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A Rural Perspective on Modern Bioethics

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A Rural Perspective on Modern Bioethics University of Montana ScholarWorks at University of Montana Graduate Student Theses, Dissertations, & Professional Papers Graduate School 2001 A rural perspective on modern bioethics Ann Freeman Cook The University of Montana Follow this and additional works at: https://scholarworks.umt.edu/etd Let us know how access to this document benefits ou.y Recommended Citation Cook, Ann Freeman, "A rural perspective on modern bioethics" (2001). Graduate Student Theses, Dissertations, & Professional Papers. 9410. https://scholarworks.umt.edu/etd/9410 This Dissertation is brought to you for free and open access by the Graduate School at ScholarWorks at University of Montana. It has been accepted for inclusion in Graduate Student Theses, Dissertations, & Professional Papers by an authorized administrator of ScholarWorks at University of Montana. For more information, please contact [email protected]. INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted.Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. ProQuest Information and Learning 300 North Zeeb Road, Ann Arbor, Ml 48106-1346 USA 800-521-0600 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Maureen and Mike MANSFIELD LIBRARY The University of Montana Permission is granted by the author to reproduce this material in its entirety, provided that this material is used for scholarly purposes and is properly cited in published works and reports. **Please check "Yes" or "No" and provide signature** Yes, I grant permission X No, I do not grant permission_______ Author's Signal Any copying for commercial purposes or financial gain may be undertaken only with the author's explicit consent. 8/98 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A RURAL PERSPECTIVE ON MODERN BIOETHICS by Ann Freeman Cook B A . Carroll College, 1971 M.P.A. University of Montana, 1991 Presented in partial fulfillment of the requirements for the degree of Doctor of Philosophy The University of Montana August 2001 Approved By: . i Dean, Graduate School M-of Date Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 3022081 Copyright 2001 by Cook, Ann Freeman All rights reserved. ___ ® UMI UMI Microform 3022081 Copyright 2001 by Bell & Howell Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. Bell & Howell Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Cook, Ann Freeman, Ph.D., December 2001 Interdisciplinary Studies A Rural Perspective on Modem Bioethics Director: Ken Lockridge 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 (JCAHO) 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 modem 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. ii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PREFACE Hilda Hensen1 serves as director of nursing in a rural hospital, an institution where she has worked for nearly fifteen years. Hilda has high expectations for the kind of care that should be provided. She notes that patients expect to be treated as though they were family members. And they have a right, she suggests, to feel that way. The hospital is closely tied to the community. Community members raised the revenue to fund the hospital, poured the concrete footings, laid the floor boards, and painted the walls. “This is not a world,” she explains during an interview, “where we can turn people away like they do in the big city hospitals. This is a world where people are tight and everybody is a little bit of kin.” This a world of connections; there are few secrets on Main Street. Throughout the interview, Hilda offered comments such as “in our town, everybody knows everybody” and “people value their own.” Certainly, there is an expectation of self reliance in this community, but so too the realization of interdependence. She explained that: “people care about each other because they have to. And sometimes they have torely on each other and not just care about each other.” While Hilda offered many positive comments about the interconnectedness of her community, she also noted that the level of ‘connectedness’ that it commonly expected in rural settings can be hard to incorporate into a patient’s healthcare plan. In recent years, the shortages of staff, equipment, and supplies have taken a heavy toll. Organizational practices have also changed and to an extent, some of the new protocols discourage dialogue. For example, reports at the shift changes are often taped. Most nurses work in iii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. three or more departments on a daily basis.2 Most of the nurses who provide direct patient care in Hilda’s hospital have not received much academic training.3 With such limitations, patients do not always receive the quality of care that they expect. Hilda knows that a lack of quality care is a serious cause for concern because if patients and families do not trust the level of care that is provided, they will leave the county when seeking healthcare. A decision to seek care elsewhere can have serious financial consequences for the local hospital. Hilda also noted that the familiarity and the sense of communal responsibility, so pervasive in a small rural community, make it is hard to separate herself from her work. “I am the nurse,” she explains, “when I leave the hospital, get into my car, and go to the grocery store or go to church.” She is frequently on call, and sometimes feels an obligation to work even when she is not scheduled to do so. “If I hear there’s been an accident, I usually head for the hospital - sometimes before I am even called. Who else can they call? We depend on each other.” Hilda discussed these problems in an articulate manner, but was not sure any of them could be termed “ethical” in nature. After participating in the interview for more than an hour, Hilda noted that the kinds of cultural differences that emerge in rural communities can be “emotionally distressing.” She recalled a recent incident in which a young, first time mother experienced a long and difficult labor. Throughout the labor and birth, the young
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