Authors, Case History and Commentary
Elliott J. Crigger, PhD
Senior Associate
Center for Ethics and Professionalism
Noel N. Deep, MD, MACP
Regional Medical Director
Aspirus Medical Group
Antigo, WI
Lois Snyder Sulmasy, JD
Director
Center for Ethics and Professionalism
Ethics case studies are developed by the ý Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues in the College's Ethics Manual or other College position statements. The current edition of the ACP Ethics Manual and additional case studies and College policy on ethics, professionalism, and human rights issues are available at /clinical-information/ethics-and-professionalism or by contacting the Center for Ethics and Professionalism at 215/351-2839.
CASE HISTORY
Like many health care institutions, in recent years Heartland Community Health (HCH) has experienced rising costs while at the same time its reimbursements have been decreasing. For Heartland, contributions from the local community help fund HCH’s hospital and associated outpatient clinics. HCH’s executive leadership now proposes a new initiative to have physicians directly solicit donations from their patients. The announcement is met with ethical and other concerns by Heartland’s physicians.
“How can they expect us to fundraise for them?” Richard Anderson, a hospitalist at HCH, asked over coffee the next morning. “Right?” chimed in Renata Masters, a general internal medicine physician. “I mean, I know Heartland’s important to this community, and our patients do appreciate us, but this just seems inappropriate. How can I ask someone under my care to donate money? That interferes with my relationship with the patient.”
“Yes. And what happens if we don’t—or can’t—raise money from our patients?” Dr. Anderson replied. “A lot of them aren’t that well off to begin with.”
“So . . . what should we do?” they ask each other.
CASE COMMENTARY
Implications for the Patient-Physician Relationship and Physician Professionalism
The patient-physician relationship “entails special obligations for the physician to serve the patient’s interest because of the specialized knowledge that physicians possess, the confidential nature of the relationship, the vulnerability brought on by illness, and the imbalance of expertise and power between patient and physician” [1] says the ACP Ethics Manual. The relationship makes physicians attractive as potential fundraisers in the eyes of administrators--but that very relationship and the trust it requires is why they should not be involved in soliciting charitable contributions from patients [2]. Involvement in “grateful patient fundraising” distorts the patient-physician relationship, can undermine care of the patient and trust, and puts the physician’s professional ethical commitments at risk.
Both the College and the American Medical Association maintain that physicians should not solicit contributions during the clinical encounter [2,3]. ACP guidance further provides that physicians should not be asked or expected to participate in "other fundraising activities that could affect the patient-physician relationship” [2]. This includes participating in a request from development or other staff to help identify potential donors, so-called “wealth screening.” Answering questions about a patient’s health status and whether the patient could be approached or is clinically too vulnerable is also ethically unacceptable. Such activities make physicians complicit in fundraising, even if they aren’t asked to approach patients directly.
The patient comes to the physician seeking help, and the physician in turn promises to use knowledge about the patient and professional expertise to provide that help. When physicians solicit or otherwise imply contributions should be made by individual patients, questions are raised about whose interests the physician is serving, the patient’s or the institution’s? Is the physician acting as healer and comforter or development officer [4]?
Imbalances inherent in the relationship between patient and physician, including of need and expertise, can give rise to a subtle form of coercion, especially if patients fear how declining—or being unable—to make a charitable contribution might affect their treatment [5]. That discomfort can arise even if the physician wasn’t involved in the solicitation. For example, one patient, who told her physician that she found a direct solicitation from the health care institution “creepy,” went on to say that “I did feel that the doctor-patient relationship—which was a continuing relationship because I have to come in and see you—made me feel that strong pull to donate the money. When they ask you for a donation, if you don’t give and you have an ongoing relationship with the institution, it does feel a little distorted” [6]. On the other hand, patients who accede to a request for a donation may harbor expectations of receiving preferential treatment in return for their gift [2,5].
Physician participation in grateful patient fundraising can also adversely affect the patient-physician relationship through its effect on the amount of time physicians have available to see patients and on how physicians allocate time and attention during encounters with patients [2,4]. Physicians have a clear fiduciary responsibility to give primacy to building a therapeutic relationship and addressing the patient’s clinical needs over administrative or institutional demands [1]. Institutional intrusions on the time that physicians have available to discharge their primary responsibility misvalue time for both the patient and the physician [7].
This is not to say that making a charitable contribution to an institution does not offer possible benefits to patients and families. It can provide a way to express altruism, as well as gratitude for the care received [4]. The problem would be the involvement of the physician. When a patient or family approaches their physician about making a contribution, they should be referred to the development office or administration [2].
Patient Confidentiality
Protecting patient privacy and the confidentiality of patient information is a fundamental professional responsibility and essential to the trust central to the patient-physician relationship [1]. Guidance from the College is clear that physicians should not reveal information about patients for fundraising purposes [2].
