Whitehead, J. Shaver, John Stephenson, Rob and Newman, Peter A 2016. Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations. PLOS ONE, Vol. 11, Issue. 1, p. e0146139.
Nelson, William A. Barr, Paul J. and Castaldo, Mary G. 2015. The Opportunities and Challenges for Shared Decision-Making in the Rural United States. HEC Forum, Vol. 27, Issue. 2, p. 157.
Chen, Yiyi Yin, Zhou and Xie, Qiong 2014. Suggestions to ameliorate the inequity in urban/rural allocation of healthcare resources in China. International Journal for Equity in Health, Vol. 13, Issue. 1, p. 34.
Pesut, Barbara Bottorff, Joan L and Robinson, Carole A 2011. Be known, be available, be mutual: a qualitative ethical analysis of social values in rural palliative care. BMC Medical Ethics, Vol. 12, Issue. 1,
Nelson, William A. Rosenberg, Marie-Claire Mackenzie, Todd and Weeks, William B. 2010. The Presence of Ethics Programs in Critical Access Hospitals. HEC Forum, Vol. 22, Issue. 4, p. 267.
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.
1. Roberts LW, Battaglia J, Smithpeter M, Epstein RS. An office on Main Street. Health care dilemmas in small communities. Hastings Center Report 1999;29(4):28–37; Nelson WA, Schmidek JM. Rural healthcare ethics. In: Singer PA, Viens AM, eds. The Cambridge Textbook of Bioethics. New York: Cambridge University Press; 2008:289–98; Rural health fact sheet. Health Resources and Services Administration, U.S. Department of Health and Human Services; available at http://www.hrsa.gov/about/factsheets/orhp.htm (last accessed 19 January 2009).
2. Bushy A.Rural nursing: practice and issues. American Nurses Association Continuing Education Program Module; available at http://nursingworld.org/mods/mod700/rurlfull.htm (last accessed 2 July 2009); Bushy A, ed. Rural Nursing. Newbury Park, CA: Sage Publications; 1991; Bushy A. Nursing in rural and frontier areas: Issues, challenges and opportunities. Harvard Health Policy Review 2006;7(1):17–27.
3. See note 1, Roberts et al. 1999; Gamm LD, Hutchison LL, Dabney BJ, Dorsey AM, eds. Rural Healthy People 2010: A Companion Document to Healthy People 2010. Volume 1. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center; 2003; U.S. Department of Health and Human Services. Tracking Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services; 2000; Seshamani M, Van Nostrand J, Kennedy J, Cochran C. Hard Times in the Heartland: Health Care in Rural America. Washington, DC: U.S. Department of Health and Human Services; 2009:3.
4. See note 1, Roberts et al. 1999.
5. See note 1, Roberts et al. 1999.
6. Purtilo RB. Rural health care: The forgotten quarter of medical ethics. Second Opinion 1987;6:10–33.
7. Cook AF, Hoas H. Voices from the margins: A context for developing bioethics-related resources in rural areas. American Journal of Bioethics 2001;1(4):W12; Cook AF, Hoas H. Ethics and rural healthcare: What really happens? What might help? American Journal of Bioethics 2008;8(4):52–6; Nelson WA. The challenges of rural health care. In: Klugman CM, Dalinis PM, eds. Ethical Issues in Rural Health Care. Baltimore, MD: Johns Hopkins University Press; 2008:34–59.
8. Nelson W, Lushkov G, Pomerantz A, Weeks WB. Rural health care ethics: Is there a literature? American Journal of Bioethics 2006;6(2):44–50.
9. See note 1, Nelson, Schmidek 2008.
10. Klugman CM, Dalinis PM, eds. Ethical Issues in Rural Health Care. Baltimore, MD: Johns Hopkins University Press; 2008; Nelson WA, ed. Handbook for Rural Health Care Ethics: A Practical Guide for Professionals. Hanover, NH: Dartmouth College; 2009; available at http://dms.dartmouth.edu/cfm/resources/ethics/.
11. See note 8, Nelson et al. 2006.
12. Morgan K, Hart AM. Families in rural settings: Values regarding acute respiratory infections. Families, Systems & Health 2009;27(1):85–97.
13. Jastifer J, Roberts S. Patients’ awareness of and attitudes toward gifts from pharmaceutical companies to physicians. International Journal of Health Services 2009;39(2):405–14.
14. Butterfield P, Postma J. The TERRA framework: Conceptualizing rural environmental health inequities through an environmental justice lens. ANS. Advances in Nursing Science 2009;32(2):107–17.
15. Jackson EW, Olive KE. Ethics committees in small, rural hospitals in East Tennessee. Southern Medical Journal 2009;102(5):481–5.
16. Heimburger RA. The ethical benefits of small community hospitals. Southern Medical Journal 2009;102(5):454.
17. Zylstra B. Medical ethics: Promise vs. practice. Southern Medical Journal 2009;102(5):453.
18. Zukoski AP, Thorburn S. Experiences of stigma and discrimination among adults living with HIV in a low HIV-prevalence context: A qualitative analysis. AIDS Patient Care and STDs 2009;23(4):267–76.
