Ethical disparities: challenges encountered by multidisciplinary providers in fulfilling ethical standards in the care of rural and minority people.

Illness burden and health-related resources are unevenly distributed across the United States.1-3 A pattern of greater burden and lessened resources exists among certain populations, such as rural and frontier residents and ethnic minority people, creating significant inequities or disparities in health for these groups.4,5 Over time, with our country comprised of nearly 60 million rural persons6 and more than 50 million ethnic minority persons,6 health disparities among these populations have been recognized increasingly as serious concerns for our society. The emerging literature has documented disparities for rural people compared to those living in non-rural areas in disease burden and disability level7 as well as regarding access to health care resources. Rural residents have higher rates of chronic illness, life-threatening medical conditions, physical and self-care limitations associated with disability, motor vehicle accidents, and environmental hazards.8 Rural residents more often use alcohol routinely and experience more severe consequences of alcohol dependence (eg, cirrhosis, nutritional compromise, fetal alcohol syndrome), alongside more rapidly escalating rates of substance abuse and dependence with compared with suburban and urban populations.9 Elders, farmers, and Native American adolescent males who live in rural areas carry very high risk for certain mental health-related health issues (eg, depression, co-occurring health conditions) and exceptionally high rates of completed suicides.10 Although prevalence of HIV is relatively low in rural areas, the incidence rates for HIV are increasing more rapidly in rural areas, and certain infections (eg, hepatitis B, hepatitis C, Chlamydia, tuberculosis) exist at higher than national averages in many rural states.11 Finally, fewer individuals who live outside of urban areas assess their personal health as “excellent” and greater proportions of rural residents reported their health as “fair or poor,” with the poorest rural residents being 4 times as likely to give this negative assessment.5 Similarly, among ethnic minority people significant disparities exist for illness burden.12,13 Various minority groups show notable disparities for infant mortality, total death rate, death rates by violent means, and death rates for most major diseases, such as cardiovascular disease, asthma, cancer, and diabetes.14,15 Disparities for various minority groups are also present for many stigmatizing illnesses such as sexually transmitted diseases (including HIV), drug abuse, and depression.15 Health status indicators developed as a part of Healthy People 2000 showed improvements for most ethnic groups during the 1990s, but these improvements were matched by generally similar improvements for nonminority groups, leaving the disparities at similar levels as a decade before.14 Ethnic minority people overall have significantly lower overall access to appropriate health care resources, including less access to a regular primary care provider, less preventive care, and lower rates of health insurance.16 Some but not nearly all such disparities can be attributed to differences in economic resources between majority and minority groups in the United States. In addition, evidence indicates that ethnic minority people often receive lower quality interpersonal health care than white patients,16-19 partly due to low levels of cultural competence of providers and partly due to discrimination, stereotyping, and other unconscious cognitive processes among providers and other members of the health care system.16,20 The Institute of Medicine report Unequal Treatment16 provides a detailed examination of ethnic disparities in health care as well as recommendations about how to reduce them. This is also the topic of the highly controversial January 2004 Changes to the National Healthcare Disparities Report from the US House of Representatives Committee on Government Reform.21 In addition, various approaches have been recently discussed for reducing health care disparities.22-25 Despite real and often greater health care needs, fewer resources exist for rural and ethnic minority people.5,26,27 Rural areas often do not have adequate or up-to-date health care facilities, nor can they sustain a continuum of necessary services for physical and mental health needs of their patients.28 Rural areas have insufficient numbers of generalists, specialists, and subspecialists, and providers in these areas take on expanded responsibilities in clinical care.29 Just as rural hospitals and health care facilities are often under threat of closure due to financial challenges, the sustainability of rural clinical practices presents many difficulties as providers are exhausted by the immense and diverse health needs in their communities.28 The lack of necessary services for rural and ethnic minority people aligns with other considerations. For instance, over 14% of rural people and over 22% of black, Hispanic, and Native American people in the United States live in poverty.6 Ethnic minority people are more likely to be uninsured for health care (over 25% uninsured).6 Moreover, geography and climate are relevant considerations outside of metropolitan settings, as many remote areas of the United States have no road or transportation system and/or are not accessible except by plane in certain seasons.30 In addition, the actual use of existing services by rural and ethnic minority people is shaped by attitudes toward illness (eg, stoicism, stigma) and by issues pertaining to cultural sensitivity and competence (eg, views of illness, trust in technology and/or allopathic care, availability of translators).31 Thus, urban health care paradigms have become increasingly characterized by specialists, high technology, individualism, better access and insurance coverage, and, ultimately, a higher standard of care, whereas rural health care models are characterized by generalists, paraprofessionals and self-help, low technology, extended families and communal systems, poor availability, inadequate insurance, and overall lower care standards.28 Attention to health disparities in the US originates in a fundamental commitment to the ethical principles of justice and respect for persons. Taken together, these principles hold the profession of medicine and the institutions of our society to the ideal of fair and equitable distribution of resources and to the expectation of nondiscrimination. For this reason, the examination of the phenomenon of health disparities is an endeavor that has an inherent ethical basis. A compelling question that arises is whether ethically important aspects of health care may themselves be disparate across distinct populations. Do multidisciplinary providers encounter greater challenges in fulfilling accepted ethical standards in establishing a therapeutic alliance, obtaining informed consent, safeguarding confidentiality, and facilitating treatment adherence while caring for rural and minority people? In essence, are ethical disparities in health care more salient for rural and minority people than in the care of other patients/clients? Answering these questions is the aim of this study.