Expanding the Definition of Gifts from Grateful Patients.

Abstract

Expanding the Definition of Gifts from Grateful Patients Reshma Jagsi “Ask her, Mama,” suggested the daughter of an elderly Latina woman I was seeing in a new patient consultation visit a couple of years after I finished residency training. We had just completed an hour-long discussion of the complex evidence regarding the relative risks and benefits of radiotherapy in her case of early-stage breast cancer, as well as her values and preferences; we had clearly bonded over the course of this brief yet intense experience of shared decision-making, as her daughter indicated by adding: “Mama, she likes to explain things—you should tell her we don’t understand what this means.” I was surprised by what came next: the patient showed me a document she had been given in the waiting room, asking her to initial if she authorized “contact for development purposes.” A well-intended effort to ensure that patients could control how their information was shared had just backfired. We had just finished a conversation about how daily radiation treatments were going to pose a substantial financial burden to her family. Her daughter would have to take time away from her work cleaning houses, and gas prices were at the time at an all-time high. It did not seem to be an optimal time to discuss what “development” meant. However, after over a decade of reflection and scholarly work that I have led on the subject, I now believe that I failed my patient because I lacked a sufficiently broad conception of development. The broader conception that I propose here is not yet commonly embraced, but I believe that it might actually help resolve some of the most troubling ethical tensions that physicians feel when asked to help with development, a subject that meeting this particular patient helped inspire me to study further over the intervening decade. Society as a whole stands to benefit when hospitals, especially academic medical centers, gain resources to pursue their clinical, educational, and research missions of service to the community. Donations from grateful patients have long been a means by which hospitals have funded major initiatives; for example, named wings and towers are commonplace at many institutions. In recent years, efforts to raise funds seem to have become more deliberate, and many physicians report a perception of increasing engagement with development professionals to support the philanthropic mission. Physicians can be particularly effective in facilitating philanthropic donations from grateful patients, but many express concerns about conflicts of obligations and worries about the impact of their involvement on the physician-patient relationship. Indeed, ethicists have articulated reservations about physician participation in encouraging donations from grateful patients out of several concerns. They are apprehensive of conflicts of interest, the inherent asymmetry of power in the physician-patient relationship that can lead to undue influence, concerns relating to privacy and confidentiality, and equity considerations relating to true—or perceived—differences in the services delivered to donors versus others. Coverage by the media and results of a public opinion survey suggest that such concerns resonate with the communities that medical centers serve. Nevertheless, both the 2004 statement from the AMA’s Council on Ethical Judicial Affairs on this subject and a more recent statement from a summit of experts expressly permit physicians to discuss philanthropy with their patients in certain circumstances. Given that a third of physicians report having been asked to solicit donations from patients and half of those have done so, further reflection seems sorely needed. Junior physicians and women appear particularly reluctant to engage in development. As a female physician who was junior myself at the time, I said, “Some patients who get their care here are able to give money to support the hospital so that we can make sure that all patients get the best [End Page 5] possible care and do the research that helps us tell patients what treatments they need. You don’t need to worry about that right now, and I promise that this has nothing to do with the care you will receive here.” At the time, I was focused on my patient’s lack of financial means. I did not think she...