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Rural Bioethics: The Alaska Context


With by far the lowest population density in the United States, myriad challenges attach to healthcare delivery in Alaska. In the “Size, Population, and (In)Accessibility” section, we characterize this geographic context, including how it is exacerbated by lack of infrastructure. In the “Distributing Healthcare” section, we turn to healthcare economics and staffing, showing how these bear on delivery—and are exacerbated by geography. In the “Health Care in Rural Alaska” section, we turn to rural care, exploring in more depth what healthcare delivery looks like outside of Alaska’s major cities. This discussion continues in the “Alaska’s Native Villages” section, which specifically analyzes healthcare in Alaska’s indigenous villages, some of the smallest and most isolated communities in the United States. Though many of the ways we could improve Alaskan health care for Alaskan residents are limited by its unique features, the “Justice and Healthcare Delivery” and “Technology and Telemedicine” sections consider ways in which certain policies and technology—including telemedicine—could mitigate the challenges developed in previous sections.

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  1. 1.

    Consider also that the largest national park in the United States is Wrangell-St. Elias, which is over 12,500 square miles. This park alone is about the size of Maryland and would be about the 42nd largest state (United States Department of Interior 2018; United States Census Bureau 2010b).

  2. 2.

    This is just counting the states: it is .003% that of Washington, D.C. (United States Census Bureau 2010b, p. 41).

  3. 3.

    The fact that this inaccessibility is due to environmental reasons also limits solutions and confounds the structure of obligations. We return to this issue in the “Justice and Healthcare Delivery” section.

  4. 4.

    Washington, D.C. has a higher cost at $11,944 (Kaiser Family Foundation 2018).

  5. 5.

    Just to be clear, Anchorage has excellent care, whether through Providence Alaska Medical Center—a major private hospital—or the public or tribal facilities, Alaska Regional Hospital and Alaska Native Medical Center (ANMC), respectively. Both Providence and ANMC are Level II trauma centers, the most advanced in a state that otherwise has nothing above Level IV (Alaska Department of Health & Social Services 2018b). The closest Level I trauma center is Harborview Medical Center, in Seattle, which services Washington, Alaska, Montana, and Idaho (University of Washington Medicine 2018).

  6. 6.

    Problems with rural-track programs are still being analyzed and their effectiveness is still unclear. The literature indicates rural-rotations and rural training tracks have high rural retention rates, but it is unclear to what degree self-selection plays a role in these programs (Parlier et al. 2018, p. 5; Pathman et al. 1994). Financial incentives similar to the loan forgiveness Alaska offers are promising, although the effects might be short-lived. As it stands, we simply have not had enough of these programs for enough time to be able to study the long-term effects (Parlier et al. 2018, p. 6; Pathman et al. 2008).

  7. 7.

    In the “Justice and Healthcare Delivery” section, we consider additional solutions, which are less sensitive to issues such as oil pricing.

  8. 8.

    Fortunately, there has started to be work done in this field, but more still needs to be done. See Pathman et al. (2008), Parlier et al. (2018), and Nelson et al. (2010).

  9. 9.

    There are a few rural states that are experimenting with ever-more desperate and extreme policies. Missouri’s 2014 law is illustrative of this: recent medical school graduates may practice primary care in underserved areas without completing their four-year residency at a hospital (Kardish 2014).

  10. 10.

    Physicians felt similarly, although they are more willing to make decisions on their personal values, which were most commonly reported to be “peers and colleagues, faith in God, what my conscience guides me to do, pray, involve my wife/husband, deal with it the best I can” (Cook and Hoas 2010).

  11. 11.

    For an excellent map, see (United States Census Bureau 2010a).

  12. 12.

    The Alaska Permanent Fund was established under Article 9 § 15 of the Alaska Constitution in 1976. It is funded by oil revenues and has a current value of approximately $55 billion. Each year, it pays out a dividend—the Permanent Fund Dividend—to qualified residents. (Eligibility requirements are low, with incarceration being the principal barrier.) The annual payout depends on a five-year average of the Permanent Fund’s performance, and has been between $1000–$2000 per resident (including children) in recent years.

  13. 13.

