Rural bioethics: Smaller communities, various views
Ethics takes on a more practical matter
It probably comes as no surprise that hospitals serving rural communities face ethical challenges foreign to their larger, big-city counterparts. And, unfortunately, they have found little help from the national bioethics community in solving these dilemmas, say those who study ethics in rural health care.
"Those who teach bioethics generally live and work in urban areas, and the scholars who write about ethical issues, and those who serve on review boards that publicize ethics-related books and journals usually have an urban orientation," says Ann Cook, PhD, associate professor and director of The National Bioethics Project (NBP) at the University of Montana-Missoula. "The ethical issues that challenge rural health care have not been well investigated."
A NBP survey of hospital administrators in a six-state area1 found that 58.8% lacked bio-ethics committees or any similar mechanism to resolve ethical dilemmas. Most hospitals also lacked accreditation by the Joint Commission on Accreditation of Healthcare Organizations. Only 10% of the existing ethics committees met regularly, and most had no role in activities related to policy, advocacy, or case consultation.
A similar survey of nurses in rural hospitals found that most (88%) lacked any access to bioethics-related resources. Only 10%-35% reported access to resources that might be considered ethics-related, such as ethics rounds, staff development programs, ethics consultation services, forums, and continuing education programs.
Even if rural providers had more access to bioethics resources, it’s not clear that they would find much that is relevant, note Cook and Helena Hoas, PhD, also an associate professor at the University of Montana and project research director at the NBP.
"Fewer than 20% of medical schools have developed ethics courses that address such topics as cultural issues, specialization-specific ethical issues, managing relationships, care of the family and significant others, patient experience of illness, and the use of ethics resources like committees and consultations," she says.
In recent years, the field of bioethics has focused more on complex moral and philosophical issues related to assisted reproduction, biotechnology, cloning, genetics, physician-assisted suicide, stem-cell research, and xenotransplantation.
Yet, surveys of rural providers indicate they need help with more practical issues. And, they want resources that take into account the context in which they practice.
Relationships are primary
For example, though professional codes often discourage "dual relationships" between physicians and patients, most rural physicians report that they have both personal and professional relationships with a number of their patients.
"In rural communities, people are connected to one another, and they expect that those connections will be honored and valued," Cook explains. "Indeed, if a physician is not sufficiently invested in a relationship, his recommendations may be disregarded and his practice less than successful."
In addition, cultural perceptions of the values of privacy and confidentiality are different in a rural setting than in an urban center.
While the bioethics literature — and most urban hospital policies — mandate strict protection of patient confidentiality, this model may not work well in a rural community.
For example, one survey respondent related that a hospital administrator, new to a rural community, realized that a local newspaper was publishing the names of people admitted to the hospital. Immediately, he forbade the release of such information, informing hospital staff, local ministers, and the newspaper that publication of the information was a breach of confidentiality, Cook and Hoas say.
The action was perceived as uninformed by the hospital staff and members of the community, and they quickly found a way around it.
A group of elderly women patrolled the halls of the hospital in the morning, taking note of who was hospitalized and then met at a local coffee shop to relay the information and start a phone tree.
The community needed the information to know which families might need rides to the hospital, casseroles sent to the home, or other types of social support.
Privacy is important to residents of rural communities, but they have a more restricted idea of what information should not be divulged, says Cook.
Financial stresses affect organizational ethics
The economically strained situation of both rural health facilities and residents also affects care delivery in unique ways.
"Several issues are at play," says Hoas. "In rural areas, the levels of reimbursement for health care services are often inadequate, the already high numbers of those who are uninsured are growing, and as a result, profit margins in rural hospitals are narrow."
Financial concerns often lead to the need to ration care in some situations. Hospital personnel are often acutely aware that decisions that adversely affect the hospital’s finances could lead to the facility’s closure — an event that would lead to loss of a large number of jobs and could leave the entire community without access to tertiary care.
"Quality of care can also be influenced by social and geographic factors, such as the inability of a rural hospital to hire experienced nurses who have adequate training and education," she continues.
Rural providers need ethics-related resources that are "interactive, accessible, practical, inclusive and nonacademic," says Hoas. "They want practical tools that give them words’ to address issues with colleagues and patients rather than journals, seminars, or mechanisms like committees."
Many rural providers are committed to remaining in their communities long-term, say Cook and Hoas. And, given the lack of financial resources for hiring outside ethics consultants, it makes more sense to offer educational and ethics training opportunities to providers already committed to rural environments.
However, new models and resources need to be developed that will reflect the cultural values and unique context of rural health care, rather than relying solely on academic principles of bioethics.
"We do think the discipline of bioethics needs to expand," says Cook. "The traditional approach of bioethics and its principalism seems too rigid and too difficult to apply. Our research suggests that bioethicists need to incorporate, in numerous ways, the context in which health care is provided, a sort of who does what to whom and how’ model. We also think a greatly expanded array of materials, models and resources are needed."
In the meantime, clinicians who are new to a rural community should seek out a mentor who is an "insider" and can teach them the ropes — someone who understands the history of the community, and its people and values.
"This is sensible because more experienced physicians and nurses reported encountering fewer ethical problems, an indication they may have developed skills to cope with common issues like confidentiality, familiarity, and patients who refuse treatment recommendations," she says.
Rural providers might want to explore ethics-related resources on the Internet as well, giving serious consideration to development and dissemination of ethics resources that are useful for patients and community members.
"That constituency needs opportunities to dialogue with healthcare providers in order to define and accept a hierarchy of shared values," says Hoas.
Suggested Reading
- Cook A, Hoas H. Are health care ethics committees necessary in rural hospitals? HEC Forum 1999; 11(2):134-139.
- Cook A, Hoas H, Guttmannova K. Bioethics activities in rural hospitals. Cambridge Quarterly of Healthcare Ethics 2000; 9(2):230-238.
- Cook A, Hoas H, Joyner J. Ethics and the rural nurse: A study of problems, values, and needs. Journal of Nursing Law 2000; 7(1):41-53.
- Cook A, Hoas H. Where the rubber hits the road: Implications for organizational and clinical ethics in rural health care settings. HEC Forum 2000; 12(4): 331-340.
- Cook A, Hoas H, Joyner J. No secrets on Main Street. Am J Nurs 2001; 101(8):67-71.
- Cook A, Hoas H. Voices from the margins: A context for developing bioethics-related resources in rural areas. Am J Bioethics 2001; 1(3):1-20.
Sources
- Ann Cook, PhD, Associate Professor, Project Director. Telephone: (406) 243-2467. E-mail: [email protected].
- Helena Hoas, PhD, Associate Professor, Project Research Director. Telephone: (406) 243-5775. E-mail: [email protected].
- National Rural Bioethics Project, Department of Psychology, The University of Montana, Missoula, MT 59812. Web: www.umt.edu/bioethics/.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content