Health Care Ethics in the Rural ContextWhy It Matters

James Stewart, MS

A (Quick) History of Health Care Ethics• 5th Century B.C. Hippocrates• 1847 American Medical Association Code

of Ethics• 1960s-1970s A combination of

circumstances and events move health care ethics into the public view• Tuskegee Syphilis Study• Medical Technology and Skills

Bioethics:

The integration of biology and values into a mechanism to shape the values of science in a service of human and environmental well-being.

Terminology and Concepts

Ethics: A systemic analysis of moral action which justifies a position through rational arguments and reflection.

Morality: Shared beliefs about right and wrong conduct in a culture or society.

Ethics is how we should act in consideration of others,not how we believe or feel.

Health Care Ethics Issues:Situations or circumstances embedded with questions of morality that require attention and reflection to assure continuing on a path consistent with the correct moral direction.

Health Care Ethics Problems:

•There is no way to act in a situation without something of moral worth being compromised.

•Ethics Conflict or Dilemma:

Occurs when faced with two alternatives that are mutually exclusive; two or more ethically required courses of action diverge.

•Ethics Distress:

The result of knowing the “right” course of action but feeling constrained to act by external influences often a challenge to personal or professional integrity.

Core Health Care Ethics Principles or Obligations

A system of health care ethics constructed around a set of principles generally recognized and understood.

BeneficenceNonmaleficenceRespect for AutonomyJustice

Beneficence

•Benefiting others, doing good for others, preventing harm

•Requires action•Action must be conducted with the

patient’s best interest as the top priority

Nonmaleficence

•Refraining from harming others•Obligation not to harm corresponds to a

right of the other person not to be harmed

Exceptions for extraordinary circumstances:

Self-DefenseWar

Respect for Autonomy

•Self-rule; self determination•Recognizing a person’s right to choose

regarding healthcare

Informed ConsentEnd-of-Life Decisions

Justice

Fair distribution of goods, benefits, burdens, services; ensuring fair processes in policies and laws; compensating for wrongs that have been done

RationingSocioeconomic factors of health

Ethics theories and principles provide a framework for the decision-maker to guide the resolution of medical ethics problems.

What is “Rural”?

•No consensus on an “official” definition.•Approximately one-fifth of the overall U.S.

population. •Distributed over more than three-quarters

of the U.S. land mass.

Rural is small populations spread over vast distances (in the Western U.S. anyway).

Rural Health

•Only 10% of physicians practice in rural areas.

•Rural residents have a lower per capita income and are more likely to live below the poverty line; nearly 24% of rural children live in poverty.

•Between 57% and 90% of first responders in rural areas are volunteers.

Abuse of tobacco by rural adults is higher•Significantly higher among rural youth; 26%

of rural 8th graders v. 12.7% of urban youth.

Alcohol abuse by rural inhabitants is higher•40% of rural 12th graders reported using alcohol while driving v. 25% of urban youth.

Seat belt use in rural areas reported as 77.6% v. 88% nationally.

Motor vehicle related deaths in rural areas more than twice the rate in urban areas.

Rural citizens are nearly twice as likely to die from unintentional injuries (other than motor vehicle accidents).

Rural Residents have higher rates of:

•Obesity•Hypertension •Diabetes•Cerebrovascular disease•Higher death rates from ischemic heart

disease and COPD.

The suicide rate among rural males is significantly higher than urban males and escalating rapidly among rural females.

Shortage of All Rural Health Care Providers

•Doctors•RNs/NPs•PAs•Dentists

•Pharmacists•Mental Health Care Services

•Social Workers

The Rural Good Life

•Peaceful•Low crime•Physical beauty•Strong family and community ties•Health care providers held in high esteem•Freedom•Clean air•Abundance of nature

Rural Culture/Society

•Hardy/tough•Independent•Self-sufficient•Stoic•Strong community identification and

allegiance•Traditional/conservative values

Definitions of Health

WHO: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

MERRIAM-WEBSTER: the condition of being well or free from disease; the condition of being sound in body, mind, or spirit; especially: free from physical disease or pain.

Rural Definition of Health

The ability to work, to do daily chores without regard to how a person feels.

Health means HARDINESS.

Rural Health

Culture

Financial/Economic Implications

Dual and Overlapping Relationships

Isolation

Privacy and Confidentiali

ty

Limited Resources and

Access

Caregiver stress

Cultural and Personal Values

Shared Decision Making

Boundary Issues

Dual and Overlapping Relationships

Multiple relationships with community members

•Daily contact•Schools/Kids•Store clerks, waitresses, town mechanic,

pastor, etc.•Social and civil organizations•Generations of service

Privacy and Confidentiality

•Intentional and unintentional

•Patient reluctance

•Provider reluctance

•Breach can be devastating

Provider Stress and Burnout

•Overlapping relationships

•Immense clinician responsibilities

•Geographic and professional isolation

•Lack of resources

Why It Matters

Likely you will have a patient or contact with rural provider.

You may live or relocate to a rural area.

Telemedicine or other technological interactions.