Diversity and Context in Health Ethics: The Case for Rural Health

This review maintains that the book, Rethinking Rural Health Ethics, is essential reading for rural health providers, rural health policy makers, and rural health ethicists because it uncovers the fundamental inadequacies of the traditional, urban-centric health ethics framework with respect to the rural health setting and formulates the basis for a more viable and distinctive rural health ethics. This review further maintains that this book possesses far-reaching, robust implications on the importance of incorporating diversity and context into ethical deliberations within the broader Résumé Abstract Ce compte rendu soutient que le livre Repenser l’éthique de la santé rurale est une lecture essentielle pour les fournisseurs de soins de santé en milieu rural, les décideurs en matière de santé rurale et les éthiciens en santé rurale, parce qu’il révèle les inadéquations fondamentales du cadre traditionnel en éthique de la santé, centré sur les milieux urbains, avec la santé en milieu rural, et formule les bases pour une éthique plus viable et distinctive en santé rurale. Ce compte rendu soutient, en outre, que ce livre a des implications profondes et solides sur l’importance d’incorporer la diversité et le contexte dans les délibérations éthiques à l’intérieur du domaine plus large qu’est l’éthique de la santé, et ce à tous les niveaux de l’analyse éthique (c.- à-d. micro, méso et macro), servant ainsi d’influence résonante et judicieuse pour les éthiciens de la santé de tous domaines. This review maintains that the book, Rethinking Rural Health Ethics , is essential reading for rural health providers, rural health policy makers, and rural health ethicists because it uncovers the fundamental inadequacies of the traditional, urban-centric health ethics framework with respect to the rural health setting and formulates the basis for a more viable and distinctive rural health ethics. This review further maintains that this book possesses far- reaching, robust implications on the importance of incorporating diversity and context into ethical deliberations within the broader field of health ethics and in all levels of ethical analysis (i.e., micro, meso, and macro), thus serving as a resonating and sage influence for health ethicists in all fields.

Article abstract This review maintains that the book, Rethinking Rural Health Ethics, is essential reading for rural health providers, rural health policy makers, and rural health ethicists because it uncovers the fundamental inadequacies of the traditional, urban-centric health ethics framework with respect to the rural health setting and formulates the basis for a more viable and distinctive rural health ethics. This review further maintains that this book possesses far-reaching, robust implications on the importance of incorporating diversity and context into ethical deliberations within the broader field of health ethics and in all levels of ethical analysis (i.e., micro, meso, and macro), thus serving as a resonating and sage influence for health ethicists in all fields.
This review maintains that the book, Rethinking Rural Health Ethics, is essential reading for rural health providers, rural health policy makers, and rural health ethicists because it uncovers the fundamental inadequacies of the traditional, urban-centric health ethics framework with respect to the rural health setting and formulates the basis for a more viable and distinctive rural health ethics. This review further maintains that this book possesses farreaching, robust implications on the importance of incorporating diversity and context into ethical deliberations within the broader field of health ethics and in all levels of ethical analysis (i.e., micro, meso, and macro), thus serving as a resonating and sage influence for health ethicists in all fields.

Mots clés
Keywords éthique de santé rurale, éthique rurale, politique de santé rurale, biais urbain, théorie féministe, diversité bioéthique rural health ethics, rural bioethics, rural health policy, urban bias, feminist theory, diversity bioethics In Rethinking Rural Health Ethics [1], Christy Simpson and Fiona McDonald argue that the traditional, urban-centric health ethics framework fails to take into account the distinctiveness of the rural context, often resulting in flawed ethical analysis within that setting. They reconceptualize what a viable rural health ethics framework might look like, while arguing that the diversity, richness, and complexity inherent in the rural health setting has much to offer the broader field of health ethics. Overall, this book provides rural health providers, ethicists, and policy makers with a strong and clear foundation for a viable rural health ethics and possesses robust, far-reaching implications on the importance of incorporating diversity and context into ethical deliberations within the broader field of health ethics.
The book is composed of two principal sections. In the first section, the authors argue that the traditional, mainstream approach to health ethics is urban-centric and possesses biased and ill-informed assumptions and stereotypes about the nature of rurality and life and work in rural settings (e.g., the deficit perspective inherently problematizes the rural context and impedes the strive for change). They highlight how urban norms and a sense of "othering" pervade ethical deliberations. They do not dismiss all the insights that the traditional health ethics framework can provide the rural context, but stress that there is a need to reassess what is and is not relevant, how what is still relevant must be further nuanced to fit the rural health context specifically, and what novel considerations must be formulated for this context. The authors use a mix of population research, survey, and anecdotal evidence from rural health providers, patients, and residents to demonstrate the inapplicability of the traditional health ethics framework to rural health and the clear need to formulate a distinctive rural health ethics. For the reader, this strong melange of evidence creates a convincing and holistic view of the distinctiveness of the rural health context and its ethical relevance. The authors also emphasize the importance of moving beyond the commonly addressed micro-level bedside issues that pervade the rural health ethics literature to entertain more complex and important meso and macro levels analyses of rural health. In so doing, they thoroughly 'deconstruct' the existing rural health ethics framework.
In the second section of the book, the authors 'reconstruct' the basis for a viable rural health ethics. In response to the dearth of meso and macro level analysis in the literature, they employ an organizational ethics framework and systems analysis framework and effectively demonstrate their applicability to the rural context. Taking a value-based approach to health ethics, they conceptualize three distinct ethical values (place, community, and relationships) that they argue are underdeveloped in both the rural and broader health ethics literatures. These three values significantly impact rural residents' health care decisions and experiences with receiving care; for example, rural patients may choose to be discharged early despite medical advice in order to return to their community or, alternatively, to receive treatment locally despite higher operative mortality risks. Thus, the authors stress that these values must be given appropriate weight in ethical deliberations, both within and outside the rural health setting (e.g., tightknit, inner-city ethnic communities). They argue that it is imperative that we consider them as three standalone values because they carry discrete ethical nuances and only by considering them separately can they each be given appropriate ethical weight. However, it remains an open question for the reader whether these values should truly stand alone. It may be argued that these values should be encompassed within the broader ethical values of beneficence and nonmaleficence, in that the best possible patient care inherently requires that we appropriately situate patients. Alternatively, these values can be meshed into a single, overarching 'value of context'which may be especially fitting given the significant overlap that exists between them.
The authors consistently lay down the philosophical principles from which they work, giving readers a very clear sense of their starting points for analysis. At the heart of this book's argument is a feminist approach to health ethics. Three key feminist theories resonate throughout the book: standpoint theory, perspectives on power, and relational autonomy. The authors use En collaboration avec / In collaboration with standpoint theory, the idea that all our knowledge and values are situated, to emphasize that ethical frameworks must be revised to incorporate perspectives of non-dominant groups. They also bring to our attention the power relationships that exist among the multiplicity of actors that play a role in health care delivery and policy making. Furthermore, since relationships in rural communities have an intensity and visibility that does not often characterize relationships in urban environments, they stress the importance of employing the concept of relational autonomy in the rural context, which emphasizes that individuals are situated within a complex web of interpersonal relationships that affect their decision-making. The authors move beyond standard notions of relational autonomy (i.e., the interpersonal) to relationships with places and communities, emphasizing that they too affect individuals' decision-making. Ultimately, they use a feminist perspective to contest the more pervading neoliberalist approach to health ethics which views health services as a good rather than a right, individuals as autonomous and rational agents devoid of context, and health care as being provided primarily by and to strangers. Through these thoughtful philosophical deliberations, the authors create a strong and sound argument for a distinct rural health ethics framework.
The authors use an approach that is equally informed by both abstract philosophical principles and concrete practical considerations. In each chapter, they apply theory to a number of renowned issues in rural health care, demonstrating practical viability (e.g., the recruitment and retention of rural health providers, professional boundaries and dual or multiple relationships, uniform standards of care, roles of rural health facilities, resource allocation, issues of access versus quality, centralized versus local governance models). Thus, although much of their analysis is conceptual, the authors maintain a keen eye on what may work in practice. This is another major strength of the book, ensuring that any proposed theoretical considerations are not too far removed from the context within which they are meant to be applied and considered.
Rethinking Rural Health Ethics [1] is valuable reading for rural health providers, rural health policy makers, and rural health ethicists because it establishes the clear need for a distinctive rural health ethics framework and formulates the basis for such a framework. This book possesses profound insights beyond the rural health ethics literature, emphasizing that to strive towards patient-centered care and firmly adhere to the principles of beneficence and nonmaleficence requires that we also fully situate and contextualize individual patients. Thus, this book serves as a resonating, sage influence for health ethicists in all fields of health ethics.