Ethical Concerns Related to Grateful Patient Philanthropy: The Physician’s Perspective

ABSTRACT

BACKGROUND

Philanthropic contributions to academic medical centers from grateful patients support research, patient care, education, and capital projects. The goal of this study was to identify the ethical concerns associated with philanthropic gifts from grateful patients.

METHODS

A qualitative study design was selected. Investigators conducted in-depth semi-structured interviews with 20 Department of Medicine physicians at Johns Hopkins who were identified by Development Office staff as experienced and successful in this realm—those having relationships with multiple patients who have made philanthropic contributions. Interview transcripts were independently coded by two investigators. Content analysis identified several themes related to ethical concerns.

RESULTS

Eighteen informants (90 %) were Associate Professors or Professors; two (10 %) were females. Four thematic domains emerged related to ethical concerns associated with philanthropy from grateful patients: (i) impact of gift on the doctor–patient relationship; (ii) gift acquisition considered beyond the physician’s professional role; (iii) justice and fairness; and (iv) vulnerability of patients. Despite acknowledging at least one of the aforementioned concerns, eleven physician informants (55 %) expressed the view that there were no ethical issues involved with grateful patient philanthropy.

CONCLUSIONS

In this paper, we report that physicians involved in grateful patient philanthropy are aware of, and in some cases troubled by, the ethical concerns related to this activity. Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy.

INTRODUCTION

Philanthropy is a vital source of financial support for academic medical centers, and grateful patients may be the single most important source for substantive philanthropic gifts.¹ Through meaningful personal experiences, patients often develop deep connections with medical centers and resolve to support them.² A strong physician–patient relationship is believed to be an essential element in facilitating philanthropic gifts from grateful patients to an academic medical institution.^2,3 Involvement of physician faculty members in grateful patient philanthropy is a complex undertaking, particularly with regard to ethical concerns and considerations associated with this activity.^4,5

Personal gifts from patients to physicians, which can range from garden vegetables to alcohol to money, are complicated and potentially problematic.^6–11Any offering from patients has the potential to influence physician behavior, perhaps in the form of augmented responsiveness and attentiveness towards gift-giving patients. Grateful patient philanthropy, described as donations that are made in recognition of excellent care received, are often used at academic health centers to support research, education, and clinical initiatives. The term implies that gratitude is the only reason for the gift; however, other motives may also be responsible for the donation. In all cases of patient gift giving, the physician must be prepared to turn down the contribution if the situation violates ethical principles.^7–10 For physicians, most of whom have no training in and little experience discussing philanthropy with patients, such discussions can be awkward and can threaten the fabric of a purely professional relationship.

Physicians who are involved with philanthropic gifting from grateful patients are in an arguably unique position with respect to knowing about and experiencing the ethical concerns associated with this phenomenon. In order to identify and better understand these issues, we conducted a qualitative interview study to explore the perspectives and insights of internal medicine physicians working in an academic medical center who had experience with such gifts.

METHODS

Study Design

This was a qualitative study that involved in-depth interviews with study subjects. This approach was selected to allow for the emergence of findings that researchers may not have anticipated.¹² One-on-one interviews permit exploration to a greater extent than may be possible with closed-ended scales, surveys, or even focus groups.¹²

Study Sampling

Development professionals were asked to identify physicians judged to be practiced and successful with grateful patient philanthropy within the Department of Medicine at the Johns Hopkins University School of Medicine. The development professional team identified 21 physicians who had been the stimulus for multiple episodes of grateful patient philanthropy during the preceding few years. This purposive sampling strategy was pursued because we were particularly interested in the perspectives of the physicians who could draw on experiences and relationships with multiple grateful patient donors.

An Institutional Review Board at the Johns Hopkins University School of Medicine approved the study, and informed consent was obtained from all subjects.

Institutional Context

At Hopkins, a single gift from our founding benefactor, Johns Hopkins, gave birth to the institution—thus philanthropy has been part of the institution’s culture from inception. That said, Johns Hopkins Medicine does not have an explicit ‘Grateful Patient Program’. Like many other academic medical centers, development professionals at Hopkins work with institutional leaders and faculty members on philanthropic initiatives to support institutional priorities.

