Amish healthcare decisions, family roles, and patient accommodations

A largely insular community since their initial settlement in the United States, the Amish community presents unique challenges for healthcare workers. The Amish eschew modern technology, including many of the tools and techniques used in modern medicine. In fact, the Amish community also forbids higher education (Adams & Leverland, 1986). Misconceptions and misunderstandings about the Amish further complicate healthcare decisions and relationships between healthcare providers and Amish patients. For example, it is commonly assumed that the Amish “lack the preventive practices of immunizations and prenatal care,” (Adams & Leverland, 1986, p. 58). While the rates of immunizations are relatively low among the Amish, the Amish church does not forbid immunization (Adams & Leverland, 1986). The Amish also have a keen interest in disease prevention, health education, and lifestyle choices that prevent health problems (Talpos, 2016). Although Amish attitudes towards health, wellness, and the healthcare system may be at odds with those outside their communities, there are important points of convergence that nurses can incorporate into a transcultural model of care.

One of the hallmarks of Amish healthcare is the community’s internal insurance program. The Amish have been exempt from paying Social Security on religious grounds since 1965, and the same principles have also exempted the Amish from participating in the Affordable Care Act and its mandated health insurance provision (Rohrer & Dundes, 2016, p. 92). Instead of participating in mainstream health insurance schemes, the Amish provide fully for the healthcare needs of members of their community. The Amish community manages healthcare costs internally by reducing or eliminating spending on non-essential services, while pooling community resources to pay for essential or emergency care. In some cases, the Amish communities have agreements with local hospitals for bulk discounts or special rates for services (Kelley, 2013). This “community-based” model of “reciprocal assistance without government interference” has been much admired and provides insight into how Americans outside of the Amish community can consider public healthcare ethics (Roher & Dundes, 2016, p. 92; Talpos, 2016).

The Amish view healthcare largely as a matter of personal responsibility. Each person has a personal responsibility to follow a minimalist lifestyle in general, which essentially prevents some of the healthcare problems plaguing Americans. For example, smoking and drinking are prohibited in Amish communities (Cleveland Clinic, 2017). Surgical procedures, dental work, anesthesia, blood transfusions, and even some organ transplants are permitted but only when absolutely necessary (Cleveland Clinic, 2017). Relying on medicine, treatments, and interventions as little as possible, the Amish keep their collective healthcare costs down, and use complementary, folk, or herbal treatments on their own.

Unfortunately, the Amish may actively “distrust the motives of hospital administrators and even doctors themselves,” partly because of pressures to conform to different standards of care but also because of the profit motive in American healthcare, which is anathema to Amish ideals (Talpos, 2016). Because the Amish do often refuse treatments or interventions, it is important to know when to support the right of patient autonomy and when doing so would violate the principle of beneficence. This is especially true when treating children. Also, Amish communities have higher rates of certain genetic mutations and genetic conditions due to the high rates of inbreeding. Yet Amish people may be resistant to genetic testing. Because Amish people are interested in preventative care, healthcare workers can engage the Amish community by providing as much information as possible about non-invasive treatments. Because the Amish view health and healthcare as spiritual values, it is possible to frame healthcare interventions to fit the Amish worldview.

Culture Care Presentation/Maintenance: In general, the Amish need little help preserving or maintaining their own cultural values and traditions. However, healthcare workers can help preserve and maintain the integrity of the Amish community by supporting the overall value of thriftiness, allowing the patient to opt into only those treatments or interventions that are absolutely necessary for the maintenance of health. Options and their potential outcomes should be clearly iterated, and the healthcare worker should enable the Amish to opt out of any treatment or intervention that does not support healthcare goals or align with their values.
Culture Care Accommodations/Negotiation: Adapting to the Amish worldview requires respect and genuine interest in the Amish approach to healthcare. The Amish are not anti-healthcare, even if they do not want to agree with every suggestion made by the healthcare team. The ethical principle of patient autonomy is critical when working with the Amish. For autonomy to be truly realized, the patients need to be offered as much information as possible in a clear and straightforward way to promote sound judgment and decisions.

Culture Care Repatterning/Restructuring: Providing information to the patient and to the Amish community can help repattern and restructure. Amish healthcare behaviors have changed, as the community does adapt to new information. Especially with regards to early detection of genetic abnormalities in children, the Amish may be amenable to certain types of treatments, tests, or interventions that would have been verboten a generation ago. Working not just with the individual but the entire community is also critical. The Amish strongly value community decision-making. Some more progressive members of the community might be able to participate in health education or outreach programs to improve health outcomes.





References

Adams, C.E. & Leverland, M.B. (1986). The effects of religious beliefs on the health care practices of the Amish. Nurse Practitioner 11(3): 58-63.
Cleveland Clinic (2017). Treating the Amish and addressing their health care concerns. Retrieved online: http://www.clevelandclinic.org/health/health-info/docs/1700/1783.asp?index=6955&src=newsp
Kelley, D. (2013). As U.S. struggles with health reform, the Amish go their own way. NBS News. Retrieved online: https://www.nbcnews.com/health/u-s-struggles-health-reform-amish-go-their-own-way-8c11345954
Rohrer, K. & Dundes, L. (2016). Sharing the load: Amish healthcare financing. Healthcare 4(4): 92.
Talpos, S. (2016). The Amish understand a crucial thing about modern medicine that most Americans don’t. Quartz. Retrieved online: https://qz.com/695101/the-amish-understand-a-crucial-element-of-modern-medicine-that-most-americans-dont/