Academic journal article The Hastings Center Report

An Office on Main Street

Academic journal article The Hastings Center Report

An Office on Main Street

Article excerpt

Health Care Dilemmas in Small Communities

The health care needs of rural populations often differ from those of their urban counterparts. And the ethical dilemmas that caregivers face are distinctively shaped in rural settings, not only by resource constraints, but by the nature of life in small, close-knit communities as well.

It is increasingly acknowledged that individuals who live in remote settings represent a large and underserved patient population in the United States. Many obstacles to rural and frontier health care have been identified, such as poor distribution of care providers and facilities, geographical barriers, and inadequate communication services.[1] What has received little attention, however, are the unique ethical dilemmas encountered in health care in small communities that may significantly influence the delivery of medical services in rural and frontier settings. The aim of this paper then is twofold: to outline the key issues in general health care needs in the rural United States, and to describe the distinct clinical ethical features affecting health care services in small communities. By clarifying these considerations, the care of rural and frontier community residents who suffer from diverse illnesses may be better understood and improved.

Rural and Frontier Health Care in the United States

The United States encompasses 3.6 million square miles and is the fourth largest country in the world. Its overall population density is 69 people per square mile, in dramatic contrast with other industrialized nations such as Germany (573 per square mile), the Netherlands (940 per square mile), Japan (865 per square mile), and the United Kingdom (609 per square mile).[2] U.S. residents are unevenly distributed, creating numerous non-metropolitan communities throughout the country. Indeed, roughly 45 percent of the U.S. land mass is frontier, and a total of 25 states have frontier regions.[3] It is estimated that more than 60 million individuals, or one-quarter of the U.S. population of 251 million, live in areas designated as rural (fewer than 2,500 people per town boundary) and frontier (fewer than 6.6 people per square mile).

Concerns have been raised about health care needs in rural areas for several reasons. First, the overall age-adjusted death rate is greater in rural areas (537 per 100,000) than in large (479 per 100,000) and medium to small (517 per 100,000) metropolitan settings.[4] Second, a higher proportion of rural residents experience chronic illnesses and life-threatening conditions, such as cancer, heart disease, arthritis, and diabetes. They also experience greater limitations on physical activity--for example, in mobility or self-care--than urban residents.[5] Rural residents' perceptions of their health are also more negative than are those reported by city inhabitants; this is especially true among the rural poor.[6] Third, rural and frontier areas have a greater proportion of children and elderly residents who generally require more health services. Fourth, rural regions have a greater prevalence of environmental hazards (for example, contaminated water supplies, pollution, pesticides, natural disasters, infectious agents, animal bites) and domestic and occupational injuries (agricultural, forestry/logging, fishing, and mining, etc.).[7] Finally, mental health concerns in smaller communities are tremendous. Early studies have estimated that 13-19 percent of rural residents experience significant psychiatric impairment. More recent evidence indicates that alcohol and cognitive disorders are higher in rural areas, and depressive symptoms are more prevalent rurally.[8] Suicide rates, previously higher in urban settings, are now greater in rural regions. Indirect indicators of substance disorders and mental illness in rural areas are also substantial, as revealed in deaths due to homicide and alcohol-related motor vehicle crashes, in the high rates of fetal alcohol syndrome, child neglect and abuse, and other social problems especially in certain sub-populations of rural dwellers. …

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