Bioethics, as a discipline, has primarily evolved in academic institutions and tertiary care centers. That growth was in response to issues posed by medical advances such as cloning, reproductive technologies, transplantation, and advanced life support technologies. In order to respond to such problems, hospitals have created services like case consultation and ethics committees. Most hospitals in urban areas use those models to help resolve difficult moral issues.
Many important characteristics such as institutional size, patient population and resource availability, are markedly different in rural settings. For these and other reasons, most rural hospitals - as was noted in the research section of this web page - do not have formal services like ethics committees or case consultation. In discussing the array of bioethics services that might be important in rural settings, many unique economic, geographical, demographic, and social characteristics must be considered.
There are few, if any, professional bioethics-related training programs in close proximity to these communities.
A number of those considerations such as social norms, relationships, cultural and religious variations are particularly important in rural areas. In part, those issues become important because of the heightened levels of familiarity that characterize rural communities. Admittedly familiarity is not a concern experienced only in rural environments. There are urban practitioners who also know their patients and may share multiple relationships with them. But familiarity is a pervasive issue in rural communities and it is key to understanding relationships. The patients and health care providers know one another outside of the boundaries of a professional practice. They may have grown up together, and their families have been long familiar with one another. They are neighbors and possibly friends. They have socialized in each other's homes, shared the same churches and schools. A patient may serve as the healthcare provider's accountant or lawyer. Most important, health care decisions are made in this larger context of a shared future. Patients and professionals both live with the consequences of decisions.
In rural communities, ethical issues develop within this context of familiarity. Background information is frequently available and can provide a reference against which decisions can be checked. Family, friends, and healthcare professionals have seen the whole family album. Familiarity, however, does not mean decisions are easier. Practitioners in rural communities suggest issues related to patient competency, patient autonomy and patient/physician relations are very complicated. Familiarity also makes it difficult to maintain confidentiality. Confidentiality is in tension with an enriched sense of obligation to families and the community as a whole. Health care decisions are discussed, weighed and balanced on Main Street.
The two-edged sword of familiarity was a theme indicated by the respondents to the nurses' survey and by the participants in the face-to-face interviews with the project researchers. Over 72% of the nurses believe ethical issues are approached differently in rural areas than they are in urban areas. When asked to explain such differences, the primary response involved the issue of familiarity. As one nurse explained: "Rural hospitals know clients. Familiarity and confidentiality problems arise often." Another stated: "we can't send an old woman home when she has an untreated bladder infection, as they can and do in a larger hospital. How can we face her daughter, her son, her grandchildren." Added another: "You know the patient from childhood." If nurses do not honor what the community perceives as a social contract they risk overt criticism, especially if there is a community perception that care was incompetent or harmful. "When something goes wrong, or someone dies, you do not even want to go to church or the grocery store. You just want to hide," noted one nurse.
Nurses also indicated resource availability has an impact on resolution of problems. Said one nurse: "we have no protocols for resolving ethical issues. " Added another: "you try to act on issues with varying degrees of success." In expressing a need for information one nurse said: "We're starting from scratch, anything you have [to offer], we are interested."
When discussing any of the issues above, the financial stability of the hospital becomes a significant factor for consideration. Understandably, rural hospitals may not, in all circumstances, be able to provide the services that are needed. At the same time the transfer of patients to an urban facility reduces hospital revenues, may jeopardize the financial well-being of the rural hospital, and may diminish confidence in local care. Rural hospitals may also encounter problems with obtaining adaquate reimbursements, given the large numbers of patients who are uninsured or underinsured. This is a problem with community-wide implications. If a rural hospital or clinic closes, important local jobs are lost and medical care becomes even more inaccessible. Admittedly, urban hospitals also face serious economic constraints but the kinds of risks that the patients and their families incur are different. For instance, the cost savings, achieved via an early discharge, may be problematic for an urban patient who lives minutes away from a medical center. For the rural patient, who may live twenty miles down an unpaved road and seventy, eighty or hundreds of miles from the hospital, the consequences can be devastating.
It is important to consider these issues when developing bioethics services in rural communities. Rural healthcare providers stated a need for resources that are useful, practical, interdisciplinary, interactive, non-academic and responsive to the issues they face. Ideas for considerations are provided in the following pages.