The establishment of conscientious monopolies in rural communities.

In the United States, healthcare providers have the federally protected right to conscientiously refuse to provide treatments or services that they feel violate their moral or religious values. This refusal of services is colloquially known as "conscientious objection," which has become a polarizing topic in today's medical and ethical landscape. Typically, physicians exercising their right to conscientious objection do not represent a barrier in access to care for most patient populations. This dynamic shifts, however, in rural America, where there are relatively few providers. In this commentary, we discuss some of the unique ramifications that are likely to occur when rural providers invoke conscientious objection in their medical practice and how this can in turn establish conscientious monopolies for the members of their communities.

How rural nurses in Southern New Zealand navigate their ethical landscape-A qualitative study.

OBJECTIVE: To explore rural nurse experiences of ethical issues and their management of these as a first step in a programme of work to address rural nurses' ethical needs. DESIGN: This study was qualitative, using mixed qualitative techniques to gather data, which was analysed using a general inductive approach. SETTING: Primary health care in 2 regions of Aotearoa New Zealand. PARTICIPANTS: Eleven nurses working in the West Coast (District Health Board) region and 9 working within the Southern District Health Board region. INTERVENTION: Participants took part in either a focus groups or an interview with members of the research team. MAIN OUTCOME MEASURES: To document ethical issues that confronted these rural nurses and how they navigated these issues. RESULTS: Three themes were identified: 'Signals and Silences,' 'One and Other' and 'Frustrations and Freedoms.' A continuous thread through these themes was the concept of phronesis, or what is sometimes called practical virtue. This practical virtue largely developed through their own experiences, rather than through educational or health system specific support or resources. CONCLUSIONS: We found that rural nurses' deal with specific issues related to the rural setting, such as resourcing and isolation, while maintaining a relationship with the communities they serve and their professional autonomy. Additionally, we discovered the ways in which rural nurses deal with the ethical issues they encounter to be practically focussed. However, rural nurses need supportive leadership not only to sustain the moral agency they demonstrate but also to further develop their ethical decision-making practices. The provision of a clinical ethics tele-service delivering both training opportunities and an on-call consult support service would provide a potential solution.

When Specialty Care Is Unavailable to Rural Families.

We present the case of a 2-year-old boy with epidermolysis bullosa and supraglottic stenosis whose parents refuse an elective tracheostomy because of the significant care the tracheostomy would require. The patient's family lives in a rural area with few health care resources and his parents are already handling hours of daily skin care for his epidermolysis bullosa. In an attempt to convince the parents to pursue the intervention, the medical team recommends that the family move to an area with additional resources to assist in the child's care. The parents refuse to move, citing the many benefits their home environment provides for their son. The medical team calls an ethics consultation, questioning whether this decision constitutes medical neglect. This case raises important questions about medical decision-making in pediatrics. First, is a parent's refusal of a recommended medical intervention because it would require moving their family to a new environment a reasonable decision? Second, how broadly can parents define their child's best interest? Should only physical interests be included when making medical decisions? Is there a limit to what can be considered a relevant interest? Third, can parents only consider the interests of the individual child, or can they consider the interests of other members of the family? Finally, what is the threshold for overruling a parental decision? Is it whenever the parent's definition of a patient's best interest is different from the medical team's, or do other criteria have to be met?

Rural Health Care and an Ethics of Familiarity.

This commentary focuses on the narratives written from a variety of voices describing the unique challenges and rewards faced in rural health care. The authors speak from various areas of the country and from many professions including medicine, nursing, social work, and ethics and reflect the experiences of learners, new graduates, and long-time practitioners. The authors also represent people who were raised in rural environments and those who are from more urban settings. The commentary includes a discussion of some major themes from the rural bioethics literature that are reflected in these very personal narratives. The themes include lack of resources; overlapping relationships; resiliency; the need for partnerships and collaboration; and creativity. The commentary will also explore the dichotomy between learners and experienced practitioners and the possible missing voice of practitioners who could not tolerate the challenges and who left rural practice.

Equitable Health Care and Low-Density Living in the United States.

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.

Exploring the Practical Meaning of Clinical Ethics When Providing Healthcare in Rural and Frontier Settings: Appreciating What Matters.

This article provides an opportunity to ponder the ethics of rural healthcare via a rural or frontier lens. The authors juxtapose the insights, offered in the narratives, with the lessons learned from their more than twenty years of empirical bioethics research in rural communities.