19. Day AS. Emergency contraception: When the pharmacist conscience clause restricts access. Nursing for Women’s Health 2008;12(4):343–6.
20. Having KM, Hale D, Lautar CJ. Ethics committees in the rural Midwest: Exploring the impact of HIPAA. Journal of Rural Health 2008;24(3):316–20.
21. Bunn JY, Solomon SE, Varni SE, Miller CT, Forehand RL, Ashikaga T. Urban–rural differences in motivation to control prejudice toward people with HIV/AIDS: The impact of perceived identifiability in the community. Journal of Rural Health 2008;24(3):285–91.
22. Pope TM. Multi-institutional ethics committees: For rural hospitals, and urban ones too. American Journal of Bioethics 2008;8(4):69–71; author reply W63–4.
23. Aultman J. Moral courage through a collective voice. American Journal of Bioethics 2008;8(4):67–9; author reply W63–4.
24. Crowden A. Distinct rural ethics. American Journal of Bioethics 2008;8(4):65–7; author reply W63–4.
25. Bolin JN, Mechler K, Holcomb J, Williams J. An alternative strategy for resolving ethical dilemmas in rural healthcare. American Journal of Bioethics 2008;8(4):63–5; author reply W63–4.
26. Vernillo A. Preventive ethics and rural healthcare: Addressing issues on a systems level. American Journal of Bioethics 2008;8(4):61–2; author reply W63–4.
27. Morley CP, Beatty PG. Ethical problems in rural healthcare: local symptoms, systemic disease. American Journal of Bioethics 2008;8(4):59–60; author reply W53–4.
28. Klugman CM. Vast tracts of land: Rural healthcare culture. American Journal of Bioethics 2008;8(4):57–8; author reply W53–4.
29. Mitchell GW. Rural hospitals: A different take on conflict of interest. Trustee 2008;61(3):30.
30. Ostertag SG, Forman WB. End-of-life care in Hancock County, Maine: A community snapshot. American Journal of Hospice and Palliative Care 2008;25(2):132–8.
31. Brua C. Role-blurring and ethical grey zones associated with lay interpreters: Three case studies. Communication and Medicine 2008;5(1):73–9.
32. Cook AF, Hoas H. Revisiting ethics and rural healthcare: What really happens? What might help? American Journal of Bioethics 2008;8(4):W3–4.
33. Wendel ML, Burdine JN, McLeroy KR. The evolving role of partnerships in addressing community public health issues: Policy and ethical implications. Organizational Ethics 2007;4(1):53–64.
34. Roberts LW, Johnson ME, Brems C, Warner TD. Ethical disparities: Challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people. Journal of Rural Health 2007;23(Suppl):89–97.
35. Minugh PA, Janke SL, Lomuto NA, Galloway DK. Adolescent substance abuse treatment resource allocation in rural and frontier conditions: The impact of including organizational readiness to change. Journal of Rural Health 2007;23(Suppl):84–8.
36. Foster PH. Use of stigma, fear, and denial in development of a framework for prevention of HIV/AIDS in rural African American communities. Family and Community Health 2007;30(4):318–27.
37. Craig A, Cronin B, Eward W, Metz J, Murray L, Rose G, et al. . Attitudes toward physician-assisted suicide among physicians in Vermont. Journal of Medical Ethics 2007;33(7):400–3.
38. Bunn JY, Solomon SE, Miller C, Forehand R. Measurement of stigma in people with HIV: A reexamination of the HIV Stigma Scale. AIDS Education and Prevention 2007;19(3):198–208.
39. Schrader SL, Nelson ML, Eidsness LM. Palliative care teams on the prairie: Composition, perceived challenges & opportunities. South Dakota Medicine 2007;60(4):147–9, 151–143.
40. Haller IV, Gessert CE. Utilization of medical services at the end of life in older adults with cognitive impairment: Focus on outliers. Journal of Palliative Medicine 2007;10(2):400–7.
41. Nelson W, Pomerantz A, Howard K, Bushy A. A proposed rural healthcare ethics agenda. Journal of Medical Ethics 2007;33(3):136–9.
42. Milmore D. Hospital ethics committees: A survey in Upstate New York. HEC Forum 2006;18(3):222–44.
43. Nelson WA, Pomerantz AS, Weeks WB. Response to commentaries on “is there a rural ethics literature?” American Journal of Bioethics 2006;6(4):W46–7.
44. Nelson W. Where is the evidence: A need to assess rural ethics committee models. Journal of Rural Health 2006;22(3):193–5.
45. Nelson W, Weeks WB. Rural and non-rural differences in membership of the American Society of Bioethics and Humanities. Journal of Medical Ethics 2006;32(7):411–3.