Data Collection

From March 1 to May 31, 2009, two investigators conducted audio-taped, semi-structured one-on-one interviews lasting about 30 min with each participant. Most interviews were conducted in person, but a few were conducted over the telephone. The interviewer began by asking subjects closed-ended questions about demographic parameters, and then switched to a broad open-ended question about grateful patient philanthropy. The one question that served as a prompt to generate comments yielding material for this manuscript was: “What are your thoughts about ethical considerations that may be associated with grateful patient philanthropy?” The interviewers, trained in qualitative interviewing techniques, used reflective probes to encourage respondents to clarify and expand on their statements. All interviews were transcribed verbatim.

Data Analysis

We analyzed transcripts using an “editing analysis style,” a qualitative analysis technique in which researchers search for “meaningful units or segments of text that both stand on their own and relate to the purpose of the study”.¹² Two investigators independently analyzed the first four transcripts, generating codes to represent the informants’ statements, and created a preliminary coding template. This coding template, which was reviewed by and discussed among all investigators, was then applied to all subsequent transcripts, and revised as coding proceded. In cases of discrepant coding, two investigators successfully reached consensus after reviewing and discussing each other’s coding. Atlas.ti 5.0 software (Atlas.ti GmbH, Berlin, Germany, 2005) was used for data management and to facilitate analysis.

Following accepted qualitative research methodology, sampling was discontinued after 20 interviews, when it was determined that recent interviews were yielding confirmatory rather than novel themes; this is referred to as “thematic saturation”.¹² Our sample size is consistent with other published qualitative studies.^13–17

The authors reviewed all excerpts related to each theme and agreed upon the representative quotes that would be presented in the Results section. In order to protect the privacy of our informants, descriptive details about the quoted informants are not provided.

RESULTS

Informant Sampling and Demographics

One physician who was invited to take part in the study refused to participate. The majority of the participating physicians (90 %) were Associate Professors or Professors, two (10 %) were women, and the informants represented a diverse range of specialties within the Department of Medicine (Table 1).

Table 1.

Characteristics of the Physician Informants with Philanthropy Experience*

Characteristic	n (%) or mean (range)
Women	2 (10)
Number of years in practice	25.8 (12–47)
Number of years on faculty	22.6 (8–45)
Professor	13 (65)
Associate Professor	5 (25)
Assistant Professor	2 (10)
Specialty
Geriatrics	4 (22)
Internal medicine	3 (17)
Pulmonary	3 (17)
Nephrology	2 (11)
Hematology	1 (5)
Infectious disease	1 (5)
Rheumatology	1 (5)
Gastroenterology	1 (5)
Cardiology	1 (5)
Endocrinology	1 (5)
Estimated number of donations acquired by a physician over career	31.8 (2–100)
Comfort level with making patients aware of financial needs
Tremendously comfortable	10 (56)
A lot	6 (33)
Some	1 (5)
A little	1 (5)
Not at all comfortable	0 (0)

*2/20 informant physicians did not complete a response to a few questions

In characterizing their current clinical efforts, the average percent time spent on clinical care was 31 %. The mean number of years in practice was 26. Physicians were asked to rate their comfort level with engaging patients in discussions about philanthropy on a 5-point Likert scale from “not at all comfortable” (1) to “tremendously comfortable” (5). The percentage of those physicians that marked either “tremendously comfortable” or “a lot”, the two highest categories, was 80 %.

Results of Qualitative Analysis

Physician informants’ comments and stories were categorized into thematic domains that describe ethical issues faced by physicians when involved in grateful patient philanthropy. Four themes emerged from the analysis and they are described below. The themes are also presented in Table 2, along with the number of times each was mentioned as well as the percent of informants referring to the theme.

Table 2.

Total Number of Times and Number of the Twenty Informants Mentioning the Major Themes Related to the Ethical Concerns Involved with Facilitating Grateful Patient Philanthropy

Theme	Total number of times theme mentioned in all interviews	Number of respondents referring to theme, n (%)
Gift changes relationship	68	18 (90)
Beyond the physician’s professional role	36	15 (75)
Justice and fairness	25	12 (60)
Patients vulnerable	6	5 (25)
No ethical issues*	19	11(55)

Respondents were not queried specifically about these themes, and these counts represent spontaneous and unsolicited responses in each subcategory

*Even though all 20 informants were able to describe ethical concerns associated with grateful patient philanthropy, 11 physicians explained that there were no ethical issues when specifically asked

Impact of Gift on the Doctor–Patient Relationship

The most frequently cited ethical concern, referred to by 18 respondents, was that many physicians felt as if their relationship with the patient had been transformed as a result of the philanthropic gift. Physician subjects expressed a concern that the purity of the physician–patient bond might be tainted and that patient expectations could change. Physicians acknowledged that facilitating and stewarding grateful patient philanthropy could alter the nature of the relationship from one entirely focused on patient well-being to one that also addressed philanthropy. The latter sometimes caused tension related to the appropriate timing of discussing health-related matters versus philanthropic issues.

