Grateful patient philanthropy: is what's good for the goose good for the gander?

In this month’s issue, Wright, et al. examine the ethical issues involved in the solicitation of grateful patient philanthropy.1 The physicians surveyed in their study identified a number of potential concerns with patient philanthropy, including the possibility of exploiting vulnerable patients and providing differential care based on patients’ level of giving. While the article does a good job of identifying the issues, we believe these issues should be considered in greater depth. Before we go into this discussion, however, we need a common understanding of what a gift is. According to Merriam-Webster, it is “something voluntarily transferred by one person to another without compensation.”2 In order to understand the ethics of gifts, it is important to understand why they are given in the first place. Richard Titmuss describes his extensive study of gifts in The Gift Relationship: From Human Blood To Social Policy.3 In this book, he looked specifically at blood donation but used this information to extrapolate towards gift giving as a whole. He did extensive surveys of the personal motivations and found that for a large majority of people, the act of gift giving stemmed from altruistic reasons, such as desire to help or express gratitude.4 In fact, the root of the word philanthropy translates to “love of humanity.” While there are definitely some individual benefits to giving, most individuals choose to give as a means of improving some aspect of society. Despite the potential upside of gifts in the form of philanthropy by grateful patients, patient vulnerability and the possibility of exploitation are perhaps the biggest ethical problems with this type of gift. Alan Wertheimer states, “an exploitative transaction is one in which A takes unfair advantage of B.”5 But is this the case in philanthropy? Philanthropy assumes that one party gives freely to another so that both can achieve a mutually beneficial goal. It assumes fairness and an equal amount of power. The donor has money, and the hospital can put it to good use.6 Certainly, there are some instances in which this is not the case. Someone who is demented or mentally ill cannot enter into a philanthropic relationship. In fact, some medical schools have deemed psychiatry departments as inappropriate for fundraising for this very reason.6 But for someone who is competent, philanthropy can be beneficial. It allows them to show gratitude for care they have received, it allows the patient to use his or her resources to help the physician combat illness, and it allows the patient to help others in a similar situation to his own. This is a consensual relationship, not unfair and the opposite of exploitation. It should be made clear that the decision to donate will not affect a patient’s care. Requests should be made outside of the clinical setting. But if these conditions are met, then philanthropy can be empowering to a patient and should be an available option. One of the other major concerns brought up by the physicians surveyed in the article was the worry that they were treating patients who had donated differently from their other patients and that they were introducing inequality into their care. Indeed, a central ethical issue in medical philanthropy is the concern that donors will get preferential treatment. Presumably, this is an expectation of some donors, and in many hospital settings, this is indeed the case. Some hospitals have developed special pavilions or medical concierge programs for donors. A survey of Connecticut emergency departments showed that more than half offered speedier service to “influential people,” including high dollar donors.7 Is this necessarily unethical, however? Most of the services offered to donors are amenities, and not crucial to the patient’s outcome. Examples of these include nicer rooms or a concierge who will attend a patient’s needs. As long as everyone receives the same basic level of medical care, there should be no ethical issues with these extra amenities. In fact, it has been argued that special treatment of “VIP’s” is beneficial to all patients.8 Diekema argued that preferential treatment for influential patients usually benefits the hospital, whether that be in terms of increased donations, political favor or good public relations. This in turn allows the hospital to improve care for all patients.8 Giving extra perks to these patients increases the utility for everyone. As long as the patient realizes that his actual medical care will stay the same, there should be little ethical problem with this. It is interesting that a majority of respondents in Wright’s study were able to identify potential ethical problems with soliciting money from patients, but did not have a problem themselves asking for gifts, similar to the belief by many physicians that gifts and inducements from pharmaceutical companies altered the prescribing behaviors of other physicians, but not themselves.9 When people realize there is a potential for unethical behavior, but don’t believe it applies to them personally, there may be a need for increased training, scrutiny, and regulation. One solution is to teach the guidelines that already exist for the appropriate time, place and manner in which to solicit gifts; they do a good job of outlining how physicians can avoid these potentially sticky issues. For example, the American Medical Association’s (AMA) Council on Ethical and Judicial Affairs (CEJA), recommends that physicians should avoid soliciting donations from their own patients, and if they do, the “ask” should be clearly separated from the clinical encounter. The AMA also indicates that the health care facility should make it clear to the patient that their welfare is the primary concern. Ideally, according to the AMA, solicitation should come from other doctors (i.e. those not directly involved in the patient’s care) or fundraising personnel.10 These limitations can decrease the potential for a conflict of interest and should be common practice. The guidelines prevent solicitations when the patient is most vulnerable and should minimize effects on the doctor–patient relationship. While care must be taken to avoid pressuring the patient or taking advantage of a patient’s illness, not all of the issues raised in the article are necessarily unethical or problematic. There should be a continuing discussion of these ethical issues as philanthropy becomes a more important source of funding for medical institutions.