Are doctors and hospitals in rural settings expected to uphold the same strict code of ethics as their urban counterparts? Are the situations always comparable? Or are rural issues and circumstances so variable and vulnerable that a different, perhaps more lenient, standard is okay?
A recently published book, Ethical Issues in Rural Health Care, attempts to explore those and many other questions in 12 compelling essays. Authors describe actual situations that caused them to weigh their medical and moral obligations to their patients against the loyalty to their economically fragile institutions.
Rural providers often know their colleagues, patients and their families socially and intimately, as well as clinically, which poses awkward issues of loyalty, confidentiality and privacy, write the book's editors Craig Klugman and Pamela Dalinis. Klugman is assistant director for Ethics Education at the University of Texas Health Science Center in San Antonio. Dalinis is director of education at Midwest Palliative and Hospice Care Center in Glenview IL.
They orchestrated the volume to launch what they say is a "much needed conversation" about the lack of a platform to explore ethical issues in rural settings.
Let's face it. Rural healthcare providers and settings must overcome special challenges. One in five Americans live in areas defined as rural, but only one in 10 physicians practice in them. Rural doctors work longer hours than their urban counterparts. Their patients must travel farther, may wait longer, and may be poorer on average and sicker, and have much more limited access to specialists, many of whom the referring physicians may not even trust with his patients, some of the authors write.
Rural doctors may also hold other pillar roles, sit on boards or hospital committees, or even public agencies.
Critical access hospitals struggle to keep the doors open and the lights on, while maintaining their patients' confidence. What will the patients think if they're frequently told to go elsewhere?
The book is divided into three sections. In the first, essays explores the difference between rural and urban cultures with examples of unique obstacles, such as the lack of hospice services in low population areas and how that may alter expectations for providers and families.
A second section is devoted to stories and examples of ethical dilemmas as told by two physicians and a psychologist who practiced in rural settings.
One, Elwood Schmidt, MD, who was often the only physician where he practiced in rural areas of the Southwest, described the troublesome belief that rural medicine should somehow be allowed to uphold a lower standard than urban healthcare. Decades ago, he wrote, "Alcoholism was rife in our West Texas/southeastern New Mexico medical community and was winked at, ignored, and even accepted by us and our patients," he wrote.
Another problem was the lack of anonymity. "In a small rural town (patients) always knew that it was Dr. Schmidt who treated them," far different than in larger urban settings where patients may easily forget their physician's name.
The third section attempts to pose solutions, such as the creation of bioethics forums devoted to special problems in rural areas.
"To date, there has been virtually no research on healthcare ethics in rural settings," wrote Frank Chessa and Julien Murphy, who described the challenges in creating their Maine Bioethics Network. They advocate that rural providers "build a case" for bioethics discussion and networks.
Quality of care, and the obligation to disclose experience levels of providers, as well as alternative options and errors to their patients, comes up frequently.
When a rural town's long-time surgeon becomes ill and must retire, a junior partner is quickly trained to perform C-sections and his credentialing is fast tracked, writes Denise Niemira, MD, a family practitioner at the Women's and Children's Health Center in Newport, VT.
But a family physician whose patients may have complicated deliveries is worried about the lack of the surgeon's experience. He wonders if he has an ethical obligation to tell his patients and give them an option to go elsewhere.
"But he is also concerned about the fragile state of surgical and obstetrical services at the hospital" which has had trouble recruiting doctors to such a small town.
At another small rural hospital, doctors struggle with a decision on what to do with heart attack patients. Should they keep them at the hospital and administer clot busting drugs, thus maintaining the hospital's necessary cardiac volume, or sent to a tertiary facility 100 miles away for more appropriate interventional cardiology. "Underlying the discussion was the tension between the need to maintain a competent critical care unit for the community and the desire to serve the best medical interests of each individual patient," Niemira wrote.
One essay by Ann Freeman Cook and Helena Hoas, of the National Bioethics Project at the University of Montana-Missoula, highlighted some disturbing findings. In nine studies they conducted over four years, they interviewed a wide range of health professionals who worked in rural settings throughout the Western U.S.
The authors concluded that "most rural healthcare providers believe that they and their hospitals are genuinely concerned about patient safety. When asked to rate their ability to make healthcare safer, respondents . . . gave themselves high scores."
But, they wrote, "rural healthcare providers consistently demonstrate discrepancies in their abilities to recognize errors, report errors, allocate responsibility for patient safety, design interventions that increase patient safety, implement new practices and sustain change.
"Moreover, among healthcare disciplines there are vastly different perceptions as to what constitutes and error."
Physicians, they wrote, "generally viewed the errors contained in the case studies as 'practice variances,' 'suboptimal outcomes' or examples of differences in 'clinical judgment.'" And as such, they deemed an disclosure to their patients, notations in charts or filing incident reports "as unnecessary and inappropriate," Cook and Hoas wrote.
"As one respondent explained during an interview: 'We just don't talk about that (error) stuff with one another.'"
Klugman and Dalinis warn "the lack of relevant resources for the rural practitioner is troublesome."
They add, "the differences between rural and urban areas are so complex that some have called for specialized training for physicians working in rural areas."
Miles Sheehan, MD, of Loyola University of Chicago's Stritch School of Medicine in a review of the book in the May 27 issue of the Journal of the American Medical Association, wrote, "Reading the essays in this volume is like acquiring a new set of glasses. It made me better able to perceive differences in how ethics can be considered based on culture, population, geographic challenges, and personal connections."
The 224-page hardcover collection of essays is published by Johns Hopkins University Press. $50.
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