Select examples of what our physician subjects thought about the impact of grateful patient gifts on the doctor–patient relationship are presented below.

A Professor who spends 20 % of his time in patient care stated:

I think donors do feel that they have more license to call you at home or on weekends.

An Assistant Professor discussed how she must accept that fact that multiple types of relationships with the same patient are necessary:

…we [also] have a philanthropic relationship, so that I feel I can separate the two, and recognize the two may begin to pose a conflict.

A Professor who spends 80 % of his time in patient care stated:

I think it affects your relationship. I think that some of them become socially friendly. Many of them have met my wife.

A male Professor describes how it is important to keep patient care as the primary focus when juggling several different types of doctor–patient relationships:

When one is perhaps disappointed with that dimension [philanthropic] of your relationship with the patient, to recognize that that’s not your primary relationship with the patient; you are their doctor and just to bend over backwards, not to compromise the care that you’re providing that person in any way.

Beyond the Physician’s Professional Role

The second most frequently cited concern was the notion that physicians often feel unprepared and even somewhat uncomfortable in discussing financial support, even when the subject is broached by the patient. Some explained that this role falls beyond the purview of the physician’s professional role; some attempted to substantiate that idea and described that doctors are not trained in this area. An issue raised by many subjects is whether it is ever appropriate to initiate the conversation about gift giving with patients.

A physician reflected upon his role and said the following:

… I feel very uncomfortable, because I’m a physician, and I’m not a solicitor or something, … I’m becoming aware of their history, that they donated, or other financial means, I feel actually it is not ethical of me to try to solicit them…

A Professor described the conflicts involved with initiating a discussion about philanthropy with a patient:

…I think that the initial questioning of the money in my view should come from the patient, not from the treating physician directly. I don’t have a problem with somebody else asking the question, so if they want to donate, I think that’s fine. If you put yourself directly in that position, it does create, in my view, a potentially ethical issue with regard to caring for the patient.

Another Professor with numerous leadership roles in the institution explained:

… physicians aren’t taught how to ask for money, so I think that can be awkward. And it takes a while before you recognize that all of these people are potential investors.

This physician discussed his approach to staying away from such discussions:

… if a patient mentioned something I’ll respond point-blank: ‘this is something I’m not real comfortable with…I’m very flattered and this is a very important part of our research effort, but it is uncomfortable for me to discuss this with you. We have wonderful development officers and if you like, I will have them contact you.’

Justice and Fairness

Physicians may feel pressure to treat philanthropic patients differently than other patients as a way of demonstrating appreciation for the grateful patient’s generosity. Physicians reported feeling uncomfortable if they thought they were responding differently to grateful patients than any of their other patients. Physicians admitted to returning calls quicker and allotting extra time and availability to philanthropic patients. Many doctors admitted that they were uncomfortable providing different levels of access to patient donors, but they also felt compelled to show their appreciation.

A Professor explained that he offers different care for generous patients:

Some of these people…I will see them outside clinic, I will go over and see them in a private setting where I can spend a little more time with them. From the egalitarian point of view, I don’t like that too much, but from a practical point of view, I recognize that these are people that give nicely and are used to a different level of attention, so I give it to them.

An Assistant Professor described that her responsiveness to all patients is not the same:

For example, I might be late to a meeting to call back the donor, where I might call a non-donor back after my meeting, but yet they both have the same patient need, and I would say neither had an urgent 911 issue.

A Professor who has been on the faculty for more than 25 years explained:

I might want more time to steward the past gift or continue to cultivate the future gift… I’m more likely to arrange a special appointment time for those patients so we’re not rushed. Not so much so the medical part is likely to be much different; so that this other aspect of our relationship doesn’t chew up clinical time.

This faculty member commented about doing more for individuals who have supported her:

… I’m asking them to go above and beyond their relationship with me as a patient so I feel like I have to go above and beyond [as the doctor].

One physician rationalized that academic medical centers cannot escape from societal norms:

… everywhere in American life, people who support the institution of a program have special access. That is just part of our society. It has been that way forever.

Yet, some of the physicians we interviewed were uncomfortable with the idea that they would give certain patients a different level of attention. An Associate Professor explained:

It just gives me an uncomfortable feeling, or maybe I double-check, maybe, I don’t know, maybe there is some unconsciousness there too, that I’m more aware of making the phone calls to them. I’m more aware of when they come to the clinic, and I may be trying harder to be a better doctor, do my job better. I don’t like that part; I feel that I’m cheating on my other patients.

