Building a One Country One Licensure Framework: Applications for the Future of Canadian Space Physicians

Space medicine provides care in the most extreme environment known to humankind. The global space economy is forecast to be a $1 trillion industry by 2040. Its increased utilization will require additional legal healthcare support frameworks. We reviewed the current Canadian medicolegal framework for the capability to adapt to this new demand. Currently, Canadian physicians are required to hold a license in each province they practice. As space medicine encompasses multiple medical specialties and its practice is beyond Canadian provincial jurisdictions, we identified medicolegal gaps in the Canadian ability to provide space healthcare. Geographical licensing restrictions have caused detriment to healthcare provision in remote communities, military medicine, and telemedicine, exacerbated by COVID-19. By examining similarities and solutions from these terrestrial situations, bi-directional translational licensing solutions may be found. Recommendations for an improved Canadian licensing framework targeting provision of space medicine may lead to improving healthcare access and universality for Canadians nationwide.


I. INTRODUCTION
T HE extreme environment of space presents unique medical challenges. Traditionally, professional astronauts have been held to stringent health standards to reduce the risks of medical emergencies during spaceflight. Private spaceflight participants may be held to less strict health standards to increase the market availability for participation in space travel [1]. Increased interest from the private sector is rapidly expanding accessibility with the space economy expected to generate $1 trillion in sales globally by 2040 [2]. This new population of space travelers will require additional healthcare support, translating to an increased need for specially trained clinicians. Specifically, as private spaceflight participants may exhibit more comorbidities including hypertension, cardiovascular disease, and diabetes mellitus [1], specialist physicians, resources, and clinical research may be required to adequately manage these conditions during spaceflight. The Royal College of Physicians and Surgeons of Canada (RCPSC) has a certification pathway in aerospace medicine. However, there is a lack of clarity surrounding medicolegal licensing of physicians participating in spaceflight missions. This commentary aims to examine the ambiguity surrounding physician licensing in space medicine, draw parallels to contemporary Canadian healthcare challenges, and provide recommendations to address future Canadian space medicolegal issues.

A. Current Physician Licensing in Canada
Nationwide institutions, such as the Medical Council of Canada (MCC), aid in the accreditation process for Canadian physicians. Nonetheless, the responsibility of physician licensure rests with provincial and territorial medical regulatory authorities [3]. The RCPSC has previously established a competency portfolio for the practice of aerospace medicine [4]. However, the diploma conferred by the completion of the portfolio does not play a role in the regulation of space medicine practice in Canada. Furthermore, licensure is restricted to geographical regions, which presents obstacles to physicians providing healthcare to spaceflight passengers since the traditional paradigm requires the practitioner and patient to be in the same province or territory [3]. These factors, coupled with the expanding role of space tourism and private space ventures, raise challenging medicolegal issues for future Canadian physicians providing direct or remote care to individuals in space. Additionally, the lack of aerospace medicine training, certification and experience amongst Canadian physicians raises questions over competency and accreditation, both elements important in licensure. Without establishing a cross-jurisdictional licensing system, Canada risks delays to participating in the expanding global space economy.

II. PARALLELS FROM CURRENT AND PAST MEDICOLEGAL CHALLENGES IN MEDICAL PRACTICE IN CANADA
Canadian medicolegal licensing regulations often affect rural and military healthcare provision. Rural human resource issues are exacerbated by licensing barriers that dissuade and/or prevent physicians from providing healthcare in rural regions [5]. During the COVID-19 pandemic, even the provision of out-of-province telemedicine was impacted by jurisdictional licensing barriers [6]. Emergency measures from the past few years may provide some insight to benefit medicolegal licensing in space medicine. Ontario passed the Emergency Management and Civil Protection Act Regulation 305/21, which temporarily licensed healthcare professionals to provide services alleviating the effects of the pandemic without undergoing a delay in care from the re-licensure process [7]. The pandemic has increased advocacy for pan-Canadian licensing to decrease barriers in cross-jurisdictional practice and provide more timely healthcare access for Canadians, especially those in remote communities [6], [8]. Benefits of a single national physician license include increased physician coverage, improved response times to healthcare needs in other provinces, reduced healthcare delays, and standardization of care [9]. National licensure is not without precedent; Australia established a national licensure system in 2010 [5]. Additionally, the U.S. modified licensure requirements in response to the COVID-19 pandemic to reduce barriers for physicians practicing between states [5], [10]. Within Canada, Alberta established the New West Trade Partnership Agreement (NWTPA), allowing physicians with full licenses from BC and Saskatchewan to obtain a practice permit in Alberta [11]. Furthermore, uniformed military physicians serving in the Canadian military are exempt from being licensed in all provinces where they provide medical care [12]. Nonetheless, provincial licensing still impacts Canadian military medicine as civilian physicians practicing at those same military facilities face administrative barriers in their roles when crossing provincial barriers [12]. Provincial restrictions are not only applied to the physical provision of healthcare but telemedicine practice as well. The Canadian approach to telemedicine is fragmented, with some provinces allowing telemedicine without need for new licensing and others requiring additional licensing or only forgoing licensing in emergencies [6]. The incumbent delays in access have prompted advocacy for removing barriers to providing telemedicine, with emphasis placed on exemption for Canadian physicians in the military [12]. Proposed alternative solutions include fast-track licenses, allowing physicians to be quickly and easily licensed in other provinces, and license portability, giving physicians ability to practice with their current licenses beyond their regular jurisdictions [13].

