Hospitals suing low-income patients, garnishing poor people’s wages, and asking for money from seriously ill patients have attracted a lot of bad publicity, and even some lawsuits.1,2

“There are so many ethical concerns with aggressive collection practices that it is difficult to narrow them down,” says Thomas D. Harter, PhD, director of the department of bioethics and humanities at Gundersen Health System in La Crosse, WI. Consider these two problematic issues:

Collection practices can fracture trust in the community. Many hospitals engaged in suing patients are nonprofit hospitals with financial assistance programs in place that presumably could have helped the very people they are suing. “There is also a concern about exploitation and the perpetuation of institutional racism,” Harter adds.

Many sued patients have little ability to navigate the complex financial web of healthcare. Some did not even realize they owed money. “Many sought services for mental health problems, such as depression,” Harter notes.

Filing lawsuits against vulnerable patients could exacerbate a hospital’s already-precarious financial situation. “Members of the community may question the integrity of the health system,” Harter cautions. “They may seek other providers to meet their healthcare needs.”

Aggressive collections clashes with the ethical principle of beneficence and the goals of medicine. “We know that socioeconomic factors impact health,” Harter says. If a health organization’s mission is to care for patients’ well-being, this sharply conflicts with lawsuits and garnishing wages. “These activities will negatively financially impact these patients,” Harter adds. “It will potentially exacerbate their physical or mental health problems.”

To ensure ethical care, Harter says that transparency and shared decision-making is needed across all aspects of patient care interactions. This includes billing and collections. “I have ethical problems with any form of payment collection from patients when it is evident there is a lack of clear communication about what is charged,” Harter explains. This is even the case in the ED, where patients are asked frequently for high-dollar copays. In this care setting, “people are likely at their most physically and mentally vulnerable,” Harter observes.

Some ED patients fear they will not be cared for if they do not pay upfront. “Ethicists should continue to think, research, and write about financial issues that occur at the intersection of business and medicine,” Harter offers. Additionally, Harter says ethicists must know what practices are occurring within their organizations and know the personnel who make decisions about billing and collection practices. “Reach out to those persons to get a seat at the table,” Harter suggests.


  1. Thomas WC. The nonprofit hospital that makes millions, owns a collection agency and relentlessly sues the poor. ProPublica, June 27, 2019. Available at: Accessed Sept. 10, 2019.
  2. Thomas WC. Memphis hospitals suspend debt collection suits, including suits against employees. National Public Radio, July 3, 2019. Available at: Accessed Sept. 10, 2019.