Vulnerable Patients

Several respondents expressed concern about accepting philanthropic gifts from sick patients, because, although the patients wanted to give, by virtue of their illness they were in a vulnerable state. Physician subjects raised concerns about whether philanthropic gifts were truly voluntary and without undue influence when patients were unwell or near death.

An Assistant Professor who cares for elderly patients expressed concern about accepting donations from a patient afflicted with a condition affecting cognitive ability:

…Dementia is such a devastating disease, and that’s why I have a big ethical concern about that, I feel there is vulnerability.

This physician specifically alluded to unease when the timing of proposed philanthropy coincided with illness:

There was a major donor that invited me to his home; he wanted to give out some of his money. He was very sick and I didn’t want to do that… I told him that he was too sick and I wanted him to get better first, and he died. I’ve had a couple of situations where people have told me specifically they wanted to give and I’ve said ‘wait until you get better—you might just be saying this because you’re emotional.’…There have been at least two major donations I’ve missed this way.

No Ethical Issues

In addition to and in spite of the findings reported above, 11 informants (55 %) concluded that ultimately, there were no ethical issues involved with the facilitation of grateful patient philanthropy. Each of these 11 informants alluded to at least one of the ethical concerns described above. Some explained that acquiring philanthropy is not unethical because the decision to give is ultimately up to the patient. It was understood that facilitating donations should not be attempted if there is any concern of discomfort or awkwardness among the physician.

A Professor explained in the following two excerpts how he does not solicit his patients for philanthropy; rather he waits for them to come to him:

To me, there is never an issue of ethics here, it’s always about patients’ wishes and interests, I’m not knocking on doors saying, can you help us, unless I’m doing it to my colleagues or for some other cause. But I have learned that people who raise these issues and want to participate really mean it, and they feel very good about it, provided they are properly stewarded.

So to me, there is no ethics involved. If you somehow believe there is an ethical issue then you don’t belong doing it; you don’t need to be doing the asking…

An Associate Professor who spends 35 % of her time caring for patients elucidated why, in her view, there are no ethics involved with facilitating philanthropy from patients:

I can cite many examples where I’ve spent a great deal of time with patients who have no capacity to give; in fact, they don’t even pay our bills, so, you know, I think the time I spend with potential donors helps the care of those who can’t pay. So I have no problems with the ethics.

DISCUSSION

Grateful patient philanthropy is an essential part of keeping academic medical centers (AMC) moving forward. This generosity is undoubtedly one of the most vital sources of financial support for academic medical centers because it is often unrestricted, and can allow for innovation in areas of high institutional need.¹ This qualitative in-depth interview study of Department of Medicine physicians at Johns Hopkins with a great deal of experience in grateful patient philanthropy identified several domains of ethical issues that may arise when patients become donors. To the extent that AMCs want to succeed in their development plans, institutions may wish to consider the issues described by our physician informants to ensure that front line physicians are supported in these efforts in ways that allow them to maintain their commitments to high ethical and professional standards.

The ethical concern most frequently mentioned by our participants was the possible effect of grateful patient philanthropy on the doctor–patient relationship. Participants worried that the primary focus of the relationship, patient well-being, might be undermined, and that physician and patient expectations of each other might change. Participants also worried about pursuing philanthropic gifts given concerns about patient vulnerability, and they were troubled by the possibility of behaving toward grateful patient donors in a manner that was different from how they treated non-donor patients.

It is known that different access is sometimes afforded to patients with means or stature, particularly those who have contributed philanthropically. When this occurs, the principle of justice may be compromised, since these approaches may be unfair to those receiving care in the ‘usual’ clinical setting or practice model.¹⁸ Proponents explain that ‘VIP programs’ do not affect the medical care that is provided, but only that extra “perks” are included as part of the process of care delivery.² Such “perks” can include catering, nicer décor, additional support staff, and different scheduling templates.² Establishing VIP or concierge clinical programs for patients who have already donated and those believed to be likely to do so has been promoted by some as a successful strategy for cultivating and stewarding future philanthropic gifts.² In our study, informants explained how they might behave differently with patient donors and one physician described feeling as if he may be “cheating on other patients”. This physician’s awareness and thoughtful reflection on the issue represent critical steps in promoting professionalism and professional growth.^19–21

