Targeting Patients for Donations: Opening a Door, or Pushing Them through It?

I was in the clinic hallway with my patient en route from the waiting room to the exam room for a routine follow-up appointment. I said, “Thank you again, so much, for your donation to the department in my honor.”

“Sure, no problem,” my patient replied. “Although I have to say, when I first opened the letter, it was kinda creepy. But I’m so grateful for your excellent care, that I felt like I had to send something.”

I stopped in my tracks. “Wait—the hospital sent you something asking for a donation?”

I had been practicing at an academic medical center as a neurologist specializing in movement disorders for six years. I was at the awkward Assistant Professor level, feeling confident in the excellence of my clinical skill but still very junior in the power hierarchy.

I chose movement disorders as a subspecialty in part because of the long-term relationships we develop with our patients. Conditions like Parkinson’s disease and dystonia are managed, not cured. During training, I looked forward to having the sacred responsibility of following “my” patients over the long course of their disease trajectory. We typically see people every three months for many years. It is a specialty that allows us, in the words of Hippocrates, “to know what sort of person has a disease,” not simply “to know what sort of disease a person has.”

Skillful use of available treatments requires attention to nuance: not only the subtle details of how the brain is controlling movement during everyday activities like writing, reaching, and walking, but also aspects of behavior arising from circuits in the brain governing mood, decision-making, and interpersonal relationships. Trust is essential for cultivating the close doctor-patient relationships that I rely on to identify how these diseases and treatments impact domains of brain function that are intimately linked to personhood.

After the appointment, I sent an email to the advancement office. “Can you please clarify—are our patients being targeted for donations?” I was informed that legislation passed the previous year made it possible for the advancement office to view the provider’s name and department associated with a patient’s most recent visit, and thereby use that information to send more targeted requests for donations. I was reassured that the reply slips included information on how to opt out of future fundraising requests.

I was distressed that the sacred space of trust that I so carefully cultivated with each patient was being breached by the institution without my knowledge or assent. Nearly a month passed before my outrage had subsided enough for me to write to departmental leadership to share my patient’s feedback about the targeted solicitation feeling “creepy.” I did my best to make the tone of my email constructive: “I thought you might want to know in case it weighs into future discussions regarding this fundraising tactic.” In their replies, the departmental leaders highlighted the “delicate balance” between potential discomfort and making people aware of opportunities to support our mission. They acknowledged my patient’s discomfort but also highlighted a recent $10,000 donation that they attributed to these solicitation letters. I was again reassured that patients were offered the opportunity to “opt out.” The failure to notify faculty of these endeavors was acknowledged; one leader expressed that it would be “TMI” to inform us of every fundraising initiative, whereas another leader proposed sharing copies of future letters with us prior to mailing.

I reiterated my personal discomfort with the tactic, acknowledging that the level of discomfort in my case likely stemmed from “the very personal nature of the discussions that transpire over the longitudinal course of caring for people with diseases that threaten their very sense of self.” I shared my opinion that offering patients the opportunity to opt out once they have received a solicitation is too late because “you can’t un-creep people out.” It would be better to allow providers the discretion to opt their patients out based on their knowledge of their patients’ circumstances. I acknowledged that institutional leaders must factor the fiscal sustainability of the institution into such decisions—a perspective wider than my individual relationships with patients—and thanked them for allowing me to contribute my perspective.

Other than a brief mention at a subsequent face-to-face annual performance review, there was no further discussion. Three years later, I received another notification that one of my patients had donated, making me aware that the solicitations had continued. As the years passed and my reputation as a local expert in my field became more widely recognized, I was asked to meet with two people from the advancement office to discuss direct face-to-face solicitation of donations from specific wealthy patients in my practice. I refused, saying I would happily facilitate a patient-initiated request but would never initiate the ask.

Although it was neither the first nor last moment of disillusionment in my 11 years at that institution, discovering that my clinical relationships were being leveraged for fundraising was the beginning of a fundamental shift in my attitude toward work. Prior to this moment, I was willing to sacrifice time with my young children to put in long hours; afterward, I noticed myself being more conservative with my time and energy investment toward institutional priorities. (I have always been willing to invest extra time and energy for patient-centered needs.) The lack of transparency around how the donated funds were being allocated contributed to my sense of betrayal. Year after year, I begged for support that would have made me more effective clinically and academically, but was told we couldn’t afford it. I can only wonder how differently my career might have evolved if I had been more willing to be complicit in soliciting donations from patients.

I resigned from my position at that institution in 2019. In February 2021, news broke that the institution had inappropriately expedited access to the COVID vaccine for wealthy donors. This immediately re-activated the unhealed moral injury from 7 years prior. I have remained in touch with the patient who made the donation in my honor, and I reached out to ask her what she thought about this news story. Specifically, I wanted to know if she had felt that donating would in any way change the quality of the care she received.

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. Part of it is that I really appreciated what you have done for me, and so I also felt that it was important to recognize you. 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.’ 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. If it just came from the institution [and not your specific department], I don’t know that I would have donated. And [regarding the possibility of receiving extra TLC if you are flagged as a donor], it actually happened. So there you go.

Unlike relationships with other entities that receive philanthropic donations, a patient’s relationship with a healthcare institution is non-discretionary. Healthcare is essential, not optional. This results in an inherent power differential that can put undue pressure on individuals who are in a vulnerable position. Moreover, because doctor-patient relationships presume that the best care is being provided regardless of financial status, any hint of preferential treatment erodes trust not just between individuals but also in institutions that provide these services. The layers of betrayed trust—between the institution and myself, and by proxy between my patient and me—fundamentally undermined the foundations of integrity that I aspired to uphold professionally, and ultimately was a significant factor in my decision to resign from my academic appointment.