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This is to certify that the

thesis entitled
PHYSICIAN ROLE CONFLICT IN RURAL MEDICINE:

PATIENT ADVOCATE OR PUBLIC AGENT?

presented by

DAVID BRIAN SCHINDERLE

has been accepted towards fulfillment

of the requirements for

INTERDISCIPLINARY PROGRAMS IN
MASTER OF ARTS degree in HEALTH AND HUMANITIES

 

 

 

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PHYSICIAN ROLE CONFLICT IN RURAL MEDICINE:
PATIENT ADVOCATE OR PUBLIC AGENT?

By

David Brian Schinderle

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Interdisciplinary Programs in Health and Humanities

1994

ABSTRACT

PHYSICIAN ROLE CONFLICT IN RURAL MEDICINE:
PATIENT ADVOCATE OR PUBLIC AGENT?

By

David Brian Schinderle

This thesis explores the tension between the rural physician's
obligations to act both as a patient advocate and as a steward of the
community's resources. In rural settings, the financial status of the local
hospital, the personal relationships between the physician and patients,
and the vulnerability of the physician to social pressures all can combine
to put these two duties at loggerheads. The first section of this thesis
examines each of these sociological features in detail.

Next the issue is evaluated from the philosophical perspectives of
autonomy, utility, and justice. I conclude that the prescriptions that
these abstract principles generate fail to address the unique social
dynamics of the rural setting. Alternatively, Rational Democratic
Decisionmaking, a method that relies on community-determined guidelines
to help physicians allocate medical resources, is advocated. This
approach provides context—appropriate specificity and balances various

relevant moral claims, yet also respects general philosophical principles.

Copyright by
DAVID BRIAN SCHINDERLE
1994

To my wife, Michele

iv

ACKNOWLEDGMENTS

I am delighted to recognize the members of my Master's committee
for their valuable assistance in preparing this manuscript. The
members include Nan Johnson, Ph.D., Dept. of Sociology; William
Wadland, MD, MS, Chairperson, Dept. of Family Practice; Judith Andre,
Ph.D., Center for Ethics and Humanities in the Life Sciences; and Leonard
Fleck, Ph.D., Center for Ethics and Humanities in the Life Sciences. Dr.
Fleck served as Thesis Advisor, and his guidance merits special thanks.

Critical review of preliminary drafts was also provided by Peter
Vinten-Johansen, Ph.D., Dean Havron, MD, and each of my classmates in
the Spring, 1994, offering of the Capstone Course for the
Interdisciplinary Programs in Health and Humanities. Brian Brown, M.A.,
a Ph.D. candidate in Anthropology, helped develop the general topic for
the thesis.

I also would like to thank my parents, Robert and Martha Schinderle,
for a lifetime of encouragement. Education has always been a top
priority in our home, and my parents have made great sacrifices so that
each of their children could achieve.

Finally, I am indebted to my wife, Michele. If not for her steady
patience and selfless support, producing this thesis would have been a

much more difficult task.

PREFACE

When I entered medical school in the fall of 1992, it was with a certain
amount of regret. Although I was certain I wanted to become a doctor, I
was disappointed that my education would now become so focused. In
particular I wanted to continue to study philosophy, 3 field I had dabbled in
as an undergraduate and had very much enjoyed. Fortunately, Michigan
State University recognizes that the social sciences and humanities can
enrich the field of medicine, and the University offers graduate programs
that study those contributions. Consequently I was able to enroll as a
Master's student in the Interdisciplinary Programs in Health and
Humanities while concurrently pursuing my medical degree.

As one might expect, one requirement of IPHH is that its students
compose theses that have an interdisciplinary focus. I approached that
task by combining my professional interest in rural medicine with my
personal interest in medical ethics. What emerged was a topic that draws
upon both sociology and philosophy: how do the social contours of rural
medical practice influence the ethical dilemmas that face rural doctors?
Subsequently, I narrowed my focus to the strain between rural physicians'
duties to individual patients as their advocates, and their duties to the
community at large as stewards of its health care resources.

Judith Andre has written that role morality is a complex instance of
ordinary morality, and that consequently role dilemmas require no special

moral frameworks for their resolution, (1991). I wanted to see if an

vi

examination of an issue as contextually rich as rural physician role
conflict would bear out that notion. After exploring the nature of the
dilemma, I concluded that conventional moral principles failed to engage
various social features that are critical to the problem.

But this should not be interpreted as a rejection of Andre's position. If
there is one thing that l have learned since beginning the Master's program,
it is that medical personnel, the general public, and even many
philosophers share a basic frustration with philosophy's tendency to lack
practical utility. The reason for this dissatisfaction, I am convinced,
stems from the discipline's reverence for remote, universal constructs
that cannot account for the particular moral details that are central to
ethical issues. These details cannot be ignored. In fact, I would argue that
ethical dilemmas are constituted by the very context in which they are
embedded. As a result, moral frameworks that attempt to achieve
objectivity by abstracting away from detail often seem not to "fit" real-
life situations.

What we need to resolve role conundrums is not a special framework,
then, but a sensitive framework. We need moral tools that are practical,
flexible, and versatile, not rigid, abstract, and distant. Andre, feminist
philosophers, many medical ethicists, and others who practice applied
philosophy all recognize this reality. So when Andre writes that no special
moral framework is required to resolve issues of role conflict, she means
that the moral instruments we apply to ordinary ethical scenarios should
have the same characteristics as frameworks that can ameliorate
dilemmas that are especially context-laden: they should be capable of

addressing the morally-important yet contextually-unique features that

vii

comprise and shape the problem itself. This idea is one of the points that I
hope readers will carry away from this thesis.

I advocate Rational Democratic Decisionmaking as a solution to rural
physicians' tension between their roles as patient advocates and their
roles as public agents because it achieves what we have just discussed.
Because it opens up ethical issues to moral debate and allows communities
to forge their own solutions, the outcomes it produces are custom-tailored
to the specific problems it is employed to address. And while this
approach may be rather unconventional, its utility is hardly limited to
special circumstances. Although I will save such an argument for a future
project, or for another author, I see no reason why Rational Democratic
Decisionmaking could not work in any setting, at any level, for any moral
dispute. In my opinion, Rational Democratic Decisionmaking exemplifies
how both "ordinary" moral dilemmas and role dilemmas could be resolved
through the very same approach.

I hope that this paper will provide readers with a better understanding
of what it is like to practice medicine against the backdrop of the rural
social milieu. Additionally, I want to demonstrate how that milieu can
generate ethical dilemmas for physicians, and why it is necessary to
approach these (and all) dilemmas through moral constructs that recognize
the centrality of context. Finally, I hope that this thesis will point out the
advantages of an interdisciplinary perspective on ethical problem-solving,
and that it will emphasize the general importance of conversation between

the various fields of academic study.

viii

TABLE OF CONTENTS

INTRODUCTION
BACKGROUND
MEDICINE IN THE RURAL COMMUNITY
THE ETHICS OF PHYSICIAN ROLE CONFLICT
The Physician as Patient Advocate
The Physician as Public Agent
INTERDISCIPLINARY APPROACHES

CHAPTER ONE: THE SOCIAL CONTEXT
THE FINANCIAL INSTABILITY OF RURAL HOSPITALS
THE COHESIVE NATURE OF RURAL COMMUNITIES
RURAL PHYSICIANS' VULNERABILITY TO SOCIAL CONTROLS

CHAPTER TWO: PHILOSOPHICAL PERSPECTIVES
AUTONOMY
UTILITY
JUSTICE
Libertarian Justice
Egalitarian Justice

CHAPTER THREE: RATIONAL DEMOCRATIC DECISIONMAKING
THEORETICAL CONSIDERATIONS
THE PROCEDURE
ADVANTAGES OF RATIONAL DEMOCRATIC DECISIONMAKING
OBJECT IONS TO RATIONAL DEMOCRATIC DECISIONMAKING

SUMMARY AND CONCLUSIONS

LIST OF REFERENCES

ix

INTRODUCTION

The goals of this paper are (I) to explore how the social dynamics of
rural communities affect the nature of many rural physicians’ dilemma
between their roles as both patient advocates and public agents, and (2) to
ameliorate this conflict by finding a method that has moral legitimacy and
is suited to the particular context of the rural arena. The first chapter of
the paper sketches a picture of what it is like to practice medicine in
many rural towns, and how ethical dilemmas arise from the nature of
these communities. In the second part of the paper, we evaluate how
effectively several classic moral constructs address these conflicts.
Ultimately each proves to be inadequate, but their weaknesses reveal the
characteristics that a successful approach to solving this problem must
possess. Finally, the third chapter examines the utility of a "bottom-up"
approach to resolving these moral conflicts that has been suggested by
Leonard Fleck. This method, called Rational Democratic Decisionmaking,
can successfully balance the various moral values pertinent to an ethical
issue and produce outcomes that are context-sensitive, and yet still

remain consistent with universal moral principles.

BACKGROUND

In order to demonstrate how rural social dynamics can generate role
dilemmas for rural physicians, we will have to examine the issue from the

perspectives of both sociology and ethics. A sociological look at rural life

2
can help us understand how these role tensions are shaped by the social
characteristics of rural communities. The field of moral philosophy can
help us arrive at methods to alleviate their role strain by offering various
theoretical frameworks through which the problem can be assessed.
However, if these philosophical approaches are to be of any real use, they
must account for the sociological features of the rural community, since
these characteristics are primary contributors to the physician's role
tension. Thus, a potential solution to the problem of rural physicians'
divided loyalties must be informed by the disciplines of both sociology

and philosophy.

MEDICINE IN THE RURAL COMMUNITY

The literature in the fields of medical and rural sociology, as well as
descriptive work published in medical journals, has described the practice
of medicine in rural areas. The character of rural medicine is shaped by
the unique social constitution of the rural town. Toennies (1963)
introduced the term gemeinschaft to capture the essence of rural
communities, stating that often they are "based on friendship,
neighborliness, and on blood relationships," (p. 4-5). The role of the small
town physician grows out of this cohesive social milieu. Klein (1976), in
a study of the attitudes of the members of a rural town in Oregon toward
the health profession, found that among his subjects, "most often
mentioned was the desire that the practitioner be a friendly, house-
calling, family doctor," (p. 41). Griffin, et. al. (1990) state that "strong
community ties and familiarity with the people in an area can contribute
significantly to the success of a rural practice," (p. 30). Hassinger, et. al.

(1980) interviewed physicians in a twenty-county area of rural Missouri

3
and in the metropolitan center of Kansas City, and found that "for rural
physicians, the outstanding difference focused on the quality of
physician-patient relationships--knowing the patient better, longer, and
in the context of the social setting," (p. 73). Magaro (I 994) cites one rural
doctor who says that he and his colleagues are so familiar with their
patients that many times they can diagnose health problems over the
phone, (p. 16). Cohesiveness and intimacy, then, are among the salient
features of medical practice in rural communities.

Some authors describe how ethical considerations can stem from the
sociological contours of rural communities. Nelson and Pomerantz (1992)
conclude that "complex ethical issues in health care are just as prevalent
(in rural areas) as in urban areas and are dramatically affected by the
cultural values of the rural setting," (p. 15). Glusker (1989) reports that
rural physicians' and rural hospitals' relationships to patients often
requires that the approaches to ethical problems in rural centers be "very
different" from the approaches taken in urban centers, (p. 413). Instead of
a "hospital ethics committee" approach, he argues that the background of
patient-physician interaction allows for a team approach to ethical
problems in which the patient, physician, and nurses all collaborate to
reach a solution. Flannery (1982) mentions rural doctors' problems with
limiting their commitments: because there is a paucity of resources, they
feel confused about whether, for lack of a more appropriate authority,
rural physicians should provide social services as well as medical care,

(p. I 1). Additionally, Flannery points to a lack of anonymity, intense
public scrutiny, and an inability to separate personal and professional
lives as consequences of "the high visibility of a physician in a small

town," (p. 12). All of these features contribute to the difficulty that

4
faces many rural physicians with respect to their conflicting role

obligations.

THE ETHICS OF PHYSICIAN ROLE CONFLICT

Physician role conflict is treated extensively in the ethics literature.
In fact, Veatch (1977) states that "one of the most significant issues in
medical ethics is the conflict between the physician's duty to the
individual and to society," (p. 59). While he is primarily concerned with
physicians' financial conflicts of interest, Rodwin (1993) also identifies
"conflicts that divide a physician's loyalty between two or more patients
or between a patient and a third party," (p. 9). He states that when
physicians find themselves in such predicaments they can either play the
role of "ideal fiduciary, promoting their patients' interests without regard
to those of other parties," or they can play the role of "neutral resource
allocators, distributing resources to maximize social benefit or promote
some principle of fairness," (p. 159). Rodwin argues that this tension
forces physicians to make "tradeoffs" requiring "discretion and subtlety of
judgment," and as a result there is a potential risk to patients (p. 160).
Wolf (1994) writes that the current movement toward health care reform
may sharpen the tension between physicians’ obligations to their patients
and their obligations to the larger community. She states that now more
than ever it is imperative to clarify doctors' roles as patient advocates in
relation to their roles as stewards of their communities‘ resources.

