? If that is the case, no doctor will certify anyone - how can any know when anyone else will or will not get ill in air?

A recent NEJM article showed that there was 1 in-flight medical emergency per 604 flights and estimated that there were 44,000 in-flight emergencies worldwide (NEJM 2013; 30 May issue). For the total number of passengers that take flights, it is not a big number. And there is no evidence that making people get certificates will reduce this number. But only to serve to inconvenience lots of people.

Generally speaking , No, but it depends on the travelling hours and the person's medical back ground

No please!

No. I think such legislation will be discriminatory against the elderly. In developing countries, it would place additional strain and financial burdens on travelers. In many African countries, getting treatment even when you are ill is onerous task! By the way, who says someone who is medically fit before boarding a plane cannot suddenly develop serious health complications after take off?

As Anthony Schapera mentioned above: there are important legal issues involved on this matter, since far beyond what someone could consider inapropiate to do, might be appropiate for one other. It does not exclude creating a global regulation to avoid high risk travelers to move inside a country or outside. There are constitutions and laws which may vary, and for which in fact, can not fully comply a standard given by IATA or any other regulation.

Regarding this, mental health also should be considered, and it may become a bigger headache, but also gives a clue on where this questioning must be directed. A time ago I worked at an airline, and to be plain, we attached to the document mentioned by Anders Nielsen, but it came to be part of the good will and proper evaluation of the airline staff to assess any abnormal behavior of a passenger to require a medical report, or any other action, which in fact was very unusual, considering as usual drunk people, narcotics transport related practices, nevertheless no airline can deny a service without a very certain reason.

The matter is common sense, social responsibility, which might encourage travelers and/or companions to ask for a medical report to make sure they can travel with no risk (when there are reasons to do so). If this subject leads to politics and legal aspects of air transport, in fact the point goes from evens to odds in discussion.

Discuss this done or written is, in principle, healthy. First are the ideas and then the rules. The free disqualification is never good. I try to convey that talk about security and cooperation of citizens for their own safety and welfare and that their behavior or decisions not alter or injure their fellows. Travelling knowing that is not indicated and may have consequences for the patient himself and those around him is a big responsibility.

On the other hand, talk about training in aerospace medicine and increased spending on public health seems interesting. However, some thought that a family doctor should know when a patient is fit to fly. Rising health care costs may be offset by the savings to the extent that it can produce.

Dear Luis - thank you for summarising the discussion above. This recent article in the New England Journal of Medicine on the subject is very helpful. It covers five airlines and 10% of all flights for two years. 1 medical emergency occurred in every 604 flights. Aircraft diversion occurred in 7.3% cases i.e. only in 12 per 100 000 flights. The authors also helpfully provide an algorithm for dealing with the common emergencies that arise.

Article Outcomes of Medical Emergencies on Commercial Airline Flights

Dear Avijit, thanks for your intervention. The study is interesting but limited because it is retrospective. I have already indicated in previous speeches the desirability of a prospective study admitted to study, among other parameters, the debate presented. I understand that the numbers are small but they are there. 875 aircraft diversion, 2804 transport to a hospital, 901 hospital admission and 36 death. Of these, how many have been avoided with a simple "not fit to fly" of the family doctor?

No for screening asymptomatic people before travel!

Do we really have a problem? What is the absolute (not relative) rates of death /pre-death states compared with the background rates among the high risk groups?

To what degree are our evaluations (physicam exam & lab) able to predict life threatening events in the asymptomatic population?

It seems if there are 12 in a 100,000 flight diversions due to medical emergencies on a plane, someone could determine what conditions in the traveler caused those emergencies. There is probably a pattern to those conditions. It has been a much touted statement that flying safer than driving. That implies the number of medical emergencies would be less on a plane than on the highways. Comparing that data would be fascinating. Also a strong definition of medical emergency would need to be agreed upon.

