A primary care physician that works in a small, remote hospital diagnoses a patient with lung cancer and refers the patient to a distant large medical center for treatment. After several overnight trips to the medical center, the patient returns to the primary care provider to indicate that she is no longer willing to travel and wants to receive care at the small hospital.
A rural psychologist, also a member of the town’s school board, discovers during a family counseling session that one of the patients, a schoolteacher, has missed many teaching days because of a significant alcohol problem.
A family physician treats a long-term patient for a minor work-related injury. The patient is very depressed and tearful but refuses to discuss it. The physician encourages the patient to see a mental health professional to be further assessed and, if needed, receive treatment. The patient acknowledges feeling depressed but does not want help. If people see his truck at the mental health provider’s office, everyone will know that he has “that” type of problem. The patient also requests that the physician not make any reference to depression in his medical record, because his sister-in-law works at the doctor’s office.
In A Fortunate Man, Berger and Mohr (1967, pp. 13–15) provided a deeply compelling portrait of an English country doctor who lives and provides care in a remote, rural community: “Landscapes can be deceptive. Sometimes a landscape seems to be less a setting for the life of its inhabitants than a curtain behind which struggles, achievements and accidents take place. For those who are behind the curtain, landmarks are no longer only geographic but also biographical and personal.” Rather than feeling discouraged by his professional isolation and stressful workload as a “one-man hospital” and its challenging situations, we are uplifted by the depth of his relationships and commitment to the people of a remote community. In this story of a country doctor, we are taken behind the curtain to a unique setting, unknown and rarely understood by many who live in metropolitan and urban settings.
Authors have reported from different countries that what makes the rural community unique is not just its small population density or distance to an urban setting but also the combination of its social, geographical, cultural, religious, and personal values as well as its residents’ economic and health status (Flannery, 1982; Bushy, 1994; Ricketts et al., 1998; Roberts et al., 1999a; Ricketts, 2000; Gamm et al., 2003; Kelly, 2003; Institute of Medicine, 2005). A rural community’s health beliefs, overall health status, geographic isolation, access to healthcare, and limited ethics services play a influential role in the nature and frequency of ethical issues faced by healthcare professionals as well as in the manner in which they respond. Rural healthcare ethics focuses ethical reflection through the application of ethical concepts and ethical standards of healthcare practices to challenges that occur in rural settings. A need exists for the rural setting to be understood as culturally distinct from the urban setting, which has been the primary focus of healthcare ethics (Purtilo, 1987; Roberts et al., 1999a; Cook and Hoas, 2001).
There are four reasons for the importance of considering rural healthcare ethics. The first reason is the large number of people living, working, and receiving healthcare in rural communities. In 2001, 30.4% of Canada’s population lived in rural communities (Canadian Rural Partnership Research and Analysis Unit, 2002). In the UK, 19% or 9.5 million people live in rural areas (Department for Environment, Food and Rural Affairs, 2004). In the USA, approximately 59 million people, roughly 21% of the population, live in rural, “non-metropolitian” communities according to the 2000 United States Census (Institute of Medicine, 2005); however, variations in the definition and methodologies used to define rural areas have resulted in several estimates (Institute of Medicine, 2005).
The second reason is the distinctive characteristics of residents of rural communities. In the USA, the rural population has a lower median income per household (US Department of Housing and Urban Development, 2000) and higher poverty rates than the urban population (Institute of Medicine, 2005). In 2000, 23% of US children in “completely rural, non-adjacent counties” lived in poverty (Economic Research Service, 2005). Rural residents are also more likely to be underinsured or uninsured (Ziller et al., 2003), further increasing the financial hardship of interacting with the healthcare system (Ricketts, 2000). Compared with the urban population living in metropolitan counties, residents of the US rural population have a higher age-adjusted mortality rate (National Center for Health Statistics, 2005); a higher probability for a chronic or life-threatening disease (Braden and Beauregard, 1994); a higher proportion of vulnerable residents, specifically children and the elderly, who require more health services (National Center for Health Statistics, 2001a); higher rates of particular mental health issues including substance abuse (Institute of Medicine, 2005) and suicide (National Center for Health Statistics, 2001b); and encounter a greater prevalence of environmental and occupational related hazards (Ricketts, 2000). A large study of US veterans concluded that, when compared with urban veterans, those living in a rural setting have worse health-related quality of life scores (Weeks et al., 2004). Similar health inequalities between rural and urban populations have been reported in other countries, for instance, in Canada (Romanow, 2002).