The Physician as Patient Advocate. According to Veatch, "historically
the Western physician has seen his duty in highly individual terms," (p.
59). Levinsky (1984) argues that this traditional stance should be

maintained, stating that "in caring for an individual patient, the doctor

5
must act solely as that patient's advocate, against the apparent interests
of society as a whole, if necessary," (p. 1573). He believes that
ultimately, both patients and society at large will benefit from this
single-mindedness: "a just society must have a group of professionals
whose sole responsibility as health-care professionals is to their
patients as individuals," (p. 1574). Kimball (1977) argues for the primacy
of the interests of individual patients based on what he claims is the very
foundation of the physician patient relationship: intimacy. He suggests
that to act in a manner other than to promote the interests of patients is
not compatible with humane doctoring, (p. 873). Similarly, La Puma and
Lawlor (1990) assert that for physicians, "conserving society's resources
is secondary or tertiary; if such conservation is brought about by
considering some patients expendable or by serving opposing masters of
patient and society, the seemingly imminent role of public agent must be
acknowledged, appealed, and refuted," (p. 2920).

The Physician as Public Agent. In spite of the considerable body of
literature that exists to support it, the primacy of the role of patient
advocate increasingly is being challenged. Many authors have called for a
shift away from physicians' conventional orientation to one that includes
considerations of social welfare as well as patient welfare. According to
Mooney (1984), "medical ethics lacks a concept of the common good," (p.
183). Mooney wants the scope of medical ethics to be broadened to
recognize not only clinical freedom and professional duty, but also a
notion of the good of society, (p. 185). Similarly, Daniels (1987), Jecker
(I 990), and Mirvis (1992) argue that patient advocacy must be balanced by
considerations of fairness and social justice. Daniels argues that in

conflicts between patients and society, justice should be of primary

6
concern: "the Ideal Advocate who plays the role of 'gatekeeper' in a just
system can nevertheless reassure himself that his denials of care are
fair," (p. 78). Jecker also points to justice as a principle that should
underlie resolutions to conflicts between society and the individual,
stating that "social justice requires instituting global policies and calls
for public debate," (p. 138). She feels that such policies will reduce the
necessity for physicians to use a situational approach to resolve these
tensions, thereby minimizing the potential for inconsistencies and errors
of judgment. Mirvis (1992) concurs with Daniels’ and Jecker’s calls for
the circumscription of patient advocacy by principles of social justice:
“Physicians should be the patient’s advocate for...things that appropriately
fall under the umbrella of professional autonomy and that are determined
by the public to be available to the patient,” (p. 1349).

David Eddy approaches this issue by formulating the notion of
"positions,"(l 991 a; 1991b). When people are in the first position, they are
healthy and do not know what health services they will need in the future.
From position one, they will probably choose to allocate health care
resources in the most effective and efficient manner. Because they do not
know what their future health care requirements will be, they will simply
play the odds. In contrast, people in the second position are patients:
they have a disease or injury, and thus know much more about what health
resources they want. Consequently, they probably will choose to spend
resources such that their immediate needs are met, regardless of whether
they would have judged such allocations to be a wise use of resources
prior to becoming sick or injured. Thus, the first position represents the
perspective of society, while the second position represents the

perspective of the individual patient. Eddy wants to point out that

7
"physicians and patients must understand that when they attempt to
maximize care from the patient's perspective, they might not only be in
conflict with society, but they might well be fostering policies that are
not even in their own long-term interest," (1 191b, p. 2406).

Menzel (1990) introduces the notion of W, which is similar
to Eddy’s idea of positions in that it recognizes that our opinions about
health care allocation can be greatly influenced by our present
circumstances. He describes prior consent this way: "if individual
patients beforehand would have granted consent to the rationing policies
and procedures in question (or more clearly yet, if they actually have
consented to them), then the appeal of those policies and procedures will
rest not merely on attachment to the morally controversial goal of overall
aggregate welfare, 'efficiency;' such policies will gain their moral force
from respecting individual patients' own will," (p. 10).

Smith (1987) places his discussion of the patient advocate vs. public
agent dilemma in the context of primary care medicine. He argues that the
nature of primary care, in which the physician acts as the patient’s first
contact with the health care system, demands that the physician pay
attention to social justice as well as personal virtue. He asserts that as
opposed to tertiary care, “primary care medicine requires a different set
of presuppositions which include, among others, (a) a willingness to say
no to some exotic therapies if using them means denying dispensation of
available and basic medical care to others in need of them and (b) a clear
preference for prevention over other kinds of intervention,” (p. 708).
While Smith's article points out a difference between the way specialist
and generalist physicians might approach conflicting obligations to

individual patients and to society, discussion of possible distinctions

8
between physicians who practice in different sociological settings is

lacking in the scholarly literature.

INTERDISCIPLINARY APPROACHES

Nevertheless, there are a precious few works that pursue the
interdisciplinary nature of this topic by addressing both the sociological
and philosophical dimensions of rural physicians’ role strain between
their duties to their patients and their duties to society. Purtilo and
Sorrell (1986) state that rural physicians are faced with many of the
same ethical problems as urban physicians, including the “patient
advocate vs. public agent” dilemma, but that in rural areas this problem is
influenced by distance from other professional facilities, the
interrelationships of physicians’ private and professional roles in a small
community, the difficulty in preserving confidentiality, and the non-
specialized orientation of rural medical practice. They conclude that
these factors combine to create a situation in which “the rural physician,
perhaps more than any other, is increasingly called upon to be both a
professional advocate for the patient and a personal resource for helping
protect the broader interests of the community,” (p. 27).

Jecker and Berg (1992) highlight the particular problems encountered
by rural doctors with respect to allocating medical resources, and
describe the strategies that physicians develop for dealing with them.
Their main focus is to point out the shortcomings of addressing allocation
conflicts through the use of the principles of justice and beneficence,
since they argue that in rural communities justice and beneficence may be
inseparable because of the blurring between physicians’ professional and

personal roles. While the work by these authors represents a beginning,

9

much room for investigation into the topic of rural physician role conflict
remains.

This paper adds to the work done by Purtilo and Sorrell and Jecker and
Berg by providing a more careful analysis of how the social
characteristics of rural communities shape the unique nature of the rural
physician’s role conflict. I will first argue that the tenuous financial
status of many rural hospitals, the relatively close relationships between
rural residents, and the vulnerability of rural physicians to social
controls imposed by their communities can complicate rural physicians’
dual obligation to serve both as patient advocates and as stewards of
their communities’ medical resources. Next I will present this issue from
various moral perspectives, and ultimately demonstrate that each
approach is inadequate. Finally, I will concretely analyze the potential
efficacy of an approach that might help resolve this role conflict. While
several authors have submitted abstract suggestions for methods that
might assist rural physicians in dealing with this dilemma, none have
elaborated upon the mechanistic details of how their suggestions might be
applied. Neither have they critically assessed the utility of their

hypotheses. In these respects, this paper is perhaps unique.

CHAPTER I:
THE SOCIAL CONTEXT

Earlier I asserted that a discussion of rural physicians' role strains
must address the social features that generate and shape these conflicts.
Three of the most salient characteristics that contribute to rural
physicians’ tension between their roles as patient advocates and public
stewards are: (1) the financial instability of many rural hospitals; (2) the
cohesive nature of rural communities; and (3) the relative vulnerability of
rural physicians to their towns’ social pressures. In order to understand
how these social features generate the ethical problem, it is necessary to

examine each factor individually.

THE FINANCIAL INSTABILITY OF RURAL HOSPITALS

One of the characteristics of rural towns that contributes most
significantly to the rural physician’s role tension is the financial status
of the rural hospital. Rural community hospitals have found themselves on
uncertain financial footing over the past several years; indeed, many have
been forced to close down. Concern about the viability of rural hospitals
began to arise as far back as the late 19705 (Geyman, p. 477). The cloudy
forecast was mostly accurate: according to Fickenscher and Lagerwey-
Voorman, between 1980 and 1987 the annual number of rural hospital
closures increased by 32.5%, (p. I I 6). And according to annual reports

issued by the United States Inspector General, of the 2593 rural hospitals

10

11
still operating as of January I, 1988, a total of 121 had folded by the end
of 1990, the most recent year for which data could be obtained. This rate
of rural hospital closure has "easily exceeded Urban closures," (Wakefield,
1989). I

To a large extent, the culprit responsible for rural hospital closure
appears to be Medicare, the government program that helps cover the
health care expenses of elderly Americans. Prior to 1983, Medicare
reimbursed whatever charges a hospital levied, trusting them to be honest
and reasonable in their billing practices. Congress put an end to this way
of doing business by devising a method of prospective payment in which
“Medicare hazards a prediction of how long each patient is likely to be -
hospitalized, and then bases its payment strictly on that forecast,”
(Margolis, p. 29). Of course, Medicare’s length-of-stay predictions are
merely estimates based on averages--patients sometimes require longer
stays than Medicare is willing to compensate.

In these cases, the hospital is faced with a decision: discharge the
patient when Medicare coverage is exhausted, or keep the patient on at the
hospital’s expense. Because of their stronger ties to their communities,
rural hospitals are more likely to choose the latter option than are urban
hospitals, (Margolis, p. 29). This tendency--combined with the fact that
Medicare reimbursement levels are 37% lower for rural than for urban
institutions—-has devastated many rural hospitals, (Wakefield, 1989). In
fact, one study reported that "83 percent of the hospitals with financial
losses during the first three years of PPS (prospective payment systems)
were located in rural areas," (Doelker and Bedics, p. 541). That in mind, it

is plain to see why a survey of small-town mayors'concluded that

12
government reimbursement practices figured heavily into the demise of
their communities' hospitals, (Hart, Piriani, and Rosenblatt, p. 232).

Yet even without Medicare reimbursement problems, rural hospitals
would still be in danger of folding because of the socioeconomic
characteristics of rural inhabitants. Rural communities have 33% more
poverty and 50% more unemployment than urban communities;
consequently, rural residents' level of health insurance coverage is well
below that of urban residents, (Fickenscher and Lagerwey-Voorman, p.

1 14). The result is that rural hospitals have to absorb the costs of
treating many of their uninsured patients who cannot afford to pay. These
facts provide some insight into why nearly half of the small town hospital
administrators polled in one survey believed that their institutions would
fail in the next five years, (Margolis, p. 31).

Regardless of cause, the consequences of rural hospital failure can be
devastating for rural residents. The most immediate damage is to the
local economy. Often, the vitality of the town itself depends on the
vitality of its hospital. The local hospital supportsudirectly and
indirectly--about 25% of the average rural community’s jobs, (Fickenscher
and Lagerwey-Voorman, p. 1 17). With the hospital playing such a pivotal
role in the rural community’s economy, the claim of one rural physician
that “the life of the town revolves around the hospital” is often literally
true, (Reece, 1990a, p. 54).

Closure of a rural hospital can also represent a setback to a
community’s collective pride. One family practitioner in Moose Lake,
Minnesota who advises small hospitals on changes in health care provision
reports that “communities have a strong sense of ownership and need for

hospitals as well as churches and schools; those are the real guts of a

13
small rural community,” (Reece, 1990b, p. 12). This physician’s personal
observation echoes scholarly research that demonstrates that “the
hospital ranks with the church and the school as one of those elements of
rural society through which communities define themselves,” (Rosenblatt
and Moscovice, p. 174). The loss of such a central symbol of their identity
represents a serious blow to rural residents’ pooled self-respect: a rural
housewife from Independence, Iowa reports that “a town that loses its
hospital has one less thing to be proud of,” (Margolis, p. 28). Indeed, a
study of the viewpoints of the residents of the rural town of Century,
Florida on the impact of the failure of their hospital revealed that they
"saw the closing as one more example of the perceived political impotence
of Century," (Doelker and Bedics, p. 542). The psychosocial impact of rural
hospital closure can be so significant that the authors of the study
recommend that "mental health workers should be prepared to deal with
the generalized depression experienced by the population, (Doelker and
Bedics, p. 542).

While the economic and social-psychological effects of rural hospital
closure on the residents of the hospital’s community can be catastrophic,
the consequences for the residents’ health status can be serious as well.
Mayors of rural communities whose hospital had closed “clearly stated
that the major effect of hospital closure was diminished access to care,”
(Hart, Piriani, and Rosenblatt, p. 241 ). The mayors felt that their
residents’ health status had decreased as well. Rural residents without a
local hospital may be more likely to miss screening and health
I maintenance procedures such as fetal ultrasonography because of the time
and trouble involved with traveling to the nearest facility that houses the

necessary technology, (Hilfiker, p. 118). And obviously, in emergency

14
situations in which time is of the essence, rural residents who lack local
hospital facilities are at a severe disadvantage. Thus, inconvenience and
increased travel time may be responsible for the fact that “rural counties
without hospitals have significantly higher rates of infant mortality and
morbidity, and higher accidental death rates, than those counties with
hospitals,” (Fickenscher and Lagerwey-Voorman, p. 1 17).

And not only can closure of a local hospital compromise rural
residents’ access to hospital services, but it can even jeopardize rural
residents’ access to office-based physicians. The connection between the
presence of a local hospital and the ease of recruiting primary care
physicians is well-documented. According to a study of the recruitment
and retention issues for physicians in a rural community in North Florida,
the “quality of (the) hospital in the community” was judged to be of
“high” or “moderate” importance for 75% of the physicians, (Conte,
lmershein, and Magill, p. 189). Surveys of Texas medical residents show
that the number one factor in choosing to practice in a rural town is the
availability of adequate hospital facilities, (Griffin, et. al., p. 28). And
Hassinger, et. al., found that physicians who practice outside rural areas
perceive one of the major disadvantages of rural practice to be a “lack of
facilities and consultative services,” (p. 73). So rural residents may lose
more than just convenient access to hospital services if the local
community hospital fails. Because physicians generally prefer to practice
near a hospital, closure can compromise rural dwellers’ ability to access
even basic doctor’s office health care.