One issues also, which is not addressed by the airlines, is the prevention of blood clots or emboli especially during long flights. These episodes may occur days after the passenger has landed.

Also terminally ill patients are often encouraged to take trips to see people or places they want to visit before they die. Does anyone know how frequently that occurs? I know of a nurse who was the companion to a relative who was terminally ill traveling by airplane back home. He died in route but the nurse didn't tell anyone and somehow managed to get this relative off the plane and into a car and to her house where he was pronounced as dead.

Would the airlines want to restrict the travel of terminally ill patients? Tough questions.

I do not know if I understand the comment of the Madelaine. The patient's death that accompanied the nurse did not officially communicated to the crew or the aircraft commander or there was an agreement with the nurse and the patient leaves the plane as live. The death of a patient on a scheduled flight has many legal consequences, even the authorities can, in theory, to seal the plane until we know the cause of death (imagine an A380 or 747 ..... arrested a week). To my knowledge there are no scheduled airlines admit patients "last will" is more, if they perceive that something happens that is unusual and it may reject not fly

I recommend entering the CDC website in the share of Travelers Health, http://wwwnc.cdc.gov/travel/page/preparing-for-appointment and read what is said in How to Prepare for Your Pre-Travel Appointment. In all sections appears: Before you travel make sure you speak with your doctor.

I think my point about the hospice patient dying in flight is more focused on the need of hospice patients. I don't know if airlines have policies about hospice patients, if not they should. It would seem to me if someone is terminally ill and wants to take one last trip and is a DNR, dying on the plane should not constitute a big legal event.

For me this has been a great discussion because of all the ramifications associated with medical issues and flying. There's a lot of research that should be done, in my opinion, before airlines make administrative decisions that are more designed to protect them then the passengers.

Currently, I believe that neither the airlines nor the insurance companies are considering studying this situation, given the complexity of the problem. The patient may die on the plane or at the destination and then having to repatriate the body to its place of origin. The airlines believe there are private companies that could do the service. At what price?. In Europe approximately € 3,000 an hour flight. The family would take care of the expenses of repatriation of the body because the insurance companies do not would. Companies take measured risks and such situations are not in their economic plans

Of course. But the patient has to travel as normal passenger without declaring their disease. If the patient says his illness is all different

I concur with Anthony Schapera.

If a terminally ill individual died during his/her travel, they may have fulfilled their final wishes to "fly away" without disclosing the fragility of their health because prior to flight, they were "strong" enough to pass all pre-flight checks and informed relatives or carers e.g. nurse.

Due to the knowledge of the carers and/or nurses/doctors, the terminally ill individual will receive necessary assistance required.

In this case supposed, is the attending physician who must tell if the patient is fit to travel. If he can travel without any help, no problem but if he needs some kind of support for the trip should tell the company to get stronger wheelchair, oxygen etc. .. and finally, if the treating physician advises against travel, patients must not travel.

Given the lively discussion we have on this topic and the real concerns of the airlines to screen patients before the flight and the public concerns of getting approvals before their intended flights, it seems reasonable that the airlines in some limited circumstances raise concerns regarding the flight of a passenger on health grounds. In this connection the airline may request the passenger to check with his or her personal physician and get an OK to fly. Based on the recommendations of the physician, the airline may permit passengers to fly, explaining fully to the passenger, the likely adverse effects of the flight on that particular passenger and that he or she may seek guidance from the insurance companies to cover for the expenses if any due to any cause. However, the real question is regarding a particular sick passenger who may likely delay or postpone or sometime cancel the flight and the impact it creates on the travel schedule of other passengers and the financial loss the airlines may have to incur. A very debatable topic.

Based on the original question, "Should airlines ask for a medical report from people of a certain age that indicates if they are able to fly?"

An individual may be susceptible to a chronic condition at any age and may have a longer-term chronic condition that is regularly treated. There should be no age bracket for requesting a medical report, thus eliminate any age discrimination.

