1. Rural Health Ethics January 9, 2008 Maria Wallington, MD Medical Ethicist Providence Health and Services Alaska

2. Etiquette Press * 6 to mute; Press # 6 to un-mute Keep your phone on mute unless you are dialoging with the group Never place phone on hold If you do not want to be called on please check the red mood button on the lower left of screen

3. Goals for today’s conversation Why talk about Rural Health Ethics? What makes Rural Health Ethics different? What are the major issues? Example cases

4. Why talk about Rural Health Ethics? Neglected population? Are the issues different? –In Kind? –In Degree? –Ethically?

5. What makes Rural Health Ethics different? Technology not the source of most issues Demographics –Older, poorer, –Communal or culturally distinct Availability of resources Distances

6. Major Issues Boundaries Confidentiality Providers –Limited selection –Call coverage –Specialists –Alternate providers Distances –Access to care –Isolation form family/support

7. Major Issues Need for transport –Expense –Availability/timeliness –Danger? Organizational issues –Whose responsible? –Service line decisions –Economic realities Ethics function needs and support

8. Case 1 A small city (3000) owns its small hospital and long term care facility and contracts with a long health system to run its facilities. The facilities are major employers for the town. The administrator is trying to create a balanced budget and is considering reducing FTEs or raising rates for services.

9. Case 1 continued The chief administrator’s administrative assistant is the city’s mayor. The renewal of the contract is up for discussion

10. Case 2 A small community in a farming area used the local radio to give “The Hospital Report” which announced who was in the hospital that day. Locals used the program to learn who needed an extra hand with the live stock and who might need a casserole to feed the kids while mama was in the hospital.

11. Case 2 continued HIPAA regulations brought the radio report to an end, much to the upset of the community. “What do the feds know about what makes our town work anyway?” Fryer-Edwards, Kelly, “On Cattle and Casseroles”. Amer. Journal of Bioethics, March-April 2006,Vol. 6 Number 2, pp 55-56