Even worse, those physicians that make the noble choice to serve a
community that lacks a hospital must use extra care to ensure that their

skills remain up to date. By providing a central location for medical

15
personnel to interact and communicate, a hospital can act as a resource to
help physicians keep their skills and knowledge fresh. According to a
study by Keeler, et. al., some rural physicians "may not have enough
patients or contact with other physicians to maintain their skills," (p.
1713). The absence of a local hospital only exacerbates this problem:
Rosenblatt and Moscovice report that “the physician without a hospital
practice is in danger of obsolescence,” (p. 175). Isolated from their peers,
rural doctors that practice in areas without hospitals must be
particularly conscientious about maintaining contemporary standards of
care. Thus, through both direct and indirect means, rural hospital closure
can threaten the quality of rural residents' health care.

The relevance of the viability of the local hospital to the rural
physician's role dilemma now becomes clearer. If physicians are
considered to be stewards of their communities’ medical resources, then
it follows that this role entails looking out for the local hospital.

Likewise, if physicians should act in the best interests of their patients,
then the previous discussion seems to suggest that they should protect
the stability of the local hospital, since its failure would threaten their
patients’ health in so many ways. PW
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But what are physicians to do in instances where it is not clear that
referral to the local hospital is in an individual patient’s best medical
interests? For instance, assume that a physician is aware that the
morbidity rate for cholecystectomies is slightly higher at the community
hospital than at the nearest urban center. Should the physician still

encourage a patient to have the procedure done locally? If we decide not,

16
then presumably we expect that the physician should recommend the urban

center for all patients who require treatments that are accomplished with

better statistical success there. MW

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n... l‘l‘o Itl‘. ‘ «.‘o l‘ .A -.n. ‘Q‘l .lnthisway,
the financial instability of many rural hospitals sets up the tension
between rural physicians’ roles as patient advocates and their roles as

public agents.

THE COHESIVE NATURE OF RURAL COMMUNITIES

The second feature that impacts this role conflict is the fact that
rural communities tend to be more cohesive than urban communities.
Before this issue is discussed in earnest, it should be noted that rural-
urban differences are neither universal nor dichotomous. I am asserting
only that in general, rural communities have a tendency to be more
cohesive than urban communities. It is helpful to understand the nature of
rural-urban differences on the basis of the continuum model, (Carlson,
Lassey, and Lassey, p. 6; Childs and Melton, p. 28; Rogers, et. al., p. 90).
This model demonstrates that, as opposed to being polar opposites, rural
communities and urban communities simply occupy different positions on
a gradient. Particularly due to advances in transportation and
communication technologies, the physical separation between the two
settings largely has been overcome: distinctions between rural and urban
communities are increasingly becoming a matter of degrees.

Even so, they are not yet insignificant. Carlson, Lassey, and Lassey
report that “formal studies of the rural-urban continuum reveal

persistent divergencies in attitudes, values, levels of income, social

17
services, and cultural attributes,” (p. 6). Decades ago, in his study of
urban and rural communities, Toennies assigned the word gemeinschaft to
small villages to describe their reliance on “friendship, neighborliness,
and on blood relationships,” (p. 4—5). This characterization is to some
extent accurate even today, and it constitutes one of the distinctions
between city life and country life. For example, Childs and Melton report
that one of the differences between rural communities and urban
communities is a higher degree of integration and solidarity among
residents of rural communities, (p. 29), and that rural dwellers are likely
to be better acquainted with their fellow residents, (p. 156). So although
social isolation might be expected to emerge from physical isolation, in
fact “social networks may actually be stronger in sparsely populated
areas than in communities which are not as isolated,” (Childs and Melton,
p. 9).

These social networks are often supported by the dynamic of “going
into town.” In most rural areas, there is a location that serves as the
center of activity, the “heart” of the town. It is where people gas up their
cars and equipment at the service station; it is where they buy their
groceries and supplies at the general store; it is where they enjoy a
sandwich and a cup of coffee at the cafe; it is where they get a haircut
and the latest gossip at the barber shop. This location acts as a social
magnet: people converge upon it from throughout the surrounding area,
inevitably (and not accidentally) bumping into each other and interacting.
In Century, Florida, the focal point was the hospital itself: "the hospital
cafeteria had been used by the community for social and business lunches
and served as a gathering spot for residents," (Doelker and Bedics, p. 542).

This dynamic lends support to the assertion that in rural areas

18
“community interactions (are) more intense and more important,”
(Rosenblatt and Moscovice, p. 6).

The organic nature of rural communities can be very satisfying for the
rural practitioner. When rural physicians characterize the Single most
salient difference between urban and rural practice, they place greatest
emphasis on the quality of interaction between physician and patient in
the community context; that is, they enjoy “knowing the patient better,
longer, and in the context of the social setting,” (Hassinger, et. al., p. 73).
A Dr. Talley, who practices in the rural West Texas town of Fort Stockton,
describes the attractive aspects of small town life this way: “it’s easier
to get to know people and to develop friendships. There is more of a
feeling of closeness with the community, which leads to greater trust,”
(Griffin, et. al., p. 30). And a Dr. Rimas from Comfrey, Minnesota, states
that the factors he likes about his rural practice are “the quality of life,
the hometown atmosphere, the friendly people, (and) the knowledge about
people and their families,” (Reece, 1990a, p. 54). Clearly, the opportunity
for rural physicians to interact more intimately with their patients is one
of the most pleasant aspects of small town practice.

The depth of familiarity that rural physicians have with their patients
sometimes enables them to make more efficient diagnoses and
recommendations. For instance, imagine that a fifty-seven year-old man
(who happens to farm wheat) presents to the physician one autumn day
with the complaint of frequent respiratory distress. Because he is a
fellow member of a relatively intimate rural community, his physician is
likely to know that the patient is a farmer, and that he is in the middle of
harvest. This knowledge alone might lead to an immediate suspicion about

the source of the man’s respiratory ailment, and before launching into the

19
standard diagnostic protocol, the physician might simply ask the man
about the onset and timing of his symptoms. If this information
correlates with the wheat harvest, then a major Step toward resolution
has been reached quickly, easily, and inexpensively.

On the other hand, if this farmer’s doctor practiced in a metropolitan
area, it is unlikely that the physician would know him personally.
Although the farmer’s occupation would be stated in his medical record, it
is less likely that the connection between the wheat harvest and the
man’s symptoms would be made because the urban doctor would probably
lack the same insight into the farmer’s lifestyle that the rural
practitioner would have. As a result, the urban doctor most likely would
have to take a complete history and perform a physical examination, as
well as possibly order costly tests, in order to get data that ultimately
might or might not point to the wheat harvest as the source of the
problem.

Hence, a holistic picture of patients’ identities often offers rural
doctors a clinical advantage in diagnosis and treatment. The knowledge
base available to rural practitioners as a consequence of the social
relationships between them and their patients can represent a valuable
clinical tool. It is the cohesive nature of many rural communities that
promotes the familiarity with which rural physicians can interact with
their patients. In fact, Magaro cites one rural physician who states that
he and his colleagues are so familiar with their patients that many times
they can diagnose their health problems over the telephone, (p. 16).

However, this kind of familiarity poses problems as well. The
relatively intimate nature of many rural towns makes it virtually

inevitable that rural physicians will treat people close to them.

20
Sometimes this is simply one of the pleasant perks of country doctoring,
but often it can make it difficult for rural physicians to separate their
professional lives from their private lives. Technically speaking, it is
preferable to refer friends to the care of a trusted peer rather than to
accept them' as patients because of the professional dictum that
physicians should “practice medicine with what may be called ‘detached
concern,’ unswayed in their clinical decisions by social, cultural, or
economic considerations,” (Eisenberg, p. 961 ). While detached concern is
an ideal that is clearly theoretical, it is nevertheless the standard for
which physicians are expected to strive. Flannery offers the example of
one of her urban colleagues who avoids accepting his friends as patients
because he believes that confusing the roles of physician and friend makes
objective medical judgments more difficult for physicians to render, (p.
12). Yet for rural physicians, the impracticality of referral makes the
blurring of the distinction between friend-friend and doctor-patient
relationships virtually unavoidable.

This obscured distinction can create a tension between objectivity and
partiality regarding physicians’ allocation decisions. That is, it can cloud
physicians’ ability to referee fairly between their obligations to their
patients and their obligations to the public at large. This tension is

described by Jecker and Berg:

In the rural health care setting especially, concerns of
justice occur in the context of close relationships with
patients. These relationships are more likely to be motivated
by a sense of personal involvement and special responsibility.
Justice therefore calls upon the physician’s skill at being
simultaneously immersed in and distanced from others, (p.
469).

21
Jecker and Berg cite a rural physician who states that he is often torn
between the responsibility he feels to specific patients to serve as their
advocate and his obligation to the larger group to make judicious resource

allocation decisions, (p. 469). Thus, Wage

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An example of this dilemma is provided by Purtilo and Sorrell, (p. 26).
They relate the story of a Dr. Palmer, who practices medicine in rural
Nebraska. The Roubal family had been patients of Dr. Palmer for twenty
years, and had been unable to afford health insurance for about a year.
Recently, Mrs. Roubal came to Ir. Palmer in acute gastric distress.
Knowing that the local hospital would not be reimbursed for services
rendered, Dr. Palmer conducted the routine battery of tests on an
outpatient basis at his own expense. However, he was unable to pinpoint
the cause of Mrs. Roubal's symptoms, and in the meantime her condition
had worsened. Dr. Palmer knew that the large metropolitan hospital sixty
miles away probably would not admit the indigent Mrs. Roubal. And at the
last meeting of the medical staff at the local hospital, the hospital
administrator reported that prospective payment schemes were hurting
the local hospital so badly that the hospital might have to close its doors
within a year.

Dr. Palmer thus found himself torn between split allegiances. 0n the
one hand, he felt that as Mrs. Roubal’s physician, his duty was to obtain

the highest quality care available to her. Since he was powerless to win

22
her admission to the metropolitan hospital, his job as her advocate
seemed clear: he should secure her admission to the local hospital. This
goal was given added impetus by virtue of the fact that Mrs. Roubal and Dr.
Palmer enjoyed a personal relationship with a twenty year history--he
felt a personal (as well as a professional) inclination to help her. But at
the same time, his role as a steward of his community’s medical
resources seemed to demand that he protect the stability of the
financially-troubled local hospital by not admitting her there. Because
Mrs. Roubal had no insurance and would be unable to pay for her care, the
local hospital would be forced to absorb the cost of treating her--

something it could ill afford to do while struggling to remain solvent.

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acknowledge, “he is expected to respond to the patient’s need while also
accepting personal responsibility for protecting the community’s best
interests. When the best interests of the community take the form of
helping to keep the hospital open, he faces a ‘no win’ situation,” (p. 27).
Because of the familiarity that often develops between rural physicians
and their patients, rural doctors sometimes have difficulty subjugating
the interests of patients for the sake of competing considerations, even

when the consequences for failing to do so could be serious.

 

InI

we

23

RURAL PHYSICIANS' VULNERABILITY TO SOCIAL CONTROLS
The final factor I want to discuss is the rural physician’s high degree

of vulnerability to social controls. The urban environment has been
described as one that promotes freedom and diversity, (Scherer, p. 17).
These values are much less characteristic of the rural community, where
the composition of the populace is likely to be relatively homogenous in
terms of background, values, attitudes, and culture, (Rosenblatt and
Moscovice, p. 7). In contrast to the tolerance for alternative ways of
living that is representative of cities, in small towns role expectations
are clearly defined and vigorously enforced. Rosenblatt and Moscovice
state that “rural dwellers...(live) in a social setting where role
constraints are more rigid,” (p. 6). Indeed, “the oppressive impact of
social criticism in small town milieus” is described as an often-
overlooked negative aspect of rural life, (Childs and Melton, p. I 51).

The effectiveness of rural communities at enforcing social controls on
their residents stems from their small size and close-knit nature. Childs
and Melton acknowledge the work of Nader and Todd, who “noted that the
interdependence and familiarity present in small, homogenous societies
result in community based social control,” (Childs and Melton, p. 372). In
describing the nature of this control, Jacqueline Scherer cites William
Whyte, who observes that “the group is a tyrant; so also it is a friend, and
it is both at once. The two qualities cannot easily be separated, for what
gives the group power over the man is the same cohesion that gives it
warmth,” (Scherer, p. 34). Scherer presents the example of the rural town
of Springdale (a pseudonym), which was the subject of sociological
investigation by Bensman and Vidich. The researchers found that the town

was capable of exerting potent social control over its residents: Scherer

 

 

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24

states that “several important groups and persons were excluded from the
population so effectively that their existence was ignored or assigned to
other citizens’ unconsciousness,” (p. 30). Likewise, in his study of Kirk’s
Ferry, Oregon, Klein found that patrons of the town’s bar were noted and
frowned upon by the town’s residents, and that the owner of the
establishment was effectively “restricted” from holding certain positions
in the community, (p. 35).

Social control may be especially effective in influencing the behavior
of prominent members of rural communities. For instance, Rogers, et. al.,

report that

Rural-urban differences may still be found in the severity of
sanctions applied against individuals who violate local
community norms relative to specific statuses. Statuses
involving service to the public, such as teacher, extension
agent, and minister, are examples where role style more
greatly affects the evaluation of performance in small towns
and rural areas than in urban settings, (p. 72).

Because their jobs place them in the public spotlight, people in these
kinds of occupations are held to stiffer standards of performance and
behavior by the community. Physicians are among the persons whose
positions in rural communities make them subject to more intense social
control, (Dean Havron, M.D., personal communication, May 1994).

Rural physicians generally are more visible members of their
communities than are urban physicians. In urban areas physicians are less
likely to live in the same neighborhoods as their patients. This is true
first because of the sheer size and diversity of metropolitan areas, and
second because of the probable socioeconomic class differences between
physicians and their patients. Although physicians may practice in a

certain sector of the city, they might well choose to reside in a different

25
sector, or in the suburbs. And even when urban physicians do practice in
the same location in which they live, the nature of city living is likely to
enable them to preserve their anonymity. As Jacqueline Scherer explains,
the migration of people from rural areas to urban areas had the effect of
“replacing a personal society in which all persons were known to each
other with one that highlighted impersonality and anonymity,” (p. 16).
Scherer’s comment is supported by Childs and Melton, who suggest that
urbanites live under conditions that promote anonymity, alienation, and
detachment, (p. 156).

In small towns, neighborhoods are less likely to be separated by
distance or along class lines, and so although rural physicians are still
likely to enjoy higher incomes than most of their patients, chances are
that they will live amongst them just the same. According to Maureen
Flannery, a rural family physician in Kentucky, “living among the people
whom I serve in a close-knit community, I do not have the luxury of
retreating to a suburban lifestyle surrounded by other ‘young
professionals’ when I end my day at an inner-city clinic,” (p. 12). It is
clear that Flannery enjoys the fellowship of her rural neighbors very
much; she envies her urban counterparts only because they are able to step
out of their roles as physicians at the end of their work day. As a family
practitioner from rural Alaska acknowledges, small town physicians often
must be “24-hour-a-day docs,” (Dean Havron, M.D., personal
communication, May 1994).

The fact that rural physicians live among their patients makes them
very visible people. In fact, often the physician is the community’s most
revered member, (Purtilo and Sorrell, p. 27). Although the status of semi-

celebrity might seem attractive, there is a down side to this high profile

26
as well. Many rural physicians have little opportunity to enjoy the
conveniences of anonymity; they must contend with a substantial lack of
privacy in their lives, (Hassinger, et. al., p. 76). For instance, Flannery
says that “I am one of the few professionals in my county, and everyone
knows where I live, how I spend my days off, and whether I dug up my
potatoes before the first frost,” (p. 12). Because small town physicians
are prominent community figures, Flannery says that anonymity is nearly
impossible for them to maintain. The result of this high profile status is
that like teachers and ministers, rural physicians are subject to social
controls that can be even more harsh than those applied to rural
laypersons.

This heightened vulnerability to social control is central to the
discussion of rural physicians' strain between their roles as patient
advocates and protectors of community interests. Their susceptibility
can pressure them into making judgments that, instead of being informed
by fair, rational, and considered guidelines, are merely consistent with
public opinion. Many times, the sentiment of rural towns can persuade
physicians to supersede the good of the society for the good of a
particular patient. This is because rural residents generally do not
consider patients’ lack of financial resources to be a legitimate reason
for refusing to care for them. In non-rural areas, patient rejection is
relatively commonplace: many physicians decide that due to finances,
they must close their practices to new non-paying or Medicaid patients.
However, a rejected rural patient is likely to be known by the residents of

the town, and they would be sympathetic toward that patient--especially

in light of the fact that, given the scarcity of rural physicians, the

27
rejected patient might not have any alternatives. According to Purtilo and

Sorrell,

Since rural residents support their neighbors with produce,
money, or skills as needed, the same behavior is expected of
the physician. Failure to do so is judged not only as unfitting
for a physician but also as irresponsible for a citizen.
Understandably, physicians feel pressed by professional and
personal loyalties to act in favor of the patient and ‘let the
system be damned,’ (p. 27).

Thus, if rural physicians reject patients, they run the risk of violating
important social norms, and hence, of incurring powerful social sanctions.
For instance, one rural physician interviewed by Jecker and Berg
“describes how ‘word gets around’ if one of his patients is treated
differently than another,” (p. 469). This physician was confronted not for
rejecting an indigent patient in need of a cholecystectomy, but for
admitting her to a less-expensive public health hospital in another town.
Trouble arose because he recently had admitted a Blue Cross patient to the
local hospital for the same procedure: the indigent patient found out
about the inconsistency and angrily demanded that he explain it.

The atmosphere of rural towns can thus encourage physicians to
promote the interests of individual patients. W
0“ ‘ lo. 1‘ I. ‘ «.1 0.00... u o l‘ .0 "0.0 ‘ A o . ‘ 'I I“! (I.
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W The penalty for doing otherwise-~which would be
exacted in terms of social sanctions that can be devastating in the
context of a small town-~often is simply too intimidating. Yet rural
residents are more distanced than their physicians from the possibility of

rural hospital closure, and so the potential consequences of unfettered

28
patient advocacy may not seem as real to them. While physicians might
perceive the mood of the public to be supportive of the best interests of
individual patients, rural hospital administrators are quick to remind
them of the potential consequences of following such a course.

To sum up then, the social contours of the rural setting can contribute
significantly to rural physicians’ role conflicts. The strain between their
roles as patient advocates and their roles as public agents is often
precipitated by the financial instability of the local hospital. This
tension is further complicated by the tendency for close personal
relationships to develop between rural patients and rural physicians, and
by the vulnerability of rural physicians to the expectations of their
communities. Thus, compelling forces pull rural physicians in many
directions as they attempt to sort out questions of divided allegiance, and
so the potential for morally inappropriate outcomes seems especially ripe
in the rural context. What is needed is a mechanism that can generate
morally-sound outcomes as well as account for the social components of
the problem. In the next section, we will put several conventional moral

principles to this task.

CHAPTER TWO:
PHILOSOPHICAL PERSPECTIVES

It is important to note that while role strain between physicians’ duty
to advocate for their patients’ best interests and their obligation to
protect the good of the larger community may be more pronounced in rural
medicine, it is certainly not unigue to rural medicine. It has been argued
that role conflicts are complex instances of “ordinary” ethical problems,
and that consequently they require no special moral framework for their
analysis and resolution, (Andre, 1991; Bowie, 1982). For this reason, I
want to explore several popular moral principles that might help guide
physicians’ allocation decisions, with an eye toward assessing their
utility in the context of the rural community. After examining the
perspectives of autonomy, utility, and justice, I will conclude that each
fails to provide appropriate guidance to rural physicians who are
wrestling with the problem of divided loyalties between their roles as

patient advocates and community stewards.

AUTONOMY
One moral perspective that might be of use to rural physicians as they

attempt to resolve these types of role conundrums is the principle of
autonomy. When associated with the work of Immanuel Kant, autonomy is
often taken to mean “the capacity of the will to follow a law that it

imposeson itself,” (Johnson, p. 445). In the context of medical ethics,

29

30
autonomy customarily refers to the prerogative of competent individuals
to select their own treatment choices. Autonomy taken this way is the
opposite of paternalism: rather than deferring decision-making power to
the physician, autonomy demands that capable persons be allowed to
choose for themselves the appropriate course of action. So that patients
can make intelligent decisions, autonomy also requires that physicians
provide their patients with the relevant medical information, and that
physicians interpret this information clearly and honestly when their
opinions and recommendations are sought. It is only when patients have a
proper understanding of their situations that the principle of autonomy
can have any real meaning.

Because autonomy emphasizes individual freedoms and rights, this
standpoint seems to support the argument for patient advocacy; that is, it
seems to require that physicians allow patients to establish for
themselves what is in their own best interests, and then that physicians
promote those interests. According to Bushy and Rauh, "with autonomy a
patient's self-determination takes precedence over the values of
medicine," (p. 209). In other words, the patient's values must be held
supreme with respect to the physician's values should the two collide.
When Levinsky says, “the doctor’s master must be the patient,” his
assertion is based on the principle of autonomy, (p. 1575). mm
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We can use the example of Dr. Palmer and Mrs. Roubal to help
demonstrate how the principle of autonomy would apply to the rural

physician’s conflict between the roles of patient advocate and public

31
agent. Recall that the indigent Mrs. Roubal has a twenty-year relationship
with Dr. Palmer, and that she has no health insurance. Dr. Palmer is
convinced that Mrs. Roubal needs to be hospitalized for extensive
diagnostic testing. He is equally convinced that her admittance at the
nearest metropolitan hospital would be virtually impossible because of
the prospects for reimbursement for her care. At the same time, Dr.
Palmer is under pressure from the local hospital administrator to be
careful about his admissions to his hospital, because the hospital is in
very serious danger of closing within the year. Dr. Palmer finds himself
caught in a conflict between his allegiance to Mrs. Roubal as her physician
and his responsibility to the local hospital as a steward of the
community’s health resources.

According to the principle of autonomy, Dr. Palmer should allow Mrs.
Roubal to make her own health care decision. Since autonomy requires
that her decision be based on informed judgment, Dr. Palmer is expected to
be forthright in disclosing his findings and interpretations regarding her
condition, and his opinion with respect to potential treatment options and
strategies. After being informed of the gravity of her situation, and of Dr.
Palmer’s assessment of her chances for admission to the urban center,
Mrs. Roubal naturally might choose to seek admission to the local hospital.
Her alternative is to continue to be monitored and tested as an outpatient,
but her condition is worsening and that strategy so far has proven to be
thoroughly ineffective. Based on the principle of autonomy, Dr. Palmer--a
fiduciary agent trusted to advocate for Mrs. Roubal’s self-determined
interests--should respect her decision by working to secure her admission

to the local hospital, even though he knows it would hurt its profitability.

32

Another example might reinforce what it is that the principle of
autonomy demands. Earlier I presented the case of the rural physician
(whom we can subsequently call Dr. Smith) who sent two patients in need
of cholecystectomies to different hospitals because one of the patients
was uninsured: she would not have to pay as much at an out-of-town
public health facility. We now can modify the scenario by pretending that
the quality of care is somewhat lower at that public health facility than
at the local hospital. Additionally, we can assume that the local hospital
is in very real financial jeopardy, and that if the woman is admitted to the
local hospital, it will have to absorb 80% of the cost of her care because
she has no third-party coverage.

Here again the principle of autonomy dictates that the woman should be
afforded the right to exercise her own judgment about where she should be
treated. Additionally, it requires that Dr. Smith fully inform her of the
pertinent medical information, including the mortality/morbidity
differential that exists between the local hospital and the public health
hospital. He must also tell her that he is able to admit her to either
facility. As a sick patient in need of treatment, the woman’s top priority
naturally might be her health; the fact that she cannot cover the majority
of the expense at the local hospital probably would be secondary. So most
likely, she would choose to have her surgery at the local hospital since the
odds for a successful outcome are better there, and because the local
hospital is more convenient. Because her decision is the choice of an
informed and competent patient, the principle of autonomy would direct
Dr. Smith to respect it by admitting her to the local facility, even though
he is aware that the hospital will be badly hurt by the cost of treating her.

'I -- o 'Io'9_-_ .ot'I -- 0.“ll‘0_! I‘9o|.The‘l
physician’s job is to educate patients so that they acquire a full
comprehension of their medical status, and then to help patients match
their personal goals and values with treatment plans. Physicians thus

play a support role; they are experts with whom patients may consult, but
final decisions must be left to the judgment of the patients themselves.
For instance, La Puma and Lawlor appeal to autonomy when they state that
“the physician’s primary duty is to meet the patient’s medical needs as
they together find them, the physician with technical knowledge and
expertise and the patient with his or her personal history and values,” (p.
2920). Once patients have made their decisions, physicians should accept
them as being in patients’ self-determined best interests, and should
advocate for them as such--even if they know that they will be at odds
with the larger goals of the community. This is Chase Patterson Kimball's
meaning when he writes that considerations of public good are “at a
different level and of another order than the ethics of personal medical
care,” (p. 873).

For physicians, the principle of autonomy can be tempting grounds upon
which to base allocation decisions. Essentially, it relieves them of the
psychological burden of having to weigh difficult allocation decisions: the
job of deciding treatment options is left to informed patients. Physicians
need only promote the choices that patients make for themselves. And in
rural areas, autonomy has a special appeal. The likelihood that rural

physicians’ patients also will be their friends gives them an added

34
motivation to respect their patients’ choices. Finally, the expectation
that rural physicians should treat patients as if they are all worthy of
equally high-quality care, regardless of ability to pay-~and the capacity
of the rural community to enforce this expectation--can make autonomy
an even more attractive guideline for rural physicians to follow.

Yet autonomy may not be an appropriate principle upon which to base a
solution the rural physician's role dilemma. Taken alone, the principle of
autonomy dismisses physicians’ roles as stewards of their communities’
medical resources when that role conflicts with patient advocacy. It
evaporates the role tension by rejecting one prong of the dilemma. Thus,
the principle of autonomy resolves physicians’ role strain by effectively
ignoring the physician's role as a public agent; that obligation simply is
not acknowledged as a legitimate competing consideration. Under
autonomy, the physician’s ultimate concern must be to further the
interests of individual patients; other concerns are secondary.

