1. Common Rural Ethical Challenges Professional-personal boundary conflicts Privacy and confidentially Caregiver stress Community values and professional guidelines Allocation of resources Access to needed care Disease stigma Training materials from Rural Health Care Ethics: A Manual for Trainers. WA Nelson and KE Schifferdecker, Dartmouth Medical School, Hanover, NH

2. Example – Overlapping Relationships Dr. Gomez, a family physician in a rural setting is a member of the town’s 3-person school board. He discovers during a routine examination that one of his patients, who is a school teacher, has missed many teaching days because of a significant alcohol problem. Dr. Gomez is also aware that the teacher has applied for the vacant principal position at the school.

3. Example – Disease Stigma A patient living in a remote, rural community drives 2 hours to University Hospital for care related to a STD. When asked about not going to the primary care clinic in her community, she replies, “My sister-in-law works at the clinic by our house, that would be bad for the whole family.” Because of the burden of the long drive she becomes non-compliant for subsequent follow-up.

4. Example – Privacy and Confidentiality NP J. Baker prescribed a partial opiate agonist to a young man, Brian, for treatment of prescription opiate dependence. Three weeks later, Brian was found unresponsive, requiring intubation and medical evacuation to a city. He recovered and didn’t want others to know he had attempted suicide. He spread rumors that Joan incorrectly prescribed a medication and was incompetent. Another patient brought up these rumors during an appointment with Joan. She wished she could set the record straight; that Brain obtained opiates from a provider in a neighboring city and had taken these in large quantities in a suicide attempt.