III. MEDICOLEGAL GAPS AND IMPACT ON SPACE MEDICINE OPERATIONS
The practice of space medicine operates on an ambiguous medicolegal basis once jurisdictional licensing is considered. The ability of flight surgeons to legally provide care during space missions, including private ventures, becomes impeded without proper licensure. This in turn impedes the access to healthcare space crew members receive. Terrestrial operations that support space operations may also have difficulty obtaining healthcare providers to support their operations. Moreover, jurisdictional boundaries on licensing may also affect medical data collection, storage, and transmission, as different Canadian provinces adopting data governance models [14], [15]. This carries implications for research and routine clinical care done, with potential delays in the provision of care for private spaceflight participants. Additionally, space medicine research carried out within the jurisdiction of space that include physicians providing care in their missions may face medicolegal challenges. It should be noted, however, that many commercial spaceflight companies only require informed consent about risks of spaceflight of onboard crew and passengers as per the U.S. Commercial Space Launch Amendments Act of 2004 [16]. As such, there is currently little in legal obligation for commercial spaceflight companies to provide physicians in support of missions. Nonetheless, jurisdictional licensing remains a complication for providing care in government-supported spaceflight missions.
It should also be noted that absence of a medicolegal framework for private space missions risks violation of international space treaties. Articles VI and VIII of the Outer Space Treaty stipulate that governments have both jurisdiction and control over their commercial and private agencies in space, and that they must authorize and continually supervise the activities of those non-governmental entities from their jurisdiction while in space [17]. By failing to regulate the provision of space healthcare in commercial contexts, and in turn relinquishing control to the private entities, governments are not fulfilling their obligations under international law. This may prove an area of interstate contention as space is increasingly shared by multiple nations with the additional medicolegal and liability complication in different foreign nationals participating in the same spaceflight missions, including private spaceflight. In addition, Article V broadly states that "astronauts of one state party shall render all possible assistance to astronauts of other state parties" in outer space activities. While this provides a potentially loose duty to provide aid, this does not specify details about rendering medical care between astronauts, creating ambiguity on medicolegal obligation as to who is ultimately medically or legally responsible to deliver that aid, and raising the prospect of cross-jurisdictional malpractice proceedings.

IV. RECOMMENDATIONS BASED ON PARALLELS DRAWN FROM OTHER HEALTHCARE AREAS IN CANADA
As space medicine is performed outside jurisdictional boundaries of Canadian provinces, licensure for space medicine presents a gap in the Canadian medicolegal framework. Moreover, physicians practicing space medicine may provide services in multiple specialties, including primary care, emergency medicine, and occupational health [1]. Thus, space medicine physicians must receive education and experience in those specialties and have that reflected in their licensure. With these unique elements of practice, current provincial and territorial licensing cannot appropriately cover the day-to-day requirements for these clinicians.
To ameliorate these challenges, licensing recommendations for Canadian space medicine clinicians may be as follows: r Develop a unique, pan-jurisdictional license allowing provision of care in-person and virtually for those clinicians certified in the competency portfolio of aerospace medicine, as defined by the RCPSC [4]. This license would be pan-jurisdictional, including all Canadian provinces and space as boundaries, available to physicians practicing aerospace medicine in support of Canadian space operations. In the absence or infeasibility of this pan-jurisdictional physician licensing approach, alternative licensing solutions could include: r Fast-track licensing options or rapid temporary licenses for physicians not licensed in space medicine but who plan to provide care, virtually or at the bedside, in support of aerospace missions, including private space tourism and private spaceflight ventures, limited to their scope of education and experience.
r License of portability for Canadian physicians providing care, virtually or in-person, on aerospace missions with partnering agencies such as the National Aeronautics and Space Administration (NASA) and European Space Agency (ESA) through memoranda of understanding or direct formal agreements between licensing and regulatory bodies. The implementation of a pan-Canadian license for space medicine would allow Canadian physicians to provide care for Canadians outside the provincial licensing jurisdictions and in space travel. This paradigm shift will enable Canada's health clinicians to engage with the rapidly enlarging space economy and provide a testbed for future framework changes to improve rural and remote access to universal healthcare.