46. Roberts LW, Johnson ME, Brems C, Warner TD. Preferences of Alaska and New Mexico psychiatrists regarding professionalism and ethics training. Academic Psychiatry 2006;30(3):200–4.
47. Klugman CM. Haves and have nots. American Journal of Bioethics 2006;6(2):63–4.
48. Anderson-Shaw L. Rural health care ethics: What assumptions and attitudes should drive the research? American Journal of Bioethics 2006;6(2):61–2.
49. Miller JP. Defining “research” in rural healthcare ethics. American Journal of Bioethics 2006;6(2):59–61.
50. Aultman JM. A foreigner in my own country: Forgetting the heterogeneity of our national community. American Journal of Bioethics 2006;6(2):56–9.
51. Fryer-Edwards K. On cattle and casseroles. American Journal of Bioethics 2006;6(2):55–6.
52. Hardwig J. Rural health care ethics: What assumptions and attitudes should drive the research? American Journal of Bioethics 2006;6(2):53–4.
53. Cook AF, Hoas H. Re-framing the question: What do we really want to know about rural healthcare ethics? American Journal of Bioethics 2006;6(2):51–3.
54. Levy CR, Fish R, Kramer A. Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit. Journal of the American Geriatrics Society 2005;53(12):2060–8.
55. Zingmond DS, Wenger NS. Regional and institutional variation in the initiation of early do-not-resuscitate orders. Archives of Internal Medicine 2005;165(15):1705–12.
56. Warner TD, Monaghan-Geernaert P, Battaglia J, Brems C, Johnson ME, Roberts LW. Ethical considerations in rural health care: A pilot study of clinicians in Alaska and New Mexico. Community Mental Health Journal 2005;41(1):21–33.
57. Culberson J, Levy C, Lawhorne L. Do not hospitalize orders in nursing homes: A pilot study. Journal of the American Medical Directors Association 2005;6(1):22–6.
58. Roberts LW, Warner TD, Hammond KG. Ethical challenges of mental health clinicians in rural and frontier areas. Psychiatric Services 2005;56(3):358–9.
59. Ricketts TC. Workforce issues in rural areas: A focus on policy equity. American Journal of Public Health 2005;95(1):42–8.
60. Clipson CR. Misuse of psychologist influence: Multiple relationships. Journal of Aggression, Maltreatment & Trauma 2005;11(1/2):169–203.
61. Nelson W. Addressing rural ethics issues. The characteristics of rural healthcare settings pose unique ethical challenges. Healthcare Executive 2004;19(4):36–7.
62. Cook AF, Hoas H, Guttmannova K, Joyner JC. An error by any other name. American Journal of Nursing 2004;104(6):32–43; quiz 44.
63. Buchanan RJ, Bolin J, Wang S, Zhu L, Kim M. Urban/rural differences in decision making and the use of advance directives among nursing home residents at admission. Journal of Rural Health 2004;20(2):131–5.
64. Cooper SP, Heitman E, Fox EE, Quill B, Knudson P, Zahm SH, et al. . Ethical issues in conducting migrant farmworker studies. Journal of Immigrant Health 2004;6(1):29–39.
65. Rural hospitals’ strategies for achieving compliance with HIPAA privacy requirements. Policy Analysis Brief. W Series 2004(3):1–4.
66. See note 8, Nelson et al. 2006.
67. See note 8, Nelson et al. 2006.
68. Oosterhoff DD, Cand SJ, Rowell M. Shared leadership: The freedom to do bioethics. HEC Forum Dec 2004;16(4):297–316.
69. Currie J, Toews S, Magwood B. Enhancing ethics services: Challenges and strategies in the Winnipeg regional health authority. HEC Forum 2004;16(4):284–96.
70. Simpson C, Kirby J. Organizational ethics and social justice in practice: Choices and challenges in a rural–urban health region. HEC Forum 2004;16(4):274–83.
71. Pullman D, Singleton R. Doing more with less: Organizational ethics in a rural Canadian setting. HEC Forum 2004;16(4):261–73.
72. Jiwani B. A mandate for regional health ethics resources. HEC Forum 2004;16(4):247–60.
73. Maddalena V, Sherwin S. Vulnerable populations in rural areas: Challenges for ethics committees. HEC Forum 2004;16(4):234–46.
74. D’Agincourt-Canning L. Genetic testing for hereditary cancer: Challenges to ethical care in rural and remote communities. HEC Forum 2004;16(4):222–33.
75. Simpson C. Challenges for health regions—Meeting both rural and urban ethics needs: A Canadian perspective. HEC Forum 2004;16(4):219–21.
76. Nelson WA, Schifferdecker KE. Practical strategies for addressing and preventing ethics issues in rural settings. In: Nelson WA, ed. Handbook for Rural Health Care Ethics: A Practical Guide for Professionals. Hanover, NH: Dartmouth College; 2009; available at http://dms.dartmouth.edu/cfm/resources/ethics/.
This work was supported by the Rural Resource Center, White River Junction, Vermont. The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States government.
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