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Rural Ethics in Healthcare: Are They Different? Should They Be?

Cheryl Clark, for HealthLeaders Media, June 10, 2009

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.

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