It is the willingness of the individual and those carers/nurse/doctors who will provide information regarding the appropriateness of travel and necessity of any medical report.

There are so many experts an airline can refer to but those closest have the best knowledge of this ability.

An example

First Situation

Mrs. and Mr. Smith live in Rome and want to make a trip to Bali 12 days. They go to a tour operator who organized the trip with your assistance included.

They arrive at your hotel from Denpasar and seven days Mr. Smith suffers a fall down some stairs. Is transferred the patient to the hospital in an ambulance, the company is talking with assistance to cover operating expenses and is a femur fracture. Mr Smith has a 78 years with a history of hypertension and COPD. The evolution in the postoperative period is torpid because it makes a exacerbation of COPD and contributes very little with chest physiotherapy. After a few days the doctor treating physician speaks with Company travel assistance and comments that the patient would be OK to travel in 12 days, but given your situation, wants to travel on a stretcher, with medical, and oxygen at 2 L / min (preventive). The treating physician issues the fit to fly and sent to the MEDIF aerial company to authorize the transfer. The insurer gets the physician, medical supplies and oxygen (concentrator approved). The aerial company accepts the transfer and sets the stretcher with all accessories. All set and ready to move Mrs. and Mr. Smith to Rome. Transfer is performed with a happy ending.

Second Situation

Mr. Smith, who has a special character, he says he will not travel on a stretcher, prefer to travel in first class, that oxygen does not want it because it has never needed, nor want a doctor to accompany him. He says, too, that the repatriation will take a long and prefers to do it and send reimbursement expenses. Mr. Smith sore on his wheelchair to the aircraft door, the crew helps, sits in business class travel with their diapers posts and Mrs. Smith at his side. They arrived home, Happy end . Travels as ordinary passenger, unfit to fly and knowing that doctors disagree with his decision without declaring their illness to Airlines.

Third Situation

Mr. Smith to three hours off the flight, begins with tachypnea, cyanosis, confusion, and low level of awareness. On the plane there is a doctor who is an ophthalmologist who puts oxygen and it says it is likely to be a pulmonary embolism or stroke. We have to land and take it to an emergency hospital. Diverted the aircraft commander and the patient was admitted to a hospital and start again.

Traveling as a normal passenger, unfit to fly and knowing that doctors disagree with his decision without declaring their illness to Airlines.

What kind of responsibilities can have Mr. Smith with the Airlines and to the rest of the passengers?

the second and third situations are not acceptable, patient's insurance should explain that they will not cover these situations.

But for the third situation, PE ( the most possible disease), i believe that , before flying, the insurance's MD would have checked the prophylactic treatment or the INR, but EP may occur ( exceptionnaly) even with these treatment.

For the reponsiibities of MR S..., they depend on international laws governing airlines

If the insured does not do what the insurance company along with the treating physician want, which is to travel with maximum safety, liability insurance is zero. The patient has acted contrary to the established medical criteria.

I think that the query has two different spheres of interest : the first interest have to be the concern of the hill person to not have dangerous damages and possible risks of life . The second interest should have to be a concern of the airlines whose interest should be to not have on board passengers conscious to have a disease but not aware to be on risk when flying or conscious to have a disease and aware to be on risk but notwithstanding wiling to fly, these conditions both possible causes of problems for the fly , the board staff and the same passenger , including any eventual claims of responsibility for the airline. In consequence of what above I believe that it could be suitable that the airlines should have to compile a document of information for the possible customers containing a well construed list of diseases with the related levels of severity for which the fly could represent a possible actual risk : this list should be offered on line for persons purchasing the tickets on line, and in printed version published or given to customers purchasing the tickets in travel agencies. In the cases both the customers should declare to have read and understood the informations. The customer having a diseased condition of the list could fly claiming the absolute need to fly and giving on boarding written informations and instructions and eventual drugs packages for a possible emergency suggested by his/her general physician or specialist.

Any person wants to answer the question about the responsibilities that Mr. Smith may have front of the airline and the passengers.

