EXECUTIVE SUMMARY

Some institutions encourage physicians to solicit donations from grateful patients. A small minority of physicians report being offered financial incentives for doing so. Some ethical concerns with this practice include the following:

  • Patients may believe a contribution is necessary to see the physician.
  • Contributors may receive preferential treatment
  • There is an apparent conflict of interest between the patient’s best interests and soliciting funds for the institution.

Grateful patient philanthropy (GPP) is “very widespread, involving many, if not most, major departments at academic medical centers,” says Joseph A. Carrese, MD, MPH, FACP, a professor of medicine at Johns Hopkins University and core faculty at the Johns Hopkins Berman Institute of Bioethics.

GPP can address some very important mission-based activities: research programs, clinical programs, and educational activities, adds Carrese.

But what if institutions offer financial incentives to doctors for getting gifts from their own patients? Carrese sees this practice as “qualitatively different in an important way” from involving physicians in the overall process of GPP.

“The worry is that money that directly goes into the pocket of the physician in question may unduly influence him or her, and affect his or her behavior and interactions with patients in ways that might not be ethically appropriate,” says Carrese.

In a 2015 survey of 405 physicians, a small minority (3%) described being offered a financial incentive to encourage them to solicit donations from their own patients.1 Carrese says the main concern is that the physician’s primary ethical and professional duty to patients will be undermined in favor of a secondary interest — in this case, personal financial gain.

“We should be taking steps to ‘shore up’ our ability to maintain the expected ethical and professional standards, and avoid actions that would undermine this objective,” he says.

Carrese says institutions need to establish “bright ethical lines” for unacceptable GPP practices — such as giving bonuses to physicians — and turn to existing guidelines and literature for guidance.

Physicians should avoid directly soliciting their own patients, especially at the time of a clinical encounter, the American Medical Association’s Council on Ethical and Judicial Affairs recommended in 2004.2

A 2013 study interviewed 20 department of medicine physicians at Johns Hopkins, all of who had relationships with multiple patients who made philanthropic contributions.3 The following ethical concerns were identified: the effect of the gift on the doctor-patient relationship; gift acquisition considered to be beyond the physician’s professional role; justice and fairness; and vulnerability of patients.

Some physicians reported being troubled by these ethical concerns. More than half (55%) expressed the view that there were no ethical issues involved with grateful patient philanthropy. “Several physicians commented about strategies they employed to guard against pitfalls,” says Carrese, one of the study’s authors. These include the following:

  • maintaining clarity that the primary relationship with the patient is the clinical relationship, not the philanthropic relationship,
  • not allowing the philanthropy to affect the care provided to the donor or to other patients who are not donors,
  • being especially cautious regarding potential donors who are vulnerable as a consequence of their illnesses, and
  • delegating cultivation and solicitation of financial gifts to development professionals, so as to not compromise the doctor-patient relationship.

Institutions need “strategies focusing on awareness, education, and efforts to promote high ethical and professional standards” for GPP, the researchers wrote. Carrese suggests institutions implement the following practices:

  • Include education about ethical considerations related to GPP as part of initiatives to encourage doctors to get involved in this activity.
  • Allow doctors to opt out of GPP activities if it makes them feel ethically or professionally uncomfortable.
  • Provide support to doctors when asking them to get involved in GPP activities, such as access to experienced development professionals.

Carrese is most comfortable with doctors being involved in GPP when the patient is the one who initiates the idea. “To the extent that a GPP activity is initiated by someone other than the patient — and the more aggressive those non-patient-initiated activities are — the greater the chance of an ethical transgression,” he says.

More institutions are looking at physicians not as healers for those in need, “but rather, as revenue generators,” according to Craig M. Klugman, PhD, a professor in the Department of Health Sciences at Chicago-based DePaul University.

“With a corporate model of healthcare, physicians are being pressured to increase the number of patients they see,” says Klugman. “When that is not enough, they are also asked to bring in grants and donations.”

Klugman says asking physicians to solicit donations from patients is unethical, regardless of whether the physician receives a financial incentive for doing so. This is because it creates a conflict of interest.

“As a patient, the idea that my physician would be looking at me as a checkbook rather than someone in need is destructive to the physician-patient relationship,” says Klugman.

The problem is that physicians are obligated to practice based on patients’ best interests, and at the same time are beholden to the institution to solicit funds. “The two goals are often at odds,” Klugman says. “It destroys trust, which is the foundation of all that we do.”

Soliciting donations strains the physician’s fiduciary relationship with their patients, says Klugman. “Physician as fundraiser brings a third party into the relationship: the institutional advancement office,” he says.

Having less power and being in a vulnerable position, patients rely on physicians to be trustworthy and honest. “This arrangement is challenged when the physician is less than trustworthy, the patient’s well-being isn’t the ultimate and sole goal of the relationship, and there is a third party involved,” says Klugman.

Financial bonuses give the appearance that the patient’s best interest and care is not the physician’s first priority, he says. Klugman sees this as similar to when physicians are rewarded by drug companies for being a frequent prescriber of a certain medication.

“Even if a conflict of interest can be managed — which is debatable — the appearance of the conflict can be damaging to the patient’s perception of the physician as his or her advocate,” says Klugman.

Studies show that most physicians believe that conflicts of interest with drug companies negatively affects their prescribing for patients.4

“Why would the results be any different just because the third party is inside the hospital rather than out?” asks Klugman. Patients may perceive that a donation to a doctor becomes necessary in order to be seen by that doctor.

“This is similar to concierge medicine, where an annual fee ensures medical care,” says Klugman. “Physician as fundraiser implies the same idea: To see your doctor, you need to donate.”

Whether true or not, says Klugman, “it is the appearance that damages the ability of physicians to do their jobs, and of patients to trust them in doing it.” Klugman worries that knowledge of a potential payoff can also have unconscious biases that affect professional behavior. “The patient who is a potential big donor may get a VIP suite, a better room, a better food menu, and more attention,” says Klugman.

These perks may not always be positive. Contributors may get more diagnostic tests than someone else would for similar symptoms, for instance. “More tests means more artifacts found, leading to more interventions and treatments for conditions that would probably never bother one in a lifetime,” says Klugman.

Social justice is key concern. Would patients of lower socioeconomic means get less time with the doctor or fewer tests? “Whether this would be seen in evidence or not, the appearance or belief is damaging enough,” says Klugman.

REFERENCES

  1. Walter JK, Griffith KA, Jagsi R. Oncologists’ experiences and attitudes about their role in philanthropy and soliciting donations from grateful patients. J Clin Oncol 2015; 33:3796-3801.
  2. American Medical Association (2004) Physician participation in soliciting contributions from patients. The Council on Ethical and Judicial Affairs. CEJA 7-A-04. Available at: http://bit.ly/1sn4wLk.
  3. Wright SM, Wolfe L, Stewart R, et al. Ethical concerns related to grateful patient philanthropy: the physician’s perspective. J Gen Intern Med. 2013; 28(5):645-651.
  4. Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: a systematic review. PLoS Med 2010; 19;7(10):e1000352.

SOURCES

  • Joseph A. Carrese, MD, MPH, FACP, Core Faculty, Johns Hopkins Berman Institute of Bioethics, Baltimore. Phone: (410) 550-2247. Fax: (410) 550-3403. Email: jcarrese@jhmi.edu.
  • Craig M. Klugman, PhD, Professor, Department of Health Sciences, DePaul University, Chicago, IL. Phone: (773) 325-4876. Fax: (773) 325-8430. Email: Cklugman@depaul.edu.