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Instituting and Teaching Ethical Standards for Grateful Patient Fundraising.

TO THE EDITOR: Walter et al highlight an important dimension of a societal challenge: how to finance medical care, education, and research. The need for funding sources is dire. Since it peaked in 2004, spending by the National Institutes of Health on biomedical research has dropped roughly 20%. Payers exert tightened control over clinical reimbursements. Medical institutions struggle to fund programs, such as community services, that generate revenues insufficient to cover expenses. Philanthropy is an increasingly important source of funds for medicine. From 2012 to 2013, philanthropic support for academic medical centers (AMCs) increased more than 16%, reaching a 15-year high. The societal relevance of giving to AMCs is noteworthy; representing 5% of hospitals, they provide 25% of care and 40% of all indigent care in the United States. In 2014, charitable giving to US healthcare organizations totaled $9.6 billion. For AMCs, philanthropy offers a lifeline to vital support. Major gifts support centers, research programs, professorships, and fellowships, thus underwriting medical research, education, and patient care. In our experience, philanthropy also benefits patients. It offers them a way to give back, from which many gain a valid sense of meaning, contribution, and fulfillment. Large-scale philanthropic gifts often not only benefit the physician and institution but also serve higher purposes such as advancing medical knowledge and increasing the well-being of patient populations. Walter et al report physicians’ discomfort with fundraising. A previous study at Johns Hopkins involved the use of qualitative interviews to gain an in-depth understanding of physicians’ attitudes toward engaging in grateful patient fundraising. Participating physicians were well aware of the ethical concerns related to this activity. Themes of justice and fairness and of patient vulnerability emerged as areas of concern when philanthropy is accepted from patients. Ethical concerns about grateful patient fundraising are certainly legitimate. Patients’ vulnerability and asymmetry in the physician-patient relationship create potential for coercion perceived or actual. Conversations could occur at an inappropriate time or place, and if so, they could negatively affect the physicianpatient relationship. Knowledge of patients’ capacities to make large donations might conceivably drive disparities in treatment, that is, delivery of higher-quality services to individuals with high giving potential. The mandate in medicine to do no harm should also be applied to development. Broadly speaking, this would mean (1) protecting patients, given their vulnerable position, (2) demonstrating respect for both patients and physicians, (3) safeguarding the physician-patient relationship, and (4) stewarding patients’ funds to achieve results that reflect their intentions. As yet, upholding these principles in the practice of medical development is left to individuals and institutions. We suggest, first, that those in medical development articulate clear, explicit, professional standards for grateful patient fundraising. Standards should define the roles of the physician and the development professional in grateful patient fundraising, with emphasis that physician involvement is voluntary; ethical considerations in and boundaries around physicians’ involvement in development; and key principles such as respect, sensitivity, and open communication. These standards might alleviate the physician discomfort Walter et al noted. Second, we suggest the development of curricula to teach the new, consensus-based, professional standards to development professionals and to physicians. A consistent, industrywide approach should promulgate a common understanding among physicians of ethical considerations in, sound practices for, and the value of inviting patients to give. Third, medical development needs credible research to determine the effectiveness of its practices. We provided proof of concept that rigorous research methods can be used to evaluate interventions used by development professionals. We subsequently established the Johns Hopkins Medicine Philanthropy Institute in 2014 to improve quality, professionalism, and performance in medical development. A core purpose of the institute is to begin building an evidence base to inform practices in medical development, as is standard in medicine. Interest in this concept among development professionals has been resoundingly positive. With professional standards to guide practice and with practices based on research-derived evidence, the field of medical development will be able to satisfy physicians that philanthropy and medicine can go hand in hand to the benefit of medical institutions, their faculty, and, yes, their patients.