Have any responsibility?. Of what kind? Civil, criminal?

He could be sued by the passengers?

He could be sued by the Air Company

Is there a law that requires you to declare your illness?

The disease is not something exclusive and intimate that does not have to be declared?

Mr. Smith has done social harm to the community?

Mr. Smith has the right to do what he has done?

Thanks towards their contributions

mental health/ status assessment in relation to one's eligibility to fly by air will open a very different debate, and importantly who has the expertise to do exactly that AND "where does it stop- who is allowed to do what?"

There is in this discussion a lot of interesting examples of different situations considering only the possible final solutions, the loss of time suffered by the passengers and the airlines as well as there are many, I would say, theoretical and philosophic argumentations about the personal freedom to choice and the right to risk

one's life. But the problem in question is fundamentally a very tangible problem with also different aspects to take into account. For instance, could you picture to you the effect that an acute pulmonary edema or a other acute disease event with very visible severe symptoms may have on the nearest persons , particularly in case of children or very young people ? These visions and to live such events have to be considered real ravages respect not only very young persons but also respect adults in lower or greater instability of psychic condition, as pregnant women or old persons or many other subjects with personal problems and using psychoactive drugs, a population expected to be very easy to meet on the bases of the present statistics. It is evident that a very severe medical and unexpected event my happen everywhere and in every time, during a fly and during a concert or in a street or in a bus, but in all these situations it is much more simple to give an useful aid and the near persons are not forced to live all the event. I am in the opinion that the persons aware to be at high risk should have to fly only in case of absolute personal or medical need, and giving the members of the crew any informations and utilities concerning their health and consequently the possibility to not have to face a fully unexpected event but on the contrary the occasion to organize previously the aid , for instance selecting if possible an appropriate location of the person and discreetly searching for the availability of physician.

What an interesting question!!!

Tomorrow if someone has heart attack in the train, or in a bus, or while crossing the road, or while travelling in a taxi ...would we ask them to keep a latest certificate of their sound health. Is health what doctors say or is it the health of the individual as he/she feels? Health is an ever evolving state of mind body and relationships perceived by an individual, a family, or a group or a commuinty for self in certain time space and context ...So where does a doctor giving a certificate stands in this?

How could a doctor decide if someone is going to get heart attack, stroke or acute respiratory failure, or even pulmonary embolism, or deep vein thrombosis while flying??? Even if someone at times could judge it after spending 5000$ in tests and fees what danger the passenger is going to be for others? S/he is more a danger to cross the road as he could be the cause triggering roadside accidents and death to others if s/he even faints in the middle of the road ...are we going to restrict people driving their vehicles or sitting in other's vehicles?

There are 100s of 1000s motor vehicle accidents occuring world over daily ....compare it to how many have died or do die while flying due to medical conditions where doctor could have diagnosed before hand more likelihood of such an event ...I beieve, hardly any. Moreover when people are serious they do travel with a nurse or a doctor as necessary, and the airlines make it sure that happens or they refuse transporting the patient.

On the one hand we have given authority to a patient to decide if s/he would like some form of treatment or not, and on the other hand if a patients wants to travel we want to restrict him. Who will be responsible for the terrorists on the plane ...why don't we have some form of certificate from psychiatrists and the CIA type agency for all passengers to see if they are risky or not ...such a certificate is more improtant as a terrorist, or a psychopath would be more dangerous to others as compared to a sick man who is or could be danger to himself!!! Are we trying to save aero company's insurance company?

There has to be some limits to taking away people's rights ...hope the next question to discuss may not be, "should we kill an old man draining national resources, public money and not contributing due to his old age as well as demetia?"

Training doctors to detect disease early, and, or death earlier is itself a huge task ... if we could do that we would have done it by now ...even if we do it now we would save atleast a million lives each week ...who would be worried about a sick, or otherwise fit person having a heart attack in the plane ...except for the flight attendents who are in any case trained in Basic Life Support and the automatic defibrillators are handy in each aircraft, O2 is already there ...furthermore, how many accidents are we talking about??? One in a year in the whole world as compared to millions dying from other causes ...