Surely a thoughtful society would not want its physicians to perform
such a narrow and exclusive role. By virtue of their occupation, doctors
have responsibilities to the larger community which cannot be neglected.
Without consideration of these broader goals, physicians would be
committed to serving the self-interested, atomisticaIIy-determined
wishes of individuals. And while a personal connection to a patient might
represent a tempting motivation to promote that patient's immediate
interests, it is not necessarily a morally legitimate justification. In such
scenarios, social ends might be difficult to achieve. For instance, in rural
communities patients might select health care options based on pure self-
interest. The ultimate result, when the sum of many such individual

choices is aggregated, could be the failure of the local hospital. As I have

35
previously argued, such a consequence could be catastrophic in terms of
its effect on rural residents’ ability to access health care. Yet the
principle of autonomy ignores the significance of this possibility by
allowing the potential for individual preferences to run roughshod over the

interests of the community. WW

lo. -‘0 l‘ 'I all. 9‘ 0 I'.‘ Q 'P‘zl 10".-v, .0 l 9‘

UTILITY

Having rejected autonomy as the principle upon which the resolution of
the rural physician's role dilemma should be based, we might now consider
utility. In contrast to autonomy, which emphasizes the importance of
individual choice, the principle of utility judges the rightness or
wrongness of actions based on their contribution to the greatest good of
the greatest number, (Johnson, p. 448). It is a very pragmatic approach to
ethical problem solving that is attributed to the philosophical thought of
Bentham and Mill. As Bushy and Rauh state, "it infers balancing the good it
is possible to do with the harm that might result from doing, or not doing,
the deed, (p. 21 1). Thus, if an action would result in more "good" to
society than harm to an individual, utility would support the action since
it would achieve a greater net good--even though this benefit would be
achieved at the expense of the individual's welfare.

To help demonstrate how the principle of utility might resolve rural
physicians' dilemma between their roles as public agents and their roles
as patient advocates, we can apply it to the examples we have already
discussed. In the case of Mrs. Roubal, who is in need of hospitalization for

testing but is unable to pay for her health care, the principle of greatest

36
good seems to require that Dr. Palmer continue to treat her as an
outpatient. Even though her condition is worsening and the outpatient
testing strategy has proven to be ineffective, under the principle of
utility Mrs. Roubal's interests must take a backseat to the interests of the
community. If she is admitted to the local hospital, the cost of her care
will compromise the stability of an institution that is already on
treacherous financial footing. Because the local hospital is a crucial
resource for the community, its interests must be protected over the
interests of Mrs. Roubal: she is an individual, while the community
consists of a great number of individuals.

Now it is true that utility demands more than just a determination of
the greatest number; it also requires an assessment of how much good and
how much harm is done to each subject before the final sum is figured.
Yet even if denying Mrs. Roubal admission to the local hospital would be
devastating from her perspective (which it probably would be), the
principle of utility still seems to direct her physician to say no. For as
we saw in the first chapter of this paper, the closure of the hospital can
have a tremendously negative impact upon the economic, psychosocial, and
medical well-being of each member of the community. Thus, in the case
of Mrs. Roubal, the principle of utility contradicts the principle of
autonomy. It demands that Dr. Palmer deny her admission to the local
hospital in order to protect its viability as a resource for the community
at large.

In the case of the patient of Dr. Smith, who needs a cholecystectomy
but would be unable to pay the majority of her bill at the local hospital,
the principle of utility again results in an outcome that is the opposite of

the result generated by autonomy. Because she has no third party

37

coverage, the hospital would be forced to absorb that portion of her costs
that she could not afford to pay out-of-pocket. Since that would
jeopardize the existence of a facility that is critical to the town's well—
being, the principle of utility seems to require that Dr. Smith admit her to
the public health hospital, even though her chances for a less-than-
optimal outcome are greater there. Because the principle of utility holds
the greatest good for the greatest number to be supreme over the rights of
individuals, it directs Dr. Smith to act as a public agent at the expense of
his role as a patient advocate.

Thus, the principle of utility will often produce outcomes that conflict
with outcomes determined by the principle of autonomy. WM

I‘C‘leO 0 1-010“ AII‘II’I'.‘ “0.0“

‘nuq‘ u:.u-u""90n. 3 ‘ ‘ on 1‘919‘0 Lon-u

I‘u- 0‘..c.'1.oo ‘Al‘l‘0l"'

W This is illustrated

by Gavin Mooney, who supports a utilitarian conception of medical ethics:
"there is too often a simplistic assumption on the part of doctors that, for
example, clinical freedom is to be defended literally at all costs--even
when these costs result in inefficiency in the sense of failing to

maximize the health of the community," (p. 184).

But the principle of utility is just as problematic as the principle of
autonomy when employed to solve allocation dilemmas in rural medicine.
First of all, it is a cold and mathematical approach: to solve ethical
problems, "good" and "harm" are simply calculated. Utility is insensitive
to other factors. Such a method seems to offer very little to rural
physicians, whose interpersonal involvements often cause their

professional and private lives to overlap. In implementing the principle of

38
utility to resolve their role conflicts, rural physicians would be forced to
deny that aspect of their identities that some philosophers refer to as the
WI, (Friedman, p. 164). The notion of the social self is central to
feminist ethics, and some feminist philosophers argue that it is implicit

in medical ethics as well. According to Susan Sherwin:

In feminist and medical ethics, it is important to consider
factors that do not carry any special weight in utilitarianism.
There is a need to look at the nature of the persons and the
relationships involved in our analysis and not merely to record
such values as preference satisfaction or pleasure or pain...(p.

61).
I- l'!‘ 09-. l‘O‘ eff-gnu ‘11.. .|_-.0 o
I'!‘-.‘ 0.000. --. .01 "I 0-0.12 ‘ o " l‘ll'v.
QIsl‘.‘ l‘ 0‘ win I! IIQa‘l 'I ‘ o ‘. o.
W. They would be forced to ignore such factors as

fidelity, implicit and explicit promises, intimacy, and personal concern.
This is one reason why utility seems to come up short as a solution to the
rural physician's role strain between the responsibilities of patient
advocacy and public agency.

One might argue that the utility calculations could be modified to
capture these sorts of contextual considerations, but such an approach
seems incompatible with the nature of utility’s orientation, which tends
toward abstraction away from uniqueness and particularity. And even if
utility could be manipulated to reflect morally-important contextual
particulars, it still would suffer from other problems that are inherent in
its design. There are many pragmatic difficulties associated with the
practical application of the principle of utility that are well-known to
those familiar with philosophy, (Bushy and Rauh, p. 21 1). For instance, is

the "greatest good for the greatest number" supposed to reflect long term

39
good or short term good? How is "good" to be quantified? Is medical good
more or less important than other types-of good, such as economic or
psychological? Who should determine the greatest good? These questions
are basic and frustrating, and limit the practical usefulness of utility as a
guiding principle.
So when its shortcomings are examined, it appears that the principle
of utility does not hold the solution to the rural physician's role dilemma.
-I-“o ‘ 0 -. o -l or O‘II‘I 0| ‘. I' 0 II«. 0| ‘ 1 ‘0.
o ‘u "I 0“-_-II_0 l9-.‘l ‘2'!!! All
11‘ -. 01‘! Cl '-‘ . ‘l -. 'IIOOI‘I o l‘ o ‘ OI-” _II
no ‘0 ‘ l‘ ‘ . ‘ II-II‘I e ,- 0.- ‘II A. I l‘ .H .. {I «u 011’
WW For these
reasons, the principle of utility must be rejected as a device for resolving
rural physicians' tensions between their roles as advocates of their
individual patients' best interests and their roles as protectors of their

communities' health care resources.

JUSTICE

Having considered the principles of autonomy and utility, we might now
turn our attention to the principle of justice. Whereas autonomy promotes
individual liberties, and utility attempts to optimize overall good, justice
concerns itself with entitlements and deserts. There are at least two
notions of justice that have dominated American philosophy in this
century. One, which is attributed to Robert Nozick, I will call
“libertarian” in the sense that, like the principle of autonomy, it stresses

individual freedoms. The other, associated with John Rawls, I will call

40

“egalitarian” because it is concerned with fair treatment. Both notions
attempt to derive methods by which distributive justice can be achieved.

Libertarian Justice. Nozick’s idea of distributive justice concerns
itself with the just acquisition and transfer of resources. Nozick asserts
that since in a free society there is no central authority that is
responsible for controlling resources and deciding how they are to be
given out, “what each person gets, he gets from others who give to him in
exchange for something, or as a gift,” (p. 149). Many different people
control different amounts of different resources, and new distributions
arise out of voluntary agreements to exchange holdings, (p. 150). Thus,
Nozick’s model is similar to the capitalist economic system. Such a
system distributes goods primarily on the basis of free trade, yet it also
allows (but does not mandate) voluntary acts of beneficence, such as
donations to charity or gifts to relatives or friends. According to Nozick,

his maxim might dictate that resources should be transferred:

from each according to what he chooses to do, to each
according to what he makes for himself (perhaps with the
contracted aid of others) and what others choose to do for him
and choose to give him of what they’ve been given previously
(under this maxim) and haven’t yet expended or transferred, (p.
160).

In other words, if one needs or desires something that one does not
possess, one must either enter into a just exchange in which one trades 3
held resource for the desired resource, or one must hope for others to
show generosity with the resources that they justly hold and now might
volunteer to donate pro bono.

One central facet of Nozick's theory is that distributive models must
not “specify that a distribution is to vary along with some natural

dimension, weighted sum of natural dimensions, or lexicographic ordering

41
of natural dimensions,” (p. 156). On this basis, Nozick rejects moral
merit, need, marginal productivity, effort, and the like as considerations
that should be allowed to determine distributions. These methods of
distribution constitute what Nozick calls “patterning,” which is
incompatible with his notion of justice. As Nozick says, “to maintain a
pattern, one must either continually interfere to stop people from
transferring resources as they wish to, or continually (or periodically)
interfere to take from some persons resources that others for some
reason chose to transfer to them,” (p. 163). Thus Nozick rejects the
maintenance of patterns because the regulation required to sustain
patterns interferes with individual freedoms. It is for this reason that
his notion ofjustice can be characterized as libertarian.

An idea of what Nozick’s sense of justice would mean for the
distribution of health care in rural areas can be achieved by applying it to
our example cases. Libertarian justice seems to offer little promise for
Mrs. Roubal, the uninsured, long-time patient of Dr. Palmer who needs
hospitalization for diagnostic testing. Up to this point, she has received
her medical care as a result of Dr. Palmer’s beneficence: she has been
unable to reimburse him for his care but he has chosen to treat her
anyway. Nozick’s notion of justice recognizes these kinds of transactions
as valid distributions of resources. Dr. Palmer donated resources that he
justly held to Mrs. Roubal of his own free will; his services were provided
essentially as a gift to her.

However, Nozick’s notion of justice does not recognize health care as a
right or desert to which Mrs. Roubal is entitled beyond the extent to which
she is able to secure it for herself by freely trading her own justly held

resources. I. .II‘ I‘L'Ielll'!‘ u {0-91 la I0- -.II

42
WW. Libertarian justice poses no
barrier to her accepting charity either in the form of monetary
contributions earmarked for her medical needs, or in the form of medical
services delivered free-of—charge. Yet Mrs. Roubal has no basis for
claiming an entitlement to health care based on Nozick’s model of justice,
since her lack of insurance and personal funds prevents her from entering
into a mutual agreement to exchange resources. Dr. Palmer thus cannot
support an attempt to gain Mrs. Roubal's hospital admission by appealing
to Nozickian justice.

Similarly, the patient of Dr. Smith, who needs a cholecystectomy but is
uninsured and is thus unable to pay for the majority of her surgery, has no
moral entitlement to select the location for the procedure under Nozick's
model of justice. Since she does not possess the resources necessary to
enter into an exchange for her treatment, she cannot appeal to the
Nozickian principle of justice to build a case for her right to have the
procedure done locally. While any hospital or doctor is free to offer (to
the extent that they justly control the necessary resources) the procedure
free-of-charge or at a bargain-basement rate, the patient has no moral
grounds, based on Nozick's model, of legitimately demanding treatment at
the hospital of her choice. Her resources are insufficient to compensate
the local hospital; as a result the local hospital is under no moral
obligation to expend its own resources to treat her. Consequently, Dr.
Smith cannot make a compelling justification on the grounds of Nozick's
model of distributive justice for an attempt to win her admission to the
local hospital .

The examples help to illustrate that NEW

I
".0“. I. ' ._ 1... 9| -.I . I0. ‘ I‘ .1 ‘I 1,... I‘

43

f“0_0ll 0 'I n ‘ ounI' 0 IN ‘ l‘ -0 IO‘. 1. 0.
0.1- .0 " h h I“ofrl0. QIQ‘I !- ‘l o ‘ ° ‘ l‘ . ‘ Iv.
WM. Freedoms and liberties are regarded

as primary; no one can be told to distribute his or her resources in a
compulsory fashion. But if it could be shown that some methods of
patteming--that is, some forms of mandated resource reallocation--are
morally permissible (or maybe even morally required), then Nozick's model
is weakened. As Jonathan Wolff writes, "if an effective defence of either
banning certain transactions, or engaging in compulsory redistributive
activity can be given, then Nozick's principle of justice in transfer is
refuted," (p. 89).

It would seem that in the case of health care, a case for patterning
could be made. While controversy regarding the moral status of health
care continues, there is growing consensus among medical ethicists that,
to one extent or another, and for one reason or another, health care must
be considered a "special" social good, like education. Descriptive evidence
for this normative belief is provided by the observation that "even in the
US, which has a much less egalitarian health-care system than many
other industrialized capitalist or socialist countries, there is the belief
that health care should be distributed more equally than many other social
goods," (Daniels, 1985, p. 17). Consequently, one would expect that most
Americans would reject a value hierarchy that would deny necessary care
to the poor by prioritizing individual freedoms over life itself. lLLttifi

11"! l . -‘ 'lmiv.‘ I-. ' {I OI‘-. I
‘ Ol‘l _- ‘ I' ‘I .HI ' _‘ o l‘ I,o.I l‘ 0. _‘ ' 0 II: I‘, r
I0 . .0-. ‘I lo. I‘ l‘ ‘ I' .I-. o ‘l ‘ °I o ‘. {Ie‘ . Othervalues

for which cases could be made might include equity and utility, but an

44

approach such as Nozick's fails to recognize them as being worthy of
consideration. As a result, Nozick's libertarian model seems to be
inappropriate. As Wolff states, "one way to reject (Nozick's) theory is to
argue that liberty is just one value among possibly many others," (p. 89).

