Abstract

For nearly thirty years, hospitals have been encouraged to provide bioethics services to patients, families and staff members. That encouragement is evidenced by federal legislation such as the Patient Self Determination Act, various legal opinions, and the standards developed by the Joint Commission on the Accreditation of Healthcare Organizations and the American Hospital Association. In spite of such encouragement, little has been known about the bioethics-related services that exist in rural healthcare settings, the ethical issues that complicate healthcare decision making in rural settings, or how those issues are resolved. The bioethics enterprise has strongly encouraged the use of two specific models for bioethics services---ethics committees and case consultation---but the efficacy of those approaches has not been substantiated in rural environments. ;This work responds to that overall research deficit by examining the ethics of healthcare in rural America. The examination begins with an historical critique of the construction of modern bioethics and its institutional establishment. That critique, in turn, provides the backdrop for a multi-method exploration of the ethics-related dilemmas, needs, and practices that are experienced by those who live in rural areas. This exploration involves nine separate studies that were conducted among healthcare providers, patients, family members and community leaders who live in rural communities. The data from these studies suggest that the models for bioethics services that have been developed in urban and academic settings do not meet the needs of rural residents. Further, the findings suggest the need for both an expanded definition of bioethics as well as the development of integrated models for bioethics services that better accommodate the moral and cultural context of health care in a given community