    Izembek forms a curious, narrow isthmus that makes for a unique set of habitats. The United States Department of the Interior (2013) argued that the most harmful environmental impacts were primarily the ground-based disturbances roads would bring to the eelgrass beds in which the Pacific Black Brant forage and prepare for migration. While migratory birds are particularly sensitive to ground-based disturbances, Pacific Black Brants are even more so. Another vulnerable avian population endangered by the road are the non-migratory Tundra Swans, who have suffered a 75% population decline since 1980 (The United States Department of the Interior 2013). The proposed road directly bisects the Tundra Swans’ nesting grounds, which would obstruct the rearing of their young. Other threatened, endangered, or affected species included the Emperor Geese (one of the rarest and most vulnerable geese in the world), Steller’s Eiders, brown bears, caribou, and wolves. The area of land they would receive in return was considered insufficient (despite its much larger size) for offsetting the environmental damage to Izembeck due to the directness with which the road interferes with the natural habitats and the kinds of nature threatened (The United States Department of the Interior 2013).

  14. 14.

    This issue was additionally sensitized by the naming of Mount McKinley, the tallest mountain in North America at 20,310 feet and a great source of pride for both the state and its indigenous communities. It was named after then-candidate William McKinley in 1896, who was from Ohio and went on to become the 25th President of the United States in 1897. McKinley favored a gold standard to which Alaskans were sympathetic given their statewide gold reserves, and so a prospector named it after him. But, the indigenous Athabascans had referred to it as Denali for centuries—meaning “high” in their language (Davis 2015).

  15. 15.

    To be sure, Hawaii is the most popular winter destination for Alaskans; Alaska Air services three islands during the winter, with multiple direct flights a day from Anchorage. But even with PFD sales and Alaska Airlines’ Visa 2-for-1 sales—many Alaskans have this card for this reason—those vacations are not financially possible for the majority of residents.

  16. 16.

    Lopez (2015) puts together a few pieces of data to make the case: marijuana mirrors tobacco in that lower-class individuals make up most of the users and marijuana is disproportionately expensive for lower-class individuals. Becoming dependent on marijuana could prove financially deadly for many Alaskan residents.

  17. 17.

    Rawlsian arguments for universal health care coverage are advanced most paradigmatically by Daniels (1981, 1985, 2008); other kinds of arguments extend from the work of Sen (1980, 1992), Arneson (1988), and Cohen (1989). Dworkin (1981, 1994, 2000) and Gibbard (1982) advanced yet a different kind. Each of these kinds of arguments have their own discussion, such as Arrow (1973) and Sen’s (1980) criticisms of Rawlsian arguments. Other opposition to universal health care coverage has taken several forms, such as Engelhardt's complete opposition to positive obligations (1979). An interesting and relatively recent line springs from research on social determinants of health, pointing out that universal healthcare programs might not much help alleviate health inequities, reducing the power of many arguments from equality (Sreenivasan 2007). For a good summary, see Daniels (2017).

  18. 18.

    While substantially outside the scope of the current paper, see Dunbar-Ortiz (2015) and Williams et al. (2009) for particularly insightful—and depressing—discussion. The strength of reparative arguments may be attenuated here because most of colonial wrongs were caused by Russians, but this argument may lose some force when considering the obligations of governments exchanging lands with wronged peoples on them. Additionally, there is plenty of harm done after America acquired Alaska (see, e.g., Peter 2009).

  19. 19.

    We thank an anonymous reviewer for pressing us to expand this discussion.

  20. 20.

    Nevada is number one and Utah is number two, with 81.1% and 61.5% respectively (Vincent et al. 2017).

  21. 21.

    Even if one were to install one in each hub community, it would cost upwards of $40 million and would alleviate few of the problems we laid out earlier for the majority of Alaska’s rural inhabitants.

  22. 22.

    Though there may be other structural features inveighing against out-of-state care, such as licensure.


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Correspondence to Fritz Allhoff.

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Allhoff, F., Golemon, L. Rural Bioethics: The Alaska Context. HEC Forum 32, 313–331 (2020).

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  • Alaska
  • Rural healthcare
  • Indigenous health
  • Bioethics