Egalitarian Justice. One value that might be suggested as an
alternative to liberty is equality. John Rawls has developed an idea of
distributive justice by elaborating the principles of justice in terms of
fairness. He begins with a basic definition: "essentially justice is the
elimination of arbitrary distinctions, and the establishment, within the
structure of practice, of a proper balance between competing claims," (p.
653). Such a definition seems to avoid the pitfalls of Nozick's theory that
are pointed out by Wolff. Justice, as intended by Rawls, recognizes that
there is more than one competing value in questions of ethical
distribution of resources; indeed, justice has as its end the equitable
compromise between those values.

Having outlined a rough definition ofjustice, Rawls formulates two

fundamental principles:

The first principle is that each person participating in a
practice, or affected by it, has an equal right to the most
extensive liberty compatible with a like liberty for all; and the
second is that inequalities are arbitrary unless it is
reasonable to expect that they will work out for everyone's
advantage and unless the offices to which they attach, or from
which they may be gained, are open to all. (p. 654)

Perhaps surprisingly, the first principle actually seems to smack of
libertarianism: Rawls says that there is no valid rationale for
circumscribing rights until they interfere with one another. Thus, the
first principle states that prima facie, we should pursue the greatest

liberty that is possible for all, without incurring a loss of liberty to any.

45

Rawls’ second principle lays out a mechanism for determining when it
is permissible to deviate from the first principle. In instances in which
inequalities will work to the advantage of every group, differences in
liberties, rights, and/or powers can be allowed. This is the moderately
egalitarian portion of Rawls’ theory: any inequalities that are allowed to
occur must improve the lot of each--including those who are least well-
off. This is often referred to as Rawls’ “difference principle.” In
articulating this system, Rawls attempts to create a notion of justice
that is richer and more complex than Nozick's. In Rawls' theory, elements
of the values of liberty, equality, and utility are synthesized. Inseam
lel'I ‘Il'leIQ- OI‘ “.!‘l ‘0 I‘Oh‘ I.
ll'!‘ 1 “ll! ,0 1 l‘ ‘ -.l ‘9- 1.- : .0 ‘l'. o . o I‘ In 1

| . . | _

Because of this balance, Rawls' theory represents an attractive tool to
help determine just resource distributions. Indeed, Norman Daniels draws
heavily upon Rawls' model in formulating his fair equality of opportunity
principle. In W, (1985), Daniels argues that health care
needs are those requirements that must be met in order to "maintain,
provide, or restore (where possible) functional equivalents to normal
species functioning," (p. 32). Furthermore, he argues that because health
care needs are fundamental to normal species functioning, they should be
given special moral weight. The logic behind his definition of health care
needs seems fairly rational and uncontroversial. However, the assertion
that health care needs derive special moral consideration from this
definition requires further exploration.

Daniels tries to make the connection by developing the notion of a

normal opportunity range. This idea holds that for a given society, there

46

exists an array of life-plans that people are likely to construct for
themselves. Such an array constitutes the normal opportunity range, (p.
33). Because only those ends that realistically could be accomplished can
be included in an opportunity range, a particular individual's share of the
normal opportunity range is directly dependent upon that individual's
capacity for “species typical functioning,” (p. 26). As Daniel's says, "if an
individual's fair share of the normal range is the array of life plans he
may reasonably choose, given his talents and skills, then disease and
disability shrink his share from what is fair," (p. 34). The extent to which
a health care procedure or treatment can be expected to restore a given
sick or disabled person to species-typical functioning, then, is the extent
to which justice requires that treatment to be performed. According to
Daniels, "in general, it will be more important to prevent, cure, or
compensate for those disease conditions which involve a greater
curtailment of an individual's share of the normal opportunity range," (p.
35).

Thus, Daniels offers what he believes is an appropriate framework

within which to apply the principles of justice so that a fair distribution

of health care resources can be achieved. Waugh

0 (9‘ OI' ell 0 ‘1 I 1‘ I ‘ 9 0901.0le o l‘ I‘! “ 0

II'I I‘II‘Q.¢ o I"0I'I Q-‘ 'OI I ‘l‘ ‘ 'I 0‘ 3 - f
_I '-I I! ll'Olel . I 1 (HI. 'IQ‘O‘II‘I o I‘ A. 0 {I
ml".-. 0 'I .OI-. _ooq‘ 00“ l‘l‘ ‘ a .- .. 0.0

It must be understood, of course, that Daniels is attempting to
formulate an approach that can help guide resource decisions at the

"macro" level. He does not intend to suggest that resources should be

47

doled out on a case-by-case basis after establishing a particular patient’s
level of functional impairment and how well it could be ameliorated by
treatment. Instead, he means to say that those technologies, cures, and
preventive measures that will significantly benefit those groups whose
level of species-typical functioning is most significantly impaired should
be prioritized above other health care resources. It is when Daniels'
theory is stated in this form that its Rawlsian flavor is most prominent:
in making macro-type allocation decisions, it does not rely on one narrow
parameter to reach a settlement. Instead, it incorporates elements of
many principles, such as autonomy (to choose from the normal range of
opportunities); utility (in that those who are worst off are prioritized--
i.e., the "most good" is sought); and equity (to the greatest extent possible,
all citizens are provided the means to achieve the possibilities presented
by the normal opportunity range via species-typical functioning).

However, its "macro" orientation is, in fact, the precise reason why
Daniels' model is of limited use to the rural practitioner. While it
provides a helpful way to think about the allocation of medical resources
on a large scale level, individual patients and physicians are able to obtain
little guidance from it. It is meant as a tool to determine just
distributions at the system-level, and not as an operational guide to
making micro-level allocation decisions. W
IIII 0.‘ ‘III‘ I-. .01 ‘IOI l‘ ‘ ‘ o I MOI-_IIOelll‘l I‘ ‘
'e‘l le‘ll'e‘lQ‘IQ-.ll 'l‘ole‘v. 00‘I

Take the examples of the two patients that we have been discussing.
Both are uninsured, indigent patients who have fairly important medical

needs. If their impairments are significant enough, then Daniels' model

48
will grant legitimacy to their claims to health care, regardless of their
ability to pay for it. Yet once it is established that they have legitimate
health needs that someone is obligated to meet, then what? Is it the
responsibility of the financially-insecure community hospital to treat
them? Or should the patients be sent to a distant urban facility? Daniels’
theory is silent on this matter: a fundamental element of this problem
remains unresolved because Daniels' theory is not (and really was not
intended to be) sufficiently fine-grained. In the jargon of medical
ethicists, his notion fails to "go all the way down." While it can lend
theoretical legitimacy to uninsured patients' claims to health care, it
provides no practical mechanism for equitably distributing the burden of
their treatment.

In summary, then, it seems as though the three major philosophical
approaches to ethical problems that we have examined all seem
inadequate. The prominent philosophical frameworks appear unable to
address issues as context-laden as the divided loyalties of many country
doctors. Libertarian-oriented notions of justice, along with the principle
of autonomy, affirm the undeniable importance of liberty in the American
sociopolitical tradition, yet neglect the significance of values such as
equity and utility. Similarly, the principle of utility fails under the
cross—analysis of equity and autonomy, and also is unable to account for
morally-important intangibles. Finally, conceptions of justice that are
based upon fairness are designed for and limited to macro-level
applications.

In fairness, it should be noted that no broad philosophical notion should
be expected to go all the way down to address a particular, morally-

complicated, contextually-complex situation. It seems doubtful that any

49
conception of health care justice simultaneously could be broad enough to
generate universal moral principles and sensitive enough to deal with
specific practical applications at the micro level. That in mind, the
problem for the last section of this paper is clear: in attempting to help
rural physicians sort out the tensions between their roles as patient
advocates and their roles as stewards of their communities' health
resources, we will need to arrive at procedures which: (1 ) are context-
appropriate and engage the relevant moral particulars; (2) are capable of
striking a balance between multiple competing moral values; and (3) can
accomplish I and 2 while simultaneously achieving compatibility with

high-level philosophical principles.

CHAPTER THREE:
RATIONAL DEMOCRATIC DECISIONMAKING

From our discussion so far, we have seen that to guide conflicts of
loyalty in rural medicine, we require a method that is capable of
generating specific protocols, as opposed to one that structures allocation
systems on only a more general level. Our method also must acknowledge
the legitimacy of various moral criteria, instead of relying on a single,
narrow, a priori principle. Yet at the same time, we need an approach that
respects the importance of high-level moral precepts. One model that
seems to fit the bill is Leonard Fleck’s Rational Democratic
Decisionmaking model, (1994). Fleck suggests that ethical conflicts such
as those that face rural doctors can be resolved by public, broad-based
community dialogue that incorporates the best scientific and moral
methodology and knowledge, followed by the submission for referendum of

proposals that arise from the deliberations.

THEORETICAL CONSIDERATIONS

Rational Democratic Decisionmaking is a conception of justice that is
non-ideal. The following example has appeared in several articles in the
ethics literature, and may help clarify the meaning of "non-ideal justice."
Suppose that two women, Alice and Betty, need a liver transplant to save
their lives, but that only one can receive it. Alice would live for two

years past the date of the treatment; Betty for twenty. The woman who

50

51
does not receive the treatment will die in a matter of days. Both have
waited the same length of time for the operation. Who should receive the
treatment? As we saw in Chapter Two, the outcome will depend on what
kind of moral approach is taken. One might decide that the woman who
will live for twenty more years should be saved since the treatment would
provide her with more years of life. Alternatively, one might opt for a
coin toss on the assumption that each woman has an equal right to life. Or
the younger woman might be selected, since the older woman has had more
"innings."

If a single moral precept could be identified that clearly seemed most
appropriate, then of course that precept should be used. But the
frustrating truth of the Alice and Betty case is that no one moral principle
seems to provide a definitive answer. Any number of solutions could be
generated that, prima facie, seem to be morally-plausible. This area of
moral uncertainty represents the domain of non-ideal justice. In
instances where no particular moral construct seems to produce a
solution that is unequivocally most appropriate, non-ideal models such as
Rational Democratic Decisionmaking are useful (perhaps necessary).
According to Fleck, under such circumstances “we have no reason to
believe that we could identify something that could be called the 'most
just' set of rationing protocols possible for our society,” (1994, p. 382).
In fact, Fleck says that we do not even have a strong moral obligation to
come as close as possible to achieving the “most just” result. This is
because there are other competing values besides justice that deserve
legitimate moral consideration. What we are obligated to achieve is an

outcome that is “just enough” or “fair enough.”

52

Rational Democratic Decisionmaking is not meant to promote moral
laxity, however. Fleck describes eight “constitutional principles” which
cannot be violated by a protocol developed through Rational Democratic
Decisionmaking. These are: (I) a Publicity Principle, aimed at
eliminating invisible rationing; (2) a Fair Equality of Opportunity
Principle (which we have discussed in a previous section of this paper);
(3) an Equality Principle, the intent of which is to assure each citizen
equal moral consideration; (4) an Autonomy Principle, which affirms
the right of every individual to participate freely in the democratic
decisionmaking process; (5) a Just Maximizing Principle, which will
specify the circumstances in which it is morally permissible to pursue
the maximization of social welfare; (6) Need Identification
Principles, to distinguish health needs from health preferences; (7)
Priority Setting Principles, to help rank health resources fairly; and
(8) a Neutrality Principle aimed at protecting the liberal character of
our society with respect to choosing health services, (1994, p. 384).

Fleck refers to the space inside the boundaries set by these principles
as “the domain of just democratic decisionmaking,” (I 994, p. 382).
Decisions that are rendered and found to be within this domain should be
considered morally-legitimate and binding; those that violate one or more
of the constitutional principles would lie outside the domain and thus
should be rejected. For instance, a proposal that emerged from
deliberations from which a particular segment of the community was
excluded could not be allowed, even if it were broadly popular. It would
have to be disqualified on the grounds that it violated the Autonomy

Principle. The constitutional principles act as a test: they ensure that

53
decisions that are made from the bottom up are compatible with higher-

level moral values.

THE PROCEDURE

A more practical description of the process is in order. Let us see how
Rational Democratic Decisionmaking might actually operate by applying it
to one of the case examples that we discussed throughout the middle
portion of this paper. Recall the case of Dr. Palmer and Mrs. Roubal. Mrs.
Roubal is an indigent patient with no health insurance who needs to be
hospitalized for extensive diagnostic testing. Dr. Palmer is her physician
of twenty years who knows that the nearest metropolitan hospital will
not accept her. At the same time, Dr. Palmer is under pressure from the
administrator of the local hospital to be stingy with his admissions for
patients who cannot pay, because the local hospital is in serious financial
jeopardy. How can Rational Democratic Decisionmaking help Dr. Palmer
resolve the conflict between his allegiance to Mrs. Roubal as her physician
(and friend), and his responsibility to the hospital as a steward of the
community's medical resources?

