It is presently unclear whether a distinct “rural ethics” of navigating professional boundaries exists, and if so, what theoretical approaches may assist practitioners to manage overlapping relationships. To be effective clinicians while concurrently partaking in community life, practitioners must develop and maintain safe, ethical, and sustainable therapeutic relationships in rural and remote healthcare. A narrative review was conducted identifying a significant body of qualitative and theoretical literature which explores the pervasiveness of dual relationships for practitioners working in rural and remote (...) healthcare. Rather than viewing dual relationships as ethically unacceptable, much contemporary work focusses on the lived experiences of healthcare workers and explores what approaches may be available that both protect the therapeutic relationship while recognizing the unique nature of rural and remote healthcare practice. We conclude that practitioners must have a means of operating within a contextually informed ethics of professional boundaries. Drawing on pre-existing work, one schema is proposed that could form the basis for further engagement through interactive teaching sessions, professional development, mentoring, or guidelines. (shrink)

Background: Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives. Methods: We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance by car (...) from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo. Results: This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change. Conclusions: The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings. (shrink)

In target articles for this special issue, Fox et al. report that ethics consultation (EC) practices have not improved significantly since 2000, and question whether the status quo affords patients...

The ethical standard for informed consent is fostered within a shared decision-making process. SDM has become a recognized and needed approach in health care decision-making. Based on an ethical foundation, the approach fosters the active engagement of patients, where the clinician presents evidence-based treatment information and options and openly elicits the patient’s values and preferences. The SDM process is affected by the context in which the information exchange occurs. Rural settings are one context that impacts the delivery of health care (...) and SDM. Rural health care is significantly influenced by economic, geographical and social characteristics. Several specific distinctive features influence rural health care decision-making—poverty, access to health care, isolation, over-lapping relationships, and a shared culture. The rural context creates challenges as well as fosters opportunities for the application of SDM as a natural dynamic within the rural provider–patient relationship. To fulfill the ethical requirements of informed consent through SDM, it is necessary to understand its inherent challenges and opportunities. Therefore, rural clinicians and ethicists need to be cognizant of the impact of the rural setting on SDM and use the insights as an opportunity to achieve SDM. (shrink)

The rural health context in the United States presents unique ethical challenges to its approximately 60 million residents, who represent about one quarter of the overall population and are distributed over three-quarters of the country’s land mass. The rural context is not only identified by the small population density and distance to an urban setting but also by a combination of social, religious, geographical, and cultural factors. Living in a rural setting fosters a sense of shared values and beliefs, a (...) strong work ethic, self-reliance, and a tendency for close-knit extended social structures where overlapping relationships are commonplace. (shrink)

The complexities of professional ethics are best understood and interpreted within their sociohistorical context. This paper focuses on the experience of 20 rural psychologists from across Canada, a context rife with demographic and practice characteristics that may instigate ethical issues. Employing hermeneutic phenomenology, these qualitative research results are indicative of professional struggles that impacted the participants’ experience of professional ethics and raised key questions about policy and practise. Concerns regarding competition highlight potential professional vulnerability, beget the idea of fostering general (...) psychological practice, and question the role of professional bodies in addressing rural shortages. Dependency on government funding models and decisions highlights the benefits and medical cost-offset effect of psychological services’ role in funded medical care. The controversial prescriptive authority debate for psychologists raises myriad concerns that are particularly salient to rural practitioners. These include changes to training and practice, with risks of psychopharmacology gaining prominence over behavioural health interventions. National inconsistencies in level of registration add to the growing shortage of practitioners. Finally, the results illuminate the need for advocacy to move beyond the literature and into public policy to increase public awareness, decrease the stigma of mental illness, and develop rural Canadian psychology. Although limited to this study, these results allowed for a fuller and more robust understanding of rural practice in consideration of professional ethics, which may inform policy, science, or ethical clinical practice. (shrink)

In the target article by Cook and Hoas (2008), the authors provide evidence from rural research and raise important generic points about ethics and rural healthcare. Their suggestion that clinical...

As a practicing clinical ethicist at a major teaching hospital, I found it reassuring to learn that ethics consultation activity has increased overall. However, it was disheartening to see tha...

With by far the lowest population density in the United States, myriad challenges attach to healthcare delivery in Alaska. In the “Size, Population, and Accessibility” section, we characterize this geographic context, including how it is exacerbated by lack of infrastructure. In the “Distributing Healthcare” section, we turn to healthcare economics and staffing, showing how these bear on delivery—and are exacerbated by geography. In the “Health Care in Rural Alaska” section, we turn to rural care, exploring in more depth what healthcare (...) delivery looks like outside of Alaska’s major cities. This discussion continues in the “Alaska’s Native Villages” section, which specifically analyzes healthcare in Alaska’s indigenous villages, some of the smallest and most isolated communities in the United States. Though many of the ways we could improve Alaskan health care for Alaskan residents are limited by its unique features, the “Justice and Healthcare Delivery” and “Technology and Telemedicine” sections consider ways in which certain policies and technology—including telemedicine—could mitigate the challenges developed in previous sections. (shrink)