EXECUTIVE SUMMARY

There is more attention paid to ethical implications of grateful patient fundraising, particularly when physicians solicit directly from their patients. Recent guidance made three recommendations for physicians:

  • Bring up the topic of donation only if it is apparent the patient wants to contribute.
  • Avoid philanthropic discussions with patients who are clinically vulnerable.
  • Receive training in how to broach the topic appropriately.

With declining reimbursement and less research funding, donations from grateful patients are an increasing source of support for hospitals.

“Ensuring that hospitals can keep their doors open to provide care to the broader community is a worthy end,” says Reshma Jagsi, MD, DPhil, director of the University of Michigan’s Center for Bioethics and Social Sciences in Medicine.

Asking patients for donations raises multiple ethical concerns: conflicts of interest, patient vulnerability, undue influence, and confidentiality (among others). “Institutions must ensure that their fundraising activities respect all patients and do not disrupt the trust of the doctor-patient relationship,” Jagsi advises.

Perception of favoritism toward donors “is certainly a concern,” says Mark A. Rothstein, JD, director of the Institute for Bioethics, Health Policy, and Law at the University of Louisville School of Medicine. Patients in the hospital’s “Smith Wing” might presume members of the Smith family receive better care. More ethically problematic, according to Rothstein, is that at least some people will worry they, or their family members, will receive substandard care because they are not donors.

Hospitals and health systems raise billions of dollars from grateful patients each year. “Yet, there was absolutely no published information anywhere, in any medical journal,” about how to mitigate ethical concerns, notes Steven Rum, MPA, vice president for development and alumni relations fund for Johns Hopkins Medicine.

Lack of Ethics Guidance

Physicians conflicted about their own involvement in patient philanthropy had nowhere to turn for guidance. “I found the biggest obstacle to physician engagement was the ethical piece,” Rum says. “Institutions were all over the map as to what was acceptable and what wasn’t.”

In 2017, a group of 29 experts participated in a Summit on the Ethics of Grateful Patient Fundraising and developed a set of recently released recommendations.1 “Fundraising activities are important but must be structured in ways that provide reassurance that these donations promote the health of all served by the institution,” says Jagsi, one of the summit participants.

For physicians, the report authors recommended the following:

  • Bring up the topic of donation only if it is apparent the patient wants to contribute and when the physician-patient relationship is well-established while also considering timing and the patient’s health status;
  • Avoid philanthropic discussions with patients who are clinically vulnerable;
  • Receive training in how to broach the topic appropriately.

The group did not reach a consensus on whether it is ethically acceptable for physicians to ask for donations directly. “The goal of the summit was to get feedback from stakeholders across many perspectives,” explains Megan E. Collins, MD, MPH, lead author of the report. Patients, ethicists, clinicians, hospital leaders, and development professionals all gave input. “We did not endeavor to reach consensus on every point, but rather to map out the ethical issues raised by grateful patient fundraising,” says Collins, associate faculty at Johns Hopkins Berman Institute of Bioethics.

Some participants voiced concern about patients losing trust in their doctors. Others maintained that a physician-initiated discussion was appropriate in some cases. The guidelines do not specifically address what constitutes acceptable behavior on the part of physicians, or whether concierge services can be offered to patients who donate. “Each institution should create their own guideline for physicians and for the institution as a whole,” Rum says.

This should include education of clinicians and development officers on ethically responsible practices. “All discussions about grateful patient philanthropy should be grounded in beneficence, professionalism, and responsible stewardship,” Collins adds.

Physician-Patient Relationship

Contributions from grateful patients or family have been an important source of revenue for hospitals. “They have permitted construction of facilities, recruitment of personnel, funding of research, and providing uncompensated care,” Rothstein notes. However, Rothstein cautions that directly involving treating physicians in fundraising efforts is “ethically troublesome.”

“Patients should not be made to feel obligated to make contributions after a positive outcome, nor made to feel guilty if they do not make a contribution,” he says.

Direct physician involvement in grateful patient fundraising “has the potential to raise concerns regarding conflicted healthcare decision-making, healthcare resource allocation injustices, financial exploitation, breach of confidentiality, and breach of privacy,” says Stacey Tovino, JD, PhD, professor of law at the University of Nevada, Las Vegas William S. Boyd School of Law.

The AMA Code of Ethics encourages physicians to participate in fundraising — but not directly, especially during clinical encounters.2 “One thing that should be considered is the effect that expectations of fundraising have on the physicians,” Rothstein says. Some may leave the hospital staff if they consider soliciting contributions from patients to be unprofessional.

Certain institutions ask physicians to solicit donations; not all physicians are comfortable doing so. Of 405 oncologists, one-third had been asked to directly solicit a donation from their patients, according to one survey.3 Half of this group declined to do so. While 37% felt comfortable talking to their patients about donation, 74% agreed it could interfere with the physician-patient relationship. Fifty-two percent said they thought a conflict of interest existed.

Notably, two-thirds of the oncologists did not believe that patients who donated could be offered even certain convenience-related services as thanks. “More research is needed to evaluate patient and public perceptions in this context,” says Jagsi, the study’s senior author. Soliciting donations from patients is only expected to increase. “Going forward, it will be critical to continue thoughtful discussions about how grateful patient fundraising can proceed in an ethically responsible manner,” Collins says.

REFERENCES

  1. Collins ME, Rum S, Wheeler J, et al. Ethical issues and recommendations in grateful patient fundraising and philanthropy. Association for Healthcare Philanthropy, Jan. 28, 2019. Available at: http://bit.ly/2S9hs5H. Accessed July 10, 2019.
  2. American Medical Association. Code of Medical Ethics Opinion 2.3.5. Available at: http://bit.ly/32lX1Ht. Accessed July 10, 2019.
  3. 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.