The first step simply is to identify and articulate the problem.
Although the Rational Democratic Decisionmaking process could be
initiated by any member of the community, I anticipate that usually it
would be started by physicians. Due to the nature of theirjobs, problems
related to health care delivery come to doctors' attention often. In this
particular example, the issue is that the financial condition of the local
hospital has created a dilemma between Dr. Palmer's duty to the hospital
and his obligations to his patients who are poor. Now that Mrs. Roubal's

case has manifested the problem to Dr. Palmer, he might approach the

54
town government and say something like "I've got this problem that I'm not
sure how to handle..." This would start the process of Rational
Democratic Decisionmaking into motion.

Next, public meetings would be set up to discuss what should be done
about the dilemma. These meetings should be given heavy advance billing
in newspapers, in radio advertisements, and on flyers tacked up in
conspicuous places like the post office, gas station, and grocery store.
Community leaders such as ministers, school officials, business people,
physicians, etc. should be persuaded to encourage their congregations,
students, associates, patients, and colleagues to attend. Special efforts
would be made to encourage the attendance of representative members of
each of the community's different cultural, racial, religious,
socioeconomic, and special interest groups. In this case, a capable
advocate for the interests of the medically-underinsured poor should be
recruited. The goal, of course, would be the fair opportunity for
everyone's interests to be represented, especially those of the politically
weak.

Specialists would be brought in to consult in their areas of expertise.

In our example, a professional medical ethicist might advise on moral
issues; a lawyer might ensure that proposals are legal; a doctor might
assess what a given proposal would mean for patients; an independent
hospital finance consultant might. determine the potential effects of
different plans on the community hospital; an economist might estimate
the consequences for the town's vitality. These experts should be neutral
and objective, serving only as consultants and not as advocates. Neither
should this panel act as any sort of "commission," for final decisions are

to be left to a democratic vote of the community at large. Essentially

55
what I mean to describe here is a town meeting, undertaken with
particular care to ensure that fair representation is achieved, and
enriched by the input of consultants who are experts in fields that are
germane to the issue.

In the meetings themselves, everyone in attendance should be given an
equal right to be heard, and no one group or individual should be allowed to
dominate the discussion. Arrangements should be made for prepared
statements to be read from those whose health, job, or peculiar
circumstances will preclude their personal attendance. After sufficient
time for discussion and deliberation, proposals should be articulated and
presented for a referendum. For example, in this case proposals might
range from limiting the treatment of indigent patients to emergency room
visits only, to levying additional taxes so that health care services to the
indigent could be expanded above their present levels. Between these two
extremes, a middle-of-the-road pr0posal might define certain
circumstances under which indigent patients could be admitted to the
local hospital, and establish a policy for arranging their admittance to the
metropolitan center under other circumstances.

The third stage of Rational Democratic Decisionmaking is to put the
potential solutions to a democratic vote of the community's residents. If
a proposal is passed, then provided it is not found to violate a
"constitutional principle" of the sort laid out by Fleck it would be deemed
morally-legitimate and binding. It is important to emphasize that the
purpose of Rational Democratic Decisionmaking is to generate standing
policies to guide the handling of various classes of cases. That is to say
that in our scenario, it is not implemented simply to solve Mrs. Roubal's

dilemma, but rather to solve her case as well as all cases that are similar

56
to hers that will be encountered in the future. Mrs. Roubal just happens to
be the patient whose situation has crystallized the larger moral problem
for Dr. Palmer. We cannot predict just what the outcome would be in Dr.
Palmer's town, of course, because results would reflect the unique

character and circumstances of individual communities.

ADVANTAGES OF RATIONAL DEMOCRATIC DECISIONMAKING

At the end of Chapter Two we concluded that in order to resolve rural
physicians' role conflicts, a method must possess three crucial features.
First, it must produce resolutions that are relevant to the unique contexts
of individual communities. Second, the approach must find a compromise
between the various competing values that pertain to the issue at hand.
Finally, the method must achieve the first two objectives while
simultaneously respecting upper-level moral principles. Rational
Democratic Decisionmaking satisfies each of these criteria.

Rational Democratic Decisionmaking's meets our specificity
requirement by virtue of its democratic nature. Resolutions produced by
Rational Democratic Decisionmaking are not the products of remote
philosophical constructs. Instead they are conceived of and implemented

by the residents of the community themselves. W

I
I
00.1‘00 .|.o . “0. 0.1.1-‘ ._I‘ 0000., {'0‘ ‘00-.

W The options are then
deliberated and put to a vote. Rational Democratic Decisionmaking
succeeds in “going all the way down” by structuring decisions from the
bottom up. What emerge from the process are policies that are virtually

tailor-made for the problems they are meant to solve. Thus, Rational

57
Democratic Decisionmaking represents an extremely flexible, practical,
and context-sensitive approach to ethical dilemmas.

The same characteristics that allow Rational Democratic
Decisionmaking to pass our specificity test also enable it to strike a
balance between multiple moral considerations. With Rational Democratic
Decisionmaking, appeal is not automatically made to any one particular
normative principle. In the course of the deliberations, various
viewpoints, values, and precepts will arise, each of which will demand
attention. Community members must weigh each of these claims, and

incorporate them in the proposals to the degree that they deem

appropriate. 'I ' II... 0| . ‘III ‘ o «.I II ‘ o..- . IIo .
lel‘l ._ or. -. 01!‘-.°l0 l‘ 01 ‘1'10 «.7 I.
0‘ I. -. Q‘llllo. ie'lsl.‘ll0 ' " 'IlsIIOII“
0_ ‘0- ‘Il‘l I-_ ' In -.I ‘ l‘ I. ‘ ‘ o 0110‘ I0 “0 ._ —.II
.. . I. I. .

Finally, Rational Democratic Decisionmaking satisfies the third
component of our test in that it acknowledges the validity of upper-level
moral principles. Although Rational Democratic Decisionmaking grants
voters wide freedom to shape their own resolutions to ethical dilemmas,

their autonomy is not unlimited. It is restricted to the boundaries

established by the constitutional principles. By laying QHI an imtiglable

0| . OI 0“” ".0111! o l‘ a OI-. ‘Q'llllel .l
“02 IO!“ {gut l‘IIo .' D‘ " II-..I-..0‘ ‘I‘ “0'. 0.0
II II . if" II I .

In addition to satisfying the criteria we have set up for distributive
models, Rational Democratic Decisionmaking also offers further

advantages. According to Fleck, "access to health care is properly thought

58
of as a public interest," (1992, p. 1602). If this is true, then Rational
Democratic Deliberation appropriately offers the community the
opportunity for self—determination regarding its public goods: decisions
that emerge from Rational Democratic Decisionmaking are self-conceived
and self-imposed. Provided that basic moral concerns are protected by a
set of constitutional principles, the fairest way to settle questions
involving the allocation of communal resources is to let the community
decide them for itself. As Rosenblatt and Moscovice recommend, "local
communities will be well served if they take (health care) planning into
their own hands and make it a joint activity engaged in by the people who
stand to benefit." (p- 272). WWW
'. 01-. "I 0 -_' I‘ 'OIII... 0. _0 09‘! ‘ IIII ‘ I‘ .0 ‘ 091' ‘
o ‘I‘I 0 ‘0 ‘QI‘Illv. I00. I‘OII OIIII.I-. ‘0- .
While it might be possible to construct a case for applying Rational
Democratic Decisionmaking to privately held resources, such an argument
would be more difficult and will not be attempted here.

Rational Democratic Decisionmaking would also make resource
allocation policies explicit. Currently, ethical decisions regarding the
utilization of a community's health resources are sometimes made by
individual physicians, hospital administrators, or medical ethicists on the
basis of idiosyncratic personal values, vested interests, or remote
phil050phical constructs. Some authors, such as David Mechanic (1992),
and Guido Calabresi and Phillip Bobbitt, (1978), believe that it is better
for rationing protocols to be implicit in order to preserve the public's
illusion that morally-difficult decisions are not being made. For instance,
it is now widely known that British physicians used to explain to their

older patients in kidney failure that "nothing more can be done," when in

59
fact they were denying them access to renal dialysis so that slots could
be kept open for younger candidates. The crucial issue here is not the
legitimacy or illegitimacy of using age as a rationing criterion. Rather,
the most morally-troubling feature of this example is that denied patients
were not told they were being denied. What they were told was that no
medical options existed. This was a lie, but it was a lie that was
successfully hidden because rationing decisions were made from behind a
veil of secrecy, away from public scrutiny.

Rationing decisions that are closed to public examination are at best
potentially capricious and idiosyncratic; at worst, they are manipulative
and morally—treacherous. Rational Democratic Decisionmaking minimizes
the potential for the veiled danger of implicit rationing by opening up
these kinds of decisions to public debate. Since it is the community itself
that formulates the terms of a policy, it is impossible for any aspect of a
proposal to be kept hidden or secret. This feature promotes fair, public,
legitimately self-determined outcomes. As Fleck states, "moral premises
need to be made explicit so that they can be publicly assessed through a
democratic consensus mechanism," (1992, p. 161 1).

In addition to these general advantages, Rational Democratic
Decisionmaking has particular appeal for rural physicians. Content in the
knowledge that policies are established by public consensus, and that they
are compatible with high-level constitutional principles, physicians
would be able to follow policy guidelines with increased moral confidence.
In granting the community the power to decide ethical questions, Rational
Democratic Decisionmaking removes from physicians the uncomfortable
burden of deliberating ethical issues in isolation. Rational Democratic

Decisionmaking makes these issues a public concern, so while physicians

60
certainly must participate in the deliberations, the need for them to
wrestle with heavy moral questions all by themselves is eliminated. As a
result, physicians would not have to worry about making mistakes due to
their own potentially faulty moral judgment. No longer would physicians
have to fret over "making the right choice," or "doing the right thing." The
choice already would have been made, and it would be patients themselves
who made it. The tension between rural physicians' conflicting roles thus
would largely be relieved. As Mirvis says, physicians would be the
patient's advocate for "things that appropriately fall under the umbrella of
professional autonomy and that are determined by the public to be
available to the patient," (p. 1349).

There is another feature of Rational Democratic Decisionmaking that
can help physicians feel more comfortable about carrying out the policies
that the procedure generates. In the United Kingdom, the health care
system operates on a global budget, and primary care physicians act as
gatekeepers. There is a kitty of common resources, and access to the
account is controlled by primary care doctors. Therefore, if physicians
conserve funds through efficiency or rationing, then more money remains
in the pot to be spent on patients with serious medical problems. Norman
Daniels (1986) refers to this kind of system as "closed," because
financially it is self-contained in the form of a hard budget.

Daniels writes that one reason why American physicians tend to
overemphasize their roles as patient advocates at the expense of their
roles as public stewards stems from the nature of our health care system.
In the United States, health care largely is left to the private domain, and
as a result there is seldom such a thing as a global budget. Because our

health care system has no fixed budget ceiling, when American doctors

61
implement a rationing protocol they "have no assurance that the resources
they save will be put to better use elsewhere in the health care system,"
(1986, p.1382). Since they cannot be sure that the resources they deny to
one patient will be used for another patient with higher-priority needs,
many physicians decide that they might as well do everything they can for
the patient who is before them.

But because of the relative geographic isolation of many rural areas,
rural health care services can approximate closed systems. In the city
there are often multiple public and private hospitals, each competing with
the others in a free market environment. When they deny patients care, it
is seldom because they have a more just purpose in mind for the resources
that would have been spent. Instead the denial is likely to be related to
considerations such as profit and incentive. But in the country, the
community's hospital might constitute practically its entire health care
system. Consequently, Rational Democratic Decisionmaking can provide
rural physicians with a clearer idea of how the resources that they
conserve by rationing treatment will be utilized in a more important
capacity. Any savings gained from carrying out policies that restrict
some services would be channeled into other services that the community
has decided are more important. Because savings would be retained
within the community and used to support high-priority services at the
local hospital, rural health care could more closely resemble the kind of
"closed system" that Daniels describes. As a result, community-
determined allocation guidelines would be easier for rural physicians to
accept.

To borrow again from our example, a guideline might be adopted that

would regulate the use of the local hospital by the uninsured poor. In the

62
event that, under the guideline, Dr. Palmer should have to deny Mrs. Roubal
care at the local hospital, he at least can be comforted in the knowledge
that there is a higher purpose for doing so (and so can she). By avoiding
the costs of unreimbursed care for lower-priority treatments, the
hospital can remain open and able to provide care that is judged to be
more important. Fleck says that when established policies dictate that a
physician must limit a patient's care, the physician "can in good
conscience implement those rationing protocols because the savings will
be recaptured for higher priority health needs, and those protocols and
priorities will have been endorsed by that patient," (1992, p. 1627).
Rational Democratic Decisionmaking thus allows physicians to make sense

out of having to deny care.

OBJECTIONS TO RA'ITONAL DEMOCRATIC DECISIONMAKING

In spite of the many advantages l have described, I can anticipate some
objections to Rational Democratic Decisionmaking. Like any democratic
process, the legitimacy of Rational Democratic Decisionmaking hinges at
least in part on fair representation and equity, and so I expect that some
skeptics would argue that these criteria would be difficult to achieve.
Critics might object that the interests of the politically weak would be
overlooked, while the interests of the politically powerful would unfairly
dominate. For example, the health care needs of the homeless might be
easy to ignore, while the mayor might push for the health care needs of
his genetically-diseased family. Essentially, this objection asks how
Rational Democratic Decisionmaking would deal with the potential for
oppression of a powerless minority, and how it would deal with individual

self-interest.