The third reason is that there are fewer healthcare providers per capita for rural populations than for urban populations. About 9% of physicians practice in rural America although roughly 21% of the population lives in those areas (Rosenblatt and Hart, 1999; Institute of Medicine, 2005). These disparities encompass a wide range of healthcare professionals other than physicians, such as nurses, social workers, dentists, and, in particular, mental health professionals (Wagenfeld et al., 1994; Goldsmith et al., 1997; Holzer et al., 1998; Rost et al., 1998; Hartley et al., 1999; Bird et al., 2001; Baldwin et al., 2006; Johnson et al., 2006; Rosenblatt et al., 2006).
In addition to these three factors shaping the frequency and nature of rural ethics issues, the fourth reason why rural healthcare ethics is important is because there are limited ethics resources focused on rural issues. In the USA, these limitations include the number of bioethicists (Nelson and Weeks, 2006), a rural-focused literature (Nelson et al., 2006), ethics committees, adequately trained ethics consultants, and opportunities for rural ethics education (Niemira, 1988; Cook and Hoas, 2001; Cook et al., 2002; Nelson, 2004). In addition, numerous barriers contribute to the lack of existing or effective ethics committees in rural communities, including the lack of ethics expertise, time and financial resources to support ethics training and education, an understanding of rural communities, and the use of a urban model for ethics committees in the rural healthcare facility (Niemira et al., 1989a, b; Bushy and Rauh, 1991; Moss, 1999; Cook and Hoas, 2000, 2001; Cook et al., 2000a; Nelson, 2006). As a consequence of the limited rural ethics-related resources, rural clinicians are hampered in their efforts to seek rural ethics training, and, when consulting the clinical ethics literature, find that the material has such an urban focus that it proves unhelpful (Roberts et al., 1999b; Cook and Hoas, 2001; Cook et al., 2000a). It has been noted that “bioethics is an urban phenomenon,” because its focus emanates from large, university, tertiary care hospitals, and the “latest hot research topic,” all intended for an urban audience (Hardwig, 2006, p. 53).
With an understanding of rural healthcare comes an emerging awareness of the special ethical considerations inherent to clinical practice in closely knit, tightly interdependent small communities (Nelson and Pomerantz, 1992a; Bushy, 1994; Roberts et al., 1999a; Cook and Hoas, 2001; Roberts and Dyer, 2004). Because of the distinct characteristics of the rural community, the identification and solutions that rural practitioners might employ to address ethical conflicts may differ from their urban counterparts (Roberts et al., 1999a; Cook and Hoas, 2000, 2001; Nelson, 2004). In a rural setting, for example, it might be necessary to provide healthcare to a family member, friend, or neighbor; whereas, in a urban setting, it permits for greater role separation and clearer personal and professional boundaries since other healthcare clinicians, facilities, and more diverse health resources might exist in more the immediate area (Purtilo and Sorrell, 1986; Sobel, 1992; Schank, 1998; Roberts et al., 1999a; Cook et al., 2001; Roberts and Dyer, 2004).
Responses of healthcare professionals to all ethical conflicts are expected to be in accordance with generally accepted ethical principles or standards of practice, such as informed consent. However, community values inherent to rural settings influence healthcare decision making, including self-reliance and self-care; the use of informal supports, such as neighbors, family, and church members; a strong work ethic; and a different perception of illness, where, illness occurs when a person cannot work (Bushy, 1994). Roberts et al. (1999a, p. 33) commented that these “Cultural issues … sometimes exert a greater influence on rural than urban healthcare because local customs and practices may affect a greater proportion of a caregiver’s practice.” Since identification and solutions to ethical issues in rural areas may differ from urban areas (Roberts et al., 1999a; Cook and Hoas, 2000, 2001; Nelson, 2004), rural clinicians may experience dissatisfaction with professional ethics codes and ethical standards of practice that are primarily urban focused (Niemira, 1988; Cook and Hoas, 2000; Roberts et al., 1999b; Cook et al., 2002) and, in general, provide inadequate insight into how the rural context might influence ethical decision making.
Several articles have suggested that the quality of care of rural residents might be adversely impacted because of the limited amount and variety of available healthcare services and the insufficient array of healthcare professionals (Moscovice and Rosenblatt, 2000; Cook et al., 2002; Gallagher et al., 2002; Weeks et al., 2004). Isolation from specialists and specialized technological resources force the provider to make decisions based more on clinical impression rather than the most up-to-date specialty knowledge and technology. Some rural providers believe this compromises the quality of care they can deliver (Turner et al., 1996; Cook and Hoas, 2000; Cook et al., 2000b) and the ethical norms of the medical profession.
Geographic isolation of rural communities might also give rise to ethical issues. Distance to and between healthcare professionals and facilities in rural regions can be extensive, thereby limiting their accessibility to rural residents (Nelson and Pomerantz, 1992b; Bushy, 1994; Rosenthal et al., 2005; Chan et al., 2006). Distance to healthcare services can be additionally problematic because of the lack of public transportation, challenging roads, and weather-related barriers (Cook and Hoas, 2001).