A breach of confidentiality can be disruptive even if physicians are not the source of information about patients. Under revisions to the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) made in 2013, hospitals can access patient names, addresses, email addresses, departments and dates of service, treating physician, insurance status, age, care provided at the institution, and certain health care outcomes [2]. Although the Privacy Rule requires that patients be notified about how their information may be used, it is not clear how many patients are aware that this includes fundraising [5].
When health care institutions ask—or expect—physicians to participate in grateful patient fundraising they not only exploit the trust patients have in their physicians and the intimacy of the patient-physician relationship to nonclinical ends. They also seek to leverage the physician’s relationships with patients, professional reputation and credibility for the institution’s financial benefit. The College’s position paper on physician employment and health care business practices holds that “ethics and professionalism must be emphasized and explicitly addressed in the implementation of business practices and employment relationships” [8]. Further ethics guidance from the College spells out the implications for grateful patient fundraising: “Physicians should not be asked or expected to participate in fundraising solicitation of their patients or patient families. Participation in fundraising should not be a condition of employment, nor should it be a performance metric or part of an incentive system for physicians” [2].
Implications for Community-Institution Relationships
Involving the organization’s physicians in identifying candidate donors or engaging in fundraising directly with patients may also have implications for the relationship between the institution and the community it serves. For one thing, the relationship between patients and health care institutions is not optional. As one physician has noted, “unlike relationships with other entities that receive philanthropic donations, patients’ relationships with health care institutions are nondiscretionary” [6].
For another, institutional solicitations that try to leverage patient altruism may ultimately make them feel obligated to donate. As one patient remarked “I remember thinking it was strange that they were asking me to donate money since I was a patient. I felt compelled because I thought it was something I was expected to do. ... But it did feel really strange to get something that basically felt to me like it was saying, ‘You come here, you’re a patient; are you grateful? If you’re grateful, then you should donate’” [6]. At the same time, solicitations may foreclose, or be experienced by recipients as foreclosing, opportunities for non-monetary expressions of gratitude, thereby excluding patients who don’t have the financial means to make contributions [9]. This can reinforce existing social disparities in the community and undermine trust that the institution will evenhandedly provide care to all its patients.
The Importance of Physician Leadership
The challenge posed by grateful patient fundraising is another issue that underscores the importance of physician leadership in health care institutions. Practicing clinicians are well positioned to recognize the negative implications of and ethical unacceptability of grateful patient fundraising for an institution’s patients and physicians. Medical staff members collectively have a responsibility to use their voice within the institution to inform nonclinical administrative leadership about the medical profession’s ethical responsibilities and forge common understandings and shared priorities that ensure institutional decisions reflect medical ethics and professional values, including on decisions about fundraising.
Conclusion
Heartland Community Health’s physicians already recognize the importance of philanthropy, done right, to the institution’s ability to continue to serve its patient community. ACP guidelines articulate why grateful patient fundraising is ethically problematic. Drs. Anderson and Masters should enlist their colleagues and together with them articulate the ways in which the proposed grateful patient initiative is inconsistent with their ethical commitments and risks compromising their relationships with their patients.
REFERENCES
1. Sulmasy LS, Bledsoe TA, for the ACP Ethics, Professionalism and Human Rights Committee. ý ethics manual, seventh edition. Ann Intern Med. 2019;170:S1-S32. doi:10.7326/M18-2160.
2. Snyder Sulmasy L, Callister B, Opole IO, Deep NN, for the ý Ethics, Professionalism and Human Rights Committee. Ethical guidance for physicians and health care institutions on grateful patient fundraising: a position paper from the ý. Ann Intern Med. 2023;176:1392–95.
3. American Medical Association. Code of Medical Ethics, .
4. Collins ME, Rum S, Wheeler J, et al. Ethical issues and recommendations in grateful patient fundraising and philanthropy. Acad Med. 2018;93:1631–37.
5. Tovino SA. Narrative themes in grateful patient fundraising. Narrative Inquiry in Bioethics 2022;12:33–39.
6. Burack, M. Targeting patients for donations: opening a door, or pushing them through it? In DuBois JM, Iltis AS, eds. Voices: Personal Stories from the Pages of Narrative Inquiry in Bioethics Baltimore: Johns Hopkins University Press; 2022:18–20.
7. Braddock CH, Snyder L. The doctor will see you shortly. The ethical significance of time for the patient-physician relationship. J Gen Intern Med. 2005;20:1057–62.
8. DeCamp M, Snyder Sulmasy L, for the ý Ethics, Professionalism and Human Rights Committee. Ethical and professionalism implications of physician employment and health care business practices: a policy paper from the ý. Ann Intern Med. 2021;174:844–51.
9. Sutton A, Rooker C. Grateful patient fundraising and the unconscious bias. In DuBois JM, Iltis AS, eds. Voices: Personal Stories from the Pages of Narrative Inquiry in Bioethics Baltimore: Johns Hopkins University Press; 2022:41–46.