Sick at sea: quality medical care stays ashore.

Vacationers who take cruises expect to be pampered, but if they should become ill, is there a doctor in the house?

According to Consumer Reports Travel Letter findings, some major cruise lines may not have qualified medical personnel or adequate equipment aboard. (CNN Interactive, Consumer Reports: Ocean Liners' Medical Care May Not Be Shipshape, May 13, 1999, http://www.cnn.com.)

The article cautioned, "Don't assume the level of medical care is the same as what you receive in the United States, because many ships lack the proper facilities, and the doctors aboard often don't have medical training comparable to doctors in the United States."

According to the Cruise Lines International Association, which represents 23 lines, "Virtually every cruise ship (except for some smaller vessels operating in coastal waters) has a fully equipped medical facility and staff to handle almost any emergency."

But the 5 million passengers who sailed last year may not have known there are no international standards governing medical care provided on cruises. Ships aren't required to have doctors, and there is no oversight of them.

Although the International Council of Cruise Lines (ICCL) has medical guidelines for its 17 member lines based on recommendations from the American College of Emergency Physicians, the ICCL does not enforce these guidelines.

The five biggest North American lines--Carnival, Holland America, Norwegian, Princess, and Royal Caribbean--all claim to have at least one doctor and one nurse on each ship. Holland America and Norwegian reported their doctors are licensed in the United States and Canada; Princess said its doctors are licensed in the United Kingdom; Carnival said its doctors are licensed in the United States, Canada, and the United Kingdom; and Royal Caribbean said its doctors are licensed primarily in Scandinavian countries.

"The whole problem in cruise-ship medicine depends on what you consider the benchmark. Compared to major metropolitan hospitals, it comes up short, but compared to [the care available] in remote areas, it's excellent," said Jeffrey Maltzman, an attorney for Carnival Cruise Lines. Even if ships don't hire many U.S.-licensed doctors, he said, the doctors they do hire have equivalent qualifications.

Most medical negligence suits involving cruise ships allege that operators failed to provide competent medical staff and equipment and that medical personnel misdiagnosed, delayed, improperly treated, or failed to provide competent care for illnesses in passengers.

Because passengers are governed by maritime laws, which often overrule state or federal laws and are interpreted in different ways by different courts, lawsuits against cruise lines may be complicated.

Official cruise policies use language that attempts to place responsibility for medical care on the passengers or doctors with independent contractor status. For example, Carnival's policy states, "The ships' infirmaries are equipped to treat minor nonemergency matters. A doctor is available to render services at a customary charge. Doctors are independent contractors."

Apart from filing suit, passengers have little recourse for medical problems they encounter on board. PassengerRights, a clearinghouse for traveler complaints (http://passengerrights.com), says that "your ticket acts like a `contract' binding you to policies regardless of whether or not you know of and understand the terms. Therefore, it is important to be aware of the cruise line's policy regarding instances such as illness." The clearinghouse advises travelers to purchase travel insurance, which may cover some expenses incurred away from home that medical insurance generally does not cover.

Passengers should have their doctors check that their health is good enough to travel, ask cruise lines what medical facilities are available on the particular ship, tell its medical staff about specific needs, and check the ship's most recent sanitation rating (available from the Centers for Disease Control and Prevention at http://www.cdc. gov/nceh/programs/sanit/vsp/vsp.htm).