I love such questions for a change ...answers sometimes are more beautiful though ...and I for sure know I may be diagonally wrong but thats how I think and feel ...love you all

In the hypothesis in which potential customers should have to declare that they READ and UNDERSTOOD the information’s published by airlines concerning disease which may induce acute potential risk, if Mr. Smith’s cardiac failure is perfectly controlled by IEC and diuretics ( for instance), if the disease “cardiac failure grade II” appears on the airlines list, what do you propose?

To declare an “absolute need “ to fly, even if the fly is “only a pleasure travel to visit Venise and the North of Italia”?

To have “an onboarding written information’s and instructions…. and eventual drugs packages …., but aircrafts are not an Emergency Medical Service?

Thus, I believe that Mr. Smith may fly (after the authorization of his general physician?), if his cardiac failure is perfectly controlled, and that there is no need for airlines to construct such a list.

And what about “Chronic renal failure”, which cut-off clearance do you propose? This list is impossible to construct….

Furthermore, as in the real life, patients with hypertension (for instance) sign insurance documents when they buy a new car, a new TV without considering HTA as a disease…, and without reading or understanding all the exclusions, do you really believe that they would change their comportment for a three or four hours airlines travel?

I suggest that airlines could ask for a “recent hospital admission within the last three months before the fly”. A more discriminant question.

Will the airlinesgive in writing and say, "you will all be safe with us if you have a medical certificate from your doctor? Would the airlines compensate very heavily if that gets breached, like that happens to so many people on the disasters that have happened ...what about the air shuttle crashes in the past? What about the invincible Titanics of the past? Why discrimination against a poor man who wishes to travel at his/her own risk? Shouldn't we get real? Would any one of us like restrictions on us wherever and whatever we do in sincerety? One of the greatest social scintist thinker of today, Habermas would be delighted to read certain answers in this debate ...but then, who am I ...just an individual as is one who is being dubbed as visiting a place to enjoy rather than may be fulfilling his/her last wish ....Mr. Smith wants to go to his roots before he dies, would like to visit his father's grave in Vienna, or Italy ...does the doctor, or the airline decides who is going for what, or is it the freedom of the passenger to know what and why s/he is travelling for ...is there no privacy to be respected in this sense ...what about young and fit person, a real life Bruce Lee who could control all the airline staff in air bare handed and kill them all ...what and who will give what certificate to such a walking killer machine??? Get real thinkers and philosophers, please. There is lots to discuss other than such things. Should America go to Seria? Should America have gone to Iraq to destroy those Weapons of Mass Destruction (never found - and we have forgotten)? Should there have been an atom bomb thrown on Hiroshima? Or should the monetary system of economy be the cornerstone of our legitimate development, or should it be resource based economy that should be the ruler....should PPP (purchasing power parity) be the cornerstone of currency value or falsly caused devaluation of other's money be the dictator??? ....So many questions, clear answers but we bow down to thy superiority and thy power ...forgive me ...can't we be real ...you run a business (be that airline or anything), you supply goods and services, you will fail at times, and so is the human body and the influence of the environment. The same environment that is our saviour, is also our greatest enemy as we are always sturggling to be one up on it rather than be symbiotic, so far airlines are symbiotic, why make them paracites?

...I think thats enough from me and my apologies to those who think contrary to what my opinion is. I am sure you will forgive me as it is my thought, my feeling, and my understanding and that is why I am what I am, as you are what you are ...and thats the greatest inter-relationship amongst all of us and the Nature almighty. Dr. Martin Luther king Jr. would be crying in heaven to listen to this debate ...nevertheless I love the debate and the people who are for it ...thats the stark reality of our being!!!