Some might argue that the best way to address ethical concerns is to eliminate the phenomenon that gives rise to such situations. For example, strict prohibition of grateful patient philanthropy would eradicate the ethical concerns identified in this paper. However, it would also eliminate a valuable funding source in the current challenging economic environment, funding that can be an important stimulus for quality improvement and innovation. Further, it is unlikely that this source of funding will be abandoned; instead, evidence suggests that academic centers and affiliated faculty are increasingly pursuing grateful patient philanthropy.^22,23 In light of this, strategies focusing on awareness, education, and efforts to promote high ethical and professional standards are arguably more practical and relevant. It is beyond the scope of this manuscript, which presents the results of our empirical study, to comprehensively address in detail all ethical concerns and related considerations involved when physicians participate in grateful patient philanthropy. Rather, we direct readers seeking a thorough account of these issues and specific guidance to three thoughtful documents published by the American Medical Association (AMA).^24–26

While discussing potential ethical hazards that can occur in the context of grateful patient philanthropy, several physician informants commented about strategies they employed to guard against pitfalls. These include: maintaining clarity that the primary relationship with the patient is the clinical relationship, not the philanthropic relationship; not allowing the philanthropy to effect 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 illness; and delegating cultivation and solicitation of financial gifts to development professionals, so as to not compromise the doctor–patient relationship. Insightfully, many of these suggestions are echoed in a recommendation found in the Report of the AMA’s Council on Ethical and Judicial Affairs on this topic²⁶: “Physicians should avoid directly soliciting their own patients, especially at the time of a clinical encounter. They should reinforce the trust that is the foundation of the patient–physician relationship by being clear that the patient’s welfare is the primary priority and that patients need not contribute in order to continue receiving the same quality of care.”

All 20 informants acknowledged ethical challenges may arise when patients become donors supporting the programs and initiatives that their physician is passionately leading. Even after explaining what these might be and how they might play out, a majority of the informants suggested that there are no ethical issues associated with grateful patient philanthropy. Such discrepant views may be explained by one of the following rationalizations, which can be explored in future studies. It is possible that some informants believe that the benefits of this activity, broadly defined, offset the potential harms, thereby justifying (in their opinion) what is done. It is also possible that some physician informants may have the illusion of unique invulnerability,^27,28 wherein they believe that while others are susceptible to interacting differently with patients who have become grateful donors, they themselves are not. Accordingly, such physicians may agree that there are ethical concerns with respect to other physicians involved in this activity, but there are no concerns with regard to their own participation. It is hoped that views of the experienced academicians presented in this study will encourage other physicians to consider their own positions on this subject, contemplate their own susceptibilities, and stimulate them to take steps to ensure that their behaviors are professional and ethical.

Several limitations of this study should be considered. First, this study relied exclusively on self-report. However, this is considered to be the most direct approach for understanding attitudes and beliefs. Second, this qualitative study is limited to a small number of predominantly male physicians, with philanthropy experience, from the same Department at a single institution. As such, our findings may not apply to other departments or institutions. This purposive, intentional sampling strategy allowed us to characterize the viewpoints of a cohort of academic physicians who are active in grateful patient fundraising; we make no claim that the full range of issues on this topic are presented in our paper. If our objectives or hypotheses were different, we might have sought out physicians who are less comfortable and more apprehensive about this source of support. One might have expected our informants to dismiss or minimize the presence of ethical issues with grateful patient philanthropy, but they did not. These physicians with considerable experience in securing donations described a variety and breadth of ethical issues they have considered and experienced in their interactions with grateful patients. Third, one physician declined participation and it is possible that his perspectives may have been different. Fourth, this not a conceptual paper intending to present and analyze every possible ethical concern related to the topic. In this empirical study, our informants identified several major ethical issues, but other issues that could arise (such as concerns about the source of the donor’s wealth) were not described. Finally, one of the themes was described by less than fifty percent of the informants. However, it is important to note that the responses emerging from the open-ended questions were spontaneous. Qualitative analysis does not really allow us to know whether one theme is more important than another merely because it was mentioned more frequently. If all subjects were specifically asked about each theme, the number of comments related to each would certainly be much higher.

CONCLUSION

Grateful patient philanthropy has become one form of fuel for innovation at academic medical centers, yet there may be ethical issues to consider when such generosity is directed to physicians and institutions. The physicians in this study were experienced in this realm and although they acknowledged multiple potential ethical concerns can arise when patients become donors, most were comfortable with their own personal approach.

Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts, so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy.