In a forthcoming article on rural bioethics, the authors describe three futility disputes in which the providers' decision whether to accede to the surrogate's request to continue LSMT depended materially on the patient's money and power. While providers thought continued treatment was medically inappropriate, they acceded to family wishes because the patient "was influential; well-known and well-respected in the community; there was no desire to antagonize the family."
Unfortunately, this works the other way as well. Less influential families may not have their treatment requests respected. And it may be not be a matter of clinical appropriateness but rather because of money.
Rural hospitals have significant economic challenges. As compared to more urban areas, the population is poorer, sicker, and more likely uninsured. ( Nelson et al., 33 JME 136 2007) A complicated, uninsired case could compromise the health of the hospital and, given the lack of alternative facilities, the entire community. Moreover, rural hospitals have fewer ethics resources that might serve as a check on the use of socio-economic criteria for allocating LSMT.