Ultrasound in rural India: a failure of the best intentions.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

Emergency care in rural settings: Can doctors be ethical and survive?

We describe below the pressures of running a small private hospital in an underserved rural area, while providing emergency healthcare for victims of poisonous stings, accidents, and other acute health conditions. Both ethics and law demand that payment is not asked for upfront in emergency cases. Yet patients and their families often fail to pay normal dues for months or even years. It is disturbing to encounter such behaviour even in villages; and doctors in small communities are easy prey. In these conditions can one be true to ethical principles and ensure one's own survival?

Challenges in conducting a community-based influenza vaccine trial in a rural community in northern India.

Evidence on influenza vaccine effectiveness from low and middle countries (LMICs) is limited due to limited institutional capacities; lack of adequate resources; and lack of interest by ministries of health for influenza vaccine introduction. There are concerns that the highest ethical standards will be compromised during trials in LMICs leading to mistrust of clinical trials. These factors pose regulatory and operational challenges to researchers in these countries. We conducted a community-based vaccine trial to assess the efficacy of live attenuated influenza vaccine and inactivated influenza vaccine in rural north India. Key regulatory challenges included obtaining regulatory approvals, reporting of adverse events, and compensating subjects for trial-related injuries; all of which were required to be completed in a timely fashion. Key operational challenges included obtaining audio-visual consent; maintaining a low attrition rate; and administering vaccines during a narrow time period before the influenza season, and under extreme heat. We overcame these challenges through advanced planning, and sustaining community engagement. We adapted the trial procedures to cope with field conditions by conducting mock vaccine camps; and planned for early morning vaccination to mitigate threats to the cold chain. These lessons may help investigators to confront similar challenges in other LMICs.

Rural blood availability: regulations must meet ethics.

Rural physicians have been practising the technique of emergency bleeding and transfusion called Unbanked Directed (to a specific recipient) Blood Transfusion (UDBT), which has been declared illegal, to meet the need for blood in rural and inaccessible areas. As a result, a crisis has emerged in the availability of blood. Is UDBT a second rate technology for the poor and the disadvantaged? And should we not rather advocate for rapid scaling up of the establishment of blood banks in all areas? We examine the ethical issues related to blood availability in the rural areas. We argue that a regulated and licensed UDBT passes muster on the ethical principles of beneficence, lack of maleficence, justice and Swaraj. Using this issue as a case in point, we further examine the idea of what constitutes appropriate or acceptable technology. While affirming that any technology has to pass muster on a litmus test of acceptability, we discuss the difference between "ideal" and "acceptable" (but less than ideal) technology. We argue there is a dynamic push and pull between the urge to regulate and restrict the use of skills by all versus the need to communitise technology. Regulated use of UDBT will allow blood to be available where it is needed most in the foreseeable future in India.

[Controversy in the treatment of a critically ill neonate in a rural health service]. / Controversias sobre el tratamiento de un neonato críticamente enfermo en un servicio de salud rural.

Cardiopulmonary resuscitation of newborns with perinatal hypoxia faces serious ethical, moral, medical and legal problems, particularly in rural areas. Ethical and moral issues have to do with the medical-parents relationship; with values, preferences and priorities of each of these groups; and with the scarce resources situation. Medical-technical problems are related to asphyxia complications, and their prognostic and therapeutic implications. Legal considerations arising from the fact of killing or letting die. In this article is analyzed the real case of a neonate with severe perinatal hypoxia in order to enhance the understanding of the incorporation of ethics in everyday clinical practice.

La reanimación cardiopulmonar de recién nacidos con hipoxia perinatal grave enfrenta problemas éticos, morales, médicos y legales, particularmente en áreas rurales. Los problemas éticos y morales tienen que ver con la relación médico-padres; con los valores, preferencias y prioridades de cada uno de estos grupos, y con la situación de la escasez de recursos. Los problemas técnico-médicos están relacionados con las complicaciones relacionadas a la asfixia, así como con sus implicaciones pronósticas y terapéuticas. Mientras que las consideraciones legales derivan del hecho de matar o dejar morir. En este artículo se discute el caso real de un neonato con asfixia perinatal grave con el propósito de fortalecer el entendimiento de la incorporación de la ética de la práctica clínica cotidiana.

Between the idea and the reality: GP liaison in a rural setting.

OBJECTIVES: To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care. CONCLUSIONS: The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.

Ethical matters in rural integrated primary care settings.

Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.