The thing was: it is necessary to ask the doctor if I can to travel because I have a chronic disease?. In my opinion is that you should go to the doctor for that advise us. The patient has two options, follow the instructions of the doctor or not. If the flies being contraindicated, assumes all liabilities and expenses. As this does not happen in the present time, would understand perfectly that airlines medical report asked in order to travel.

If you want to die on the plane, get a private jet ...... and do not bother.

My freedown ends where starts the neighbor's one

This is a list of pathologies that contraindicate any trip by plane and that Mr and Mrs Smith should respect and when traveling must have the fit to fly the treating physician and the authorization of Air company

Cardiac

Uncomplicated myocardial infarction or PCI within past two to three weeks for most patients (unless very low risk: age 45 percent, no symptoms of angina or heart failure; such patients may fly after three days)

Complicated myocardial infarction within past six weeks, or until stable

CABG within past two weeks

Unstable angina

Severe decompensated heart failure

Uncontrolled severe or symptomatic hypertension*

Uncontrolled arrhythmias

Severe, symptomatic valvular heart disease

Neurologic

Stroke within past two weeks

Uncontrolled seizures0

Pulmonary

Pneumothorax with persistent air leak

Severe, unstable asthma

Severe, unstable COPD

Major hemoptysis

Usual oxygen requirement at sea level exceeds 4 L/minute

Pregnancy

Post 36 to 37 weeks gestation (or medical certification done by an obstetrician may be required, at airline discretion)

Symptoms consistent with ectopic pregnancy (eg, first trimester bleeding and/or abdominal pain) until evaluated by physician

Women at increased risk for complications during pregnancy should probably not fly

Respiratory infection

Active or contagious infection

Nasal and sinus

Severe sinusitis

Large obstructing polyps

Nasal or facial surgery within one to two weeks

Severe, recurrent epistaxis

Surgery

Procedure-dependent: generally discouraged within two weeks

Uncomplicated, simple laparoscopy or uncomplicated colonoscopy with polypectomy within two days

SCUBA diving•

Single, uncomplicated dive within 12 hours

Multiple dives or dive requiring >1 decompression stop within two days

Psychiatric

Psychiatric disorders that predispose to violent, disruptive, unsafe, or unpredictable behavior

Risk for alcohol or drug withdrawal

Ophthalmologic

Retinal detachment surgery with gas bubble (two weeks for sulfur hexafluoride; six weeks for perfluoropropane)

It is very interesting to see how many persons claim for the right of a person with an actual medical risk to fly only because a very personal but not an absolute need to fly, even if this can result in a damage for other persons. But the core of the problem is not to forbid the fly to the persons having a REAL risk of an acute medical and dangerous event during the fly but to formally remind to these persons their personal absolute duty to minimize the consequences of such an event, because possibly expected , giving to the interested members of the staff the possibility of a better aid , because organized and to the all passengers a lower burden of alert, anxiety, and stress.

Not only no, but hell, no. If a physician feels a person should not fly, then they should notify the patient of that and the patient should be responsible for their own safety. This is just another lame brain proposal that would add tons of paperwork for physicians and further increase the costs of our healthcare, and burden the 99% of people who don't have problems flying with having to schedule physician appointments and get paperwork done before they can fly. This is just the further medicalization of our daily lives. Please stop it.

Some cool questions and information on the traveller's form to laugh at our stupidity: Remember this form needs to be signed in front of a Notary, Justice of Peace, or a court judge.

"Do you think you will die during the flight"

"Do you think you will get a heart attack in the plane?"

"You or your family would have to pay for all the insurance and, or other losses of not only the airlines, but also the passengers thus affected and their families if emotional trauma of dreaded death that no one has seen before."

"Many people get serious and die in our planes."

"After doctor gave u certificate did you feel burning in the chest and discomfort in the chest, even while you were waiting to board the plane?"

"Your doctor says there is some T wave inversion in one lead, but its okay. you don't have full cardiologist's report. sorry u cant fly, have good day Mr Smith."

