OBJECTIVES: Old Order Amish define their existence as “in” but not “of” the world, giving rise to a spiritual expression that is unique among Christian sects. The Healthcare professional - “of” the world, by definition - faces the daunting task of providing culturally sensitive services. METHODS: This article examines modifications to accommodate patient expectations of equality, and respect for the boundaries that must always exist. RESULTS: In recent years, a handful of authors have addressed the Healthcare of the Amish. CONCLUSIONS: Their work, and the experiences of the authors highlight the challenge of providing nursing, medical, and dental services to the Old Order Amish.

The Old he Order is the most visible of Amish groups1, publicly identified by their plain dress and use of horse and buggy as primary mode of transportation (Hosteller, 1993). A splinter group during the 17tn century formation of the Anabaptists, they are both a sect (in their view) and a culture (in the view of those providing services), espousing fundamental Christian beliefs. Persecuted in Europe, many accepted the invitation of religious tolerance, and immigrated to Pennsylvania during the 18tn century. As their numbers grew, they migrated westward. Currently, there are over 175 settlements in North America, with a total population estimate exceeding 110,000. The largest settlements are located in Lancaster County, Pennsylvania, Holmes County, Ohio, and LaGrange County, Indiana, although smaller settlements dot the United States and Canada (Kraybill, 1989).

Separation from the “world” as Christians is imperative to Amish beliefs. Other core beliefs include loyalty to community and family over loyalty to self, commitment to physical labor, humility in interactions with others, a recognition of, and commitment to the church as authority and discipline (Hosteller, 1993; Kraybill, 1989; NoIt, 1992). Life on earth preludes heavenly rewards; although friends and family may grieve death, they also rejoice in the promise of eternal life (Bryer, 1979)

The practical aspects of Amish theology have been sorely tested in recent years. Amish traditionally farm. However, decreasing availability of affordable land and the poor financial return on small farms displace many young men into non-agricultural activities to support themselves and their families (Kraybill, 1989; 1994). Primary external sources of employment include factories, construction, and woodworking. At the same time, tourism among the larger Amish settlements is a lucrative enterprise. Brochures and magazines lure visitors by touting their quaint lifestyle as “a step back in time.” The Amish initially ignored the onslaught of tourists. Gradually, in recent years, some settlements where tourism is strong have learned to capitalize on their status (Hawley & Hamilton, 1996; Savells, 1998; Martineau & MacQueen, 1977). “Cottage industry” is a staple commerce in some Amish settlements, as women and female children work to provide quilts, crafts, and baked goods for the tourist trade. Unmarried young women often find work in shops and restaurants owned by “English” (the generic term for non-Amish persons), or in housecleaning services.

As noted, the Amish embrace a strong sense of community. From a mainstream American perspective, their beliefs are highly group-oriented. In all important areas of life and decision-making, they strive for consensus within the church. Church size is dictated by the capacity for Amish families to meet comfortably in one home for worship. Internal tensions and conflicts among the Amish are as common and the issues as familiar as those found in any community. Nevertheless, they are likely to present a united front to the world, including Healthcare providers. In order to maintain a strong, spiritually sound community the Amish also practice humility. While this serves the group well, it can hinder attempts to understand the individual. Few behaviors or traits will be mentioned directly that might be perceived as boasting or pride, or conversely, critical of others.

The Amish leave school after the eighth grade, believing further education unnecessary. Legal recognition of this right was hard won. A 1972 United States Supreme Court decision in their favor represented a rare departure from their pacifist response to government (Minogue, 1977; Nolt, 1992). Children attend either Amish or public schools, depending on the practice of their group. “Dutch” a German dialect, is spoken in the home. English was traditionally taught as a second language after entering school, but more and more Amish preschoolers are bilingual, using either Dutch or English.

The Amish limit formal education for several reasons. Excessive education is considered an effort to mimic omniscience, a state only God enjoys. A less clearly articulated, but equally powerful consideration is the reliance on tradition and folklore over critical thinking (Hosteller, 1955; 1993). From an ethnocentric 21st century European-American standpoint, the scientific method is paramount. From an ethnocentric 21st century Amish standpoint, 1st century Biblical teachings, and accumulated tradition and folklore serve as the guiding principles for life and problem solving.