Resistance or refusal to be transferred to urban and tertiary-care centers through fear of the unfamiliar urban setting is not uncommon among rural patients (Nelson and Pomerantz, 1992a). This resistance or refusal leaves many rural clinicians conflicted because a competent patient refuses care that the clinician believes is essential. Related ethical conflicts include how aggressively the clinician should attempt to persuade a patient to seek treatment in a distant, urban medical center. If the patient maintains their refusal, the clinician must address the burden by providing, presumably, less than an optimal level of care. This ethical issue is accentuated by legal concerns when professionals believe they are practicing outside their scope of competence (Roberts et al., 1999b).
Overlapping or multiple relationships can influence and become the source of many ethical conflicts faced by rural healthcare professionals. Because healthcare clinicians might have multiple roles within the community, for example as a physician, as a school board member, and as a neighbor, relationships with patients in rural settings might foster boundary-related ethical conflicts (Purtilo and Sorrell, 1986; Miller, 1994; Roberts et al., 1999a, b; Cook and Hoas, 2001; Cook et al., 2001; Larson, 2001). However, disengagement of the provider from multiple relations may lead to a sense of rejection, a lack of trust, and produce a less productive clinical relationship (Cook and Hoas, 2001). Rural clinicians might experience ethical conflicts since they routinely try to balance competing needs, such as that of the individual patient versus the community.
Because of the familiarity and frequent contact among healthcare professionals with patients, their families, and other community members, rural healthcare providers might often face situations that make privacy and confidentiality difficult (Woods, 1977; Spiegel, 1990; Jennings, 1992; Sobel, 1992; Ullom-Minnoch and Kallail, 1993; Rourke and Rourke, 1998; Schank, 1998; Roberts et al., 1999a, b; Simon and Williams, 1999; Glover, 2001; Cook et al., 2002; Campbell and Gordon, 2003) resulting in ethical conflicts (Simon and Williams, 1999; Henderson, 2000). For example, healthcare facilities are one of the largest employers in some small towns, so it is not uncommon for a patient’s relative or neighbor to be a member of the healthcare professional’s staff or even the billing clerk who records diagnoses.
Disease stigma might lead to ethical conflicts because of the extent of knowledge rural residents have about one another (Roberts et al., 1999a). Clinicians may be reluctant to record in a medical record a stigmatizing diagnosis, such as HIV, a mental illness, or a sexually transmitted disease. Rural residents may be uncomfortable with the prospect of disclosure of such information to the clinician or may not seek necessary care (Flannery, 1982; Purtilo, 1987; Nelson and Pomerantz, 1992a; Bushy, 1994; Ricketts et al., 1998; Ricketts, 2000; Kelly, 2003).
Rural populations are a critical concern in discussions of the provision of an appropriate standard of care, health disparities, and the allocation of government healthcare resources in many countries, including the UK (Cox, 1997), Canada (Romanow, 2002; Maddalena and Sherwin, 2004), and the USA (Institute of Medicine, 2005). For instance, in the USA, the Institute of Medicine’s report Quality Through Collaboration: The Future of Rural Health Care outlined a five-point strategy and made 11 recommendations regarding the quality of healthcare provided to or in rural populations (Institute of Medicine, 2005, pp. 1–18). The recruitment and education of physicians and other healthcare professionals to rural areas are recognized in many countries as particularly significant policy concerns. Strategies have been developed to address these needs of the vulnerable rural population (Cox, 1997; Boffa, 2002; Romanow, 2002; Institute of Medicine, 2005).
Since healthcare policy is regionalized in Canada, ethics committees to aid governing authorities exist to provide specialized reviews regarding research, clinical, or organizational ethics issues (Maddalena and Sherwin, 2004, p. 235). Ethics committees that help to supplement rural and remote health authorities face challenges and might even not exist owing to geographical isolation, the lack of adequate trained members, and insufficient financial support. Some authorities utilize the services of an urban ethics committee; however, such a committee is unable to take into account the rural perspective (Maddalena and Sherwin, 2004, pp. 235–7).
Various studies have identified ethical issues encountered in rural settings in the USA (Purtilo and Sorrell, 1986; Robillard et al., 1989; Ullom-Minnich and Kallail, 1993; Turner et al., 1996; Roberts et al., 1999a, b, 2005; Cook et al., 2000a, b, 2002; Cook and Hoas, 2000, 2001; Warner et al., 2005). The commonly noted ethical issues arising in rural communities included safeguarding confidentiality and privacy, boundary conflicts due to overlapping relations, access to healthcare services, allocation of healthcare resources, inability to pay for healthcare, disease stigma, clinician–patient relationship, informed consent, and community cultural value conflicts. In India, another study explored patient satisfaction with medical professionals’ ability to communicate medical information among hospitalized patients between urban and rural settings (Sriram et al., 1990). Although these studies provide an understanding of ethical issues occurring in rural settings, the generalizability of four studies (Purtilo and Sorrell, 1986; Robillard et al., 1989; Turner et al., 1996; Ullom-Minnich and Kallail, 1993) are limited since many had a small sample size, a low response rate, or were conducted in limited geographic locations (Roberts et al., 1999a, p. 31). These limitations have continued in other studies.
Cook and others have noted differences between the availability, frequency, and competency of rural ethics committees (Cook et al., 2000a). A survey of 117 rural hospitals, mainly of administrators, in six states in the USA found that only 41.2% of the hospitals had an ethics committee or similar mechanism. Data suggest a predictive relationship between the size of the hospital, the presence of an ethics committee, and accreditation from the Joint Commission on Accreditation of Healthcare Organizations.
In a literature review using an established methodology for conducting literature searches, Nelson and others found that despite initially identifying 57 000 articles broadly related to bioethics published between 1966 and 2004, only 86 publications specifically and substantively addressed rural healthcare ethics issues, with 55 of the publications related to the USA, including seven original research articles (Nelson et al., 2006).
Using members of the American Society for Bioethics and Humanities (ASBH) as a representative cross-section of professional resources for healthcare ethics, Nelson and Weeks (2006) analyzed how ASBH members were distributed along the rural–urban continuum. The ratio of ASHB members to urban hospitals is about one in three, whereas in rural hospitals the ratio is one to one hundred. The ratio is even more dramatic when using hospital beds as the denominator. Using various comparisons, the authors consistently found that ASBH members are underrepresented in rural settings compared with urban settings, suggesting that the availability of professional bioethical resources may be inadequate in rural settings.
Rural clinicians respond to ethical challenges based on their personal beliefs and experiences, community values, and/or their understanding of ethical guidelines. The quality of care a patient receives can be greatly influenced by the clinician’s response to ethical challenges. Several strategies are suggested to support the efforts of rural clinicians in addressing ethical challenges.
All healthcare professionals must address ethical challenges. The clinician in each case must address ethical challenges that are inherent to the rural context and are familiar to all rural clinicians.
In the first case, limitations of resources generated healthcare access and quality of care concerns. The rural physician referred the patient to improve clinical care. However, the patient declined the specialized care because of the travel distance, possibly challenging roads, and the lack of her normal support system at the urban medical facility. After disclosing to the patient his clinical limitations as a non-specialist, the rural physician ought to provide the needed care. The physician, ethically, cannot refuse to provide care to the patient. To enhance quality of care of the patient, the physician should seek consultation with specialists for guidance, possibly by the usage of colleagues, professional organizations, or the Internet to create a consultation network. Proactively, physicians should educate their patients and the community about rural health issues, including the need of access to specialized care, and they should work with local social service agencies to diminish the barriers to receiving care in distant communities.
In the second case, competing professional obligations, as a physician and as a school board member, force the clinician to weigh whether or not to take administrative action against a teacher based upon privileged medical knowledge. There are no easy resolutions in this case; however, the patient did come to the psychologist to address family relationship issues. The psychologist should pursue a suitable treatment of the patient’s alcohol problem and avoid using the information ascertained in the counseling session as a school board member. The situation could change if, the psychologist believed, students were harmed by the teacher’s alcohol problem. Proactively, healthcare professionals should discuss over lapping relationships with all patients prior to providing healthcare. As in this case, there also needs to be a clear understanding with all school board members on ways to separate or diminish conflicting roles.
In the third case, the physician should encourage the patient to seek needed mental healthcare in the nearby community or in a more distant community where his truck may not be recognized. If the patient still continues to be unwilling to seek the needed specialized care, the family physician should attempt to address the mental health concerns using mental health colleagues to provide guidance on an adequate course of treatment. The concern of the patient regarding charting of the depression is reasonable because of the nature of a small, close-knit community. The physician may consider keeping personal notes out of the medical record. The physician should implement a privacy and confidentially protocol that includes discussions with patients only behind closed doors, keeping all records locked, and only sharing patient information and records with those that have a “need to know.” The physician should proactively educate staff about the importance of privacy and the associated problems, including how breaches in confidentiality can be detrimental to care. Physicians can work collaboratively with mental health professionals using a single clinic to avoid stigma (Roberts et al., 1999a; Roberts and Dyer, 2004).