"were you ever refused to fly by airlines?"

"Its clear that the report says you are fit. but the cardiologist had referred you to a nephrologist to see if there was any chance of renal artery stenosis. We don't find any report. Please go and get it and we will let you fly. I will ask the pilot to delay the plane and will wait for you. We are a customer centered organisation. Always think of customer needs - safety and prevention are better than cure in the aeroplane."

"We work with medical industry, their CEO and our VP both meet at the pub daily. They pay Airlines 30% of their 'take' As a result we have all the facility in the plane like first aid kit, definrillator, BLS and ACLS trained the crew, etc. All our staff including the pilots are trained and certified in BSL, ACLS. Therefore have a pleasant flight."

"Have you ever visited a doctor's surgery?"

If yes," have you got a certificate handy describing your illness and danger to others then or in future."

If no, "you are irresponsible to not have had your regular medical check done. Thats why family physicians (GPs) always complain."

"Airline reserves the right to change the questions any time, charge a fee of 1500$ for a voluntary checkup (if wish to fly). For your ease we have a doctor 24/7 at the airline office behind the toilets Ring in case of no emergency 08008888"

Gordon, I understand what you mean and I agree to what you had to say.. I thought stopping of the 'human rights' discussion could be made scientifically hillarious to have good impact. How medicine has progressed in execution and for the patient since 1967 (when I joined medical school) is phenomenal in deterioration. It is a shame to our profession that allows certain non medicos to decide how medicine should be played abused.

Think of some more questions to be asked from passengers in future, and put your thoughts about passengers' responsibility in case of sea and land travel. The same emotionally disturbed neighbour who was sitting next to Mr Smith (now dead) could have been sitting in a train next to Mr Smith. Would s/he?

I would recommend read for example, UpToDate, Patient assessment for air travel. Prout M, PineJR. Rind DM Ed. It is very interesting and learn a lot

Thanx for the announcement, Anthony.

Hi Luis

Any person can ask his/her family physician if s/he could fly for whatever reason (or travel on sea or the road, rail, etc. need to be checked properly as per one's medical expertise. However, this is true for any person, travelling or not, sick or not, or for regular routine check ...If and when people are sick they generally do ask their family doctors if they could fly. Further, appropriate health educatyion could make people avare. Nevertheless many sick people fly to other countries where certain treatments/surgeries like heart surgery meet their need.

Narayana Hrudayalaya hospitalin Bangalore, India gets serious children with congenital heart disease for complex cardiac surgeries that are 15-20 times less expensive than the 1st world, performed by world's highly experienced surgeons. People come there mainly because of two reasons, quality and expenses. This hospital doesn't refuse treatment/surgery to thepoorest of thepoor even if they have no moneytopay. A poor person who comes to this place for surgery with child gets surgery done in around 2000$. If we start telling them not to travel by passenger plane but try hire a private jet (as suggested in one of the write-ups), we must be insane to even think on those lines. I think the key problem is not the airlines, but us,. the leaders in health service.

I wonder if we should ban medical tourism to and from the 3rd world countries, and, or the 1st world countries?

Hi Suresh

First, in my experience, I have to say that we take care of health care during the holidays than 900,000 people per year, pensioners, over 65 years. I can tell you only go to the doctor and obligation to those who go to spa treatments. The rest, in most high percentage, they will not ask if they are able to travel by plane. Feel-protected by the administration and the health system and if something happens the insurance company will solve the problem.

Second, my country, Spain, is suffering the health tourism.En 2009 the administration is spending 1.2 billion dollars attending to 700,000 immigrants.

Third, congratulate the Narayana Hrudayalaya Hospital for their great humanitarian work, which is admirable. A great institution.

Fourth, by what you said the transfer of children is done with the supervision of the physician indicating the transfer and admission to the hospital and if the baby needs some special condition, eg oxygen I suppose the doctor will ask you to the airline. In any case, I think these cases justify any action we take even heroic because it is the only solution for for the baby. but we can not extrapolate these measures universally.

