Handbook for rural health care ethics

With an eye to small-town health professionals as well as to the people training students to practice medicine beyond metropolitan settings, Dartmouth's Department of Community and Family Medicine is unveiling the Handbook for Rural Health Care Ethics.

William A. Nelson, Ph.D., director of the Dartmouth Medical School's (DMS) Rural Ethics Initiative, is the editor of the guide, subtitled A Practical Guide for Professionals. The National Institutes of Health awarded a National Library of Medicine Grant to the three-year effort to assemble and write the e-book, which is accessible here.

Its authors include physicians, nurses, ethicists and hospital administrators sharing case studies from their experiences or scholarship in rural settings.

"Despite the unique character of rural ethics issues, there are very few ethics resources for regional clinicians," says Nelson, an associate professor of community and family medicine at DMS. "The Handbook is designed to fill this significant gap."

In the chapter he coauthored, Nelson encourages faculty of medical schools to augment the guide by "relating personal ethical challenges that they have encountered, and strategies (effective or not effective) that they used to address such challenges."

The challenges belie the pastoral surroundings. In the handbook's sixth chapter, DMS Associate Professor Andrew Pomerantz, M.D., describes this case study of overlapping roles creating an ethical dilemma:

"Andy Cox is a nurse in a physician's office some 30 miles from his hometown. He is also a member of his town's school board. One day Mr. Richards, a teacher from the school, visits the physician for a check-up. Mr. Cox thinks it odd that Mr. Richards has traveled so far to see the doctor, since most people in his hometown see a family physician in the town. Andy Cox says hello, but has little contact with the patient. A few days later, Nurse Cox is retrieving lab information and learns that the teacher has tested positive for several drugs, suggesting substance abuse. The nurse wonders if he could or should warn school administrators or fellow school board members about the teacher's drug use."

The book grew out of a retreat that Nelson directed in 2006, at which most of the authors-to-be discussed the minefield of issues that Nelson says he has been researching "on or off for about 15 years."