63

First let us tackle the issue of oppression. l have already stated that
special measures to encourage representation from politically-
disadvantaged groups would have to be a part of the Rational Democratic
Decisionmaking process. And failing that, the constitutional principles
would be in place to protect their moral status. Yet there is a third
aspect of Rational Democratic Decisionmaking that would add an
additional safeguard against disrespecting the politically powerless. In
the matter of health care, says Fleck, "we are capable of a rare degree of
impartiality because we really do not know enough about our future health
needs," (1992, p. 1632-33). David Eddy has described this ignorance of
our future medical needs in terms of positions, (1991a). Position 1 is the
position in which people are healthy. Before they fall ill or become
injured, most people have no idea what kinds of health care options they
might require in the future. From position 1, then, people operate from
behind a veil of ignorance with respect to the choices they make for their
future health care: their lack of insight into what their own personal
needs will be tends to ensure that their choices will be impartial.

Additionally, it is unlikely that people will vote so as to exploit a
particular group if it is understood that, should they unexpectedly find
themselves members of that group, the rules will not be bent for them.
For example, residents are likely to vote for a proposal that respects the
rights of the uninsured if they are aware that should they lose their own
coverage they will be treated like any other uninsured patient. An
understanding that exceptions cannot be made would help prevent the
adoption of guidelines that discriminate against a weak minority in the
event that the many other safeguards inherent in the Rational Democratic

Decisionmaking process were to fail.

64

But how would Rational Democratic Decisionmaking prevent domination
by a self-interested and powerful minority? After all, the mayor's family
has a pretty good idea about what kinds of medical care they will need.
These people are in Eddy's position 2; that is, they are presently sick or
hurt, and so have significant insight into what their health care needs will
be. As a result, they might be tempted to shape decisions that seem to be
in their immediate personal self-interest, instead of choosing impartially.
But first of all, even if each member of the family were to vote selfishly,
their ballots would be diluted by the other members of the community,
who presumably are impartial. This is a democratic process where all
votes are equal: those of the mayor's family carry no special weight.

Second, the mayor's family would have to be made to understand that if
they monopolize the community's resources to deal with their genetic
disease, then sufficient resources might be unavailable to treat other,
more common conditions. Further, they must understand that their friends
and relatives and future children who are not afflicted with the condition
might be denied treatment for these common illnesses, because resources
would be committed to treating the genetic disease. To avoid "hogging,"
then, it is important to make it clear that since allocation protocols will
apply to all members of the community, people should consider what the
effects would be on everyone they care about before they decide to vote
selfishly. In rural towns, where "everybody knows everybody," it seems as
though this type of safeguard would be particularly effective at curtailing
the ability of a minority to dominate the political process.

Some authors, such as E. Haavi Morreim, have raised another concern.
They object that no proposal for distributive justice will permit

physicians to completely avoid the need to make bedside ethical choices.

65
Even with explicit guidelines in place, Morreim states that "the physician
cannot escape reckoning with awkward decisions," (p. 101 S). Rodwin
argues that in such situations, physicians rely on their own discretion and
subtlety of judgment, with the resulting tradeoffs representing a moral
risk to patients, (p. 160). If bedside allocation decisions are indeed
inevitable, one might wonder what is to be gained by investing in Rational
Democratic Decisionmaking.

While Morreim's point about the inevitability of rationing at the
bedside is probably true, explicit guidelines would reduce the need for it
significantly. Rational Democratic Decisionmaking minimizes the risks to
patients by generating explicit protocols, thereby limiting the need for
physicians to rely on their own moral judgment. If the guidelines
produced by Rational Democratic Decisionmaking are sufficiently fine-
grained and specific, then a small, unavoidable degree of "play" would be
acceptable—-a sort of grey area within which the public must trust
physicians to make judgments in good faith. .And physicians must strive
to be worthy of that trust by exercising their best moral reasoning. Thus,
in those minor circumstances where a guideline fails to provide clear
direction to physicians, trusting them with their discretion would seem to
pose little danger. Rational Democratic Decisionmaking would ameliorate
the problem substantially, and so the fact that it might fail to eliminate
the need for physicians to make ethical decisions hardly seems like a
valid reason to reject it.

A situation that could not be tolerated, however, would occur if
physicians step outside of this grey area to subvert the system because
their personal beliefs conflict with a hard and fast guideline generated by

Rational Democratic Decisionmaking. "Gaming the system" must be

66
strictly prohibited. For instance, suppose that a morally-legitimate
protocol emerged from Rational Democratic Decisionmaking that
prevented Dr. Palmer from admitting Mrs. Roubal for the testing that he
felt she needed. As her personal friend, Dr. Palmer might be deeply
frustrated by the fact that his hands are tied by the guideline. However, it
would be unacceptable for him to decide to change her diagnosis or
exaggerate the seriousness of her condition in order to win her admission.
Such arrogance and selfishness would undermine the very purpose of
Rational Democratic Decisionmaking, and would be plainly dishonest.
Furthermore, it would disrespect the autonomy of the community at large,
and indeed of Mrs. Roubal, who presumably consented to abide by the
protocol at some point in the past. If Rational Democratic Decisionmaking
is to be of any utility, then, it will have to be free of "gaming" by
disgruntled physicians. As Mirvis states, "it is not appropriate to subvert
the system by political manipulation or deceit in order to gain for
patients things to which they are not entitled by social or legal
contracts," (p. 1349).

This point about gaming suggests a final objection to Rational
Democratic Decisionmaking. Imagine a scenario in which a town has
passed a guideline that directs its physicians to deliver uncomplicated
pregnancies at the local hospital so that enough income is generated by
the hospital's obstetrical service to keep the service open. Now imagine
that upon becoming pregnant, a wealthy member of the community decides
that she would rather deliver her child at a nearby metropolitan hospital,
because although her pregnancy has been uneventful she feels that the
urban facility is better equipped to handle an unanticipated emergency.

She has secretly been seeing a specialist in the city who has agreed to

67

admit her to the metropolitan hospital for her delivery. She is paying him
out of pocket to avoid double-billing her insurance company. When her
labor begins, she calls the specialist, has her husband drive her into the
city, and delivers a healthy child. The problem illustrated by this example
is obvious: what measures are in place to enforce the guidelines set by
Rational Democratic Decisionmaking? In other words, how can we ensure
that people follow the rules?

First and foremost, it should be noted that "opting out" is morally-
unacceptable behavior. Due to the fact that patients previously granted
consent to the guidelines (or at least to the process that produced the
guidelines), the policies "gain their moral force from respecting individual
patients' own will," (Menzel, p. 10). Nevertheless, the rural physician
cannot assume the role of cop. The responsibility to enforce protocol
guidelines cannot rest with physicians, because such a duty would be
incompatible with the trust that the doctor-patient relationship demands.

The goal would be to prevent these sorts of behaviors in the first
place. The residents of the community must be made aware of the
potential for a "tragedy of the commons" situation to develop, in which
residents vote to promote the good of the general community, but act so
as to maximize their own individual good. If this selfish behavior is
sufficiently widespread, then the broader good will fail to be achieved and
everyone will be worse off than if they had acted unselfishly. Thus, when
patients try to escape their responsibility to abide by just guidelines,
"they might not only be in conflict with society, but they might well be
fostering policies that are not even in their own long-term interest,"

(Eddy, 1991c, p. 2406). It is important that community members have a

68
solid understanding of this concept in order to decrease the frequency
with which they choose to break the social contract.

Additionally, the social features of rural communities make it even
less likely that rural patients would attempt this sort of betrayal. Recall
from Chapter One that privacy is relatively difficult to preserve in rural
towns. Secrets are difficult to keep, and so the prospects of getting away
with breaking the guidelines without being discovered would be rather
slim. Remember also our discussion about the considerable power rural
communities can bring to bear through social controls. The offending
party would be subject to social sanctions whose severity would depend
directly upon the seriousness of the infraction. With little chance of
pulling it off, and a stiff penalty to pay for getting caught, it is doubtful
that residents would dare to disregard the guidelines with any kind of
frequency.

For the most part, then, the potential objections to Rational
Democratic Decisionmaking only help to illustrate in greater relief why it
could be of particular use in resolving the tension between rural
physicians' duties to their communities and their duties to their
individual patients. With that in mind, it appears that we have achieved
the goal that we set for ourselves at the end of Chapter Two: we have
arrived at a distributive mechanism that is capable of coupling respect
for a variety of generally-recognized, broad moral precepts with a high
degree of context-appropriate specificity. Because it grants communities
free reign to determine--within boundaries marked by a set of high-level
constitutional principles--their own policies for allocating public
resources, Rational Democratic Decisionmaking can strike a successful

balance between various competing moral criteria while simultaneously

69
engaging morally-relevant particulars. The result is a good "fit" with the
social contours of rural communities, and the alleviation of the role

strain that those social features generate for rural physicians.

SUMMARY AND CONCLUSIONS

This thesis stresses the importance of an interdisciplinary approach to
the problem of rural physician role strain. Solutions derived from
abstract philosophical theories will be of little practical value unless
they can contend with the particular sociological make-up of rural
communities. Specifically, a potential solution must account for the
financial instability of many rural hospitals, the cohesive nature of rural
communities, and the vulnerability of rural physicians to social controls.
The first chapter of the thesis deals with each of these elements
individually.

The shaky financial status of rural hospitals sets up the dilemma for
physicians. The local hospital is a critical communal health resource, and
as a consequence it is incumbent upon physicians to protect it. However,
sometimes it becomes difficult to protect the viability of the community
hospital while simultaneously maximizing the care of particular patients.
In these instances, physicians find themselves torn between their roles as
patient advocates and their roles as stewards of their communities'
health resources.

The cohesive nature of many rural towns exacerbates this dilemma.
Rural physicians often have a unique familiarity with their patients. This
makes "clinical detachment" hard for them to achieve, and can create a
tendency for rural physicians to disregard larger, more remote goals in

favor of the patient who is presently before them.

70

71

Similarly, the heightened vulnerability of rural physicians to social
controls exerted by their communities makes them more likely to
overemphasize their roles as patient advocates. Social pressures can be
extremely intense in small towns, and as particularly conspicuous
members of the community physicians are especially susceptible to them.
Rural residents often believe that people should be treated regardless of
their economic status, and their ability to enforce this belief is another
factor that makes patient advocacy more attractive than public agency for
rural physicians.

In Chapter Two, rural physicians' role tension is assessed from the
perspectives of several conventional, high-level moral principles. The
principle of autonomy favors patient advocacy since it supports individual
rights. However, autonomy does not recognize the moral legitimacy of the
physician's role as a public agent, and therefore cannot be used to solve a
problem whose nature it cannot grasp.

In contrast to autonomy, the principle of utility stresses the interests
of the community, since utility is concerned with maximum aggregate
good. However, utility does not account for the nature of physicians' roles
in a cohesive community: it ignores morally significant interpersonal
factors. Furthermore, utility is plagued by mechanistic difficulties
surrounding its proper practical application.

Libertarian justice resolves allocation questions by leaving them to
the free market. What is central is the capability to enter into economic
negotiations; there is no recognition of a right to health care beyond one's
ability to pay for it. Because it fails to acknowledge the legitimacy of
other competing considerations, libertarian justice is an inappropriate

solution to this conflict.

72

Egalitarian justice recognizes that many moral criteria are relevant to
ethical problems, and attempts to render outcomes that strike a balance
between them. However, like most general moral systems, it has a
"macro" orientation, and thus is unable to achieve sufficient specificity.

In rejecting these conventional moral principles, the characteristics of
a potentially-successful approach become clear. First, the approach must
be able to generate solutions that are appropriate for a particular rural
community. Second, it must be capable of balancing numerous competing
moral values. And finally, it needs to accomplish these two objectives
while simultaneously preserving moral rigor.

Chapter Three explores Rational Democratic Decisionmaking. This
method generates solutions to ethical dilemmas by opening the issue to
public debate, and then putting proposals to a democratic vote. Although
outcomes are community-determined, they are constrained by a
"constitution" of high-level moral principles.

Rational Democratic Decisionmaking is advocated as an approach to
resolving rural physicians' conflict between their roles as patient
advocates and public agents for several reasons. First, its structure
allows it to satisfy the criteria we formulated at the end of Chapter Two.
In allowing residents to construct their own tailor—made solutions to
issues regarding community resources, Rational Democratic
Decisionmaking achieves a high level of specificity to context. The broad
community discussions and deliberations identify a variety of relevant
moral values, and each is weighed into the final solution to the extent
that is deemed appropriate. Thus, the need for balance is met. And
finally, the autonomy of the voters is restricted to the space bounded by

the set of constitutional principles, thus insuring moral stringency.

73

Additionally, Rational Democratic Decisionmaking's reliance on the
democratic process is the fairest and most appropriate way to settle
issues that involve public resources, such as community hospitals. Also,
the fact that the policies it produces are self-conceived and self-imposed
provides a solid foundation for the moral legitimacy of the approach.
Patients are not morally injured when they are denied care on the basis of
a guideline to which they have granted their prior consent.

Rational Democratic Decisionmaking is especially attractive to country
physicians. It liberates them from the struggle of having to sort out
painful ethical questions by themselves: Rational Democratic
Decisionmaking is a community process. Additionally, it provides them
with a clear idea of how the savings that are achieved by carrying out the
protocols would be recovered and used for higher-priority purposes.

In summary, Rational Democratic Decisionmaking seems to fit the bill
for rural physicians. It provides a method of resolving the conflict
between their roles as patient advocates and as public agents by finding a
balance between the assortment of competing values such that the
generated policies are context-appropriate and account for the morally-
important sociological features of rural towns. Yet at the same time,
these policies are also compatible with abstract, higher-level moral
principles. Thus, Rational Democratic Decisionmaking is capable of
generating morally sound outcomes that are suited to the unique social

dynamics of rural areas.

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