I feel in this world it is easier to make a mountain out of a mole hill.

Start any topic and you will find views of the greatest people in the field like myself who never had any experience of witnessing death in flight.

I could find zero stats on in flight death accuring because of illness that could have been detected before. Its like who will buy airline ticket knowing he is going to die of a massive heart attack in flight. Would his doctor have known that he would die in flight while he was all hale and hearty?

Within the history of passenger airlines its is logical that when ever in flight death has occured has occured to the people who had serious illness. These people have had to go through all the processess of the airlines, and, or cared for by a nurse or a doctor.

Could anyone amongst us know where to find the stats. and details like; healthy looking, or healthy feeling people who have unfortunately died in flight. Moreover could have been diagnosed to likely die in flight?

Sick people in first world (as they have their family doctors) most (99%) ask their doctor if they could fly. People from 3rd world do not. But, majority of them cannot afford to fly. Rich mostly know that they could die in flight (some increase their flight insurance, I hear)

To backup the truth, please guide me to find stats of people who died in flight . It would be very helpful to find the details like the treatment he was on, if he had had medical check been done for his ailments and when. Did he ask his doctor if he could fly and what was doctor's answer? Was airline already in the know that this person had asked for diabetic meal, mentioned on the booking slip, could mean he was diabetic?

These kind of stats must already be collected by each and every airline if sme one dies in their flight. Most times even postmortem is carried out to find the cause of death, as when unaccompanied passenger dies. Please someone with airline contacts get these stats for us to be enlightened. Also please help me find how many patients preflight are known to the airlines. Death in flight occuring amongst these known sick people will not be taken into any condideration.

There are no stats I could find, and could not find any recent stories about healthy thinking and healthy feeling people dying in flight.

Moreover, our encestors used to say "....there is nothing perfect not even health because death is inevitable, certainly no one knows the time it dawns upon mortals."

My conclusion: It is absurdity to ask public to get a medical fitness to travel, or fitness to travel with support person/team where necessary ,...except certain conditions that already is being followed by the airlines and the public alike.

Personally, in my lighter mood ....Innovation: 300-500 seater RedCross AirED supersonic jet planes started by Medical World. Key stakeholders; the public paying one $ a year for each member of the family. Atlest one flight froom each major destination to destination. This will make around 7+ Billion dollars a year. In addition all fair, service, etc. would be paid by the travellers ...ED specialists team would be there on board for any resuscitation required. It will increase satisfaction to the patients through getting treatment wherever they had wished and there would be no access barriers left except for the poor ...but do poor fly??

The only request: Please try to avoid a question like, "Should a surgical team be made available on the long flights for the general public?"

Thanx Luis, I do understand your view and advise ...in principle, I strongly feel that it is against human rights, against the law of Nature to restrict people. Would you restrict people 'peeing' on the road side without giving the facility of proper 'loos' on the road side? Or, would you advise a man not to take furosemide (Diuretic). while travelling and risk his life for the 'loo'.

Habermas, the great social scientist tells that rules are facilitatory (for smooth and fast progress/travel/health/running, etc.) rather than restrictive as the system then starts disctating. human beings.

Human beings are already fully enslaved by monetary system of pseudo economy. The same humans waste hours on discussing things they have never been in, seen or first hand experienced ...but then thats why we are all different. Listening to people and opinions makes one feel "am I wrong, or am I?"

I have a lot of doubts that the statistics certainly elaborated by airlines and concerning fatal or in any case very severe medicals events during fly could be at disposal of every person asking for them , I think including medical doctors , if not licensed by some Authority : events certainly of very uncommon happening. But following my basal concept, I should prefer to know the statistics of the various aids that the crew had to give not only to the person affected by the event but to the passengers, including the need of interventions of a doctor casually available within the passengers.

Thanx Giancario for your good suggestion.