V. FUTURE DIRECTIONS IN ADDRESSING MEDICOLEGAL CHALLENGES IN SPACE OPERATIONS
While some challenges facing medicolegal licensing in space medicine can be addressed through licensing precedents, unresolved issues remain. There remains uncertainty over the standards to which physicians practicing space medicine must be credentialed. While a RCPSC competency portfolio exists [4], credentialing and physician competency may be contentious to settle in multinational missions or future civilian spaceflight missions where astronauts may be expected to treat spaceflight participants not from their own country. Another issue is the delegation of regulatory oversight of healthcare provided during spaceflight missions. Multinational missions, especially private ones, could raise questions over which country or agency is responsible for astronaut healthcare. Moreover, malpractice suits, especially in space tourism, may require new legal precedents in how plaintiffs and defendants are served, particularly cases spanning national or even provincial borders. Even in telemedicine, different provincial jurisdictions have differing malpractice and oversight laws [6], which may complicate even pan-Canadian licenses given for aerospace medicine unless there is a single regulatory body. A single regulatory body would remedy variability among the medical standards of commercial entitiesensuring an adequate and consistent standard of care in orbit. The foregoing will also ensure compliance with the Outer Space Treaty, as government input can be considered as exercising control.

VI. IMPACTS OF EMERGING HEALTHCARE TECHNOLOGIES ON PROVISION OF CARE
The practice of medicine has traditionally consisted of physician-to-patient interaction, grounded in a physical location in which both patient and healthcare team shared the same space. Emerging healthcare technologies challenge this paradigm by allowing interactions to occur with participants in different physical spaces. While policy changes to physician licensure are necessary to properly provide healthcare for spaceflight participants, both state-sponsored and private, examining the medicolegal considerations of new healthcare technologies must not be neglected as they hold both solutions and complications for physician-licensed practice.
Space medicine has had a hybrid model of direct physicianpatient care terrestrially and telemedical care while astronauts are in space. The increasing inclusion of telemedicine for routine terrestrial healthcare carries medicolegal implications for physicians practicing space medicine. The global telemedicine market size surpassed $60.9 billion USD in 2020 and is expected to reach a market value of over $186 billion USD by 2027 [18]. Its expanding global and commercial presence provides Canada an opportunity to alleviate its medicolegal burdens on space physicians if licensure for telemedicine may be unified across provinces and pan-jurisdictionally provided for territories including space. A medicolegal development in this area may benefit private spaceflight travelling by increasing physician access on commercial missions. A similarly related technology is Holoportation TM , developed by Microsoft and using their HoloLens 2 technology [19]. This device has previously been used to "holoport" a physician to the ISS [20]. While this technology bears similarities to telemedicine, its function and application remain distinct. The HoloLens 2 can be held as an example of emerging technologies that challenge the current paradigm of healthcare delivery, but to which current medicolegal licensure structures do not have adequate scope in addressing.
Artificial intelligence (AI) is another emerging technology being explored by healthcare providers to assess and make clinical decisions. Currently, one of the main areas of research for AI in medicine is in the interpretation of diagnostic radiology [21]. The impact of AI in space medicine may be significant as the possibility not only remains in it complementing clinical decision-making by a physician but replacing aspects of it. This bears medicolegal consequences as the lack of need for physician participation in spaceflight missions may make physician licensing concerns for specific missions not a consideration. AI use has been suggested as a solution to overcome optimization limitations decision-making protocols limiting individual patient care [22]. However, its adoption in the practice of space medicine would raise other medicolegal and ethical issues. There is concern over data bias in datasets used to train AI and its inability to account for individual patient preferences [23]. Furthermore, novel medicolegal policies may have to be developed surrounding its jurisdictional use in space at the risk of neglecting its regulation in the care of spaceflight participants and astronauts. Additional issues would arise again in concerns of medicolegal liability and duty in caring for spaceflight participants requiring medical care. While AI bears tremendous potential for improving healthcare access in the face of medicolegal licensing restrictions of physicians, it is not currently sufficiently developed to engage in independent decision-making and raises new ethical and legal apprehensions that must be addressed.

VII. CONCLUSION
In the age of the Lunar Gateway, commercial low earth orbit destinations, increased space ventures by the private sector, and anticipated deep-space exploration missions, aerospace medicine must adapt to new operational requirements to safeguard the health of space travelers. Enabling Canadian healthcare providers to participate in these missions outside of the traditional government sphere will require changes to the current medicolegal licensing framework for clinicians. This includes accounting for solutions in policy and emerging healthcare technology. If Canada remains unable to address rising medicolegal and healthcare provision challenges in space medicine, it may risk being surpassed in spacefaring capabilities within the immediate future. As healthcare access and services remain increasingly difficult to access in remote areas, military and civilian physicians may benefit from medicolegal innovations brought to the Canadian healthcare system in space if they can be translated for terrestrial use.