Roughly 15 million of the 62 million rural U.S. residents struggle with men
tal illness and substance abuse. These rural dwellers have significant heal
th care needs but commonly experience obstacles to obtaining adequate psych
iatric services. Important but little-recognized ethical dilemmas also affe
ct rural mental health care delivery. Six attributes of isolated settings w
ith limited resources appear to intensify these ethical dilemmas: overlappi
ng relationships, conflicting roles, and altered therapeutic boundaries bet
ween caregivers, patients, and families; challenges in preserving patient c
onfidentiality; heightened cultural dimensions of mental health care; "gene
ralist" care and multidisciplinary team issues; limited resources for consu
ltation about clinical ethics; and greater stresses experienced by rural ca
regivers. The authors describe these features of rural mental health care a
nd provide vignettes illustrating dilemmas encountered in the predominantly
rural and frontier states of Alaska and New Mexico. They also outline cons
tructive approaches to rural ethical dilemmas in mental health care.