According to the U.S. Census Bureau, nearly 60 million people, representing 20% of the United States population, live in rural areas within the country. From a medical ethics perspective, rural areas face a broad range of health and health care challenges which must be addressed. There are increasingly dramatic physician shortages in rural America. Rural areas also suffer from severe lack of medical support providers such as pharmacists, therapists, clinicians, dentists, rehabilitation centers and hospitals. Compounding these challenges is the fact that rural residents face an increasing gap in life expectancy in comparison to healthier urban dwellers. Additionally, due to lack of adequate health care over long periods, rural residents face greater illness and injury-related disabilities. Drug addiction is also prevalent in rural areas, as well as disproportionate deaths from overdoses. In all, rural health care in America is a fragile system that warrants an ethical approach to prioritizing rural access to medical professionals and treatment.
Some reasons for the disparity in health outcomes for rural areas are because of systemic, historical frameworks and challenges. There are long-entrenched economic, cultural, social and educational differences at play in rural areas which impede rural Americans’ ability to enjoy a healthy life at the standard of other more urban areas. Economically, rural America has lower income per capita and extremely high poverty rates as compared to urban residents. Rural inhabitants are also more likely to be uninsured, which increases their hardship in successfully interacting with any health care institutions available to them. Higher cost medical services are not economically viable for most rural residents, so they must forgo both primary care and specialized care options. Instead, rural populations tend to utilize emergency rooms or understaffed free clinic services to address health problems.
In addition to economic limitations, rural residents have a very limited scope of medical services available to them. Physician shortages in rural areas have continued unabated for decades for remote communities. It’s been shown that few medical schools are able to attract students interested in primary care medicine in rural settings. It is not only a dearth of physicians which complicates health outcomes, but rural residents also have a limited offering of the variety of medical services that are commonly available in populated areas. Nearly all types of health care professionals are in short supply in remote locations: there are fewer social workers, nurses, home-care aids, therapists, rehabilitation professionals, audiologists, and dental technicians, just to name a few. Mental health services are especially limited. Isolated areas simply present more challenges to accessing health institutions, and existing medical treatment centers can be often unreachable. On average, rural residents must travel far greater distances than urban residents to access any health care system. Public transportation is limited, and extreme weather conditions often adversely affect rural areas to a greater extent, impeding the ability to travel. Hospitals and clinics are similarly few and far between. Even if residents can access hospitals, those hospitals still in existence are extremely small with few acute care beds and few emergency personnel. Also, many rural communities are seeing their hospitals fully close. In the last twenty years, hundreds of rural hospitals have closed. As a result, residents must travel on average 40 miles or more for basic health services. Also, given that burden of illness for rural populations is higher than in urban areas, greater demands are placed on already poor-resourced clinical care system.
Adding to the lack of health care providers is an even more important concern. Rural residents have worse overall health during their lifetimes, than urban and suburban residents. Rural citizens have higher rates of cigarette smoking, hypertension and obesity. They face more chronic and life-threatening disease. Specifically, they have more deaths from heart disease, cancer, respiratory disease and stroke than other citizens. Infant mortality rates are consistently higher in rural areas, as are suicides and overdoses. Rural occupations in agriculture subject residents to increased environmental and work-related accidents. Rural children in small communities are more likely to have behavioral and developmental disorders than those living in cities and suburbs. Finally, rural residents have far lower life expectancies than urban populations.
Given the poverty, lack of health services, and worsening health outcomes for rural populations, rural residents have been increasingly recognized as an underserved special population in the United States. Finding ways to obtain an equitable and appropriate standard of care for rural citizens has become an important topic in national health policy determinations. There is also a growing awareness that rural populations require special ethical considerations in clinical practice because tight-knit, small communities present unique challenges when it comes to issues of informed consent, trust of medical personnel, adherence to treatment, overlapping personal and professional relationships, protecting confidentiality and navigating conflicts of interest. For example, it may be hard to protect the privacy of rural patients when their care occurs in clinics where the health care workers actually know the patients and their families in a personal context. Boundary issues can present challenges especially where there are overlapping relationships between clinician and patient who might know each other outside of the medical context. Specifically, it is difficult to establish a professional medical relationship with a clinician when the patient and clinician know each other from school or church or business. Moreover, the close-knit nature of rural communities can cause an increase in stigma associated with mental illness or substance abuse disorders.
Guidelines have been created by medical ethicists to address these ethical challenges in rural healthcare. First, it is important to tailor the training of healthcare professionals in rural areas to be focused on ameliorating the unique conflicts of interests in those communities. Additionally, healthcare professionals must foster supportive environments which encourages open communications and openness in addressing and tackling any ethical dilemmas to make patients more comfortable. Healthcare professionals should also implement models to deliver healthcare more easily despite geographic barrier, such as using telemedicine and mobile health clinics. Medical Schools and state and federal governments should incentivize healthcare professionals to practice in rural areas either by offering scholarships or loan repayment programs to help address shortages. Finally, healthcare professionals should focus on building trust with and ensuring culturally sensitive care for rural citizens. Acknowledging these important ethical issues in rural healthcare and implementing an ethically responsible framework and approach will help to ensure access to improved and quality healthcare in our rural underserved communities.
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