To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original research articles while (12) (...) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues. (shrink)

The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional–patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional–patient relationship and allocation of resources. To date, there exists a limited (...) focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad-ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence—informed, rural-attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population. (shrink)

This paper has described three uses of Extreme Case formulationsto assert the strongest case in anticipation of non-sympathetic hearingsto propose the cause of a phenomenonto speak for the rightness (wrongness) of a practice.The interactants in the illustrations were engaged in several types of activities, among which were complaining, accusing, justifying, and defending. As concluding remarks, a few comments will be made about why participants use Extreme Case formulations in these activities.Part of the business of complaining involves portraying a situation as (...) a legitimate complainable. This may take the form of protraying the offense committed and/or the suffering endured in a way such that it would not be dismissed as minor. So as to legitimize a complaint and portray the complainable situation as worthy of the complaint, a speaker may portray the offense and/or the suffering with Extreme Case formulations. In both accusing and defending, participants ofyen present their strongest cases, including specifying Extreme Cases of their claims.Part of justifying a course of actions may involve portraying the precipitating circumstance as necessitating the action. The precipitating circumstance may be a problem circumstance which is portrayed as unfair, immoral, embarrassing, uncomfortable, or in some other way undesirable and/or intolerable. There is a shared assumption that the worse the problem, the more necessary it is to do something about it. In justifying, speakers use Extreme Case formulations to portray the circumstances that precipitated their actions as demanding their actions.A problem that participants have when engaged in, or reflecting on, conflicts, complaints, criticism, compliments, praise, etc. is to attribute the cause of the phenomenon. Who or what is responsible for the conflictual, complainable, praise-worthy state of affairs? One method that is used to determine what or who is responsible, i.e. to make an attribution, involves comparing the case in question to other similar cases. Through this procedure, persons determine that they are (are not) responsible for the state of affairsin questions. Extreme Case proportional formulations (‘everyone,’ ‘all,’ ‘every time’) are used to indicate that any individual member of that category is not responsible for the state of affairs; that responsibility is to be attributed elsewhere.The social order essentially is a moral order (Garfinkel, 1967). One of the ways of knowing what is acceptable and right is by finding out how people behave. There often is a shared assumption operating (one that is called into question on occasion): how people behave tells us what is the right way to behave. Proportional measures reporting the frequency or prevalence of practices are used to propose and substantiate the rightness and wrongness of those practices. Extreme Case formulations (‘all the time,’ ‘everybody,’ ‘no one’) propose behaviors are acceptable and right or unacceptable and wrong. (shrink)

The analysis in this article considers how dispatchers in a 911 wireless call center direct callers’ orientations from one possible trajectory of action to keeping the caller engaged and prepared to speak with a second dispatcher. We describe how dispatchers deploy two distinct actions, a directing action and an informing action, timed at a precise moment to execute successful transfers. The analysis presents largely unexplored features of the call transfer environment, including dispatchers’ management of callers’ expectations and how the transfer (...) phase contributes to a reshaping of the overall structural organization of a 911 call. (shrink)

Psychologists are ethically obligated to obtain informed consent to psychotherapy "as early as is feasible" (American Psychological Association, 2002, p. 1072). However, the range of topics to be addressed includes both information that may be immediately and uniformly applicable to most clients via policy or rule, as well as information that is not immediately presentable because it varies widely across clients or emerges over time. In this study, licensed psychologists were surveyed regarding the earliest feasible point at which they could (...) provide information regarding specific aspects of psychotherapy. Results indicate that, although psychologists believe that they are capable of presenting some information, such as payment and confidentiality policies, at the outset, they believe that a discussion of more substantive issues, such as psychotherapy duration, goals, orientation, and activities, can take place only after some therapy has transpired. Implications are discussed regarding the process and event models of informed consent. (shrink)

To what extent does payment method (managed care vs. out of pocket) influence the likelihood that an independent practitioner will assign a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis to a client? When a practitioner does diagnose, how does payment method influence the specific choice of a diagnostic category? Independent practitioners responded to a vignette describing a fictitious client with symptoms of depression or anxiety. In half of the vignettes, the fictitious client intended to pay (...) via managed care; in the other half, the fictitious client intended to pay out of pocket. Payment method had a very significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to receive diagnoses and more likely to receive adjustment disorder diagnoses in particular. We discuss implications involving informed consent and other ethical issues. (shrink)

The present study examined nonprofessionals' perceptions of culturally based and noncultural ethical violations. One hundred seventy-four undergraduates students read 12 vignettes depicting situations in which a clinician committed either a culturally based violation (e.g., sexist or ageist behavior) or a noncultural violation (e.g., breeching confidentiality or multiple relationship). Results indicated that participants were more likely to have unfavorable views of clinicians who had committed culturally based violations. In addition, results suggested that participants would be more likely to report a clinician (...) who had committed a culturally based violation to a supervisor or ethics board. (shrink)

Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004; Pomerantz & Segrist, 2006) indicates that when psychologists consider a client with symptoms of depression or anxiety, payment method significantly influences diagnostic decisions. This study extends the scope of the previous research to consider clients with symptoms of social phobia and attention deficit hyperactivity disorder (ADHD). Psychologists in independent practice responded to vignettes of clients whose descriptions deliberately included subclinical impairment. Half of the participants were told that the clients would pay via (...) managed care; the other half were told that the clients would pay out-of-pocket. Confirming previous studies, payment method had a highly significant impact on diagnosis such that compared to out-of-pocket clients, managed care clients were much more likely to be assigned Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnoses. Ethical implications relate to informed consent, accuracy and truthfulness in diagnosis, and psychologists' integrity. (shrink)

Although psychologist impairment has received attention from researchers, there is a paucity of empirical data aimed at determining the point at which such impairment necessitates action. The purpose of this study was to provide such empirical data. Members of Division 42 ( n = 285) responded to vignettes describing a psychologist whose symptoms of either depression or substance abuse varied across five levels of severity. Results identified specific levels of impairment at which psychologists were deemed too impaired to practice psychotherapy, (...) as well as significant differences between ratings of increasingly severe impairment. Practical and ethical implications of these results are discussed. (shrink)

In response to an article by Waring, Creider, Tarpey and Black, the author argues that the nature of the analytic aims of a research project determines whether or not participants’ reported goals and motives are relevant and useful. Her position is that for traditional conversation analytic studies aimed at explicating culturally shared methods for producing conversational actions and for interpreting interactional behavior, participants’ reports of their goals and motives are irrelevant. She differentiates between explanations based on participants’ reports of their (...) goals and motives and conversation analytic explanations consisting of preferences or principles to which members of a culture orient while interacting. (shrink)

Are psychotherapy clients who pay via health insurance more likely to receive Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) diagnoses than identical clients who pay out of pocket? Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) indicates that when psychologists consider a mildly depressed or anxious client, payment method significantly influences diagnostic decisions. This study extends the scope of the previous study to include clients whose symptoms are even less severe. Independent practitioners responded (...) to vignettes of clients whose profiles deliberately included subclinical impairment and a high level of functioning. Half of the participants were told that the clients would pay via managed care; the other half were told that the clients would pay out of pocket. As in the earlier study, payment method had a highly significant impact on diagnosis such that relative to out-of-pocket clients, managed care clients were much more likely to be assigned DSM-IV diagnoses. In addition, a noteworthy percentage of participants assigned diagnoses regardless of payment method. Ethical implications are discussed. (shrink)

Modal responses to items from a recent survey of independent practitioners regarding the impact of managed care on their practices and ethics were presented to participants as the responses of a hypothetical independent practitioner. Participants were asked to consider seeing this hypothetical practitioner both before and after being informed of the practitioner's responses to the managed care survey. Results indicate that when participants were informed of the practitioner's views toward managed care, their own attitudes toward therapy changed significantly. Specifically, compared (...) to uninformed participants, informed participants were significantly more likely to believe that managed care would have a negative impact on treatment and significantly less likely to see an independent practitioner, use insurance benefits, expect to benefit from treatment, expect to form a strong working relationship, and trust that the practitioner would work in their best interest. Implications regarding ethics and informed consent are discussed. (shrink)

When physicians take readings of health indices such as temperature or blood pressure, the practices that physicians and patients employ in discussing the readings both reflect and propose a set of expectations regarding the level of technical medical information the patients should acquire and understand. In this article we demonstrate how physicians’ reporting practices reflect and propose the roles of paternalism or independent expertise and how patients’ responding practices either ratify or contest the roles cast by the physicians’ practices. In (...) contrast to the usual assumption that roles are relatively stable for individuals over the course of encounters, we treat role enactments as matters that are negotiated turn by turn in interaction. Physicians’ practices for reporting test results implicate various sets of expectations about the knowledge, interest, and responsibility state of each participant; patients employ responding practices that ratify or contest the expectations implicated by the physicians’ prior report. In each subsequent turn within the information exchange sequence, a speaker indicates whether the level and kind of information being exchanged is appropriate/inappropriate and sufficient/insufficient for the participants. (shrink)

Research on multiple relationships by practicing psychologists has typically presumed the presence of a professional relationship and focused on the ethicality of subsequent, nonprofessional relationships. Instead, this study focused on the question of what, exactly, constitutes the professional relationship in the first place. Practicing psychologists and undergraduates responded to vignettes portraying various early stages of interaction between a therapist and a prospective client. Participants' responses indicated that determinations of professional relationship establishment, and the ethicality of subsequent nonprofessional relationships, depended upon (...) the degree of engagement. Some differences emerged between perceptions by professionals and nonprofessionals. Ethical and professional implications are discussed. (shrink)