HEC Forum

, Volume 27, Issue 2, pp 157–170 | Cite as

The Opportunities and Challenges for Shared Decision-Making in the Rural United States

  • William A. Nelson
  • Paul J. Barr
  • Mary G. Castaldo


The ethical standard for informed consent is fostered within a shared decision-making (SDM) process. SDM has become a recognized and needed approach in health care decision-making. Based on an ethical foundation, the approach fosters the active engagement of patients, where the clinician presents evidence-based treatment information and options and openly elicits the patient’s values and preferences. The SDM process is affected by the context in which the information exchange occurs. Rural settings are one context that impacts the delivery of health care and SDM. Rural health care is significantly influenced by economic, geographical and social characteristics. Several specific distinctive features influence rural health care decision-making—poverty, access to health care, isolation, over-lapping relationships, and a shared culture. The rural context creates challenges as well as fosters opportunities for the application of SDM as a natural dynamic within the rural provider–patient relationship. To fulfill the ethical requirements of informed consent through SDM, it is necessary to understand its inherent challenges and opportunities. Therefore, rural clinicians and ethicists need to be cognizant of the impact of the rural setting on SDM and use the insights as an opportunity to achieve SDM.


Ethics Health care ethics Shared decision-making Informed consent Rural health care 



The authors want to express their appreciation for the thoughtful insights offered by members of the Vermont Ethics Network; also, Drs. Don Kollisch, Robert Macauley, Denise Niemira, and Cathleen Morrow; Ms. Robin Paradis Montibello and Ms. Linnea Spelman in preparing the manuscript.


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Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  • William A. Nelson
    • 1
  • Paul J. Barr
    • 2
  • Mary G. Castaldo
    • 2
  1. 1.Psychiatry, Community and Family Medicine, The Dartmouth Institute for Health Policy & Clinical PracticeGeisel School of Medicine at DartmouthHanoverUSA
  2. 2.The Dartmouth Insitute for Health Policy & Clinical PracticeGeisel School of Medicine at DartmouthHanoverUSA

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