Skip to main content Accessibility help

Rural Healthcare Ethics: No Longer the Forgotten Quarter



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.



Hide All

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 (last accessed 19 January 2009).

2. Bushy, A.Rural nursing: practice and issues. American Nurses Association Continuing Education Program Module; available at (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

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

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.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed